The Journal of hand surgery
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Case Reports
The treatment of upper extremity reflex sympathetic dystrophy with prolonged continuous stellate ganglion blockade.
Twenty-nine consecutively treated patients over a 5-year period with upper extremity reflex sympathetic dystrophy were admitted to Massachusetts General Hospital for prolonged continuous stellate ganglion blockade. Diagnosis was based on the presence of pain, decreased joint motion, trophic changes, and vasomotor disturbances. ⋯ Improvement during treatment was documented in all but two patients with regard to pain and decreased joint motion and in two-thirds with regard to trophic and vasomotor changes. Long-term follow-up demonstrated a relapse rate of 25%, but marked improvement persisted in the rest and normal status was attained in four of 26 patients at an average of 3 years later.
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From July 1, 1978, to July 1, 1980, 26 patients required pedicle flap coverage for acute skin loss defects in the hand and upper extremity. Eighteen patients had groin or abdominal flap coverage, and the pectoralis major island flap (PMIF) was used in eight patients. The circumstances of injury were approximately the same in both groups, consisting of a gunshot wound or electrical injury in over half of the cases. ⋯ Two of 13 groin flaps sustained partial necrosis, but none of the abdominal or PMIF flaps necrosed. The principle advantages of the PMIF in these selected cases was fourfold: (1) an extremity placed in a less dependent, sling-like position, (2) mobility, (3) reliability, and (4) a complete inset into the defect. The chest wall donor site defect, however, must be given some consideration.
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The surgical treatment of 50 patients with 101 neuromas over the last 10 years is reported. Simple excision and implantation into local muscle resulted in an unacceptable reoperative rate of 65%. ⋯ There appears to be a correlation between delayed healing after the initial injury and the severity of neuroma symptoms. Dorsal translocation of the neuroma consistently resulted in decreased sensitivity without longterm recurrence.
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Observations on early pathophysiology of burning suggests that the release of prostaglandins and thromboxanes plays a role in dermal ischemia. Because of the similarities of the early-phase frostbite wound, blister fluids were aspirated from 10 patients with frostbite, and routine biochemical analysis, immunoelectrophoresis, immunodiffusion, and evaluation of prostaglandins E2, F2 alpha, and thromboxane B2 were performed. ⋯ PgE2 was present in levels less than normal, but PgF2 alpha and TxB2 were markedly elevated. Since the vasoconstricting metabolites of arachidonic acid, PgF2 alpha and TxB2, are known to mediate dermal ischemia in burns and pedicle flaps, it is suggested they may play a role in the pathogenesis of frostbite.
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Fresh cadaver nerves were examined by serial cross-sections and microdissection with the operating microscope. The findings are compared with those of previous authors, primarily Sydney Sunderland. Our study confirms and amplifies Sunderland's findings: although it is true that funicular prexus formation and interchange takes place in the nerves of the human forearm, these connections are not of such a degree as to preclude operative procedures such as intraneural neurolysis, fascicular nerve repair, and interfascicular nerve grafting. ⋯ This arrangement lends itself to the application of modern microneurosurgical techniques. Clinical applications of these findings in the repair, lysis, and grafting of the major nerves of the forearm are described. The possibility of using such branches as the dorsal cutaneous branch of the ulnar nerve(if irreparably damaged) as a donor nerve for grafting is noted.