Epinephrine in digital block: color Doppler flow imaging

BACKGROUND

Epinephrine is currently added to local anesthetics for its advantageous vasoconstrictive effects. Traditionally, however, its use is not advised for digital block anesthesia due to the risk of digital gangrene.

OBJECTIVE

To observe vasoconstrictive effect of epinephrine in digital block anesthesia.

METHODS

Digital blocking with epinephrine containing lidocaine was performed in 24 subjects undergoing surgical procedure of their finger and toes. Digital artery blood flows were studied with color Doppler ultrasonography before digital blocking and at 10th, 60th, and if needed 90th minutes after blocking. Doppler parameters such as peak systolic velocity, end diastolic velocity, and resistive index values were studied.

RESULTS

There were statistically significant decrease of blood flow rates and an increase of resistive index in all patients within 10 minutes. At the 10th minute of digital block, four patients had no measurable blood flow, which was restored within 60 or 90 minutes. Others showed diminished but persistent blood flow, which returned to normal within 60 minutes. No systemic or local complication related with epinephrine usage was observed.

CONCLUSION

Vasoconstrictive effect of epinephrine in local anesthetics is not persistent and resolves within 60 or 90 minutes. Its use seems to be safe in selected patients.

Assessing peripheral arteries in South African black women with type 2 diabetes mellitus

OBJECTIVES

To determine the value of ankle and toe blood pressure indices and pedal pulse palpation in the assessment of peripheral arterial disease in subjects with type 2 diabetes mellitus (DM).

DESIGN

Cross-sectional study.

SUBJECTS

A convenience sample of 85 female subjects with type 2 DM underwent a series of peripheral vascular assessments at the diabetes clinic of a community hospital.

OUTCOME MEASURES

Palpation of the pedal pulses, Doppler-derived ankle brachial systolic blood pressure indices, photo plethysmographic-derived toe brachial systolic blood pressure indices and antero-posterior radiographs of both feet.

RESULTS

Mean values were 1.15 (standard deviation (SD): 0.17) and 0.76 (SD: 0.17) for ankle brachial index (ABI) and toe brachial index (TBI) respectively. The differences between the two indices increased from 0.36 (95% confidence interval (CI): 0.32-0.41) to 0.58 (95% CI: 0.46-0.70) depending on whether ABI was less or greater than 1.3. The correlation coefficient for left versus right foot was 0.62 and 0.71 for ABI and TBI respectively. The relationship between ABI and TBI is non-linear with a cut point close to 1.3. Both ABI and TBI were significantly lower in subjects who had both pedal pulses absent on palpation.

CONCLUSIONS

The relationship between ABI and TBI is linear below an ABI of 1.3. but with a wide 95% prediction interval. If both pedal pulses are absent the ABI is significantly diminished compared with when both pulses are present, even though not necessarily below 0.9.

Unusual presentation of a giant cell tumor of the tendon sheath in the foot

Giant cell tumor of the tendon sheath has frequently been described in the hand, but it is much less common in the foot. The case report presents an apparent cystic bony lesion of the proximal phalanx of the second toe of the foot. The operative findings and histological examination revealed a giant cell tumor of the tendon sheath that had eroded the phalanx. The case demonstrates that in the differential diagnosis of a cystic lesion of bone, extrinsic soft-tissue lesions should be considered.

Confirmation of alleged falanga torture by bone scintigraphy?Case report

Any objective persisting signs of previous torture would be very valuable in the late assessment of the individual claiming such abuse of human rights. We present the case of a 32-year-old man referred to our hospital for an opinion on alleged torture by the falanga method. Magnetic resonance imaging and bone scintigraphy were evaluated and compared as methods of confirming such torture.

Salter Harris type II injury of the proximal phalanx of the fifth toe: case report

Fractures of the growth plate are unique to childhood. The risk of growth disturbances depends on the type of fracture, its location, the age of the patient, the vascularization to the epiphysis, the state of the surrounding soft tissues, and whether the injury is open or closed. Epiphyseal fractures of the foot are uncommon, and only rarely are the phalanges involved. We report a Salter-Harris type II injury in the fifth toe. The patient, a 3-year-old girl, was successfully managed conservatively with no sequelae.

[Bone lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique]

OBJECTIVES

We evaluated the results of lengthening of congenitally short metacarpus and metatarsus by the callus distraction technique.

METHODS

We treated congenitally short metacarpus (n=7) and metatarsus (n=4) of five patients (4 females, 1 male; mean age 15 years; range 10 to 21 years) by callotasis. Callus distraction was performed with the use of mini-Orthofix or Ilizarov type semicircular external fixators. The distraction rate was 0.25x2 mm/day for both types. The mean follow-up period was 23 months (range 12 to 33 months).

RESULTS

The mean metacarpal and metatarsal lengthenings were 20 mm (range 15 to 25 mm) and 25 mm (range 20 to 30 mm), respectively. The mean healing index was 1.4 months/cm for metacarpal lengthening, and 1.8 months/cm for metatarsal lengthening. No neurovascular complications were encountered. One patient required autogenous fibular grafting for union. Pin tract infections were found in three patients. The overall complication rate was 36%.

CONCLUSION

Callotasis is an effective and reliable method for lengthening of short metacarpal and metatarsal bones. In addition, it preserves the periosteal bone tissues, which has a favorable effect on the duration of treatment.

Fuhrmann syndrome: two Brazilian cases

We describe two unrelated boys with bilateral fibula aplasia, poly- and oligodactyly, and bowed tibiae in two non-consanguineous Brazilian families. These cases are similar to those reported by Fuhrman et al. [(1980). Skeletal Dysplasias. New York: Alan R. Liss Inc. pp. 519-524].

Ainhum (dactylolysis spontanea): a radiological survey of 6000 patients

Dactylolysis spontanea is an idiopathic condition affecting the fifth toe, and sometimes other toes, that is frequently bilateral, with lesions in different stages. Between 1977 and 1999, a total 6000 radiographic studies of the feet were reviewed in a mainly African American population in Chicago, Illinois. After an initial screening based on the Cole criteria, 581 patients were selected and re-examined, and amplification techniques were performed. After reviewing the complementary exams, 102 patients were diagnosed with dactylolysis spontanea or ainhum. Soft-tissue constriction was the most frequently presented radiological sign on the initial screening. Kurtosis at the digit plantar fold and marked rotation of the fifth toe were normal findings in asymptomatic patients. Demographics, comorbidities, and radiological findings were analyzed in the selected population. Associated diseases occurring in these patients appeared to have no specific etiologic correlation with ainhum. African Americans and the dark-skinned population are affected exclusively by this condition, presumably due to the fibrogenic tendency of these individuals. Early diagnosis and accurate staging of ainhum are facilitated by radiological examination of the feet. The findings suggest that this condition is underdiagnosed and overlooked because its low prevalence and variable clinical presentations that might mimic more common etiologies, including localized trauma.

A new automated toe blood pressure monitor for assessment of limb ischemia

OBJECTIVE

toe blood pressure (TBP) is an important method to assess peripheral arterial disease especially in patients with diabetes, but remains difficult to measure. We have developed a simple portable device for TBP measurements.

METHODS AND RESULTS

first, TBP was determined in 40 ischemic legs with both laser Doppler and photoplethysmography for perfusion monitoring, to assess if laser Doppler can be used for measurements. The median values recorded were identical, but slightly higher values were obtained with laser Doppler (p=0.03). Secondly, a computer based algorithm for automatic TBP readings with laser Doppler was compared to manual assessment in 28 legs of 20 patients. The median values differed 3mmHg (p=0.10). Finally the applicability of the new device was tested in eight legs of six patients by two nurses.

CONCLUSION

laser Doppler is appropriate for perfusion monitoring during TBP measurements and automatic pressure readings seem accurate. The automatic portable device is simple to use and can probably determine TBP.

Hard palate mucosal grafts for defects of the nail bed

The authors present 2 children in whom a hard palate mucosal graft was used for a defect of the nail bed after resecting subungual exostosis. After the tumor was resected with the overriding nail bed, hard palate mucosa without periosteum was grafted to the nail bed defect. In both patients the graft took completely, and within 2 weeks after the operation the patients were able to enjoy activities of daily life, including athletic movement, without any symptoms. Nail growth was uneventful and was complete in 4 or 5 months after the operation without any complications. The authors think that a hard palate mucosal graft is a valid choice for a defect of the nail bed, and the mucosa does not need to be harvested with periosteum. The grafting of hard palate mucosa without periosteum to a defect of the nail bed contributes to a shorter healing time, resulting in a reduction in the period of restriction of movement in activities of daily life, and this is a great advantage in children.

[Frostbite of the upper and lower limbs in an expert mountain climber: the value of bone scan in the prediction of amputation level]

A 38 year old man was admitted to our hospital 10 days after suffering a frostbite injury in hands and feet while practicing mountain climbing, at 8,100 meters of altitude, while he was trying to reach the top of the K2 mountain. A 99mTc-MDP bone scan performed in aseptic conditions showed: in hands: absence of bone uptake in the 3rd phalanx and distal portion of 2nd phalanx of the 5th finger of the left hand, and multiple areas of increased uptake in the distal portion of both hands. In feet: uptake decreases in the 2nd phalanx of the first toe of the left foot, and absence of bone uptake in the 3rd phalanx of the 2nd toe of the left foot, and in 2nd phalanx of the 1st toe and 3rd phalanx of the 2nd, 3rd and 4th toes of the right foot. As in the hands, there were multiple areas of increased uptake in the distal portion of both feet. The phalanges with absence of bone uptake had to be amputated, while those that presented increased uptake recovered with conservative treatment. Bone scan is indicated in the evaluation of frostbite injuries and helps to establish the prognosis early.

Tc-99m MIBI scintigraphy in a patient with primary and metastatic malignant melanoma

Malignant melanoma is a rare malignant tumor arising within the melanocytes of the skin. The authors report a case of primary and metastatic malignant melanoma revealed with Tc-99m MIBI in one patient. Tc-99m MIBI images showed uptake in possible malignant melanoma skin lesions of the left calf and great toe of a 73-year-old man. Malignant melanomas (primary and metastatic) were diagnosed on excisional biopsies. Tc-99m MIBI scintigraphy might be useful not only in the diagnosis of possible primary malignant melanoma lesions but also in the diagnosis of metastatic or recurrent disease.

Effect of synergistic motion on flexor digitorum profundus tendon excursion

Clinical and experimental studies have shown that postoperative rehabilitation is an important factor that improves digital function after flexor tendon repair. In the current study, the effect of synergistic wrist and finger motion therapy and fixed flexed wrist motion therapy on the in vivo gliding excursion was evaluated after repair of partial laceration of the canine flexor digitorum profundus tendon. The gliding excursion of the repaired tendons treated with synergistic wrist and finger motion therapy was significantly greater than that of tendons rehabilitated with the wrist fixation therapy, suggesting that wrist extension generates force that can pull the repair site through the pulley, thereby increasing passive excursion of the tendon. As a result of increased tendon excursion, synergistic therapy may improve the clinical outcome after repair of partial tendon lacerations.

Radiographic analysis of growth in pediatric microsurgical toe-to-hand transfers

Microsurgical toe-to-hand transfers may provide improved hand function in children with absent digits. To date, documentation of the growth potential of these transferred digits has not been performed. This study reviewed the authors' series of pediatric toe-to-hand transfers, with specific attention paid to measuring growth by radiographic analysis. From 1995 to 2000, 23 toe-to-hand transfers were performed in 18 children. Age at time of transfer ranged from 2.8 to 13 years. Indications included constriction band syndrome, transverse deficiency, longitudinal deficiency, traumatic amputation, and vascular malformation. The transfers were successful in 22 of 23 procedures (96 percent success rate). Radiographic analysis of growth was performed using three criteria: (1) appearance of open epiphyseal plates, (2) comparison with preoperative radiographs, and (3) comparison with radiographs of the contralateral control toe. Epiphyseal plates remained open on postoperative radiographs in 27 of 28 phalanges (96 percent) at a mean of 12 months' follow-up (range, 1 to 36 months). The preoperative foot radiographs were compared with serial radiographs of the transferred toe over time. In 10 toe transfers with follow-up greater than 6 months (mean, 21 months), nine patients had increased bony length in the transferred digit. In four patients, radiographs of the toe transfer were compared with radiographs of the corresponding toe on the opposite foot. With a mean follow-up of 29 months, all patients had equal length measurements of the toe transfer with the contralateral toe control. These data provide objective evidence that digital growth potential is preserved in toe-to-hand transfers. Furthermore, this bone growth is comparable with that of the corresponding toe on the contralateral foot. Therefore, microsurgical toe-to-hand transfers may provide children with extra digits that maintain growth and improve hand function.

Limb/pelvis hypoplasia/aplasia with skull defect (Schinzel phocomelia): distinctive features and prenatal detection

Schinzel phocomelia syndrome is characterized by limb/pelvis hypoplasia/aplasia: specifically, intercalary limb deficiencies and absent or hypoplastic pelvic bones. The phenotype is similar to that described in a related multiple malformation syndrome known as Al-Awadi/Raas-Rothschild syndrome. The additional important feature of large parietooccipital skull defects without meningocele, encephalocele, or other brain malformation has thus far been reported only in children with Schinzel phocomelia syndrome. We recently evaluated a boy affected with Schinzel phocomelia born to nonconsanguineous healthy parents of Mexican origin. A third-trimester fetal ultrasound scan showed severe limb deficiencies and an absent pelvis. The infant died shortly after birth. Dysmorphology examination, radiographs, and autopsy revealed quadrilateral intercalary limb deficiencies with preaxial toe polydactyly; an absent pelvis and a 7 x 3-cm skull defect; and extraskeletal anomalies including microtia, telecanthus, micropenis with cryptorchidism, renal cysts, stenosis of the colon, and a cleft alveolar ridge. A normal 46,XY karyotype was demonstrated, and autosomal recessive inheritance was presumed on the basis of previously reported families. This case report emphasizes the importance of recognizing severe pelvic and skull deficiencies (either post- or prenatally) in differentiating infants with Schinzel phocomelia from other multiple malformation syndromes that feature intercalary limb defects, including thalidomide embryopathy and Roberts-SC phocomelia.