Factitious lesions of the hand

The presence of a lesion with atypical presentation, obscure clinical history, which does not improve with classic treatments, shall raise the red flag of the medical team. In such cases, the hypothesis of a factitious lesion shall be considered. Many times the correct diagnosis on the initial assessment may avoid high-cost diagnostic tests, unnecessary treatments, and time consumption of the medical team. We present here two classic cases of factitious lesions that, similar to those described in the literature, is difficult to diagnose and difficult to treat.

Factitious disorders/diagnosis; Factitious disorders/psychology; Hand injuries; Self-injurious behavior

Authorship

Ricardo Kaempf de Oliveira ^**Corresponding author at: Rua Leopoldo Bier, 825/301, Santana Porto Alegre, RS, Brazil CEP: 90620-100 E-mail: ricardokaempf@gmail.com (R.K. Oliveira).

Hospital Mãe de Deus, Porto Alegre, RS, BrazilHospital Mãe de DeusBrazilPorto Alegre, RS, BrazilHospital Mãe de Deus, Porto Alegre, RS, Brazil

Leohnard Roger Bayer

Complexo Hospitalar Santa Casa de Porto Alegre, Porto Alegre, RS, BrazilComplexo Hospitalar Santa Casa de Porto AlegreBrazilPorto Alegre, RS, BrazilComplexo Hospitalar Santa Casa de Porto Alegre, Porto Alegre, RS, Brazil

Daniel Lauxen

Felipe Roth

Pedro Delgado Serrano

Hospital Fremap, Madrid, SpainHospital FremapSpainMadrid, SpainHospital Fremap, Madrid, Spain

Paulo Henrique Ruschel

*Corresponding author at: Rua Leopoldo Bier, 825/301, Santana Porto Alegre, RS, Brazil CEP: 90620-100 E-mail: ricardokaempf@gmail.com (R.K. Oliveira).

Conflicts of interest The authors declare no conflicts of interest.

SCIMAGO INSTITUTIONS RANKINGS

Hospital Mãe de Deus, Porto Alegre, RS, BrazilHospital Mãe de DeusBrazilPorto Alegre, RS, BrazilHospital Mãe de Deus, Porto Alegre, RS, Brazil

Hospital Fremap, Madrid, SpainHospital FremapSpainMadrid, SpainHospital Fremap, Madrid, Spain

Figures

Figures (9)

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Figure 1
A 39-year-old female patient with an ulcerative lesion on the back of one hand, with an initial six months of evolution after a supposed bite from a spider. Cutaneous lesion with exposure of bone and a lesion of the extensor tendon of the third finger. The patient had already undergone three surgical procedures and had been treated by four medical teams.

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Figure 2
Preoperative planning to construct a skin flap from the volar region of the forearm based on reverse flow of the radial artery (Chinese flap), of dimensions 7 x 5 cm (A). During the operation, after debridement and covering the defect with the flap; note the good vascularization of the flap after releasing the tourniquet (B).

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Figure 3
Excellent initial evolution with complete integration of the flap (A). After a period of four weeks, an area of necrosis appeared on the back of the hand. This complication started quickly and had exacerbated symptoms. The border of the lesion went beyond the borders of the flap. This lesion would be impossible from an anatomical and pathological point of view (B).

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Figure 4
After the possibility of a factitious lesion had been diagnosed, the patient underwent debridement of the lesion and closure of the dressing using a plaster cast (A). Serial changes of dressing and plaster cast every 15 days produced complete healing of the wound (B, C, D and E).

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Figure 5
A 34-year-old female patient was attended presenting a necrotic lesion on the dorsum of the third finger after a supposed knife injury in an assault. The wound had evolved for 20 days and presented exposure of the extensor tendon (A). Surgical treatment consisting of a local advancement skin flap and full skin graft in the donor area was indicated (B).

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Figure 6
After initially good evolution for two weeks, the patient started to present pain and necrosis in part of the flap. After a few more days, the area of necrosis increased and the extensor tendon again became exposed (A and B). New surgical reconstruction using a reverse-flow dorsal deepidermalized homodigital flap was indicated (C and D).

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Figure 7
Once again, after initially adequate evolution and after removal of the stitches and dressing, there was an acute episode of pain and evolution towards necrosis of the flap (A). New surgery using a cross-finger heterodigital flap was then indicated (B).

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Figure 8
This procedure initially healed the wound but, after a new episode of acute pain, the wound evolved in a catastrophic manner, with necrosis along almost the entire dorsum of the finger. Also like in case 1, there was necrosis at points beyond the initial lesion and the flap, which caught the team's attention, thus suspecting a factitious lesion (A, B and C).

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Figure 9
As the definitive procedure, amputation of the fingertip was performed, with construction of an inguinal flap (McGregor flap) (A). After new distress of the flap (B), there was reasonable evolution, with complete healing of the wound (C).

Figure 1 A 39-year-old female patient with an ulcerative lesion on the back of one hand, with an initial six months of evolution after a supposed bite from a spider. Cutaneous lesion with exposure of bone and a lesion of the extensor tendon of the third finger. The patient had already undergone three surgical procedures and had been treated by four medical teams.

Figure 2 Preoperative planning to construct a skin flap from the volar region of the forearm based on reverse flow of the radial artery (Chinese flap), of dimensions 7 x 5 cm (A). During the operation, after debridement and covering the defect with the flap; note the good vascularization of the flap after releasing the tourniquet (B).

Figure 3 Excellent initial evolution with complete integration of the flap (A). After a period of four weeks, an area of necrosis appeared on the back of the hand. This complication started quickly and had exacerbated symptoms. The border of the lesion went beyond the borders of the flap. This lesion would be impossible from an anatomical and pathological point of view (B).

Figure 4 After the possibility of a factitious lesion had been diagnosed, the patient underwent debridement of the lesion and closure of the dressing using a plaster cast (A). Serial changes of dressing and plaster cast every 15 days produced complete healing of the wound (B, C, D and E).

Figure 5 A 34-year-old female patient was attended presenting a necrotic lesion on the dorsum of the third finger after a supposed knife injury in an assault. The wound had evolved for 20 days and presented exposure of the extensor tendon (A). Surgical treatment consisting of a local advancement skin flap and full skin graft in the donor area was indicated (B).

Figure 6 After initially good evolution for two weeks, the patient started to present pain and necrosis in part of the flap. After a few more days, the area of necrosis increased and the extensor tendon again became exposed (A and B). New surgical reconstruction using a reverse-flow dorsal deepidermalized homodigital flap was indicated (C and D).

Figure 7 Once again, after initially adequate evolution and after removal of the stitches and dressing, there was an acute episode of pain and evolution towards necrosis of the flap (A). New surgery using a cross-finger heterodigital flap was then indicated (B).

Figure 8 This procedure initially healed the wound but, after a new episode of acute pain, the wound evolved in a catastrophic manner, with necrosis along almost the entire dorsum of the finger. Also like in case 1, there was necrosis at points beyond the initial lesion and the flap, which caught the team's attention, thus suspecting a factitious lesion (A, B and C).

Figure 9 As the definitive procedure, amputation of the fingertip was performed, with construction of an inguinal flap (McGregor flap) (A). After new distress of the flap (B), there was reasonable evolution, with complete healing of the wound (C).

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Sociedade Brasileira de Ortopedia e Traumatologia Al. Lorena, 427 14º andar, 01424-000 São Paulo - SP - Brasil, Tel.: 55 11 2137-5400 - São Paulo - SP - Brazil
E-mail: rbo@sbot.org.br

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