Pediatric hand disease. Diagnosis and treatment.

Proper care of the pediatric hand requires a careful, systematic history, and physical examination, and is facilitated by recognizing common disease patterns, making it easier to determine which conditions require specialty referral, and the timing of those referrals. The article outlines pertinent details of examination and discusses diagnosis and treatment of a number of common diseases entities of the hand.

Pressure changes in Guyon's canal after carpal tunnel release.

We measured pressure changes in Guyon's canal and the carpal tunnel before and after endoscopic (11 cases) and open (10) carpal tunnel release. We found that release of the flexor retinaculum by endoscopic and open techniques measurably decreased pressure in both the carpal tunnel and Guyon's canal. This study provides an explanation for relief of ulnar tunnel syndrome symptoms following carpal tunnel release and may indicate that carpal tunnel release alone may be sufficient to provide symptomatic relief for most patients with carpal and ulnar tunnel syndromes.

Early versus delayed treatment of enchondroma.

Enchondromata are among the most common primary neoplasms of the hand, which often present as pathologic fractures. The purpose of this study is to determine whether there are any differences between cases in which both fracture and tumor were treated primarily and those in which tumor treatment was delayed. We reviewed a total of 16 cases; six were treated immediately, 10 were delayed. The immediate treatment group had four complications, the delayed group had one. The theoretical advantages of immediate treatment include a decrease in both the period of disability and delay of definitive diagnosis. This study supports that supposition. However, we did note a significantly higher complication rate for the immediate treatment group (67% versus 10%). Our results indicate that while there is an apparent decreased disability period, there may be reason for caution in immediate treatment of both the fracture and the tumor in pathologic fractures through enchondromata.

The physiology and technique of skin grafting.

Skin grafting is one of the earliest described surgical procedures. In the age of microsurgery and free-tissue transfer, it remains a utilitarian means of achieving tissue coverage. This article discusses the physiology of skin grafting as well as current grafting techniques.

The effect of metacarpal shortening on digital flexion force.

Metacarpal shaft fractures are common injuries that frequently unite with some shortening of the metacarpal. The aim of this study was to determine the effect of metacarpal shortening on digital flexion force. The index metacarpal of six cadaveric upper limbs was incrementally shortened. The flexion force produced at the end of the finger was recorded using a small load cell. At full extension, there was no significant change in flexion force produced regardless of the amount of shortening. However, at 50% aggregate flexion the loss of force became statistically significant at a shortening of 7.5 mm or more. At full digital flexion, the loss of force became statistically significant at shortening of 5 mm or more. At increasing amounts of finger flexion, progressive metacarpal shortening produces proportionally greater loss of fingertip flexion force. From this study it appears that metacarpal shortening of up to 5 mm should give minimal loss of finger flexion force.

Morphologic changes following endoscopic and two-portal subcutaneous carpal tunnel release.

This study describes the morphologic changes that occur following single incision endoscopic and two-portal subcutaneous carpal tunnel release. Seventeen patients were studied preoperatively and an average of 24 weeks postoperatively. Canal volume, carpal arch width, and median nerve palmar displacement and cross-sectional area were measured by use of multiplanar reformation and three-dimensional reconstruction of magnetic resonance images. Both methods produced a marked increase in canal volume and median nerve cross-sectional area; neither resulted in a significant change in carpal arch width. These data provide a morphologic basis for the belief that endoscopic or subcutaneous carpal tunnel release will produce clinical relief equivalent to open carpal tunnel release.

Effect of high-energy phosphates and free radical scavengers on replant survival in an ischemic extremity model.

In replantation surgery, preoperative and intraoperative ischemia can lead to irreversible changes that prevent reperfusion during the subsequent re-establishment of circulation. These changes are termed the no-reflow phenomenon. Ischemic phase damage was addressed by comparing the dose-response effects of controls vs. five different high-energy phosphate compounds on replanted limb survival. Reperfusion damage was evaluated via comparisons of controls with superoxide dismutase (SOD). Ischemic hindlimbs treated with high-energy phosphates displayed improved survival compared with controls. Limbs treated with SOD demonstrated no change in survival at 4 hours and improved survival at 8 hours. Combining adenosine and SOD had no improved effect on survival. Adenosine was the most effective high-energy phosphate in limiting ischemic damage. The free radical scavenger (SOD) was beneficial only at the later stages of ischemia. In this experimental model, there appears to be a role for both phosphates and free radical scavengers in enhancing ischemic tissue survival.