Carpal tunnel syndrome caused by a giant cell tumour of the flexor tendon sheath.

A 76-year-old woman developed right carpal tunnel syndrome after being conservatively treated for tenosynovitis of the flexor tendons with associated mild carpal tunnel syndrome. A magnetic resonance imaging scan showed a tumour in the carpal tunnel. Re-exploration showed that the median nerve was being compressed by a giant cell tumour of the flexor tendon sheaths. Appropriate imaging is advised in patients with additional findings (such as swelling) or in patients with secondary carpal tunnel syndrome and incomplete response to conservative treatment, to exclude a space-occupying lesion.

Recovery of two-point discrimination function after digital nerve repair in the hand using resorbable FDA- and CE-approved nerve conduits.

This article aims to provide an overview of all clinical studies reporting sensory outcome as measured by two-point discrimination after digital nerve repair in the hand using resorbable Food and Drug Administration (FDA)- and CE-approved nerve conduits. The minimum follow-up for inclusion in this review was 11 months. In total, 235 nerve reconstructions could be classified. A total of 169 (72%) nerve reconstructions with a synthetic polyester-based nerve conduit were included; the other 66 nerves were reconstructed with collagen-based nerve conduits. To obtain the most reliable and comparable data, outcomes of each study were reclassified in the classification system as was used in the first two prospective randomised multicentre studies on the use of resorbable nerve conduits for repair of digital nerve gaps in the hand. Of the 235 nerve reconstructions, 171 (73%) nerve reconstructions showed good to excellent functional outcome. As many as 64 (27%) of the nerve reconstructions had a poor outcome. Based on the available data in this article at this moment, we conclude that digital nerve gaps up to 4 cm can be bridged by resorbable nerve conduits with a sensory outcome that can be qualified as good to excellent in almost 75% of cases after 11 months. Differences between FDA- and CE-approved nerve conduits could not be detected, apart from the rates of protrusion that were not observed using collagen-based nerve conduits.

Bilateral macrodystrophia lipomatosa of the upper extremities with syndactyly and multiple lipomas.

Macrodystrophia lipomatosa is a rare disease that causes congenital local gigantism of part of an extremity, which is characterised by an increase in all mesenchymal elements, particularly fibroadipose tissue. This is the first report to our knowledge of a case of histologically confirmed bilateral macrodystrophia lipomatosa of the upper extremities with syndactyly and multiple lipomas.

Sixty-year follow-up in an untreated patient with Kienböck disease.

Kienböck disease can be treated either conservatively or by various operations. We describe the findings of the progression of Kienböck disease over 60 years in an 84-year-old man who had had no surgical treatment. This is the longest follow-up ever reported to our knowledge of a patient with avascular necrosis of the lunate.

Repairing injured peripheral nerves: Bridging the gap.

Peripheral nerve injuries that induce gaps larger than 1-2 cm require bridging strategies for repair. Autologous nerve grafts are still the gold standard for such interventions, although alternative treatments, as well as treatments to improve the therapeutic efficacy of autologous nerve grafting are generating increasing interest. Investigations are still mostly experimental, although some clinical studies have been undertaken. In this review, we aim to describe the developments in bridging technology which aim to replace the autograft. A multi-disciplinary approach is of utmost importance to develop and optimise treatments of the most challenging peripheral nerve injuries.

Aberrant branches of the radial digital nerve in the index and middle finger: two case-reports.

This report describes two incidental findings of aberrant branches of the radial digital nerves in the middle finger of a 52-year-old man who cut himself with a grinding machine, and in the index finger of a 45-year-old female who sustained a flexor sheath infection following a dog bite. In both patients, two equally sized radial digital nerves were found and both nerves originated from one common digital nerve.

Plexiform malignant peripheral nerve sheath tumour of infancy and childhood of the index finger: Surgical treatment.

We describe a rare case of plexiform malignant peripheral nerve sheath tumour (MPNST) of infancy and childhood in a 3.5-year-old girl. The tumour was located in the proximal phalanx of the left index finger. After initial excisions and a ray amputation, exarticulation of the third and fourth rays was required.

Treatment of a little finger synovial cyst by repair of an opening in the wrist capsule: case report.

As synovial fluid from the wrist may leak into the ulnar bursa and from there into the flexor synovial sheath in the little finger, the origin of a synovial cyst of the pulp of the little finger may be in the wrist. Here we present the surgical treatment of a patient with a synovial cyst of the pulp of the little finger by surgery of the wrist and palm of the hand after failed conservative treatment.

Porosity of the wall of a Neurolac nerve conduit hampers nerve regeneration.

One way to improve nerve regeneration and bridge longer nerve gaps may be the use of semipermeable/porous conduits. With porosity less biomaterial is used for the nerve conduit. We evaluated the short-term effects of porous Neurolac nerve conduits for in vivo peripheral nerve regeneration. In 10 male Black Hooded rats, a gap of 10 mm was bridged by a porous Neurolac nerve conduit. Evaluation point ranged from 3 to 12 weeks. The sciatic nerve function was not measurable due to automutilation and flexion contractures. The gait-stance duration showed no improvement with time, indicating a disturbed walking pattern. The nerve guides showed very fast degradation with swelling, fragmentation, and collapse. Furthermore, a severe foreign body reaction occurred. Nerve regeneration was severely hampered. This study showed no beneficial effects of porous Neurolac nerve conduits when compared with previous findings with nonporous copolymeric nerve guides of a slightly different composition.

Sound-induced facial synkinesis following facial nerve paralysis.

Facial synkinesis (or synkinesia) (FS) occurs frequently after paresis or paralysis of the facial nerve and is in most cases due to aberrant regeneration of (branches of) the facial nerve. Patients suffer from inappropriate and involuntary synchronous facial muscle contractions. Here we describe two cases of sound-induced facial synkinesis (SFS) after facial nerve injury. As far as we know, this phenomenon has not been described in the English literature before. Patient A presented with right hemifacial palsy after lesion of the facial nerve due to skull base fracture. He reported involuntary muscle activity at the right corner of the mouth, specifically on hearing ringing keys. Patient B suffered from left hemifacial palsy following otitis media and developed involuntary muscle contraction in the facial musculature specifically on hearing clapping hands or a trumpet sound. Both patients were evaluated by means of video, audio and EMG analysis. Possible mechanisms in the pathophysiology of SFS are postulated and therapeutic options are discussed.

Two years after in vivo implantation of poly(DL-lactide-epsilon-caprolactone) nerve guides: has the material finally resorbed?

Long-term nerve guide studies on nerve regeneration in vivo are scarce. Previously, we showed that small fragments of biomaterial could still be found on the edge of the epineurium of the regenerated nerve after implantation of poly(DL-lactide-epsilon-caprolactone) [poly(DLLA-epsilon-CL), Neurolac(R)] nerve guides. As these nerve guides are assumed to fully resorb, we studied the 2-year degradation and possible long-term foreign body reaction against the nerve guides after implantation in the sciatic nerve of the rat. In addition, the distribution of both collagen type III and IV, and nerve regeneration through the nerve guides were studied and compared with the non-operated control side. The results demonstrate that nerve regeneration took place through the poly(DLLA-epsilon-CL) nerve guides. After 2 years of implantation, biomaterial could not be found macroscopically. Biomaterial fragments in company of multi-nucleated giant cells and macrophages were found along the regenerated nerve tissue. Collagen III and IV were both found around the epineurium and perineurium in the regenerated nerve, the organization of these layers resembled that of the contra-lateral non-operated nerve. Although sufficient nerve regeneration was obtained after long-term implantation in the rat sciatic nerve, biomaterial fragments and foreign body reactions against these fragments, even after 24 months of implantation, could still be found. The poly(DLLA-epsilon-CL), Neurolac nerve guides do resorb, however, not complete up to 2 years of implantation. It is not known whether the remaining biomaterial fragments and foreign body reactions may cause granulomas or other complications after longer implantation periods.

Open versus percutaneous release of the A1-pulley for stenosing tendovaginitis: a prospective randomized trial.

A prospective randomized trial for release of the first annular pulley (A-1 pulley) in trigger fingers with a percutaneous technique versus the open surgical technique is presented. Thirty-six patients were randomized to either open (n = 16) or percutaneous (#15 blade; n = 20) release of the A-1 pulley. All patients were evaluated for grip strength, active range of motion of the proximal interphalangeal joint, and residual pain at 1 and 12 weeks after release. Furthermore, the operation time was assessed, and the costs were calculated. Overall, 100% success in terms of grip strength, active range of motion of the proximal interphalangeal joint, and residual pain was obtained in both groups. Mean operation time was significantly longer with the open technique. Because of lower costs and quicker procedure with equal functional outcome when compared with open surgery, we recommend the percutaneous technique using a #15 blade for trigger finger release.

An aberrant branch of the radial digital nerve in the index finger: case report.

This report describes an incidental finding of an aberrant branch of the radial digital nerve in the index finger of a 39-year-old woman who cut herself with a knife.

Modification of Phalen's wrist-flexion test.

Phalen's test, with more than 100 degrees of elbow flexion, is not always comfortable for patients with elbow pathology. Therefore, we suggest a modification of the test with the patient having both arms resting on a pillow or arm-holders in a relaxed position, the hands floating at the end, and the examiner passively flexing (or reversed: extending) the hands up to 90 degrees.