Reliable treatment of pyogenic granuloma of the hand.

Pyogenic granuloma (PG) is a common skin tumour whose aetiology is unknown. There is a significant recurrence rate whatever method of treatment is used, and there are many studies in the literature on the treatment of recurrence. In our experience, the most effective way of preventing recurrence is the complete removal of the tumour using the microscope, operating in a bloodless field. Only then can the whole tumour with its supply vessels be reliably removed. 20 cases of PG on the hand, three cases in the shoulder-neck area and one case on the foot have been treated in our department over a period of 4 years. Five of these were recurrences and all involved the hand. Three of these were infected. 17 patients were followed for 3 months to 3.5 years. There were no recurrences in these patients, all of whom were operated on using the method described above.

Intermittent axillary nerve palsy caused by a humeral exostosis.

We report an uncommon case of intermittent axillary nerve palsy caused by a humeral exostosis in an 11-year-old boy. After excision of the cartilagenous exostosis of the proximal end of the left humerus, the pre-operative symptoms of axillary nerve compression were alleviated.

[True trigger wrist (a case report)]. / Das echte schnappende Handgelenk (Ein Fallbericht).

Clicking at the wrist, in association with movements of the fingers, has been commonly but erroneously called "trigger wrist". In true trigger wrist, triggering occurs only in relation to movements of the wrist. The authors report a case of true trigger wrist in a 23-year-old professional tennis player. Triggering was caused by a "synovial mass" around partially destroyed tendons of the ECRB, ECRL, and EPL at the level of the extensor retinaculum.

[Compression of the median nerve by chondrosarcoma of the hand]. / Kompression des Nervus medianus durch ein Chondrosarkom der Hand.

The authors report a case of median nerve compression due to a chondrosarcoma of the wrist. A 30 year-old right handed man complained of typical symptoms of median nerve compression. X-ray examination showed normal findings. During operation a more proximal lumbrical origin was the only abnormal finding. After nerve decompression pain relief was prompt. Six months later the patient again complained of symptoms of median nerve compression. Now X-ray examination showed scattered punctuate calcific densities of dystrophic calcification. The tumor was histologically shown to be a chondrosarcoma. It was treated by wide local excision and radiation therapy.

[Isolated compression of the dorsal branch of the ulnar nerve]. / Die isolierte Kompression des Ramus dorsalis nervi ulnaris.

The dorsal branch of the ulnar nerve was dissected in 20 upper extremities. The nerve arises from the ulnar aspect of the ulnar nerve at an average distance of 8.5 centimeters from the proximal border of the pisiforme. It courses deep to the palmar carpal ligament and pierces the ligament dorsal to the tendon of the flexor carpi ulnaris, becoming subcutaneous. The palmar carpal ligament has been found to be a cause of isolated entrapment of the dorsal branch of the ulnar nerve. A report of eleven operative cases is presented.

[Education and training in microsurgery without experiments on live animals]. / Ausbildung und Training in der Mikrochirurgie ohne Versuche am lebenden Tier.

A theoretical concept of a training programme for microsurgery is presented. This programme--as an alternative to the presently existing types of microsurgical education using the living laboratory animal--pursues the training of microsurgical skills exclusively on non-living objects. This paper describes the training laboratory as well as four training procedures, each using separate objects with an increasing degree of difficulty and educational benefit: surgical glove; silastic tube; sciatic nerve of a chicken; perfused coronary arteries of a pig's heart. Completion of this programme conveyed to the trainee the same basic abilities as training on a living laboratory animal.

[A realistic practice model for learning microneural surgery without experiments on live animals]. / Ein realitätsnahes Ubungsmodell zur Erlernung der mikroneuralen Chirurgie ohne Experimente am lebenden Tier.

The increasing importance of microneurosurgery in hand and plastic surgery makes it necessary for surgeons to familiarize themselves with these techniques. In most training programs, anesthetized rats have been used to learn basic microneurosurgical techniques. Ethical considerations, the costs involved, and the legislation concerning experiments with live animals permit extensive training in microneurosurgery in only a few medical centers. This paper relates our experience with an alternative training program not involving live animals. Instead, we chose the legs of slaughtered pigs. Mono-, oligo-, and poly-fascicular nerves, structurally similar to the configurations found in human extremities, can be found in pig legs. Neurolysis, primary nerve sutures, and nerve transplantations can be practiced.

[Long-term spontaneous course of carpal instability]. / Langzeit-Spontanverläufe bei karpalen Instabilitäten.

The authors report on the natural history of 26 cases of carpal instabilities observed over a period of 25 to 74 months. Apart from the subjective criterion pain, the parameters range of motion and grip strength have been documented in the course of their development. In addition, radiographic findings have been evaluated. We confirm that carpal instabilities can lead to degenerative arthrosis. The expectation that there would be a progressive deviation from the norm of the angles between radius, scaphoid, lunate, and capitate bones measured in lateral radiographs did not prove to be true.

[Premature maturation of the carpal bones as an early diagnostic sign of juvenile rheumatoid arthritis]. / Vorzeitige Reifung der Handwurzelknochen als frühdiagnostisches Zeichen einer juvenilen rheumatoiden Arthritis.

A rare premature maturation of the carpal bones in combination with swelling and flexion contracture of the wrist is demonstrated in two cases of juvenile rheumatoid arthritis. The radiologically verified premature and asymmetrical maturation of the carpal bones was the earliest diagnostic sign in juvenile rheumatoid arthritis.

[An unusual case of metastasis to the soft tissues of the palm of the hand with compression of the median and ulnar nerve by kidney cancer. Case report]. / Ungewöhnlicher Fall einer Metastase in die Weichteile der Hohlhand mit Kompression des N. medianus und N. ulnaris in Folge eines Nierenkarzinoms. Fallbericht.

The incidence of secondary tumors in the hand is set slightly over 0.1%, the primary tumor localized in the lung, followed by the breast and the kidney. The authors describe a case of a renal carcinoma metastatic to the soft tissue of the palm of the hand in a patient who had undergone nephrectomy for carcinoma of the right kidney eleven years previously. The sixty-one year old female patient developed a swelling of the palm of the left hand and showed symptoms of median and ulnar nerve compression. The patient had neurosurgery because of a solitary metastatic brain tumor of the right hemisphere three months earlier and did not approve to an additional surgical intervention in the hand at that time. The decision was made to treat the tumor with a local radiation therapy. Five months later, the treatment showed no effect and the patient decided to have the operation done. Histologic examination established the diagnosis of a metastatic renal cell carcinoma. The healing was prolonged. An ulceration developed in the distal part of the wound area and healing took seven weeks. Seven months after the operation the patient was alive and well without evidence of disease. The hand showed a good function with little impairment and the symptoms of nerve compression had completely disappeared.

[Unusual course of scapho-capitate syndrome]. / Ungewöhnlicher Verlauf eines Scapho-Capitate-Syndroms.

The scapho-capitate-syndrome has been defined as combined fractures of the scaphoid and capitate with rotation of the proximal fragment of the capitate through 90 or 180 degrees. Most injuries are due to falls from heights or car accidents. Only 26 cases of the scapho-capitate fracture syndrome have been reported since 1937. In nearly one third of these cases, there was a delay of more than two weeks in diagnosis. We report a case of a young man in whom the complex injury was erroneously diagnosed as an isolated fracture of the scaphoid. The scaphoid fracture was treated by a screw and healed well. Although the patient suffered persistent pain in his wrist, the correct diagnosis was made only two years later. During revision operation we found the head of the capitate still inverted and with marked signs of avascular necrosis and destruction of the lunate cartilage. The avascular fragment was removed and substituted by a graft from the iliac crest. The capitate and lunate were fused.

[The supinator syndrome. An anatomic and clinical study]. / Das Supinatorsyndrom. Eine anatomische und klinische Studie.

The posterior interosseous syndrome appears in two forms, a) paralytical, and b) painful. In this investigation the authors report on twelve operated patients with painful posterior interosseous or "radial tunnel" syndrome. The intraoperative findings in the arcade of Frohse are compared with the findings on preparation of ten recently deceased. It was especially significant that in ten of twelve cases there was found intraoperatively a tendinous type of arcade. In the cadaveric studies the authors encountered this type of tendinous arcade in only two of ten specimens. Based on these findings, the authors conclude that the tendinous arcade of Frohse is an important factor in the development of the posterior interosseous syndrome.

[Diagnosis and therapy of tendovaginitis of the extensor carpi ulnaris (stenosis of the 6th extensor compartment)]. / Die Diagnostik und Therapie der Tendovaginitis des Extensor carpi ulnaris (Stenose VI. Streckerfach).

Stenosing tenosynovitis over the dorsum of the wrist in the sixth compartment is seldom mentioned in literature. We have collected 28 cases in a four-year period which demonstrate that the incidence is quite high. This condition should be considered in the differential diagnosis of pain over the dorso-ulnar aspect of the wrist. On examination firm, fusiform swelling in the sixth compartment was present. Pain was elicited by active ulnar deviation against resistance. All 28 patients had local infiltration with cortisone, but only 8 patients obtained complete relief. 18 of 20 patients had complete relief of their symptoms after surgical release of the sixth compartment. We conclude that stenosing tendovaginitis of extensor carpi ulnaris is a relatively common condition. Awareness of the syndrome allows accurate diagnosis and treatment.

[Melorheostosis of the hand (report of 2 cases)]. / Melorheostose der Hand (Ein Bericht über 2 Fälle).

Melorheostosis is a rare monostotic or polyostotic bone disease of unknown etiology. It is characterized by a slowly progressing linear hyperostosis, fibrosis of the skin and subcutaneous tissues, contractures of joints and aching pain. The lower extremities are involved much more often than the upper extremities. The distribution of the lesion usually follows sclerotomes. Bone scanning complements standard radiologic studies and permits evaluation of the extent and activity of the disease. Here we report two cases of melorheostosis. Conservative treatment was disappointing. Thus we recommend the excision of the exostosis.

Training in basic microsurgical techniques without experiments involving animals.

Until recently, anaesthetised rats have been the usual material employed for learning basic microvascular and microneurosurgical techniques. However, ethical considerations, the costs involved and legislation controlling experiments with animals allow training in microsurgery for extended periods of time at a few medical centres only. This paper reports on our experience of an alternative training programme largely conducted without using live animals. As the basic material we selected legs of slaughtered pigs. According to the developing skill of the trainee, basic microsurgical techniques can be practised on arteries and veins of various sizes in these legs. To verify positive results, the vessels are subsequently perfused with human blood under pressure. The model described is particularly suited to the acquiring of skills in microneurosurgery. Mono-, oligo- and polyfascicular nerves, structurally similar to the configurations found in human extremities, are found in pig legs. The ever-increasing importance of microsurgery in modern medicine requires more and more surgeons and orthopaedists to familiarize themselves with these techniques. The model we propose for teaching and training substantially facilitate such further professional training in an efficient way, and at the same time allows a substantial reduction in the number of experiments conducted on animals.

[The supinator syndrome--an anatomical and clinical study]. / Das Supinatorsyndrom--eine anatomische und klinische Studie.

The interosseus posterior syndrome appears in two forms: a) the paralytical interosseus posterior syndrome, b) the painful (afferent) interosseus posterior syndrome. We report in this investigation about 12 operated patients with painful interosseus posterior syndrome. The intraoperative findings in the arcade of Frohse are compared with the findings we made at the preparation of 10 recently deceased. It was especially significant, that we found in 10 of our 12 cases intraoperatively a tendinous type of arcade. In our directioned cases we encountered this type of tendinous arcade in only 2 of 10 cases. Based on these findings we are of the opinion that the tendinous arcade of Frohse is an important factor in the development of the interosseus posterior syndrome.

[Long term results with a new lunate bone prosthesis]. / Langzeitergebnisse mit einer neuen Lunatum-Prothese.

In the University of Essen Orthopaedic Clinic a lunate prosthesis was developed. Three different sizes are available. The strongest indication for this prosthesis is complete destruction of the lunate. Advanced arthritis and heavy manual work are contraindications. Since 1974, fourteen prostheses have been implanted. Nine patients have been followed for an average of 2.1 years. Range of motion and strength of the wrist were reduced on the average of 50 percent. A higher proportion is free of pain despite evidence of progressive arthritis. This prosthesis may be a reasonable treatment modality for a problem without good therapeutic alternatives.

[Treatment results in fractures and pseudarthrosis of the scaphoid bone]. / Behandlungsergebnisse bei Kahnbeinfrakturen und-pseudarthrosen.

In 258 patients with fractures and pseudarthroses of the carpal scaphoid the cause and type are given and the results of treatment are presented. It is verified that the majority of fresh fractures are united by plaster immobilisation. In fractures with delayed healing and in cases with non-union the best results are achieved by autologous bone grafting.

Performance of village pharmacies and patient compliance after implementation of essential drug programme in rural Burkina Faso.

After implementation of a nation-wide essential drug programme in Burkina Faso a prospective study was undertaken consisting of non-participant observation in the health centre and in the village pharmacy, and of household interviews with the patients. The study covered all general consultations in nine health centres in three districts over a two-week period as well as all client-vendor contacts in the corresponding village pharmacies; comprising 313 patients in consultations and 498 clients in eight village pharmacies with 12 vendors involved in dispensing 908 drugs. Additionally patients were interviewed in their households. Performance and utilization of the village pharmacy: 82.0% of the drugs prescribed in the health centres were actually dispensed at the village pharmacy, 5.9% of the drugs were not available at the village pharmacy. Wrong drugs were dispensed in 2.1% of cases. 41.3% of the drugs dispensed in the village pharmacy were bought without a prescription. Differences are seen between the district and are put in relation to different onset of the essential drug programme. Patient compliance: Patients could recall the correct dosage for 68.3% of the drugs. Drug taking compliance was 63.1%, derived from the pills remaining in the households. 11.5% of the drugs had obviously been taken incorrectly to such an extent that the occurrence of undesired drug effects was likely. The study demonstrates the success of the essential drug programme not only in performance but also in acceptability and utilization by the population.