[THE ADVERSE EFFECTS OF SMOKING ON THE HANDS].

Cigarette smoking is known to cause a multitude of harmful effects throughout the body. There are only a few accounts in the literature of these effects as related to the hands. This is a review of the literature, demonstrating the collected knowledge of decreased hand vascularity due to tobacco use and assessing the evidence connecting smoking and supposed resultant maladies, including Raynaud's phenomenon, hand-arm vibration syndrome, Buerger's disease, Dupuytren's contracture, carpal tunnel syndrome, effects on skin and fingernails, decreased skin and bone healing, complications of digit replantation and complex regional pain syndrome. Also presented is the possible increased risk of congenital hand malformations as related to maternal smoking.

Latent pisotriquetral arthrosis unmasked following carpal tunnel release.

The causes of persistent wrist pain following carpal tunnel release include scar tenderness and pillar pain. The goal of this study was to evaluate latent pisotriquetral arthrosis as a source of ulnar-sided wrist pain following open carpal tunnel release. Seven hundred consecutive carpal tunnel releases were reviewed, looking for postoperative presentation of pisotriquetral arthrosis, as well as management and outcome. Fourteen patients with long-standing postoperative pain at the base of the hypothenar eminence had clinical and radiographic signs of pisotriquetral degenerative arthrosis, which conceivably had existed preoperatively and been unmasked thereafter. In 6 patients with persistent symptoms despite conservative measures, excision of pisiform was curative. Altered isometric stresses over the pisotriquetral articulation as a result of releasing the transverse ligament, which constitutes a major radial static stabilizer of this joint, seems to cause articular maltracking, and consequently aggravates a preexisting asymptomatic pisotriquetral arthrosis. Long-standing discomfort is characteristically associated with loss of grip strength and dexterity. Pisotriquetral dysfunction and arthrosis should always be considered in the differential diagnosis of persistent wrist pain following either open or endoscopic carpal tunnel release that does not respond to nonoperative measures. Clinical scrutiny, adequate clinical inspection, and radiographic evaluation readily establish the diagnosis. Conservative treatment includes immobilization, nonsteroidal anti-inflammatory drugs, and intra-articular injection of corticosteroids under fluoroscopic control. The corticosteroid injection combined with a local anesthetic also serves as a diagnostic test. Excision of the pisiform is indicated where conservative treatment has failed.

Dupuytren's palmar contracture in women.

BACKGROUND: Dupuytren's disease is a fibroproliferative disorder of the palmar fascia that can cause disabling digital contractures. The pathogensis of the disease is still unclear, and it afflicts predominantly white males of northern European origin. Gender-related differences of Dupuytren's disease and the distinctive characteristics of the disease in females are not yet well defined. OBJECTIVES: To evaluate and illustrate the distinctive characteristics of Dupuytren's disease in females. METHODS: A retrospective study was performed of all female patients with Dupuytren's disease seen and followed at our Hand Surgery Unit over a 20 year period. The study group consisted of 48 women (56 hands). The collected data included clinical and epidemiological features on admission, and outcome of surgical intervention. RESULTS: Of the 48 women (56 hands) with Dupuytren's disease, 23 (26 hands) underwent limited fasciectomy. The average age at presentation was 60.1 years. A few of the patients originated from Asia and Africa. Manifestations and pattern of the disease were nearly comparable to those observed in the male group, except for a slightly higher incidence of proximal interphalangeal joint contracture in female patients. Generally, females expressed less severe contractures on presentation and a slower progression thereafter. A favorable functional postoperative outcome was observed. Seven patients had minor complications including local hematoma and painful scars. Two patients developed moderate signs of complex regional pain syndrome. CONCLUSIONS: Further investigations are needed to assess the potential role of androgens in the pathogenesis of Dupuytren's disease, and a possible protective role of estrogenic hormones, rendering Dupuytren's contracture a postmenopausal affliction.

Safety of elective hand surgery following axillary lymph node dissection for breast cancer.

The development of lymphedema is the most feared complication shared by breast cancer survivors undergoing hand surgery after prior axillary lymph node dissection (ALND). Traditionally, these patients are advised to avoid any interventional procedures in the ipsilateral upper extremity. However, the appropriateness of some of these precautions was recently challenged by some surgeons claiming that elective hand operations can be safely performed in these patients. The purpose of this study was to evaluate our experience and determine the safety of elective hand operations in breast cancer survivors. The medical records of patients operated for different hand conditions after prior breast surgery and ALND at our institution between 1983 and 2002 were reviewed. The techniques and preventive measures performed, use of antibiotics, and upper extremity complications associated with the operations were analyzed. Overall, we operated on 27 patients after prior ALND performed for breast cancer. Follow-up was available for 25 patients. Four patients had pre-existing lymphedema. The surgical technique used was similar to that performed in patients without prior ALND and antibiotic prophylaxis was not given. Delayed wound healing was observed in one patient and finger joint stiffness in another. Two patients with pre-existing lymphedema developed temporary worsening of their condition. None of the patients developed new lymphedema. The results of the present study support the few previous studies, suggesting that hand surgery can be safely performed in patients with prior ALND. Based on these findings, the appropriateness of the rigorous precautions and prohibitions regarding the care and use of the ipsilateral upper extremity may need to be reconsidered.

[Osteoid osteoma of the wrist joint resembling tenosynovitis].

Osteoid osteoma of bones of the wrist joint is a relatively rare lesion. This article presents a series of three patients, one with osteoid osteoma of the styloid process of the radius and two with osteoid osteoma of the capitate bone. All of them had clinical symptoms resembling those of stenosing tenosynovitis of the wrist joint. X-rays, tomography and bone scan revealed the characteristic findings of osteoid osteoma. Histological examination confirmed the diagnosis. Treatment consisted of "en bloc" excision of these tumors. Following surgery patients were asymptomatic and had normal mobility of the affected wrist. In the first patient this has been maintained for the succeeding 27 years. It is suggested that in any case of persistent unexplained pain of the wrist or clinical symptoms resembling those of tenosynovitis, osteoid osteoma of the styloid process of the radius or of the carpal bones should also be included in the differential diagnosis. The recommended treatment of osteoid osteoma is "en bloc" excision of this tumour in the affected bone, resulting in complete relief of pain and absence of functional disturbances.

Simple wrist ganglia in children: a follow-up study.

Our study aimed at characterizing the natural history and defining the indications for surgical intervention for pediatric ganglia. Thirty-four cases of children under the age of 17 years were reviewed. Twenty-nine children were treated conservatively, with spontaneous resolution in 27 within an average of 9 months; four were treated by aspiration; recurrence was observed in one, and one underwent surgical excision without recurrence. We recommend a conservative management coupled with reassurance for the child and parents. Surgery should be considered for ganglions with atypical appearance or complaints, and large cysts that do not show signs of resolution within a year.

Failure of flexor pollicis longus repair caused by anomalous flexor pollicis longus to index flexor digitorum profundus interconnections: a case report.

We describe a case of an early rupture of a repaired flexor pollicis longus tendon in a young woman. The cause of failure was an anomalous tendinous band that connected the tendon of the flexor pollicis longus to the tendon of the flexor digitorum profundus of the index finger. Forceful flexion of the unrestricted index finger applied a tensile force that was transmitted through the anomalous band to the repaired site and resulted in repair failure.

Comparison of two methods for the evaluation of treatment in medial epicondylitis: pain estimation vs grip strength measurements.

INTRODUCTION: Determination of a precise and reproducible diagnostic tool for the evaluation of patients with medial epicondylitis (ME) is important for an effective follow-up. The commonly suggested use of grip strength measurements with a hand dynamometer is not always easily available and may be affected by the patient's compliance. We propose that pain estimation based on the visual analog scale can be considered for this purpose as well because it addresses the painful degenerative lesion in the common flexor origin, which is the basic pathological process in ME. MATERIALS AND METHODS: We analyzed and compared 237 different sets of measurements of grip strengths and pain evaluation, according to the visual analog scale, in 79 patients with ME. For the purpose of this comparison, we developed a qualitative grading system based on the statistical data of the grip strength values in the normal population. RESULTS: High dependency between the graded pain evaluation and measured grip strength was found. CONCLUSION: We suggest that evaluation of patients with ME according to the proposed grading method of pain evaluation is as accurate as grip strength measurements.

Surgical treatment of painful neuroma in medial antebrachial cutaneous nerve.

The branches of the medial antebrachial cutaneous nerve (MACN) are located at the medial site of the elbow. The MACN, especially the posterior branches, may be injured or transected during cubital tunnel surgery or other medial approaches to the elbow. Damage to the nerve can cause a neuroma, which leads to disabling pain and restriction of elbow movement. The initial treatment of the neuroma is nonsurgical, and includes local massage, desensitization, physiotherapy, and systemic medication. If after 6 months of these nonsurgical treatments there is no improvement, surgery is indicated. The authors report their experience with 12 patients treated surgically for painful neuroma by high resection of the proximal end or its implantation into the triceps muscle. After surgery there was a high success rate of pain relief and functional improvement in both elbow movement and handgrip strength.