[The establishment of the fact of the application of an electric circular saw with the high-speed reciprocating motion of the blade]

This paper reports a case of forensic medical expertise of an unintentional (accidental) injury inflicted by an electric circular saw with the high-speed reciprocating motion of the blade (jigsaw) under conditions of human operational activities.

Complications of common hand and wrist surgery procedures: flexor and extensor tendon surgery

Orthopaedic and hand surgeons frequently treat disorders of the flexor and extensor tendon systems. Common conditions, such as trigger finger, de Quervain tenosynovitis, extensor tendon injury, and zone II flexor tendon injury, can be challenging to treat. Complications that limit normal hand function still occur despite advances in surgical techniques and therapy protocols. It is helpful to be aware of the complications related to the treatment of these hand disorders and understand surgical techniques to minimize their frequency.

[Hand injuries caused by fireworks and treated by plastic surgeons]

OBJECTIVE

To make an inventory of the number and nature of hand injuries caused by private firework use in the Netherlands during the New Year celebrations 2013-2014 and that were seen and treated by plastic surgeons.

DESIGN

Descriptive study.

METHOD

In October 2013 the Netherlands Association of Plastic Surgeons (Nederlandse Vereniging voor Plastische Chirurgie) asked its members to register patients treated for hand injuries caused by fireworks during the New Year celebrations 2013-2014. The registration form was sent to all members by email. Patient data, the sort of firework, the nature of and treatment for the injury and the legality of the fireworks were registered. It was also important to note which hand was affected, whether it was the dominant hand and how many fingers were involved. Finger, thumb and hand amputations were also recorded.

RESULTS

A total of 76 patients were seen by a plastic surgeon for the treatment of hand injuries caused by fireworks. The patients were all male. In 50% of patients the injury was caused by setting off illegal fireworks. The largest group of victims were aged < 18 years. In 7 patients the hand was amputated to the level of the radiocarpal joint. A total of 232 fingers were injured by fireworks, leading to 63 total finger amputations, including 11 total thumb amputations. Many serious injuries occurred outside the legally permitted time period for setting off fireworks.

CONCLUSION

The number of victims with serious hand injuries caused by fireworks was high during the New Year celebrations 2013-2014 and had increased in comparison with the preceding year. The majority of victims were aged < 18 years and were injured while setting off illegal fireworks by themselves.

Mobile garbage bins and hand injuries in older people

OBJECTIVES

To conduct a database search, chart and literature review of open extensor tendon and proximal interphalangeal joint injuries incurred while handling mobile garbage bins.

DESIGN, SETTING AND PARTICIPANTS

A review of medical records at a Sydney tertiary referral hospital and a NSW rural Level 2 trauma hospital from 1 January 2006 to 31 December 2010, identified through database searches of appropriate medical record codes and followed by a chart review.

RESULTS

We identified 11 patients with finger injuries from handling mobile garbage bins that necessitated hospital-based treatments. Their average age was 75 years. Eight patients required surgery. Patients typically fell while maintaining their grip on mobile garbage bin handles, causing abrasive injury to the dorsal aspect of the proximal interphalangeal joint.

CONCLUSIONS

Older patients are at risk of significant injuries to the dorsal side of their fingers when manoeuvring mobile garbage bins. This risk could be reduced by providing older members of the community with help to move their bins, or by modifying the design of bin handles. We propose a simple modification to the design of bin handles.

Upper body musculoskeletal symptoms of Latino poultry processing workers and a comparison group of Latino manual workers

BACKGROUND

Upper body musculoskeletal injuries are often attributed to rapid work pace and repetitive motions. These job features are common in poultry processing, an industry that relies on Latino immigrants. Few studies document the symptom burden of immigrant Latinos employed in poultry processing or other manual jobs.

METHODS

Latino poultry processing workers (n = 403) and a comparison population of 339 Latino manual workers reported symptoms for six upper body sites during interviews. We tabulated symptoms and explored factors associated with symptom counts.

RESULTS

Back symptoms and wrist/hand symptoms lasting more than 1-day were reported by over 35% of workers. Poultry processing workers reported more symptoms than comparison workers, especially wrist and elbow symptoms. The number of sites at which workers reported symptoms was elevated for overtime workers and workers who spoke an indigenous language during childhood.

CONCLUSION

Workplace conditions facing poultry processing and indigenous language speaking workers deserve further exploration.

[Unexpected abdominal trauma from a fireworks explosion]

BACKGROUND

Fireworks injuries are common and often affect children. Such injuries should be considered high energy trauma in the emergency room and taken care of according to the principles of the Advanced Trauma Life Support (ATLS).

CASE DESCRIPTION

A 7-year-old boy was a victim of an explosion when he set off illegal fireworks. During evaluation in the emergency department he presented with a superficial laceration on the belly and extensive hand injury. Upon examination he had small-intestinal perforation that required immediate resection. The patient recovered well, but suffered permanent damage to the hand.

CONCLUSION

Potentially life threatening injuries may accompany hand injuries after modern illegal fireworks. Hand injuries are serious. Despite prolonged treatment, they often result in permanent disability. The structured approach to trauma according to ATLS was important in detecting an accompanying abdominal trauma in this case.

[A man with acute, painless swelling of the hand]

A 48-year-old man visited the hand surgery outpatient clinic with acute, painless swelling of the dorsal side of the right hand and fingers. We found erythema and crepitations of the skin. Laboratory tests showed no signs of infection. After X-ray and echography of the hand we made the diagnosis subcutaneous emphysema. It was caused by a microtrauma with high pressure air.

Reverse flow posterior interosseous flap: experience with 53 flaps at Nishtar Hospital, Multan

OBJECTIVE

To assess the efficacy of reverse flow posterior interosseous artery flap for the coverage of large variety of hand/wrist defects.

METHODS

The prospective study was conducted a the Department of Plastic Surgery and the Burns Unit of Nishtar Hospital, Multan, Pakistan, from June 2008 to June 2010. The study comprised 53 reverse flow posterior interosseous artery flaps in 50 patients for the coverage of hand/wrist defects both in emergency and elective settings. Data was analysed using SPSS 10.

RESULTS

The hand/wrist defects in the study population were caused by different etiologies. All the flaps survived in all the patients. Marginal loss over the distal edge of the flap was noted in one patient. Mild oedema developed in all patients, but it subsided except in one case. None of our cases showed any evidence of venous congestion. Regarding the donor site morbidity, only one case had partial STSG loss. Mean hospital stay post-flap coverage in the patients ranged from 7 to 21 days.

CONCLUSION

Reverse flow posterior interosseous artery flap in experienced hands is safe, versatile and reliable for the coverage of hand/wrist defects.

Mycobacterium chelonae hand infection following ferret bite

We present a case of hand infection caused by Mycobacterium chelonae. The patient was a 58-year-old woman with Type II diabetes mellitus and stage 4 chronic kidney disease. The infection occurred following a ferret bite and had not responded to oral antibiotics in the primary care setting. She developed signs of pyogenic flexor tenosynovitis of the index and middle fingers of her left hand. Laboratory parameters showed high C-reactive protein, raised erythrocyte sedimentation rate and leucocytosis. Ultrasound imaging confirmed the clinical diagnosis. Plain radiographs showed no osseous involvement. The infection was treated with surgical debridement and broad spectrum parenteral antibiotics. The intra-operative tissue specimens were initially negative on aerobic and anaerobic cultures. Following transient improvement of her inflammatory parameters and clinical signs, she developed a recurrence with added features of osteomyelitis of the index and middle finger metacarpal heads on repeat radiographs. A revision surgical debridement of the flexor tenosynovitis and osteomyelitis with specific long-term antibiotic cover has led to resolution of the infection. Extended cultures of the tissue specimens at the regional laboratory confirmed the causative organism to be M. chelonae. To our knowledge, this is the first reported case of M. chelonae infection resulting from a ferret bite. This case reminds us of the need for a high index of suspicion for infection with uncommon pathogens following animal bites, especially in patients with altered immune status.

Risk factors for occupational hand injuries: relationship between agency and finger

BACKGROUND

The aim of this study was to define the risk factors for occupational hand injuries and explore the relationship between the machines and the fingers injured, based on the records of a hospital in Turkey specialized in hand and microsurgery.

METHODS

Five thousand twenty seven occupational hand injuries treated at a hand and microsurgery hospital between 1992 and 2005 were included in the study. All the injuries were retrospectively recoded according to ICD-10, (ICECI) and ILO recommendations. Logistic regression and chi-square for trend analysis were used to evaluate the risk factors for occupational injuries.

RESULTS

The most frequent injuries were traumatic amputation of wrist and hand (53.2%), open wound of wrist and hand (46.3%). Considering all injuries, 60.9% of agricultural machines, 52.7% of metal working machines, 54.7% of transmission machinery, and 42.8% of wood and assimilated machines affected the right hand. Powered wood cutters, presses, planning and milling machines, and machine belts were the most frequent five machines involved in injuries, each having a different finger pattern. The proportion of machinery among all hand injuries was significantly decreasing with time.

CONCLUSION

A stricter and more frequent supervision of the use of protective equipment and prohibition of the purchase of machinery not complying with the regulations could contribute to the prevention of hand injuries.

Epidemiology of occupational hand injury in Hong Kong

OBJECTIVES

To study the epidemiology of occupational hand injuries and associated social and industrial factors. DESIGN. For this retrospective case series of patients with occupational hand injuries, case records were retrieved to gather data. In addition, all the subjects were interviewed by a single interviewer using a predesigned questionnaire.

SETTING

Division of Hand Surgery, Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong.

PATIENTS

A total of 250 patients with occupational hand injuries were treated during the period from 1999 to 2001. This period was chosen to obtain 10 years of follow-up data to assess return to work and any secondary injuries.

MAIN OUTCOME MEASURES

Personal particulars (gender, age, marital status, education level, length of stay in Hong Kong, type of employment, wage system, personal habits, family size, number of breadwinners, income), type of industry and mode of injury, causes of injury according to the worker, work conditions, type of injury, and treatment given.

RESULTS

Two groups of workers in our study had more occupational hand injuries, namely those with less than 1 year of experience on a new job and immigrants from China. Factors associated with a large proportion of occupational hand injuries were male gender with personal risk factors (smoking and regular consumption of alcohol, long working hours), and in the case of machine operators, inadequate training and use of safety devices.

CONCLUSION

Occupational hand injuries lead to loss of working hours and compensation. For prevention, the workplace should be made into a safer and work-friendly environment. Workers should also have sufficient training.

Bites to the hand: are they more than we can chew?

Animal bites to the hand caused by dogs, cats and humans are common conditions that general practitioners, emergency physicians and hand surgeons encounter in their practice. These bites are prone to infection and represent great cost to the patient in terms of time, money and disability, if not treated optimally from the outset. Other than lacerations to the skin, injuries to the tendons, nerves, bone and joints are commonplace given their proximity to the skin surface in the hand. Optimal treatment of acute animal bites to the hand should include clearance of contamination by surgical debridement, prophylactic antibiotics and tetanus toxoid, as well as staged reconstruction of all damaged tissue, including the skin, once the wound is deemed clean.

Accidental tear gas injuries in security agents

BACKGROUND

Tear gas is a noxious vapour used in quelling civil disturbances. The law enforcement agents who usually handle this are well trained and rarely injured by the use of this weapon especially during peace times.

METHODS

We report injuries sustained by two policemen handling tear gas as a result of accidents. Case notes of the patients were the source of information.

RESULTS

Two policemen were injured while handling tear gas. The equipment accidentally dropped and exploded on attempting to pick them. The mechanisms of injuries and parts of the body injured were similar ie the hands and face with traumatic cataract of an eye in one patient.

CONCLUSION

We conclude that proper training of the law enforcement agents will go a long way in reducing these types of morbidity from tear gas use.

'Biting the hand that feeds': fever and altered sensorium following a dog bite

Capnocytophaga canimorsus infection is the most severe and rapidly progressive bacterial infection transmitted by dog bite and fortunately is very rare. The authors describe a 68-year-old gentleman who presented in an acute confusional state 2 days after having been bitten on the left hand by a dog. Despite immediate broad-spectrum intravenous antibiotics, he developed significant sequelae including disseminated intravascular coagulopathy, microvascular emboli leading to peripheral necrosis, widespread local tissue destruction and septic arthritis. Our case illustrates a life-threatening presentation of infection with C. canimorsus, which is known as 'the dog bite organism'. Early diagnosis and aggressive treatment is key to survival.

Case report: Hyperbaric oxygen in the treatment of puff adder (Bitis arietans) bite

INTRODUCTION

The puff adder (Bitis arietans) is a venomous viper mainly found in sub-Saharan Africa. Due to its common occurrence and potent venom, it is considered to be the most dangerous snake in Africa, responsible for most snakebite fatalities there. Puff adder bites outside Africa are rare and involve captive vipers. We present the unusual case of puff adder envenomation in an Austrian man.

CASE REPORT

A 26-year-old Austrian man was bitten by a puff adder that he kept illegally in his home. On admission he showed signs of local and systemic toxicity. He was stabilized with antivenom, intravenous fluids, catecholamines and packed platelets. Hyperbaric oxygenation was begun due to incipient compartment syndrome on the second day and continued until the eleventh day, when the patient had recovered completely and could be discharged.

DISCUSSION

The venom of Bitis arietans can cause serious systemic and local complications. Our patient suffered from both. Systemic signs included hemodynamic as well as hemostaseologic impairment. Local effects included swelling and incipient compartment syndrome. Systemic and local treatment, including hyperbaric oxygenation, effected a full recovery. We suggest that, whenever feasible, hyperbaric oxygenation should be considered as adjunct treatment in snake bites to avert adverse outcomes.

Hyperbaric oxygen therapy after Bothrops lanceolatus snake bites in Martinique: a brief report

Every year 10 to 20 cases of snake bites are reported on the Caribbean island of Martinique. The only snake involved, Bothrops lanceolatus, is endemic on the island, and its bite may lead to systemic multifocal thrombotic complications in the'absence of the monospecific antivenom. Between January 1988 and January 2009, more than 250 snake bites have been reported, and five patients were treated with hyperbaric oxygen (HBO2) therapy for local complications. The patients were male, bitten on the leg or the hand, and presented with severe complications such as necrotizing soft tissue infections, compartment syndrome or abscesses despite prompt wound care and administration of antivenomous serum. Outcomes were favorable for these five patients, except for one who was left with a functional defect of the hand. Although snake bites are not part of the currently recommended indications for HBO2 therapy, local complications, namely compartment syndrome, necrotizing soft tissue infections and enhancement of healing in selected problem wounds, are approved uses of HBO2 therapy as defined by the Hyperbaric Oxygen Therapy Committee and would benefit from prospective studies.

Epidemiology and management of surgical upper limb infections in patients with end-stage renal failure

INTRODUCTION

Hand infections in patients with end-stage renal failure (ESRF) are more diffi cult to treat and have had the worse outcomes. This paper examines the epidemiology, bacteriology and outcomes of surgically managed upper limb infections in these vulnerable patients.

MATERIALS AND METHODS

All patients from a single centre with surgically-managed upper limb infections between 2001 and 2007 were reviewed. We collected epidemiological data on demographics, type and site of infection, bacteriology, surgical treatment, complications and mortality.

RESULTS

Forty-seven out of 803 (6%) patients with surgically managed upper limb infections in the study period had ESRF. The average age was 59 years. ESRF was secondary to diabetes in 88% of cases. Patients presented on average 7 days after onset of symptoms. Abscesses (34%), wet gangrene (26%) and osteomyelitis (11%) were the commonest infections. Methicillin-resistant Staphylococcus aureus (MRSA) was the commonest pathogen (29%), occurring either in isolation or with other organisms. Eighteen percent of single organisms cultured were gram-negative. Multiple organisms occurred in 29%. A median of 2 operations were required. Thirty-six percent of all cases required amputation. Twenty-fi ve percent of patients had a life-threatening event (myocardial infarction or septic shock) during treatment.

CONCLUSIONS

ESRF patients present late with severe upper limb infections. Nosocomial infections are common. Initial empirical antibiotic treatment should cover MRSA and gram-negative bacteria. Immediate referral to a hand surgery unit is recommended. Multi-disciplinary management of the patient with input from physicians and anaesthetists or intensivists in the perioperative period is necessary to optimise the patient for surgery and to manage active medical comorbidities and complications after surgery.