Cases of Mycobaterium Marinum Tenosynovitis of the hand and wrist: clinical features. management and results

Selected paper for 2010 APOA-Pfizer Best Scientific Paper Award for Orthopaedic InfectionOpen Access JournaleCM XII: Implant Infection Conference Main Focus: Orthopedic and trauma related infectionsAsia Pacific Orthopaedic Association SessionINTRODUCTION: Mycobacterium marinum infections followed an unpredictable clinical course and delay in definitive diagnosis was frequently encountered. Chow et al. found that the average duration of infection before patients were seen by the Orthopaedics unit was 3.3-3.7 months.1 The initial diagnosis was commonly found to be mistaken for conditions such as rheumatoid arthritis and trigger finger which may lead to inappropriate management like steroid injections. The objective of this study was to review our experience with treatment of Mycobacterium marinum tenosynovitis of the hand and wrist and to assess for any clinical parameters that were associated with poor functional outcome and also suggest a treatment algorithm for these …published_or_final_versio

一個患有重度地中海型貧血病人因克雷白氏肺炎菌引發壞死性筋膜炎

We present a case of Klebsiella pneumoniae necrotizing fasciitis in a patient with thalassaemia major. Klebsiella sp. is known to cause severe infections in patients with thalassaemia, with high mortality rates. © 2011. 我們敍述一個患有重度地中海型貧血病人因克雷白氏肺炎菌引發壞死性筋膜炎的病例。克雷白氏菌屬已知會對地中海型貧血的病人造成嚴重的感染並有很高的死亡率。published_or_final_versio

Lateral tibial condyle reconstruction by pedicled vascularized fibular head graft: Long-term result

The technique of pedicled vascularized fibular graft for lateral tibial condyle reconstruction after en bloc resection of aggressive giant cell tumours was described by SP Chow et al. Early follow-up of two patients was presented in 1986. We present the 25 years follow-up of one patient with a literature review of alternative present day treatment options. The patient maintained community ambulant status despite developing late stage osteoarthritis. Although this procedure is performed rarely, it remains an alternative to the more sophisticated treatment options making it a useful method in centres with limited facilities and expertise. © 2011 The Author(s).published_or_final_versio

Mycobacterium marinum infection of the hand and wrist

PURPOSE: To review records of 166 patients who underwent treatment for Mycobacterium marinum tenosynovitis of the hand and wrist to identify factors associated with functional outcome. METHODS: Records of 97 men and 69 women aged 13 to 85 (mean, 50) years who underwent treatment for suspected M marinum tenosynovitis of the hand and wrist were retrospectively reviewed. All underwent open biopsy; synovectomy was performed when florid synovitis was present. Rifampicin and ethambutol were usually prescribed. Clarithromycin, minocycline and/or levofloxacin were used as adjuvants if there was drug intolerance, allergy, or relapse. The duration of antibiotic treatment depended on the clinical recovery. Patients were followed up for one year after completion of drug treatment. Functional outcome was considered excellent for those with >195 masculine total active motion (TAM) and >75% return of motion, good for those with 130 masculine to 195 masculine TAM and 50 to 75% return of motion, fair for those with 65 masculine to 129 masculine TAM and 25 to 49% return of motion, and poor for those with2 months after injury (27% [21/79] vs. 9% [7/77], p=0.004, Pearson Chi squared test), and have undergone synovectomy (23% [28/124]) vs. 0% [0/32], p=0.001, Fisher's exact test). Worse functional outcome correlated with late presentation (r=0.218) and the greater number of debridement procedures (r=0.453). CONCLUSION: Delayed antibiotic treatment of M marinum infections and steroid injections were associated with unsatisfactory outcome. Clinicians must have a high index of suspicion for this condition and avoid inappropriate management such as intralesional steroid injections. Public awareness to this condition should be raised.published_or_final_versio

Occupational repetitive strain injuries in Hong Kong

OBJECTIVE: To review currently available evidence on the epidemiology and management of occupational repetitive strain injuries with particular reference to Hong Kong. DATA SOURCES AND STUDY SELECTION: Medline, PubMed and Cochrane Library searches of local and internationally published English journals from 1990 to 2007 regarding repetitive strain injuries. DATA EXTRACTION: All articles involving occupational repetitive strain injuries in Hong Kong were included in this review. DATA SYNTHESIS: There were 16 articles contributing data on the impact of repetitive strain injuries both in Hong Kong and around the world. There were seven articles dealing with the problem of computer station set-ups and methods for improving the workstation environments. CONCLUSION: Currently there were significant data on the impact of repetitive strain injuries in Hong Kong. The data took the form of compensation claims, days away from work, and cost of medical consultations. Other articles described proper workplace adjustments to help prevent repetitive strain injuries. However, there were no figures in the current literature showing the impact of these adjustments in reducing the incidence of repetitive strain injuries. More research could help to delineate the relationship between different types of interventions and occupational repetitive strain injuries.published_or_final_versio

Dynamic treatment for proximal phalangeal fracture of the hand

PURPOSE: To assess a protected mobilisation programme (dynamic treatment) for proximal phalangeal fracture of the hand, irrespective of the geometry. METHODS: Clinical and radiological results of 32 consecutive patients with proximal phalangeal fracture of the hand treated from January 2001 to February 2007 were evaluated. Our supervised rehabilitation programme was strictly followed to gain full range of movement of the proximal interphalangeal joint and to prevent the development of an extension lag contracture. Patients were followed up for a mean period of 15 (range, 13-16) months. Results were evaluated using the Belsky classification. RESULTS: The results were excellent in 72% of the patients, good in 22%, and poor in 6%. Some patients defaulted follow-up, which made long-term assessment difficult. The poor results may have been related to patient non-compliance or default from rehabilitation. Many good results upgraded to excellent following further rehabilitation. CONCLUSION: Skeletal stability, not rigidity, is necessary for functional movements of the hand. Proximal phalangeal fractures can be effectively treated by closed methods, using the stabilising effect of soft tissues (zancolli complex-metacarpophalangeal retention apparatus) and external devices (metacarpophalangeal block splint), thus enabling bone healing and movement recovery at the same time.published_or_final_versio

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.published_or_final_versio

Review article: Mycobacterium marinum infection of the hand and wrist.

Misdiagnosis and delayed treatment of Mycobacterium marinum infection is common because of its diverse manifestations. This leads to inappropriate use of antimicrobials, extension of the infection from the skin to the tenosynovium, and a poor prognosis (loss of tendons and prolonged immobilisation, secondary to multiple debridements and joint contractures). Clinicians should be aware of this type of infection, especially in subjects at risk (fishermen and aquarium enthusiasts), and those with a history of trauma coupled with exposure to water or marine life. A proactive approach to obtain a biopsy for histopathological and microbiological diagnosis is advised. Anti-mycobacterial treatment should be started promptly. The combined use of rifampicin, ethambutol, and clarithromycin appears to be effective, and debridement is indicated in patients with deep-seated infections.published_or_final_versio

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.published_or_final_versio

A review of necrotising fasciitis in the extremities

Objective: To review currently available evidence on the epidemiology and methods of management for necrotising fasciitis, with particular reference to Hong Kong. Data sources and study selection: Medline, PubMed, and Cochrane Library searches of local and internationally published English language journals, from 1990 to July 2008 using the terms 'necrotising fasciitis', 'Hong Kong', 'diagnosis', 'epidemiology', 'vibrio', 'streptococci', 'clostridia', and 'management'. Data extraction: All articles involving necrotising fasciitis in Hong Kong were included in the review. Data synthesis: The incidence of necrotising fasciitis in Hong Kong and around the world has been increasing. This rapidly progressive infection is a major cause of concern, due to its high morbidity and mortality. Up to 93% of affected patients at our hospital were admitted to the Intensive Care Unit and many still died from septic complications, such as pneumonia and multi-organ failure. Radical debridements in the form of amputations and disarticulations were considered vital in 46% of the patients. Early recognition and treatment remain the most important factors influencing survival. Yet, early diagnosis of the condition is difficult due to its similarities with many other soft tissue disorders such as cellulitis. Repeated surgical debridement or incisional drainage continues to be essential for the survival of sufferers from necrotising fasciitis. Many authorities have reported that carrying out the first fasciotomy and radical debridement within 24 hours of symptom onset was associated with significantly improved survival, which also emphasises the importance of early diagnosis. Conclusion: Clinicians must adopt a high index of suspicion for necrotising fasciitis. Empirical antibiotics must be started early and repeated physical examinations should be performed, while maintaining a low threshold for tissue biopsy and surgery. The timing of the first fasciotomy and radical debridement within a window of 24 hours from symptom onset is associated with significantly improved survival.published_or_final_versio