[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.

Iatrogenic Mycobacterium abscessus infection in a trigger finger.

An immunocompetent 63-year-old lady developed Mycobacterium abscessus soft tissue infection of the hand following local corticosteroid injection for trigger finger. The patient was successfully treated with repeated radical debridement and prolonged antimicrobial therapy. Atypical mycobacterial infections, including those caused by M. abscessus, albeit rare, should be considered in cases of late-onset indolent infection following local injury surgical procedures, and injections. Clinical vigilance, timely diagnosis, combined directed antimicrobial treatment, coupled with adequate surgical debridement are key for successful management.

Amputation of finger by horse bite with complete avulsion of both flexor tendons.

Amputation of fingers with tendon avulsion occurs through a traction injury, and most occur through a ring avulsion mechanism. Usually the flexor digitorum profundus is torn out with the amputated finger. Replantation usually is recommended only when the amputation is distal to the flexor digitorum superficialis insertion. Animal bites are relatively common, with a decreasing order of frequency of dogs, cats, and humans. Horse bites are relatively infrequent but are associated with crush injuries and tissue loss when they occur. This article describes a 23-year-old man with amputation of his middle finger at the level of the proximal phalanx after being bitten by a horse. The amputated stump was avulsed with the middle finger flexor digitorum profundus and flexor digitorum superficialis torn from the muscle-tendon junction from approximately the middle of the forearm. The patient had no other injuries, and he was able to move his other 4 fingers with only mild pain. As the amputated digit was not suitable for replantation, the wound was irrigated and debrided. The edges of the phalanx were trimmed, and the edges of the wound were sutured. Tetanus toxoid and rabies vaccine were administered, along with intravenous amoxicillin and clavulanic acid. The patient was discharged from the hospital 2 days later, with no sign of infection of the wound or compartment syndrome of the forearm. This case demonstrates the weakest point in the myotendinous junction and emphasizes the importance of a careful physical examination in patients with a traumatic amputation.

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.

Complications associated with prolonged tourniquet application on the battlefield.

The use of a tourniquet to control bleeding is a necessity in both surgical and prehospital settings. Tourniquet application, if performed properly, can be a lifesaving procedure, particularly in a traumatic setting such as the battlefield. A tourniquet is easily applied and requires the use of a relatively uncomplicated piece of equipment. However, improper or prolonged placement of a tourniquet because of poor medical training can lead to serious injuries, such as nerve paralysis and limb ischemia. Here we present five case reports of improper tourniquet applications on the battlefield that resulted in nerve damage. We conclude that there is a need for improved training among medical personnel in the use of tourniquets, as well as a need for an adjustable-pressure, commercial-type sphygmomanometer cuff with a large surface area that is appropriate for application to all limbs parts. We also recommend that, in cases requiring the use of a tourniquet, the caregiver remove the tourniquet every 2 hours and assess the bleeding; if the bleeding has stopped, then the tourniquet should be replaced with a pressure bandage to minimize tissue damage.

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.

Comparison of intraarticular injection of depot corticosteroid and hyaluronic acid for treatment of degenerative trapeziometacarpal joints.

BACKGROUND: Trapeziometacarpal joint arthritis is a disabling condition presenting with pain at the base of the thumb causing impairment of hand function. Nonoperative treatment at an early stage includes intraarticular steroid injection. Although this treatment may bring about prompt symptomatic relief, its efficacy is unpredictable. OBJECTIVES: There is previous evidence that injection of sodium hyaluronate is effective and safe in the treatment of knee arthritis. We proposed that intraarticular injection of sodium hyaluronate, for the symptomatic treatment of trapeziometacarpal joint arthritis, could provide symptomatic relief without the adverse effects of steroids. METHODS: Fifty-two patients with trapeziometacarpal joint grade II arthritis were randomized prospectively either for methylprednisolone or hyaluronate intraarticular injections. Initial evaluation included an estimation of pain, grip, pinch strengths and the functional Purdue Pegboard Test (PPT). This evaluation was repeated after 1, 3, and 6 months and statistically compared with the initial evaluation. RESULTS: In both groups, the intraarticular injection produced a relief of pain after 1 month. Grip strength improved significantly in the group treated by the steroid during the whole evaluation period. The patients treated by hyaluronate showed improvement in grip strength after 6 months and in the pinch and the PPT after 3 months. CONCLUSIONS: Steroids and hyaluronate injections were found effective in reducing pain. Hyaluronate was more effective in the improvement of some aspects of fine hand function.

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.

Vibrio vulnificus infection of the lower limb after fish spine injuries.

Five patients with soft tissue infection of the lower extremity caused by Vibrio vulnificus after penetrating injuries by fish spines are described. Despite previously reported dismal rates of morbidity and mortality associated with Vibrio septicemia, early measures including wide-spectrum intravenous antibiotics and surgical excision of devitalized tissues resulted in complete resolution in all cases. Although penetrating injury is the common route of infection, indirect seeding may occur by the contamination of open wounds or injury to a limb previously submerged in contaminated water.

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.

Complex bilateral polysyndactyly featuring a triplet of delta phalanges in a syndactylised digit.

The delta phalanx is a rare congenital skeletal anomaly. An abnormal C-shaped epiphysis is usually responsible for a progressive angular digital deformity observed either in hands or feet. Solitary delta phalanges are usually described. We report a case of bilateral congenital hand malformations featuring a triplet of delta phalanges affecting a single digit on one hand, together with a concealed central polydactyly on the other.