Although carpal tunnel syndrome (CTS) occurs due to intrinsic or extrinsic causes, the idiopathic group outnumbers the rest by far. Compression of the median nerve may be due to mechanical or ischemic causation. The cause of idiopathic CTS is thought to be intermittent compression of the median nerve in predisposed people, especially working females, producing ischemia of the nerve. Reperfusion injury may occur during periods of recovery. Intermittent perfusion of the cellular tissue following ischemia releases free oxygen radicals. With continued oxidative stress, the normal antioxidant system is overwhelmed and cellular injury ensues, affecting both nerve and synovial cells. This is confirmed by changes seen locally in nerve and synovial tissue both serologically and histologically. These changes are reverted or checked by the use of antioxidants in vitro. Simulated compression of the nerve in laboratory animals also confirms these findings, further corroborating the pathophysiology and suggesting means of preventing idiopathic CTS.
Ischemia-induced reperfusion injury seems to play an important role in the pathophysiology of "idiopathic" carpal tunnel syndrome (CTS). The common final pathway in this developmental sequence is thought to be an intermittent increase in interstitial pressure, leading to degenerative changes in the flexor tenosynovium and fibrotic changes in the perineural tissue. We hypothesize that this concurrently leads to alteration in the physical properties of the synovium, leading to its rapid and persistent swelling. A prospective study was conducted on synovial tissue obtained from 27 CTS patients. The in vitro synovial absorption rate of CTS patients was significantly higher in the first hour compared to controls (n = 7). This difference was maintained up to 5-6 h, albeit at a slower rate. Rapid absorption and retention of fluid by the synovium led to increased interstitial pressure and nerve compression, resulting in early and persistent manifestation of symptoms in sensitized patients.
Although the primary objective of replantation is revascularization and ultimately viability of the amputated digit(s), skeletal stabilization is an important cornerstone of the composite repair and reconstructive process. If performed rapidly and securely, anatomic (or near anatomic) fracture reduction and fixation may contribute profoundly to the protection of the revascularization and the repair or reconstruction of nerves, tendons, and integument; reliable fracture healing; functional restoration; and final outcome. Conversely, less than anatomic (or near anatomic) reduction or unreliable and insecure fixation may deter successful early revascularization and, later, good function. This article reviews the various methods of fracture stabilization that may be employed, and their advantages and disadvantages. We believe that anatomic (or near anatomic) fracture reduction, reliable and stable fracture fixation, minimal additional dissection, and early active range-of-motion exercises will have a substantial effect on both viability and functional outcome in digital replantation.
Acute presentation of an inguinal hernia is a common presentation to general surgery in the United Kingdom (UK). Rarely intra-abdominal organs, outside of small bowel and colon, can present within an inguinal hernia e.g., appendix or bladder. There has been limited publication involving an incarcerated hernia containing the stomach. We present the case of an 84-year-old male with a background of COPD and hypertension who presented to Accident & Emergency with a three-day history of vomiting and diffuse abdominal pain. On examination, the patient had a distended abdomen with generalized peritonitis, and an irreducible non-tender inguinoscrotal hernia. A CT scan of the abdomen and pelvis demonstrated small bowel obstruction and gastric outlet obstruction secondary to a large incarcerated right inguinal hernia containing stomach. The patient rapidly deteriorated clinically, which led to a decision to palliate the patient. The patient died eight days after initial presentation. The cause of death was documented as likely perforated viscus in an inguino-scrotal hernia. This case illustrates the devastating prognosis of an acute presentation of an inguinal hernia containing the stomach. This should be considered a surgical emergency and immediate operative intervention should take place if the patient is clinically able to have surgery.
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