The snapping scapula in association with the thoracic outlet syndrome.

Thirteen of 100 patients treated for thoracic outlet syndrome by first-rib resection postoperatively developed an associated painful superior angle of the scapula, or snapping scapula syndrome. The scapula angle was painful in 15 scapulas and the pain persisted in these 13 patients. Resection of the superior angle of the scapula was performed on 9 patients (11 snapping scapulas) with complete relief of symptoms. We propose that snapping scapula syndrome be considered a causative factor for apparent failure of thoracic outlet surgery.

Results of upper plexus thoracic outlet syndrome operation.

A review of 181 patients with thoracic outlet syndrome treated in our clinic revealed that 22 (12%) showed symptoms of compression of the distal median nerve only. Although there are several distinct anatomic abnormalities involving the upper brachial plexus, a first rib resection using the transaxillary approach was found to relieve these patients' symptoms as well as it did in those who exhibited the classic findings of ulnar nerve paresthesias. A comparison of the patients' outcomes showed no appreciable differences in the results obtained in those with distal median nerve compression symptoms only, lower plexus involvement, or combined upper and lower plexus symptoms.

Double-crush nerve compression in thoracic-outlet syndrome.

We studied 165 cases of thoracic-outlet syndrome in 142 patients in whom resection of the first rib had been performed. In seventy-three cases (44 per cent), there was compression of a nerve distally, as shown by electromyography and conduction studies. The most common secondary compression was carpal tunnel syndrome (forty-one cases). Thirteen patients needed an operation at three sites or more. Our results show that proximal compression of a nerve lessens its ability to withstand more distal compression. Once the diagnosis of thoracic-outlet syndrome has been made, the possibility of an additional distal compression neuropathy should be investigated.

Rotator cuff tears associated with os acromiale.

We studied the cases of eight patients, one with bilateral involvement, who had a rotator cuff tear and an associated lesion delineated roentgenographically - a separate fragment of the acromion that we believe to be an ununited ossification center of the acromion (os acromiale). In reviewing the literature, we found no mention of an association between a rotator cuff tear and os acromiale. It is highly unlikely that such an association is coincidental because it appears that in our patients abnormal motion existed through the site of fibrous union of the acromion and may have contributed to the impingement of the acromion on the rotator cuff. Repair of the rotator cuff with removal of the loose fragment of acromion was done in the six patients who had operative treatment.

Congenital skin fossae about the shoulder.

Congenital fossae, skin pits, or dimples can form about the shoulder. Little has been written about congenital supraspinous fossae or dimples. They are thought to result from the catching of tissues between a sharp bony post and the uterine wall. The skin and structures become compressed and adherent, and when the pressure is released, the surrounding parts remain tied down, forming small pits or dimples. I report on a congenital fossa in the scapular region of an infant who cried each time the arm was abducted. This congenital fossa did communicate with and adhered to the scapula. Excision of the fossa with its surrounding scar tissue about the scapula plus gentle manipulation gave free motion to the shoulder.

Thoracic outlet syndrome. The results of first rib resection in 100 patients.

We examined 100 patients with the TOS treated surgically. One hundred and twenty first ribs were resected using the transaxillary approach. Ninety per cent good and excellent results were obtained. EMGs and conduction studies through the outlet are of little value. Many of our patients presented with a double crush syndrome. Trauma was a significant antecedent in 44 per cent of our patients. The diagnosis of TOS depends on a careful clinical evaluation. There are no laboratory tests, x-rays, electrical studies, or infallible clinical tests to establish the diagnosis. There will always be some errors in diagnosis, and surgery must be advised on a basis of exclusion and with great reservation.

The sesamoid bones of the hand and their pathology.

Three cases of sesamoid bone pathology are presented, including two cases of sesamoid fracture and a case of sesamoid periostitis. The literature is reviewed. Sesamoid bones probably function in the body as pulleys. Most people have five sesamoid bones in each hand. Two at the thumb metacarpophalangeal joint, one at the interphalangeal joint of the thumb, one at the metacarpophalangeal joint of the index finger on the radial side, and one at the metacarpophalangeal joint of the little finger on the ulnar side. Sesamoid bones have been seen with periostitis in Reiter's syndrome. The medial sesamoid bone of the thumb metacarpophalangeal is frequently enlarged in acromegaly. The sesamoid bones of the thumb have been fractured or trapped inside the joint during injury to the thumb metacarpophalangeal joint. The treatment of disabling pain in a sesamoid bone is enucleation of the bone.

Unusual complication of a silicone implant arthroplasty at the base of the thumb.

Pain developed after arthroplasty of the carpometacarpal joint of the thumb. It was due to perforation of the shaft of the metacarpal by the prosthesis, and was cured by a bone graft.

Trauma-related thoracic outlet syndrome.

181 patients treated for thoracic outlet syndrome by first rib resection were reviewed. 88 (49%) indicated a single traumatic event which precipitated the thoracic outlet syndrome. 79% of patients with a history of a single traumatic episode had good to excellent results after first rib resection. A separate group of 18 patients developed work-related thoracic outlet syndrome due to repetitive activities. Ratings of good to excellent results were lower (66%) among workmen's compensation cases.

Surgical treatment of the thumb in the Rubinstein-Taybi syndrome.

In a review of 530 individuals with Rubinstein-Taybi syndrome, 182 (34%) were found to have thumbs in severe radial angulation ("hitch-hiker thumbs"), which prevented opposition and functional gripping strength. Surgery has been performed on 35 thumbs (from 20 patients), usually to correct a delta phalanx deformity. The preferred approach was a closing wedge osteotomy, with a Z-plasty on the concave side to straighten the thumb. In eight and possibly 11 of the 35 thumbs, the angulation deformity or stiffness recurred, emphasizing the importance of proper and careful surgery. We conclude that surgical correction of the deformity is best done before the age of two, so that the thumb is functional during the initial development of hand-eye coordination. Deviation persisting at the age of ten can be corrected by fusing the metacarpophalangeal joint.

Duplicated longitudinal bracketed epiphysis 'kissing delta phalanx' in the hand.

The duplicated longitudinal bracketed epiphysis ("kissing delta") phalanx has been described rarely. These delta bones have a bizarre appearance and are often associated with other developmental abnormalities such as central polydactyly. We have seen a total of 13 kissing delta phalanges in the hands. We discuss their natural history, look at the associated anomalies and consider the treatment options for this very rare congenital anomaly.

Treatment of the upper limb in Charcot-Marie-Tooth disease.

Even though Charcot-Marie-Tooth (CMT) disease is seen frequently, relatively little has been written about the successful treatment of upper limb involvement using tendon transfers. It appears that there are several types of CMT disease and there is extreme variability in the clinical symptoms. The results of treatment were assessed by looking at four specific areas of hand function: decreased conduction velocity of the nerves, lack of opposition, weak pinch, and clawing of the fingers. A plan has been developed for tendon transfers that has worked well in clinical practice.

Intra-uterine and juxtanatal repair of syndactyly in foetal mice.

39 foetal mice with genetic syndactyly were identified in utero at 17 days of gestation, and the right hindfoot extruded through the uterus. The syndactylous digits were separated by simple incisions. In one group (n = 25) digit separation was maintained during wound healing by the interdigital application of a silver microclip. Digit separation was also assessed in a second group of newborn mice less than 24 hours old (juxtanatal population, n = 24). Two foetuses (5%) and six newborns (25%) developed digital necrosis following microclip application. In the remaining microclipped animals (23 intrauterine and 10 juxtanatal), microclip application maintained digit separation, allowing wound healing to occur with epithelialization of the separated digits. No inflammation or scar formation occurred. In the third group (n = 22) without microclip application, the digital skin reapproximated and webbing recurred during wound healing. These studies demonstrate the need to maintain digit separation during wound healing following intra-uterine or juxtanatal syndactyly repair.

An experience of the Snow-Littler procedure.

This paper reviews the results of the Snow-Littler procedure performed in twelve hands with classical central longitudinal deficiency and in one hand with symbrachydactyly, cleft type. There were no instances of major flap necrosis although two flaps showed tip ischaemia. The width of the first web was, in the main, satisfactory but four webspace revisions were performed. Supplementary skin grafting at the time of surgery was necessary in complete and/or complex thumb index syndactylies and in the patient with symbrachydactyly. In eight cases, a transverse metacarpal ligament was reconstructed. In the five other cases, no clinical instability or radiological divergence of the index and ring fingers occurred, in spite of no transverse metacarpal ligament reconstruction. Three de-rotational osteotomies of transposed index fingers were performed in patients who had a transverse metacarpal ligament reconstruction. These results indicated significantly improved appearance and improved function following the Snow-Littler procedure.

Super digit.

This article describes a clinical entity under the new name "super digit." The anomaly represents a conglomerate of several different malformations and syndromes. Twenty patients with 24 super digits are presented. The two main types of super digits are discussed: Type I, which has two metacarpals that support a single oversized digit; and Type II, which has a single metacarpal that supports two or more digits distally. These digits, with growth, display several complications such as enlargement, deviation, angulation, loss of motion, and undergrowth. The anomalies singly and collectively present problems that require similar surgical procedures for correction.

Hand involvement in multiple hereditary exostosis.

In summary, patients with multiple hereditary exostosis often inherit hand involvement but rarely show hand deformity. The principal area of involvement appears to be around the MCP joint but the PIP joint is the most common area of deformity. Metacarpal shortening usually does not cause functional problems and need not be treated. Angular deformity, though rare, does cause problems and needs surgical treatment. Unfortunately, there is no evidence that prevention of deformity is possible by early excision of osteochondromas. Treatment, therefore, requires both osteochondroma excision and closing-wedge corrective osteotomy.

The treatment of crossbones of the hand.

Over a thirty-year period at Loma Linda University, we have seen eight patients with nine crossbones of the hand. These patients fall into the group of central deficiency with a cleft hand and central polydactyly. As will be noted in the paper, these two conditions may have a similar developmental relationship. Although the literature in the past specifies mainly one option - to remove the crossbone - we consider several different options that one should think about before removal of the crossbones.