ROUNDS RESPONSE.
Rounds is your vehicle for sharing your orthopaedic skills and experience. Your response to Rounds will be published in a future issue of Body Cast. We invite you to suggest questions for this column. Please address all submissions to: The Editor, Body Cast, 18 Wynford Drive, Suite 715A, North York, Ontario, M3C 3S2.

This Issue's Rounds Question (responses to be published in next issue)
A youth is in the emergency department with an ankle injury. An x-ray of the tibia is performed, and a fibrous cortical defect is observed on the tibia. The parents are concerned. Tell us about non-ossifying fibroma.

In the last issue of Body Cast, Rounds asked:
Does dorsal swelling signify an injury or infection in the dorsum of the hand?

The following responses were received:

From Mardy McPolin and Gary James:
This may not always be the case. As part of your casting/splinting examination routine, always inspect for a palmar wound when a patient presents with dorsal swelling. The reason for that, aside from the obvious, is most of the palmar lymphatics drain to lymph channels and lacunae located in the loose areolar layer on the dorsum of the hand.

From Mary Perkins:
After reviewing with orthopaedic and plastic surgeons, the short answer is yes. Fractures, dislocations, rheumatoid arthritis, cysts and soft tissue injuries can cause dorsum swelling. However, the most common cause of swelling on the dorsum of the hand is infection in the palm. The palm area of the hand is very thick and hard, whereas the dorsum area is much thinner and softer, thus allowing and swelling to occur of the dorsum. A good history, radiograph, and clinical exam should help make a correct diagnosis.

From Mary Anne Lash:
In normal use, the hand is in constant motion. The motion engages intrinsic muscles to force venous and lymphatic return to prevent swelling. In an injured appendage, this process is not happening due to pain or the inability to move the limp. Thus, swelling. It does not necessarily indicate infection. Our hands may swell even as we sleep, or if we have them at our sides on a long hike. Under normal circumstances, mobility and elevation help to prevent fluid accumulation. Dorsal swelling is due to the inability to pump back the fluid.

From Tom Broughton:
A blunt trauma to the dorsal area of the hand may cause a mass of blood (usually clotted) which is confined to a tissue piece causing swelling.

An infection of the hand could be caused by an invasion of bacteria through an open wound or pin site causing cellulites or, in extreme cases, inflammation of cellular or connective tissues.

Osteoarthritis, which causes degenerative changes and/or inflammation of the synovial membrane of the joints, will also cause swelling in the dorsum of the hand.

From Livain Arseneau:
Dorsal swelling in the hand could signify injury or infection.

Infections are caused by direct penetrating trauma, spread from a neighbouring compartment or hematogenous seeding.

Due to dorsal location of the hand lymphatics, erythema and swelling commonly appear over the dorsum of the hand, even when the injury is of the palmar origin

Responses were also received from Adrian Crossman, Melvin Gillingham, Richard Grenier, Edd Hayes, Lena Head, Richard Klatt, Brian Lavallee, Cam Longphee, Lori Macdonald, Gary Marshall, Blair Matheson, Joe Maulucci, Irene Mills, Javad Movasseli, Earl Oborowsky, James Punwassie, Cheryl Rivers, Vital Robichaud, Tony Romeo, Ales Sedlak, Bert Sheppard, Neuville Yao, and Mary Young.