Scaphotrapezial arthritis after a carpometacarpal fusion in a patient with Marfan's Syndrome: case report.

We report a case of scaphotrapezial arthritis that developed in a patient with Marfan's syndrome many years after a carpometacarpal fusion, which placed the thumb metacarpal in adduction. This problem was effectively treated with an abduction/opposition osteotomy, which both increased the patient's first web space and improved her arthritic symptoms.

Outcomes assessment in hand surgery: when are they meaningful?

Hand surgeons currently are challenged with the task of measuring and establishing the connection between the diagnosis and treatment of health-related quality-of-life problems. Although true quality of life cannot be measured directly, instruments in the form of questionnaires have been developed that use self-reporting to account for functional performance, health status, and health-related quality of life. Instruments must be reliable, valid, responsive, and appropriate. Misunderstanding these properties often hinders interpreting the recent stream of outcome studies in the literature. Most physicians are not sure what if any outcome information should be collected routinely or if any outcome instrument is diagnostically useful. Currently there is no convincing evidence to support the routine use of patient-based outcome measures in hand surgeons' practices. Those hand surgeons who would like to carry out an outcome study should consider seeking help from others with expertise in outcomes design and analysis.

Necrobiosis lipoidica in a 9-year-old girl with new-onset type II diabetes mellitus.

Necrobiosis lipoidica (NL) is an idiopathic dermatologic condition that is strongly associated with, but not pathognomonic for, diabetes mellitus. It is more commonly seen in women than men and in adults than children. We present the youngest child, to our knowledge, diagnosed with NL at initial presentation with type II diabetes mellitus. We review the literature and discuss pathogenesis, clinical features, and treatment options for NL.

Repetitive stress injury: diagnosis or self-fulfilling prophecy?

* The vague definitions of so-called repetitive stress injuries are indicative of the fact that scientific studies have failed to show that repetitive motion causes injury. * Given the uncertainty about causation, work-related musculoskeletal disorders (WRMSDs) is a more readily accepted term to describe these phenomena. * There is little doubt that most ergonomic interventions increase comfort in the work environment, which is of great benefit to the worker. Many proponents of ergonomics assert that the elimination of certain risk factors related to force, repetition, and posture can prevent or even cure work-related musculoskeletal disorders of the upper extremity. However, there is little scientific support for this position. * Undue reliance on ergonomics to treat musculoskeletal disorders, to the exclusion of proper diagnosis and attention to medical and health risk factors, can have adverse consequences for the patient. * Science rather than politics and public policy should determine what causes injury and disease. * The failure of numerous plaintiffs in litigation regarding repetitive stress injury due to use of computer keyboards is important because, when judges and lay jurors were presented with both sides of the issue, they rejected these claims in a forum (the judicial system) that traditionally compensates individuals bringing so-called mass-tort cases.

The effects of hypothyroidism and thyroid replacement on the development of carpal tunnel syndrome.

Hypothyroidism is commonly included as an important risk factor for carpal tunnel syndrome (CTS), yet no study clearly defines the nature of this association. The purpose of this study was to evaluate the relationship between hypothyroidism and CTS in a controlled study. Twenty-six hypothyroid patients (45 hands) meeting our inclusion criteria with a diagnosis of primary hypothyroidism were questioned regarding date of diagnosis of hypothyroidism, duration and dose of thyroid replacement, and the presence, character, and duration of CTS symptoms. Twenty-four healthy volunteers (47 hands) were used as controls. Clinical examination included sensibility testing with Semmes-Weinstein monofilaments, Weber 2-point discrimination testing, examining for thenar muscle atrophy and weakness, Phalen's test, Tinel's sign at the wrist, and the manual compression test. Electrodiagnostic testing including distal motor latency and distal sensory latency was performed on the median nerve at the wrist on all subjects. Nineteen patients (73%; 31 hands [68%]) displayed symptoms of CTS; of these, 16 patients (25 hands) had clinical examinations consistent with CTS. Only 6 of the 16 patients with clinical CTS (7 of 25 hands) had electrical studies that supported a diagnosis of CTS. All these symptomatic patients were biochemically euthyroid. All control subjects had normal electrical study results and normal sensibility testing. Two subjects had positive clinical examinations, giving a false-positive rate of 4%. Carpal tunnel syndrome symptoms are common in hypothyroid patients even when they are euthyroid. In this group of patients, normal median nerve latencies at the wrist in the presence of CTS symptoms and a positive physical examination are more prevalent than expected by the reported sensitivities of electrodiagnostic testing. Standards for assessing normal median nerve latencies may be significantly different in hypothyroid patients.

The value of diagnostic testing in carpal tunnel syndrome.

The purpose of this study was to determine the validity of tests or a combination of tests for the diagnosis of carpal tunnel syndrome. Three groups of 50 subjects each were studied: group 1 had definite carpal tunnel syndrome as defined by history, clinical presentation, and improvement of symptoms following carpal tunnel release; group 2 had a variety of nontraumatic upper extremity disorders other than carpal tunnel syndrome; and group 3 subjects were asymptomatic healthy volunteers. Subjects submitted a self-administered hand diagram, and were queried about night pain, symptom duration, and coexistent medical conditions. Phalen's test, Tinel's sign, Durkan's compression test, and Semmes-Weinstein monofilament testing both before and after a Phalen's maneuver for 5 minutes were performed on each subject. Grip and pinch strengths were measured. Univariate analysis of groups 1 and 2 showed that the tests with the highest sensitivity were Durkan's compression test (89%), Semmes-Weinstein testing after Phalen's maneuver (83%), and hand diagram scores (76%). Night pain was a sensitive symptom predictor (96%). The most specific tests were the hand diagram (76%) and Tinel's sign (71%). Analysis of groups 1 and 3 without group 2 increased the specificity and predictive value of a positive test. A regression model was used to develop a multivariate equation with 4 variables. If a patient has an abnormal hand diagram, abnormal sensibility by Semmes-Weinstein testing in wrist-neutral position, a positive Durkan's test, and night pain, the probability that carpal tunnel syndrome will be correctly diagnosed is 0.86. If all 4 of these conditions are normal, the probability that the patient has carpal tunnel syndrome is 0.0068. We found that the addition of electrodiagnostic tests did not increase the diagnostic power of the combination of 4 clinical tests.

Forearm interosseous ligament isometry.

Biomechanical testing was performed to determine isometric interosseous ligament graft placement as a preliminary step for reconstruction after an axial forearm disruption. Twenty-five combinations of potential ligament graft placement were studied on 7 fresh-frozen cadavers. Suture was used to simulate these potential ligament reconstructions, and suture excursion was used as an index of isometry. Ligament orientation was defined by the angle formed between the ulna and the suture (surrogate graft). Ligament position was defined by its insertion on the ulna as a percentage of ulna length. Suture-ulna angles from 9 degrees to 38 degrees produced significantly less suture excursion than angles of > or = 39 degrees. Minimal suture excursion was noted at angles of < or = 20 degrees, which we feel represents the optimal range for reconstruction. The optimal location on the ulna for isometric interosseous ligament reconstruction was at 25% to 30% of total ulna length, as measured proximally from the distal ulna articular surface. The radius isometric location is optimally located by a vector starting from the ulna isometric point and directed toward the proximal radius at an angle of < or = 20 degrees relative to the long axis of the ulna. Interosseous ligament reconstruction may prove beneficial in the long-term outcome of reconstruction after axial forearm disruption.

Dorsal intercarpal ligament capsulodesis for scapholunate dissociation: biomechanical analysis in a cadaver model.

The purpose of this study was to evaluate in cadavers a new method for treating scapholunate dissociations, dorsal intercarpal ligament capsulodesis (DILC), and to compare its performance with that of a previously described soft tissue reconstruction, Blatt capsulodesis (BC). A cadaver model was used to simulate normal and abnormal wrist motions. The positions of the scaphoid and lunate and their changes with wrist motion and ligament condition were recorded using biplanar radiographs taken posteroanteriorly and laterally. The scapholunate gap was measured on the posteroanterior radiographs and the scapholunate angle was measured on the lateral view radiographs. Following scapholunate interosseous ligament sectioning, a diastasis developed between the scaphoid and lunate that was maximum in the clenched fist position 2.1 +/- 0.33 mm (mean +/- SEM) with the ligament intact versus 8.0 +/- 1.74 mm after the ligament was sectioned. Dorsal intercarpal ligament capsulodesis reduced gap formation more than BC, including when the specimens were in the clenched fist position: increased gap versus intact specimens equals 1.0 mm for DILC versus 3.7 mm for BC. The differences in diastasis were statistically significant between BC and DILC when the wrist was in extension, radial deviation, and clenched fist positions. After the scapholunate interosseous ligament was divided, the scaphoid flexed relative to the lunate. Both capsulodeses improved scapholunate alignment and there was a trend for DILC to correct the scapholunate angle more than BC. The results demonstrate that DILC is an attractive alternative to BC ex vivo. Because DILC does not tether the scaphoid to the distal radius, as BC does, improved wrist motion, especially flexion, might be possible in vivo. The use of DILC in the treatment of scapholunate dissociation warrants further investigation and clinical trials.

Latissimus dorsi pedicled graft. An unusual cause of shoulder pain.

An unusual complication after the use of a pedicled latissimus dorsi flap is reported. The flap was used to reconstruct a facial defect after excision of a high grade mucoepidermoid carcinoma of a parotid gland. The tendinous insertion of the latissimus dorsi on the humerus was left intact and the flap pivoted around this point. Subsequent use of his arm caused the patient disabling shoulder pain from traction on the tendon. Symptoms resolved after the tendon was divided.

Displacement and strain of the median nerve at the wrist.

Median nerve displacement and strain in the carpal tunnel region were measured as functions of wrist position and carpal tunnel pressure in 5 cadaver forearms during simulated active finger flexion. The positions of spherical stainless-steel markers embedded within the median nerve and flexor digitorum superficialis of the long finger were measured in 3 dimensions by a radiographic direct linear transformation technique. Each limb was tested in 3 wrist positions (60 degrees extension, neutral, and 60 degrees flexion) and 4 carpal tunnel pressures (0, 30, 60, and 90 mmHg). Carpal tunnel pressure was controlled with a balloon angiocatheter inserted deep to the flexor digitorum profundus. The ratio of median nerve to flexor tendon excursion was linear and was affected by wrist position but not carpal tunnel pressure. Patterns of strain in the median nerve proximal to the flexor retinaculum were different from those of strain within the carpal tunnel. Nerve strains were affected by wrist position, but carpal tunnel pressure had no effect. The hydrostatic pressure effect associated with carpal tunnel syndrome does not appear to influence median nerve kinetics or kinematics for the wrist positions studied.

The use of frozen-allograft radial head replacement for treatment of established symptomatic proximal translation of the radius: preliminary experience in five cases.

Five patients with disabling symptoms related to proximal translation (> 1 cm) of the radius following radial head excision (Essex-Lopresti lesion) were treated with implantation of a frozen-allograft radial head prosthesis. Following restoration of neutral ulnar variance at the wrist, a size-matched frozen radial head allograft was implanted and secured to the proximal radius with internal fixation. In three patients, this was a two-stage procedure; radial length was restored gradually using an ilizarov external fixation device and the allograft was placed later. Patients were evaluated clinically and radiographically at a mean follow-up time of 3 years (range, 1-7 years). All patients had relief of wrist and elbow pain and were satisfied with the outcome of the operation. Forearm rotation improved by a mean of 37 degrees and wrist motion improved by a mean of 45 degrees. Forearm reconstruction with frozen radial head allograft implantation may be a beneficial method of treatment for this difficult problem.

Focal posterior interosseous neuropathy in the presence of hereditary motor and sensory neuropathy, type I.

A 30-year-old male with hereditary motor and sensory neuropathy, type I (HMSN I), presented with asymmetric weakness of finger extension and radial deviation with left wrist extension, previously felt to be a manifestation of the peripheral neuropathy. Nerve conduction studies confirmed HMSN I; however, needle EMG revealed marked, ongoing axonal loss in muscles innervated by the left posterior interosseous nerve (PIN) only. At surgery there was focal fusiform swelling in the PIN at exit from the supinator muscle, compatible with localized hypertrophic neuropathy, which has not been reported before in HMSN I. A concomitant focal mononeuropathy should be considered in cases of hereditary neuropathy with marked asymmetry of weakness.

Innervation of the lumbrical muscles.

It has long been recognized that the first and second lumbricals are normally innervated by the median nerve, whereas the third and fourth lumbricals are innervated by the ulnar nerve (Sunderland and Ray, 1946). However, the courses of the motor nerves, particularly to the first two lumbricals and their loci of insertion, have not been clearly described. Because this information may be useful to a surgeon operating in the palm, we undertook a cadaver study to define more precisely the pathways of innervation of the lumbrical muscles.