The Scratch-Collapse Test: Are Electrodiagnostic Changes Measurable?

INTRODUCTION: Carpal tunnel syndrome is commonly managed by hand and upper extremity surgeons. Though electrodiagnostics are considered the gold standard diagnosis, the scratch collapse test (SCT) was introduced to address uncertainty, despite remains controversial. To address this, we sought to identify if the SCT can correlate with EDS studies if the SCT can identify actual changes in measures of nerves. METHODS: We reviewed patients who underwent electrodiagnostic studies (EDX) and SCT for carpal tunnel syndrome (CTS). Demographic data as well as sensorimotor amplitudes, latencies, and velocities on nerve conduction and electromyography were collected. Analogous values based on SCT findings were analyzed for statistical significance. RESULTS: Three hundred fifty patients with CTS were included. Sensory and motor velocities and amplitudes were significantly lower in patients with a positive SCT. Motor values were independent of age, though younger patients had larger measured changes. Obese patients did not show any motor EDX changes with the scratch collapse test, though thinner patients did. All changes were seen in nerve conduction only. CONCLUSIONS: Carpal tunnel can be a difficult problem to diagnose as one study does not singularly determine the condition. The SCT was introduced to facilitate easier diagnosis. We demonstrate that the SCT correlates with changes on nerve conduction studies, especially in relation to decreased amplitudes and velocities, suggesting that it does identify changes in nerve with compression, specifically axonal, and myelin damage. These findings support the use of the SCT maneuver to evaluate and diagnose in appropriate patients.

The Use of Montage Bone Putty in Assisting in the Maintenance of Reduction in Comminuted Distal Radius Fractures.

Background The distal radius fracture is the most common fracture in the United States. Achieving stable reduction and fixation of complex fracture patterns can be challenging. In order to help maintain reduction of comminuted fracture to simplify plating, the calcium phosphate-based bone putty Montage has been developed. Questions/Purposes Does Montage assist in achieving stable reduction and fixation of complex distal radius fractures with an acceptable complication profile? Patient and Methods We retrospectively analyzed all patients who were treated intraoperatively with Montage bone putty along with volar plate fixation at a large-volume urban county hospital. Preoperative, intraoperative, and postoperative measurements of radiographic features were recorded at 2 and 6 months, as were any complications. Statistical analysis was then performed on these values. Results Preoperative and postoperative radiographs demonstrated significant improvement in standard distal radius fracture measurements, reflecting adequate reduction with the use of Montage intraoperatively. Critically, radiographs demonstrated maintenance of reduction compared to intraoperative fluoroscopy images at 2 months, showing short-term stability of the use of Montage in these fracture patterns as well as long-term stability at 6 months in a subset of patients. There were no major complications in this study. Conclusion In this study, we demonstrate the utility of Montage bone putty for complex distal radius fractures with short-term follow-up and limited long-term follow-up. This initial study underlines its efficacy in maintaining reduction without major complications. Level of Evidence IV, Therapeutic.

A Clinical Scoring System for Distinguishing Patients With Coincident Cubital Tunnel Syndrome Among Patients With Carpal Tunnel Syndrome.

Background: Coincident carpal and cubital tunnel syndromes present a diagnostic challenge, exacerbated by the limitations of nerve conduction study (NCS) for confirming cubital tunnel syndrome. This study develops a diagnostic scoring system, the Koh-Benhaim (KB) score, to identify patients with coincident compression neuropathies. Methods: A retrospective review of 515 patients was performed from patients surgically treated for carpal and/or cubital tunnel release. These patients were divided as patients with isolated carpal tunnel syndrome (n = 337) or coincident carpal and cubital tunnel syndromes (n = 178), then characterized according to demographics, medical history, physical examination, and NCS results. Univariate and multivariate logistic regression identified predictors of coincident neuropathy. A clinical score was constructed by integerizing regression coefficients of predictive factors. Receiver operating characteristic (ROC) curves were generated for each iteration of the score. Sensitivities, specificities, and positive and negative predictive values were calculated to identify the best cutoff value. Results: Decreased intrinsic muscle strength, decreased ulnar sensation, positive elbow flexion test, positive cubital tunnel Tinel's sign, and abnormal NCS result were selected. The cutoff value for high risk of coincident compression was 3 points: positive predictive value, 82.9% and specificity, 93.4%. Model performance was very good-ROC area under the curve of 0.917. Conclusions: A KB score of 3 or greater represents high risk of coincident cubital tunnel compression. The variables involved are routinely used to assess the cubital tunnel, and all component factors of the KB score were of equivalent clinical weight in assessing patients with potential coincident compression neuropathy.

Does the gatekeeper model work in hand surgery?

BACKGROUND: Most managed care plans use a physician "gatekeeper" to control referrals to hand surgeons. The appropriateness of this model for upper extremity complaints has never been challenged. The purpose of this study was to evaluate the prior management of patients with elective hand disorders who present to a hand surgery clinic. METHODS: All patients presenting to a tertiary, academic medical center for a new-patient hand surgery evaluation from February 3, 2011, to June 15, 2011, were prospectively enrolled. Patients were evaluated for prior provider, diagnosis, treatment, and complications. Actual diagnosis, recommended workup, and appropriate treatment were determined independently by two experienced hand examiners. Traumatic injuries and surgeon disagreements in diagnosis and treatment were excluded, leaving 125 patients. RESULTS: Ninety-eight percent of patients had been evaluated by a primary care provider. Overall, the correct diagnosis was established 34 percent of the time. Nerve compression syndromes were diagnosed with the greatest accuracy (64 percent), whereas stenosing tenosynovitis was diagnosed correctly only 15 percent of the time. Before presentation, 74 percent of patients had undergone a study or intervention. On review, 70 percent of studies/interventions were deemed unnecessary. Advanced imaging was unwarranted in 90 percent of patients who received it. Seventeen percent of patients experienced a complication. Most (67 percent) were caused by a delay in diagnosis, whereas 33 percent resulted from an intervention. CONCLUSIONS: Health care providers less familiar with an examination of the hand often misdiagnose and mistreat common problems. A referral system may not be the most efficient means of delivering care to patients with elective hand maladies.

Range of motion measurements in hand surgery: should they be used for assessing outcomes?

PURPOSE: The purpose of the study was to assess how context influences range of motion measurements in hand surgery. METHODS: One hundred seventy-five consecutive patients presenting to a hand surgery clinic were evaluated over 7 sessions. Passive and active motion were measured with a goniometer and by visual estimation. The affected joint was measured by 3 different examiners-one hand surgeon and 2 research assistants (RAs). Measurements by the RAs were performed under the pretense of imaginary project titles and purposes. RESULTS: Range of motion measurements were easily influenced. As the invented project's purpose became more specific and dependent on physician intervention, the bias became more pronounced. Measurements performed under construed project titles that promoted surgical intervention garnered outcomes that supported surgery (P < 0.01). Conversely, when the manufactured study's intent was to find support in conservative treatment, this outcome could also be generated (P < 0.01). DISCUSSION: Range of motion measurements can easily be influenced by the context of the study, even in seemingly blinded examiners. Reliable range of motion measurements can only be made when the examiner has no knowledge of the study's intent.

Allergic dermatitis due to topical antibiotics.

In this report we present a case of allergic dermatitis from chronic use of antibiotic ointment mistakenly diagnosed as a localized finger infection.

Technical aspects of the recipient operation in hand transplantation.

The goal of hand allotransplantation is to achieve graft survival and useful long-term function. To achieve these goals, precise surgical technique is of critical importance. The key surgical steps and sequence of events in hand allotransplantation are similar to major upper extremity replantations, but are modified to accommodate major conceptual differences that exist between the two procedures.

Surgical and technical aspects of hand transplantation: is it just another replant?

The ultimate goal of hand allotransplantation is to achieve graft survival and useful long-term function. To achieve these goals, selection of the appropriate patient, detailed preoperative planning, and precise surgical technique are of paramount importance. Transplantation should be reserved for motivated consenting adults in good general heath, who are psychologically stable and have failed a trial of prosthetic use. While the key surgical steps of transplantation are similar to those of replantation, there are major differences. This article describes the steps in hand allotransplantation, and the importance of patient selection as well as preoperative and postoperative care.

Donor-related issues in hand transplantation.

The policies and procedures for solid-organ donation, under the auspices of the Organ Procurement and Transplantation Network, currently cannot be applied to hand donation, because a hand allograft is considered a tissue in the United States and is under the jurisdiction of the Food and Drug Administration. Hand transplant centers have developed their own protocols. This article discusses the unique elements of such protocols, including training and education, the consent process, the necessary recipient and donor data, donor management, and operating room procedures. Candidate listing, allocation, and oversight of hand donation in the future are also discussed.

Microsurgical reconstruction for canalicular laceration using Monostent and Mini-Monoka.

Many surgical techniques are available for repairing a lacerated canaliculus, such as, Worst pigtail probing, and monocanalicular or bicanalicular procedures involving silicone intubation. Despite this, controversy still exists regarding the best surgical method in terms of subjective and objective outcomes. We report the experience of microscopic canalicular repair using monocanalicular stents; Monostent (Eagle Vision Inc., Memphis, TN) and Mini-Monoka stents (FCI Ophthalmics, Marshfield Hills, MA) and compare these 2 products. Seventeen cases of canalicular lacerations in 15 consecutive patients underwent microscopic canalicular repair using a monocanalicular procedure with either a Monostent (Eagle Vision Inc.) (5 cases) or a Mini-Monoka stent (FCI Ophthalmics) (12 cases). Microscopic anastomosis of the canalicular mucosa was performed following the placement of a juxta canalicular suture to reduce tension. Subjective and objective flows of repaired lacrimal drainage systems were checked by saline injection using a Healon needle (Advanced Medical Optics, Inc., Santa Ana, CA) and dacryocystogram. Patent lacrimal drainage systems were achieved in 16 of the 17 cases, and mild epiphora was acceptable in 14 patients during follow-up. No cases of spontaneous punctal plug migration, stent displacement, eyeball irritation or inflammation, or granuloma formation were encountered. However, in one case, a Mini-Monoka stent (FCI Ophthalmics) was repeatedly extruded or clogged internally and replaced by Monostent (Eagle Vision Inc.). Although the latter had a larger conduit diameter, it was more flexible and had potentially folded on itself in the lacrimal sac, thus, obstructing flow in this case. Microscopic canalicular reconstruction using a Monostent (Eagle Vision Inc.) or Mini-Monoka stent (FCI Ophthalmics) offers a safe, effective, and straightforward means of acute lacrimal system injury treatment.

Successful composite graft for fingertip amputations using ice-cooling and lipo-prostaglandin E1.

In distal fingertip amputations where microanastomosis may not be possible, composite grafting might offer the possibility of maintaining digital length and function using the patient's own tissue. Many trials such as ice-cooling, pharmacologic enhancement and hyperbaric oxygenation have been reported to improve the survival rate of the composite graft. Twenty-four cases of unreplantable fingertip amputation were classified as types I to III according to the level of injury. We performed the composite grafting followed by immediate ice-cooling for 2 weeks and intravenous lipo-prostaglandin E(1) (lipo-PGE(1)) injection for 8.8 days each on average. Twenty-two fingertips in 24 patients survived completely with acceptable appearance and sensibility over the 8 month follow-up period. Confirming that therapeutic angiogenesis using ice-cooling and lipo-PGE(1) can increase the survival rate of the composite graft in unreplantable fingertip amputation, we describe the procedures and postoperative care in detail.

Metastatic adenocarcinoma of the colon presenting as a mass in the mandible.

BACKGROUND: Metastatic adenocarcinoma of the colon is a frequently encountered medical situation. Metastasis to the mandible from adenocarcinoma of the colon is very unusual and rarely reported. We report the case of a 73-year-old man with metastatic adenocarcinoma to the mandible. METHODS: The patient was referred for evaluation of a mass of 2 months' duration in the right parotid gland. He gave a history of watery bowel movements of unknown duration. Physical examination revealed a 7- x 6-cm hard mass, which seemed to be fixed to the right mandible. A CT scan revealed a destructive process involving the ramus and condyle of the right mandible that invaded the pterygopalatine fossa, pterygoid muscles, and middle cranial fossa. CT scans of the abdomen and pelvis revealed a 5-cm mass in the sigmoid colon with metastases to the liver. RESULTS: A biopsy of the mass in the mandible was performed, and metastatic adenocarcinoma of colonic origin was diagnosed. Colonoscopy and biopsy of the colonic mass substantiated that the sigmoid colon was the primary site of the cancer. Because the patient had disseminated disease, he declined treatment, and he died shortly thereafter. CONCLUSIONS: Although rare, metastatic adenocarcinoma from the colon to the mandible and parotid area should be included in the differential diagnosis of masses in this area. After analysis of our case and a review of the literature, we conclude that metastasis from adenocarcinoma of the colon is quite rare and represents incurable disseminated disease.

Flexor tenolysis.

Flexor tenolysis is a challenging procedure with valuable clinical usefulness in the restitution and enhancement of digital function in the appropriate patient. In the absence of complications, improvement in digital flexion can be expected. The requisites for success are a skilled surgeon, a motivated and well informed patient, and a closely monitored hand therapy program.