Pediatric elbow and forearm fractures requiring surgical treatment

In the modern pediatric orthopedic practice, operative management plays a vital and not infrequent role in the management of significant and difficult forearm and elbow fractures in the skeletally immature. Although the majority of forearm and many elbow fractures can be treated successfully by nonoperative measures, operative intervention is warranted in selected cases to optimize outcomes. Anatomic reconstruction of articular surfaces, along with obtaining and maintaining a stable, anatomic fracture reduction, are the goals of any operative treatment. Appropriate use of surgical techniques for pediatric forearm and elbow fractures, when indicated, is essential to optimize results and achieve the ultimate goal of a pain-free functional extremity for the child.     

An uncommon cause of unilateral hand and forearm oedema

A case with an uncommon cause of unilateral hand and forearm oedema in a 37-year-old man is presented. Complex regional pain syndrome type I was diagnosed and treated with mannitol infusion, dimethyl sulfoxide, vitamin C, ketanserin and carnitine. Also, physiotherapy and occupational therapy were started. None of these treatment modalities resulted in reduction or prevention of recurrence of the oedema. All diagnostic procedures did not reveal a cause for this oedema.     

Lymphangioma of the forearm and hand

Cases of cavernous lymphangioma of the forearm and hand were reviewed in five female and four male patients. The tumor was first observed at a median age of 2 weeks, and tissue diagnosis confirmed at a median of 1.75 years. At a median follow-up of 11 years, all patients were symptomatic, describing pain when the affected area was bumped, pain with use, swelling, and extremity weakness. Five patients had experienced a previously undescribed episodic pain syndrome of simultaneous pain, swelling, induration, erythema, and fever. All cases responded favorably to elevation, analgesics, and antibiotics. Nine patients underwent a total of 18 operative procedures, including incisional biopsy, excisional biopsy, and excision of recurrent tumor, with a 33% complication rate. In only one case did surgery eliminate a small superficial tumor of the thumb; all other patients had recurrence of the tumor. Following attempted excision of cavernous lymphangioma of the forearm and hand, tumor recurrence, hypertrophic scars, and persistence of symptoms may be anticipated.     

Severe group a streptococcal infection and streptococcal toxic shock syndrome

PURPOSE: To review the literature on group A streptococcal toxic shock syndrome, (STSS). DATA SOURCE: Medline and EMBASE searches were conducted using the key words group A streptococcal toxic shock syndrome, alone and in combination with anesthesia; and septic shock, combined with anesthesia. Medline was also searched using key words intravenous immunoglobulin, (IVIG) and group A streptococcus, (GAS); and group A streptococcus and antibiotic therapy. Other references were included in this review if they addressed the history, microbiology, pathophysiology, incidence, mortality, presentation and management of invasive GAS infections. Relevant references from the papers reviewed were also considered. Articles on the foregoing topics were included regardless of study design. Non-English language studies were excluded. Literature on the efficacy of IVIG and optimal antibiotic therapy was specifically searched. PRINCIPAL FINDINGS: Reports of invasive GAS infections have recently increased. Invasive GAS infection is associated with a toxic shock syndrome, (STSS), in 8-14% of cases. The STSS characteristically results in shock and multi-organ failure soon after the onset of symptoms, and is associated with a mortality of 33-81%. Many of these patients will require extensive soft tissue debridement or amputation in the operating room, on an emergency basis. The extent of tissue debridement required is often underestimated before skin incision. CONCLUSIONS: Management of STSS requires volume resuscitation, vasopressor/inotrope infusion, antibiotic therapy and supportive care in an intensive care unit, usually including mechanical ventilation. Intravenous immunoglobulin infusion has been recommended. Further studies are needed to define the role of IVIG in STSS management and to determine optimal anesthetic management of patients with septic shock.     

Vascular tumors of the hand and forearm

Although blood vessel tumors are rare, they are frequently encountered in the hand and forearm, being the fourth most common tumor of the hand. The treating physician should be aware of the acquired, traumatic, and congenital vascular tumors that are so prevalent in this area.     

Neurilemmomas of the forearm and hand.

Neurilemmoma is the most common tumor arising from peripheral nerves. Although infrequently encountered, it must be included in the differential diagnosis of soft tissue tumors. Because of its cystic consistency, a neurilemmoma in the hand or wrist may be mistaken for a ganglion. In this series of 17 neurilemmomas, 6 were present in the forearm, and 11 were in the hand and wrist. There were 5 tumors in fingers, 1 in the thumb, 3 in the palm, and 2 in the wrist. In the forearm, 3 tumors involved the median nerve, 2 involved the ulnar nerve, and 1 arose from a small sensory branch of the radial nerve. Neurilemmomas arise from a benign proliferation of the Schwann cells and rarely disturb the function of the involved nerve. The tumors are well encapsulated and may be easily enucleated from the parent nerve. Resection of the involved nerve is seldom necessary except when small nerves are extensively involved.     

Incidence of donor site skin graft loss requiring surgical intervention with the radial forearm free flap

BACKGROUND: Many methods of managing the fasciocutaneous radial forearm free flap (RFFF) donor site have been described. Ideal management would be technically easy to perform, reliable, cost-effective, and prevent further complications. METHODS: The clinical records of 54 consecutive patients undergoing RFFF surgery by the senior author were reviewed. Records were reviewed to identify donor sites with significant breakdown that required intervention. RESULTS: Fifty-four patients were identified. Only 1 patient had significant tendon exposure. A V to Y closure was performed. The site healed well following this procedure and no further intervention was required. No other donor site complications were noted in this group. CONCLUSION: The incidence of wound breakdown requiring surgical intervention at the RFFF donor site is less than 2% utilizing a simple technique of split thickness skin grafting, bolster, and short-term splinting. This study demonstrates the low donor site morbidity of the RFFF.     

Nerve transfers in the forearm and hand

In the forearm, vital and expendable functions have been identified, and tendon transfers use these conventions to maximize function and minimize disability. Using similar concepts, distal nerve transfers offer a reconstruction that often is superior to reconstruction accomplished by traditional grafting. The authors present nerve transfer options for restoring motor and sensory deficits within each nerve distribution on the forearm and hand.     

Giant lipomatous tumours of the hand and forearm

This study examines the presentation, management and outcomes of a series of 10 patients with giant lipomatous tumours (defined as greater than 5 cm diameter) of the hand and forearm who presented to our orthopaedic oncology service. All patients underwent local staging and were discussed at our multidisciplinary tumour meeting prior to definitive surgery. In all cases, neurovascular structures required mobilization in order to excise the tumour. Seven of the tumours were benign lipomas and one was a neural fibrolipoma. The other two were well differentiated lipoma-like liposarcomas/atypical lipomatous tumours. Giant lipomas and well differentiated lipoma-like liposarcomas/atypical lipomatous tumours of the hand and forearm present infrequently and a multidisciplinary approach is recommended in the investigation and surgical management of these patients.