Therapeutic Level IV.

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A 13-year-old boy presented with a diagnosis of intra-articular myxoinflammatory fibroblastic sarcoma of the ankle. There had been no previous description of a sarcoma arising directly from the synovium of the ankle and limb salvage for malignant tumours of the ankle has rarely been reported. We treated him by peritalar extra-articular resection, and draw attention to this rare tumour and to a technique of limb-sparing resection of the ankle joint.

surgery, we noticed significant swelling of the right hand caused by extravasation of the intravenous fluids. The pulse oximeter on the right index finger showed damped wave form and the fingertips were "dusky" with delayed capillary refill. The peripheral arterial pulses were palpable, and the hand showed no motor or sensory deficits. Since warm compresses and elevation of the right hand did not improve the capillary circulation, we proceed to try hyaluronidase. We requested and obtained from the pharmacy 150 units of hyaluronidase, mixed in 10 mL of normal saline. Using a 25-gauge needle, multiple subcutaneous injections of 0.5-1.0 mL were performed around the periphery of the extravasation. The pulse oximeter was left in place, and a plastic surgery consult was called. The hand was examined every hour. The swelling diminished after 6 h and was completely resolved by the next day. The surgical service closely followed the uneventful resolution of swelling and felt no further intervention was necessary.It must be recognized that extravasation of even small amounts of hyperosmolar fluids, if untreated, could easily swell in size from drawing in free water and rapidly escalate to compartment syndrome. Mannitol is a potent osmotic fluid, and each 50 g of mannitol causes an intracellular to extracellular shift of 1 liter of water (2). Hence, early treatment with hyaluronidase of extravasation of hyperosmolar fluids/drugs such as mannitol, parenteral nutrition solution, 10% dextrose, and 30% urea could save the patient fasciotomy.While we cannot be sure that our treatment with hyaluronidase contributed to the positive outcome in our patient, it is worth mentioning as a low-risk treatment option in early stages of hyperosmolar solutions extravasation. The technique involves subcutaneous infiltration of hyaluronidase in a pin cushion fashion at 5-10 sites along the leading edge of the extravasation. Hyaluronidase may be diluted with normal saline or 1% lidocaine to provide a concentration of 10 -15 units per milliliter. The recommended total dose is 150 -900 units (3).