An unusual case of bilateral pyoderma gangrenosum with Achilles tendon rupture

Pyoderma gangrenosum (PG) is a rare, noninfectious, inflammatory disease characterized by neutrophilic infiltration of the dermis and destruction of tissue. PG is a diagnostic challenge, which can lead to late diagnosis, delayed treatment and detrimental surgical interventions. We describe a presentation not previously reported, affecting deep muscle and tendon leading to tendon rupture. Furthermore, we show the multidisciplinary team approach to management of a patient with PG and the reconstructive surgical element. A 31-year-old woman presented with a rapid onset painful, tender, left calf and ankle, which was associated with a mild flare of ulcerative colitis. Investigations revealed a white cell count of 26 × 10(9) cells L(-1) , a C-reactive protein count of 226 mg L(-1) , no deep vein thrombosis on ultrasound, no bone or joint involvement on X-ray and no organisms on joint aspirate. Debridement was undertaken after the left ankle developed a foul-smelling discharging wound. Repeat debridement led to worsening of the condition (pathergy). Intraoperative tissue cultures and microscopy showed no evidence of fungi, bacteria or mycobacteria. Histology showed granulation, inflammatory infiltrate, abscess formation and focal necrotizing vasculitis. Dermatology opinion confirmed PG. Awareness of the diagnosis of PG, and early involvement of dermatology, in a rapidly progressing wound is essential to avoid delayed treatment and prevent worsening through pathergy.

The outcome following fixation of bicondylar tibial plateau fractures

Unstable bicondylar tibial plateau fractures are rare and there is little guidance in the literature as to the best form of treatment. We examined the short- to medium-term outcome of this injury in a consecutive series of patients presenting to two trauma centres. Between December 2005 and May 2010, a total of 55 fractures in 54 patients were treated by fixation, 34 with peri-articular locking plates and 21 with limited access direct internal fixation in combination with circular external fixation using a Taylor Spatial Frame (TSF). At a minimum of one year post-operatively, patient-reported outcome measures including the WOMAC index and SF-36 scores showed functional deficits, although there was no significant difference between the two forms of treatment. Despite low outcome scores, patients were generally satisfied with the outcome. We achieved good clinical and radiological outcomes, with low rates of complication. In total, only three patients (5%) had collapse of the joint of > 4 mm, and metaphysis to diaphysis angulation of 75º, and five patients (9%) with displacement of > 4 mm. All patients in our study went on to achieve full union. This study highlights the serious nature of this injury and generally poor patient-reported outcome measures following surgery, despite treatment by experienced surgeons using modern surgical techniques. Our findings suggest that treatment of complex bicondylar tibial plateau fractures with either a locking plate or a TSF gives similar clinical and radiological outcomes.

Intravenous regional guanethidine blockade in the treatment of post-traumatic complex regional pain syndrome type 1 (algodystrophy) of the hand

A total of 57 patients, aged between 23 and 86 years, with complex regional pain syndrome (CRPS) type 1 nine weeks after an isolated closed fracture of the distal radius, was randomised to receive either serial intravenous regional blockade (IVRB) with 15 mg of guanethidine in 30 ml of 0.5% prilocaine or serial IVRB with 30 ml of normal saline at weekly intervals until the tenderness in their fingers had resolved or they had received a maximum of four IVRBs.

The analgesic efficacy was assessed at 24 hours, 48 hours and one week after each procedure by the dolorimetry ratio and verbal pain scores, and at intervals up to six months after the fracture.

There was no significant difference in the number of IVRBs administered or in finger tenderness, stiffness or grip strength between the two groups. The guanethidine group experienced more pain in the affected hand (p = 0.025) and at six months had more vasomotor instability (p < 0.0001) compared with the control group.

IVRB using guanethidine offers no significant analgesic advantage over a normal saline placebo block in the treatment of early CRPS type 1 of the hand after fracture of the distal radius. It does not improve the outcome of this condition and may delay the resolution of vasomotor instability when compared with the placebo.

Intravenous regional guanethidine blockade in the treatment of post-traumatic complex regional pain syndrome type 1 (algodystrophy) of the hand

A total of 57 patients, aged between 23 and 86 years, with complex regional pain syndrome (CRPS) type 1 nine weeks after an isolated closed fracture of the distal radius, was randomised to receive either serial intravenous regional blockade (IVRB) with 15 mg of guanethidine in 30 ml of 0.5% prilocaine or serial IVRB with 30 ml of normal saline at weekly intervals until the tenderness in their fingers had resolved or they had received a maximum of four IVRBs. The analgesic efficacy was assessed at 24 hours, 48 hours and one week after each procedure by the dolorimetry ratio and verbal pain scores, and at intervals up to six months after the fracture. There was no significant difference in the number of IVRBs administered or in finger tenderness, stiffness or grip strength between the two groups. The guanethidine group experienced more pain in the affected hand (p = 0.025) and at six months had more vasomotor instability (p < 0.0001) compared with the control group. IVRB using guanethidine offers no significant analgesic advantage over a normal saline placebo block in the treatment of early CRPS type 1 of the hand after fracture of the distal radius. It does not improve the outcome of this condition and may delay the resolution of vasomotor instability when compared with the placebo.

Algodystrophy and its association with Dupuytren's disease

Seventy-two patients were examined 9 weeks after sustaining a Colles' fracture of the wrist for evidence of algodystrophy. They were examined 18 months later for evidence of Dupuytren's disease to determine the incidence of the association between the two conditions. Forty-one per cent of all patients had evidence of Dupuytren's disease at 18 months following Colles' fracture. Sixty-seven per cent of patients with algodystrophy had evidence of Dupuytren's disease compared with 19% of patients who showed no features of algodystrophy.