Epidermoid cysts in the hand.

This study details our series of epidermoid cysts in the hand, characterising the incidence, clinical characteristics and recurrence rate after marginal excision. A historical cohort of 101 epidermoid cysts that were excised from a soft tissue or intraosseous location in the hand over a 27 year period were reviewed. The incidence of epidermoid cysts, patient age, sex, occupation, anatomic location, history of trauma, treatment complications and cyst recurrence rate were noted. Key findings of the study were as follows. Epidermoid cysts represented a significant portion of our relatively large series of hand tumours. The majority occurred in male patients, most often involving the soft tissues on the palmar aspect of the hand. Four percent were intraosseous epidermoid cysts. After excision with a marginal tumour margin we found that 11 cysts (11%) recurred.

Fibroma of tendon sheath in the hand.

Seven cases of fibroma of tendon sheath in the hand are reviewed. These tumors are common enough to be considered in the differential diagnosis of a soft tissue tumor in the hand, as they comprised 7 of our series of 208 soft tissue hand tumors excised over a 15-year period. A marginal excision was performed in each case, and no tumor recurred after a mean follow-up interval of 8 years. The fibromas were adherent to tendons, tendon sheaths, and neurovascular structures, and thus were more difficult to excise without morbidity than other soft tissue hand tumors.

Plant thorn synovitis: an uncommon cause of monoarthritis.

Plant thorn synovitis (PTS) is an uncommon cause of monoarthritis. Seven cases of PTS were identified at our institution from January 1979 to July 1990, six of whom were men. Mean age was 27 years (range, 7 to 56 years). Symptoms included pain, swelling, and stiffness. Synovitis was present on examination along with decreased range of motion of affected joints in all patients. Roentgenograms were unremarkable in five patients, but disclosed demineralization in two others. Initial conservative treatment with nonsteroidal antiinflammatory drugs (NSAIDs), antibiotics, or splinting was usually unsuccessful; surgery was necessary in six patients. Findings included marked inflammatory synovial reactions with evidence of retained thorn in all patients. One patient had a positive operative wound culture (Enterobacter agglomerans) without evidence of osteomyelitis. All patients improved after surgery without sequelae. Despite a history suggesting thorn injury in many cases, diagnosis was often delayed; mean time to diagnosis was 10 weeks (range, 2 weeks to 9 months). PTS must be included in the differential diagnosis of monoarthritis. Histologically, PTS can mimic sarcoidosis, tuberculosis, or fungal infection. Optimal treatment of PTS is arthrotomy, foreign body removal, and extensive synovectomy.

Prototheca wickerhamii tenosynovitis.

Prototheca wickerhamii is an algae-like organism rarely implicated in skin or soft tissue infections. We describe the first case (to our knowledge) of Prototheca tenosynovitis which followed median nerve release for carpal tunnel syndrome. Clinical presentation, operative findings, histopathology, microbiology and treatment of this unusual infection are discussed.

Intraneural steroid injection as a complication in the management of carpal tunnel syndrome. A report of three cases.

Steroid injection can provide symptomatic relief in patients with carpal tunnel syndrome (CTS). Its role should be limited to a diagnostic aid in cases in which symptoms are atypical, a temporizing agent in patients with severe symptoms either who are awaiting surgery or in whom spontaneous remission might be expected, and as a definitive treatment in patients who do not desire surgery. Injection should be performed using proper technique by physicians skilled in carpal tunnel surgery. A soluble preparation of dexamethasone is recommended. Immediate paresthesia in the median nerve distribution or exacerbation of symptoms beyond 48 hours following injection is suspect for inadvertent nerve injury; therefore, early surgical decompression is indicated.

Suppurative extensor tenosynovitis caused by Staphylococcus aureus.

Suppurative tenosynovitis is a rare infection, occurring almost exclusively in the flexor tendon sheath as a posttraumatic event. We report the case of a systemically ill woman with suppurative tenosynovitis of the extensor tendons caused by Staphylococcus aureus. Early recognition of this unusual infection may prevent unnecessary morbidity.

Primary care of flexor tendon injuries.

The approach to the acute flexor tendon injury is an area of hand surgery that has seen considerable change in the last 25 years. Direct repair in the early postinjury period, at all levels of injury, is the accepted procedure provided wound conditions permit. The procedures performed along with the tendon repair in zone 2 are based on both clinical experience as well as laboratory evidence, but additions such as sheath closure have not been completely proven to improve the clinical result. At this time, both flexor tendons are repaired in zone 2 and the flexor sheath is repaired. All patients are mobilized in a protected mobilization program. The last modification is probably the chief reason that results from flexor repairs are improving at this time.

Acute calcific tendinitis of the hand and wrist: a report of 12 cases and a review of the literature.

Acute calcific tendinitis is a frequently unrecognized cause of hand and wrist tenderness and swelling. We report 12 cases seen over an 8-year period. Roentgenograms showed deposits in various peritendinous sites especially near the pisiform. Special views may be required for visualization. A correct diagnosis was made in 5/12 cases; other etiologies considered included closed-space infections. In most cases, treatment consisted of immobilization plus nonsteroidal antiinflammatory drugs or local steroid injections. Results were uniformly good. Seven of 7 patients demonstrated resolution of calcium deposits on subsequent roentgenograms. Failure to recognize this entity may cause unnecessary investigation and therapy.

Flexor tendon rupture associated with an anomalous muscle.

A rupture occurred in the substance of an apparently normal flexor digitorum profundus tendon of a left small finger. It was associated with a previously undescribed anomalous flexor digitorum superficialis of the brevis type to the same finger. Clinical reports of 20 anomalous flexor digitorum superficialis muscles were found in the literature; all but one were on the right side or bilateral and occurred predominantly in females. Three cases were of the brevis type and all involved the index finger. Although the precise reason for rupture is not known we have speculated that the anomalous superficialis may have given rise to a deficient vinculum longus to the profundus predisposing it to failure.

Hand rehabilitation--retrospective.

From the exercise principles of Galen through the compassionate practices of Canute and the leadership of Tissot, Dunton, Bunnell, Brand, and Hunter, hand rehabilitation has grown. Surgeons, nurses, physical therapists, and occupational therapists now work together for a common goal--to restore the patient with the injured hand to the greatest possible productivity in the shortest period of time.

Tuberculosis of the hand and wrist.

Over the past 5 years we have encountered 11 cases of Mycobacterium tuberculosis of the hand and wrist. The most striking feature of this series was the delay between the onset of symptoms and the correct diagnosis. Many patients had a diagnosis of rheumatoid arthritis or nonspecific synovitis prior to the diagnosis of tuberculosis. There was a striking lack of pulmonary symptoms. Only two patients had a prior history of tuberculosis and only one had significant pulmonary involvement. Most had tenosynovitis involving the flexors or extensors. Three had tenosynovitis and arthritis whereas one had only tuberculous arthritis. Two patients had carpal tunnel syndrome as a result of carpal canal involvement. Ten of the 11 patients had apparent cures of tuberculosis subsequent to surgical debridement and antituberculosis therapy.

Isolated fracture of the humeral capitellum.

Twenty-nine patients with fractures of the capitellum of the humerus were treated at the New York Orthopaedic Hospital during 15-year period; 17 were available for follow-up assessment. A classification based upon the specific nature of the fracture and the degree of trochlear involvement is a suggested guide to treatment and prognosis. Long-term follow-up studies compare resection, replacement with fixation, and closed reduction. Choice of treatment should be selective and individualized depending on age, character of the bone, and type of fracture.