Dorsum Of Right Hand Research Articles

Role of Plastic Surgery in a Venomous Snake Bite: A Case Report

Snake bite is one of the major cause of accidental morbidity & mortality worldwide. In riverine Bangladesh people of rural areas are mostly affected by snake bite. Majority of bites are caused by non-venomous snake and usually no casualty occurs but in case of venomous snake bite it can cause physical disability even death. Venom can cause local and systemic effect. Acute management is done by medical specialist but some patient develop surgical complication that need to be addressed by a plastic surgeon. A 43 years old male presented with a wound over dorsum of right hand and right middle finger with exposed MP joint (Metacarpophalangeal). He had history of snake bite 25 days back. Reconstruction done with flap and skin graft. Patient of venomous snake bite need a multidisciplinary team approach including plastic surgeon who take responsibility to restore both form and function.

Porphyria cutanea tarda: A case report

The porphyria's are a rare group of metabolic disorders produced by acquired or hereditary deficiency of the enzyme UROD, fifth enzyme in the chain of production of the heme group, which results in an accumulation of photosensitive by products, such as uroporphyrinogen, which leads to the fragility and blistering of sun-exposed skin. Porphyria can manifest with neurovisceral and/or cutaneous symptoms, depending on the defective enzyme. Prevalence of porphyria's varies, from 1 in 500 to 1 in 50,000 people worldwide. PCT, the most common. A 59-year-old Indian man presented with multiple non healing ulcers on dorsum of right hand and scalp associated with photosensitivity and reddish discoloration of urine, and surrounding depigmentation with scarring. He was diagnosed as having PCT after clinical investigation and was treated symptomatically. PCT is the most common of the seven porphyrin metabolism disorders. The misdiagnosis and mismanagement of this disease can have a significant impact on a patient's life and does management of PCT in our case is focused on the signs and symptoms and findings.

Dermatofibroma Frequent Disease, Uncommon Location

Dermatofibroma (DF) is a very common benign tumor, which occurs most often in middle-aged women. In general, DF presents as a solitary lesion on the extremities, shoulders or buttock, which occasionally develops following minor trauma or an insect bite. We describe a case of dermatofibroma involving the dorsum of right hand.

Open reduction of carpometacarpal fracture dislocations: a case report

<p class="abstract">Dislocations of the carpometacarpal (CMC) joints are uncommon injuries. Up to 70% of carpometacarpal dislocations are missed or misdiagnosed. Post traumatic dislocation of carpal and CMC joint results most commonly due to high energy trauma. A 24 year old male with right hand dominant presented 5 days after in emergency room with alleged history of fall from 4 feet height on right hand with wrist in extension. On clinical examination revealed marked swelling over dorsum of right hand with wound over volar aspect of hand. There was minimal movement of fingers due to pain. There was no finger paresthesia. CRT was normal. Radiography revealed a volar dislocation of 2nd to 5th CMC joint with intra-articular fracture of base of proximal phalanx of the thumb. He was treated by open reduction and percutaneous fixation using Kirschner wires. The functional results were excellent at 6 months of follow-up.</p>

P43-S Different stimuli painful or not may explore diffuse noxious inhibitory control in humans

Background Diffuse noxious inhibitory control (DNIC) can be studied when using different painful stimulations before and after a cold pressor test (CPT). The aim of this study is to affirm a modulation of pain responses when applying CPT in healthy subjects. Methods 15 normal subjects (9 males, 6 females) were included. They signed informed consent. The stimulus was applied on the dorsum of right hand. The CPT was applied on the left foot for five minutes. The intensity of pain was noted on a visual analogic scale (VAS). Evoked potentials (EP) were recorded. The three different types of stimulation were: heat laser stimulus, electrical stimulus with a circular electrode (elec-pain-4 Walter graphtek), cold stimulus with an air puff. The paradigm was: time 1 stimulation baseline; time 2 repeated stimulation baseline then CPT applied for 5 min; time 3 stimulation 5 mn after CPT; time 4 stimulation 30 mn after CPT. Values of VAS were noted. Latencies and amplitudes of vertex potentials N2/P2 were measured. The different sessions were compared between them (student test) as well for psychophysical and EP data. Results Whatever the stimulus, VAS and EP in time 1 and time 2 were not different. The responses were diminished five minutes after CPT and could return to baseline or remain diminished after thirty minutes. Conclusion These paradigms confirm the lack of stimulus specificity able to induce the startup of DNIC. Such techniques may help to study pain control in patients.

Abdominal Flap: A Reconstructive Option for Hand Defect in Rural Setting

Reconstruction of hand injury is the challenge for the surgeon especially in rural settings. This case report is about a 10-year-old boy, who sustained large degloving wound of dorsum of right hand with extensor tendon injury following a road traffic accident. We performed a staged abdominal flap with tensor fascia lata graft for tendon reconstruction as microsurgery facilities was not available. Post-operatively he was subjected to physiotherapy and he has a functional right hand. This case report aimed to highlight abdominal flap as reconstructive option as compared to skin grafting which is reproducible with limited resources. Besides that, overall exposure to all surgical options is of paramount importance in the training of trainees to equip them with skills to serve in rural setting.

Corneal Ulcer and Epidermolysis Bullous Acquisita, an Unsual Presentation of Inflammatory Bowel Disease (IBD)

Inflammatory bowel disease (IBD) is a systemic inflammatory disorder that has specific predilection for gastrointestinal tract but can affect multiple organs including eyes, that can present as keratitis, episcleritis or uveitis causing significant visual morbidity. These ocular manifestations may present before the usual intestinal signs and symptoms. We report an extremely rare case of corneal ulceration with epidermolysis bullous acquisita (EBA) in a patient with no gastrointestinal symptoms. A 37-year-old female presented to the emergency department with severe sharp left eye pain and photophobia. The eye discomfort started five days ago and gradually worsened. Patient also reported an ulcerative lesion on the dorsum of right hand and both legs that started as blisters and gradually developed into ulcers over the past 10 days. She had low-grade fevers at times, but denied weight loss or any history of sexually transmitted diseases including syphilis and herpes. Ophthalmological exam revealed left eye's corneal ulceration. Since there was a concern for herpes ophthalmicus and bacterial infection, patents was started on vancomycin and tobramycin along with intravenous acyclovir but were discontinued later as corneal cultures did not grow any organisms. Skin lesions on hand and legs were compatible with a presentation of epidermolysis bullous acquisita (figure 1 and 2), confirmed by skin biopsy. Blood work-up revealed iron deficiency anemia, hence she underwent a colonoscopy that showed focal ulcerations with adjacent normal mucosa, cobblestoning, thickened wall and long fissures. Biopsy confirmed Crohn's disease. Crohn's disease is a chronic inflammatory bowel disease characterized by transmural inflammation of the gastrointestinal tract, and 4-8% patients have been reported to have ocular manifestations. However corneal ulcerations are far less common than conjunctivitis, episcleritis and uveitis. EBA is a chronic autoimmune skin disease and can involve mucous membranes. Antibodies target type VII collagen; fibrils connecting basement membrane to dermis, and presents as blisters that can develop into dense scars on extensor surfaces or trauma prone areas along with mild mucosal lesions. Corneal ulceration and epidermolysis bullous acquisita in an undiagnosed IBD have rarely been reported and hence considering IBD as a differential in such presentations leads to early diagnosis and treatment preventing visual morbidity.Figure: Hand Ulcer.Figure: Leg Ulcers.

A Case of Sporotrichosis Caused by Sporothrix globosa in Japan.

Dear Editor: Sporotrichosis is the most common subcutaneous mycosis. Sporothrix schenckii was once considered a single species, but a recent study has demonstrated that S. schenckii is actually a complex of distinct species with similar morphological features, called the S. schenckii complex1. To our knowledge, this is the first case report of sporotrichosis caused by S. globosa, a member of the S. schenckii complex, in Japan. A 77-year-old Japanese man presented to our department with a three month history of crusted erythematous nodules on the dorsum of his right hand and forearm, in a linear arrangement (Fig. 1A). The right hand was scratched by a cat two weeks before the onset. Because sporotrichosis was suspected, a skin biopsy was performed. Histopathological examination demonstrated a mixed granulomatous reaction with focal neutrophilic microabscesses. Spores were identified in the tissue sections using periodic acid-Schiff stains (Fig. 1B). The biopsy specimen was also submitted for culturing, using enriched glucose-containing media and Sabouraud's agar, at two different conditions, 25℃~27℃ and 35℃~37℃. Microscopic morphology obtained from the 25℃ culture showed septate hyphae and hyaline or slightly pigmented conidia that grouped in rosettes at the tips of the conidiophores (Fig. 1C). Interestingly, there was no conversion to the yeast form in the 37℃ culture. Because the features was atypical of classical S. schenckii, we considered the causative microorganism as another member of S. schenckii complex. Genetic analysis of DNA by polymerase chain reaction identified this agent as S. globosa with 99% homology compared to the known genetic sequence. Thus, we diagnosed this case as sporotrichosis caused by S. globosa. Three months of oral potassium iodide (1,200 mg/day) and two months of oral itraconazol (200 mg/day) achieved the resolution of the symptom. Fig. 1 (A) Skin lesion on the dorsum of right hand and forearm with multiple erythematous crusted nodules along lymphatics. (B) Periodic acid-Schiff stain (×200). (C) Microscopic morphology obtained from 25℃ culture showing septate hyphae and ... Recent molecular biological studies have revealed that S. schenckii complex comprises at least six closely related dimorphic fungi including S. brasiliensis, S. globosa, S. mexicana, S. albicans, S. luriei, and S. schenckii sensu stricto1,2. Retrospective studies using strains isolated from patients with sporotrichosis revealed that many cases deemed of classical S. schenckii morphology were not necessarily caused by S. schenckii in a strict sense, but by other species of the S. schenckii complex. Through DNA analysis, Marimon et al.2 examined 112 cases of sporotrichosis that were originally considered to be caused by classical S. schenckii. They found that almost half of the isolates were other S. schenckii complex members such as S. globosa and S. brasiliensis. A similar study was also performed in Japan, and 15 strains out of 20 cases were identified as S. globosa3. Our causative agent neither grew at 37℃ on Sabouraud's agar nor converted to the yeast form. Referring to species identification methods proposed by Marimon et al.2, these are typical features of S. globosa. Thus far, it is not known that if there are differences in clinical features and treatment sensitivity between species4,5. Therefore, detailed identification of causative species in each individual case of sporortrichosis may prove useful for future research and treatment.

Complex regional pain syndrome type I following pacemaker implantation

A 70-year-old woman presented with burning pain and swelling over dorsum of right hand and small joints of the fingers, associated with redness, feeling of warmth, and stiffness of the fingers, with inability to bend the fingers since 2 months. The symptoms were progressively increasing in intensity for the past 1 month. There was no history of fever or trauma to the hand. Two months before her symptoms started, she had permanent pacemaker implanted for complete heart block with syncope. She was hypertensive and was on regular medication. Her X-ray of right hand showed decreased bone density (demineralisation), suggestive of osteopenia. A diagnosis of reflex sympathetic dystrophy syndrome or complex regional pain syndrome type I induced by pacemaker insertion was made. She was treated with amitriptyline and steroids, after which her symptoms improved dramatically.

Mycosis Fungoides Diagnosed with an Initial Sign Resembling Benign Dermatosis on the Upper Eyelids.

Dear Editor: Mycosis fungoides (MF) is a mature T-cell non-Hodgkin's lymphoma that presents with persistent and slowly progressive skin lesions of varying size and shape1. As the skin lesions of MF are variable, MF can be misdiagnosed as a benign dermatological condition1,2. A 21-year-old man presented with a 4-month history of skin lesions on his eyelids. The skin lesions were diffuse erythematous to violet-colored patches on both upper eyelids with multiple 1~2-mm papules scattered on the patches. Both eyelids were edematous, making the patient look like he had swollen eyes (Fig. 1A). The patient did not complain of symptoms at the lesional area but did complain of feeling weak and lethargic over the last few months. We performed laboratory tests and skin biopsy of his right eyelid, and made a preliminary diagnosis of a heliotrope rash in dermatomyositis. We decided to withhold treatment until the diagnosis was confirmed. Laboratory tests including complete blood count, liver function test, fluorescent antinuclear antibody test (FANA), and creatinine kinase showed no abnormalities. Histopathological examination revealed epidermotropic and diffuse dermal infiltration of atypical lymphocytes with some eosinophils (Fig. 1B, C); the epidermotropic and dermal atypical lymphocytes were positive for CD3 and CD4, and some lymphocytes were positive for CD30 and negative for CD20 (Fig. 1D~F). Fig. 1 (A) Erythematous papules and patches with edematous swelling on the right eyelid. (B, C) Histological specimen showing diffuse dermal infiltration of atypical lymphocytes (HE B: ×40, C: ×400). Atypical lymphocytes infiltrating ... On the second visit, an erythematous papule 5 mm in diameter (Fig. 2A) had developed on the dorsum of the right hand, and there was no improvement in the skin lesions on the eyelids. Skin biopsy of the papule showed similar histopathological findings to those of the eyelids, i.e., epidermotropism and diffuse dermal infiltration of atypical lymphocytes with some eosinophils (Fig. 2B, C). Nested polymerase chain reaction for T-cell receptor-γ gene rearrangement showed monoclonality. Fig. 2 (A) Erythematous nodules on the dorsum of right hand at the second visit. (B, C) Epidermotropism and diffuse dermal infiltration of atypical lymphocytes stained with CD4 (B: CD4, ×40; C: H&E, ×40). Bone marrow biopsy, abdominal pelvic computed tomography-multiplanar reformation, and chest computed tomography showed no internal organ involvement. With this histological and immunophenotypic information, the patient was diagnosed with MF and was treated with chemotherapy and total skin electron beam therapy. MF is the most common type of cutaneous T-cell lymphoma and accounts for half of all primary cutaneous lymphomas1. Clinically, early in the course of MF, the skin lesions may be nonspecific and variable, making the diagnosis difficult even for dermatologists1,2. A new variant of MF was recently proposed, in which papular lesions are present in the absence of patches with the presence of histopathologic features of the classic patch/plaque stage2. Moreover, advanced MF can infiltrate or metastasiaze to the eye, causing blepharitis and cicatricial ectropion3. Eyelid lesions must be differentiated from many conditions that can produce redness of the eyelids. Eczematous dermatological conditions such as contact dermatitis, atopic dermatitis, and seborrheic dermatitis commonly involve the eyelids4,5. Allergic contact dermatitis often affects the upper eyelids, while atopic dermatitis causes dermatitis in both the upper and lower eyelids. Seborrheic dermatitis is accompanied by lesions at other sites. Because the present patient had erythema and edema only on the upper eyelids without any subjective symptoms, we made an initial diagnosis of heliotrope rash in dermatomyositis. The diagnosis of MF should be made carefully on the basis of detailed history taking and physical examination if the skin lesion is persistent without changes in the shape or symptoms after conventional dermatological treatment. The present case illustrates the diversity of the cutaneous manifestations of MF, such as mimicking the heliotrope rash of dermatomyositis or eyelid eczema, and highlights the importance of skin biopsy for correct diagnosis and treatment.

I16 Pain Stimuli Processing In Pre-symptomatic And Early Huntington's Disease

Huntington’s disease is a neurodegenerative genetical autosomal dominant disorder, caused by an abnormal expansion of CAG on the IT-15 gene which results in movement, cognitive and psychiatric disorders. Data suggest that the basal ganglia may be involved in the sensory-discriminative, affective and cognitive dimension of pain, as well as modulation of nociceptive information and sensory gating of nociceptive information to higher motor area. A delay in nociceptive input processing emerged in HD patients, concurring with the main features of the disease, in absence of clinical evidence of abnormalities in pain perception. Recent theories about Laser Evoked Potentials (LEPs) outlined that they reflect cortical–not pain specific activation through salient stimuli, probably preparing to motor action. In this sense HD patients seem to be affected by a slowing in detecting salient stimuli, potentially related to a motor activation. This may be relevant for sensory-motor integration. The aim of the present study was to evaluate evoked responses by laser stimuli (LEPs) and auditory event related potentials (Auditory ERPs) in pre-symptomatic and early Huntington’s disease (HD) patients. Ten HD patients, 10 pre-symptomatic subjects (pre-HD) and 20 controls subjects were selected. LEPs were obtained by 62 scalp electrodes, stimulating the dorsum of right hand. All patients were also evaluated by Auditory ERPs. Preliminary results confirm LEPs N2 latency increase in HD patients in respect to controls, while no difference was detected in comparison with pre-HD. An amplitude decrease of LEPs late P2 component emerged, concurring with Auditory ERPs reduction in both HD patients and pre-HD in respect of controls. HD patients and pre-HD may be characterised by a disturbance in salient stimuli processing, with a reduced activation of cortical zones devoted to stimuli processing and motor response planning (cingulate). This may explain a normal pain perception, with a probable deterioration of voluntary and involuntary motor reaction and pain syntoms expression.

Linear verrucous hemangioma.

A 7-year-old boy presented with multiple warty lesions on an erythematous background over the right upper extremity. These lesions had been present since birth as erythematous rash. These lesions increased in size and number as well as became warty as the boy grew up. The course of the disease was complicated by recurrent ulcerations, minor bleeding and infection in the lesions. Other history was noncontributory. Cutaneous examination revealed several well-circumscribed, hyperkeratotic erythematous plaques present in a linear fashion over the medial aspect of the right upper extremity (extending from tip of fingers to axilla) [Figure 1]. Similar lesions were present over medial part of dorsum of right hand and to some extent, the forearm. Some of these plaques had central ulceration (crateriform plaques). Of note, palmar lesions were devoid of any verrucous lesions on their surface. Both upper limbs were of equal length and girth. Clinically, angiokeratoma circumscriptum neviforme (ACN) and linear verrucous hemangioma (LVH) were considered as differential diagnoses. Routine blood investigations did not reveal any abnormality. Histopathological examination revealed epidermal hyperkeratosis, parakeratosis, and irregular acanthosis. Dermis showed numerous dilated blood vessels of various sizes extending down into the subcutaneous tissues [Figure 2]. A diagnosis of linear verrucous hemangioma was made and boy was referred to department of plastic surgery for further management.Figure 1: Hyperkeratotic erythematous plaques in a linear pattern. Note: Some of the verrucous plaques are crateriformFigure 2: Hyperkeratosis, parakeratosis, acanthosis, and increased number of vascular spaces throughout the dermis and hypodermis without any inflammation. (H and E, ×100) Higher magnification of epidermis and upper dermis (inset A, H and E, ×100) and hypodermis showing increased blood vessels (inset B, H and E, ×100)Verrucous hemangioma is a rare vascular malformation involving whole of the dermis and hypodermis, with a predilection for the lower extremities. It is usually present at birth, but it may present later in adulthood also. The lesions initially appear as bluish red, well-demarcated, soft, and compressible swellings. Later on, they become verrucous and tend to increase in size and number. Secondary bleeding and infection are frequent complications.[1] The linear or serpiginous form of verrucous hemangioma (LVH) is extremely rare, and only a few cases have been reported. It is not known whether linear lesions actually follow Blaschko's lines or the linear arrangement represents genetic mosaicism.[2] The most important differential diagnosis for linear form is ACN. Clinically, both conditions are indistinguishable from each other. The histologic features of both conditions are similar, as both lesions show vascular spaces just beneath a papillomatous and hyperkeratotic epidermis. However, in contrast to ACN, the vascular spaces in LVH also involve the lower dermis and subcutaneous tissues. Deep excision is the most preferred modality of treatment for verrucous hemangiomas, as a superficial therapeutic approach would be unsuccessful because of the deep angiomatous proliferation.[13] Recently, treatment with a combination of CO2 and dual pulsed dye laser (PDL)-Nd YAG laser has provided a satisfactory response in some cases.[3]

The rare aggressive osteoblastoma in a two year old child in an unusual localization

A rare bone tumor of 3rd metacarpal bone in a male child aged 2 years is being described. The patent presented with a gradually increasing, painful swelling over the dorsum of right hand which radiologically revealed an expansile, radioluscent mass, in 3rd metacarpal shaft with cortical destruction. The clinic-radiological differential diagnosis was aggressive cartilage tumor or an osteomyelitis. Histological examination of surgical biopsy material revealed randomly arranged woven bone lined by epithelioid osteoblast and after correlating the clinic-radiological features the diagnosis was an aggressive osteoblastoma. Appropriate diagnosis of such a rare tumor in an unusual location and age group facilitate adequate management by surgery alone without radiotherapy or chemotherapy.

Workplace sun protection policies and employees' sun-related skin damage.

To investigate whether mandatory sun protection for outdoor workers in tropical regions is associated with reduced sun damage. Survey of 26 employees working under mandatory sun protection policy was compared to survey of 21 employees working under voluntary sun protection policy. Voluntary sun protection associated with employees having more solar keratoses on dorsum of right hand (P=0.006) and more previously excised self-reported skin cancers (P=0.008). Employees working under mandatory sun protection policy had reduced sun damage, a likely consequence of less sun exposure.

Free Thin Anterolateral Thigh Adipofascial Flap for Reconstruction of Hand Dorsum Defect

There are many flap choices for reconstruction of dorsal hand defect with extensor tendon exposure. Free flap, such as superficial temporal fascia flap or dorsalis pedis flap, is an optional choice because it provides thin, pliable coverage and good gliding surface for extensor tendons. The anterolateral thigh flap is an another alternative, however, thick and bulky of flap lead to unfavorable results. We modified the anterolateral thigh flap with only including adipofascial layer to reconstruct the soft tissue defect of hand dorsum. A 60 year-old of female patient suffered from metastatic Transitional Cell Carcinoma of the bladder. The extravasation of the chemotherapeutic agents led to skin necrosis over her right dorsal hand. We reconstructed the defect of her right dorsal hand by the free thin anterolateral thigh adipofascial flap. The result of the right dorsal hand was satisfactory after 3 months follow-up. The anterolateral thigh adipofascial flap provided vascularized, thin, and gliding coverage. The donor side can be closed primarily. However, it still bears the disadvantages of needing for skin graft and risk of skin graft failure due to fatty necrosis.

Case Report: Meningococcal Meningitis

A case of meningococcal meningitis in an adult male in March 2000 in Hong Kong is reported. The main features were fever for one day with headache, vomiting, dizziness, diffuse maculo-papular rash, and one purpuric rash on the dorsum of right hand and stable vital signs. Incidentally, there were three other unreported cases of meningococcal infection in the city during that period. It is important for emergency physicians to recognise this life-threatening condition in the initial stable phase to promptly provide the emergency management and to administer the antibiotic treatment to reduce mortality.

Cutaneous inflammatory pseudotumor: a case report with immunohistochemical and ultrastructural studies

An unusual case of inflammatory pseudotumor of the subcutaneous tissue in a 44-yr old black male who presented with a 4 cm soft tissue mass on the dorsum of right hand is described. The mass was sharply circumscribed and composed of a polymorphous infiltrate of plasma cells, eosinophils, lymphocytes and some giant cells mimicking Reed-Sternberg cells. The giant cells, corresponding ultrastructurally to primitive mesenchymal cells, were immunoreactive for vimentin and were negative for actin, desmin and histiocytic markers. The patient remained well with no sign of recurrence 8 mths postoperatively. The present case is compared with the (4) previously reported cases in literature. The histologic differentiation from other neoplastic and non-neoplastic lesions is discussed.