Síndrome del martillo hipotenar. A propósito de un caso / Hypothenar hammer syndrome. A case report

El síndrome del martillo hipotenar es una infrecuente lesión de la arteria cubital a su paso por el canal de Guyon relacionada con los traumatismos repetitivos. Su diagnóstico requiere un elevado índice de sospecha y una adecuada historia clínica. Su tratamiento no está bien definido en la literatura, y va desde tratamiento médico hasta cirugía reconstructiva. Presentamos el caso de un varón de 52 años con parestesias de los dedos cuarto y quinto tras un traumatismo en la eminencia hipotenar. En el test de Allen destacó la ausencia de vascularización por parte de la arteria cubital, por lo que se sospechó una trombosis de la arteria que se confirmó mediante angiorresonancia. Se realizó resección del fragmento trombosado y bypass con una vena antebraquial para reconstruir el flujo distal. Presentó una evolución satisfactoria a los 6meses de seguimiento (AU)

Hypothenar hammer syndrome is an uncommon injury of the ulnar artery in its passage through Guyon's canal, and has been associated with repetitive trauma. Its diagnosis requires of a high level of suspicion and a careful clinical interview. The appropriate treatment is not well defined in the literature, ranging widely from medical treatment to reconstructive surgery. A clinical case is presented of a 52 year-old healthy male, who presented with numbness of his fourth and fifth fingers after a trauma at the hypothenar eminence. The Allen test highlighted an absence of vascularisation from the ulnar artery, thus suspecting an ulnar artery thrombosis, which was later confirmed by angio-MRI. The thrombosed segment was resected and a by-pass with a forearm vein was performed to reconstruct the distal arterial flow, presenting with a good functional outcome at 6months follow-up (AU)

Hypothenar hammer syndrome. A case report. / Síndrome del martillo hipotenar. A propósito de un caso.

Hypothenar hammer syndrome is an uncommon injury of the ulnar artery in its passage through Guyon's canal, and has been associated with repetitive trauma. Its diagnosis requires of a high level of suspicion and a careful clinical interview. The appropriate treatment is not well defined in the literature, ranging widely from medical treatment to reconstructive surgery. A clinical case is presented of a 52 year-old healthy male, who presented with numbness of his fourth and fifth fingers after a trauma at the hypothenar eminence. The Allen test highlighted an absence of vascularisation from the ulnar artery, thus suspecting an ulnar artery thrombosis, which was later confirmed by angio-MRI. The thrombosed segment was resected and a by-pass with a forearm vein was performed to reconstruct the distal arterial flow, presenting with a good functional outcome at 6months follow-up.

Bilateral carpal tunnel surgery in one operation: Retrospective study.

Carpal tunnel syndrome is the most common entrapment syndrome. The incidence of a bilateral condition varies between 22% and 87%. The aim of our study was to assess the level of satisfaction and the clinical outcomes in a group of patients operated on through a bilateral neurolysis on the median nerve in the carpal tunnel, in one operating session. This is a retrospective study involving patients with an electromyographic and clinical diagnosis of bilateral carpal tunnel syndrome. Patients were treated on an outpatient basis and the bilateral neurolysis was performed by endoscopy. The postoperative data was collected during consultation by a senior surgeon or during telephone interviews. Patients were asked to respond to a satisfaction questionnaire and the functional outcome was assessed through the Quick-Disabilities of the Arm, Shoulder, and Hand (Quick-DASH) questionnaire. Twenty-nine patients with bilateral carpal tunnel syndrome were operated on in single operating sessions between January 2009 and January 2014. The average follow-up was 46 months. The average age at the time of the intervention was 45 years. Two patients were lost to follow-up, and 27 were able to be assessed. In relation to the clinical and functional outcomes, the average Quick-DASH score was 6.78 (ranges: 0-43.2). Twenty-five patients (92.5%) were satisfied with this simultaneous treatment and 26 patients (96%) would choose the same technique again. One-stage surgery in cases of bilateral carpal tunnel syndrome appears to constitute a benefit for the patient, the surgeon and the anaesthetist, but it is reserved for patients who request it and who are motivated by this type of intervention.

Thermodynamic temperature assignment to the point of inflection of the melting curve of high-temperature fixed points.

The thermodynamic temperature of the point of inflection of the melting transition of Re-C, Pt-C and Co-C eutectics has been determined to be 2747.84 ± 0.35 K, 2011.43 ± 0.18 K and 1597.39 ± 0.13 K, respectively, and the thermodynamic temperature of the freezing transition of Cu has been determined to be 1357.80 ± 0.08 K, where the ± symbol represents 95% coverage. These results are the best consensus estimates obtained from measurements made using various spectroradiometric primary thermometry techniques by nine different national metrology institutes. The good agreement between the institutes suggests that spectroradiometric thermometry techniques are sufficiently mature (at least in those institutes) to allow the direct realization of thermodynamic temperature above 1234 K (rather than the use of a temperature scale) and that metal-carbon eutectics can be used as high-temperature fixed points for thermodynamic temperature dissemination. The results directly support the developing mise en pratique for the definition of the kelvin to include direct measurement of thermodynamic temperature.

Conservative treatment versus scaphotrapeziotrapezoid arthrodesis for Kienbock's disease. A retrospective study.

Efficiency of surgical treatment in Kienböck's disease has never been proven in the long term. We retrospectively reviewed the charts of the 104 patients treated by various techniques for Kienböck's disease from 1981 to 1999 in our unit. A comparison was made between 19 cases treated conservatively (amongst 59) and 11 cases (amongst 25) treated by scaphotrapeziotrapezoid (STT) arthrodesis with a mean follow-up of 13 years. The two groups were statistically comparable in stage, age, sex ratio, number of manual workers. STT arthrodesis was responsible for an increased loss of mobility, an increase of barometric pain, a longer rehabilitation time and more fractures of lunatum than conservative treatment. Those results question about indications for STT in Kienböck's disease.

Reconstruction of fingertip defects with the neurovascular tranquilli-leali flap.

For many years, bipedicled palmar advancement flaps were used rarely in fingers because they sacrificed the dorsal branches of the digital arteries, risking dorsal skin necrosis. In 1995, a short bipedicled neurovascular VY advancement flap raised distally to the PIP flexion crease, which spared the dorsal blood supply, was described by Elliot et al. (1995). This paper includes an anatomical study on 28 fresh cadaver fingers to evaluate the advancement potential of this flap. It also reviews 22 fingertip reconstructions in 22 patients using this flap. The mean advancement of the flap in the cadaver study was 14 (range 10-16) mm. This procedure gave good clinical results in respect of healing, sensibility, bone cover and appearance. Complications occurred in four fingers (18%), viz. two infections, one neuroma and one stiff proximal interphalangeal joint. Our study suggests that this flap can be used to treat fingertip defects of a size of approximately half of the pulp of the distal phalangeal segment of the finger.

High Mallampati score and nasal obstruction are associated risk factors for obstructive sleep apnoea.

Induced nasal obstruction can cause obstructive apnoeas in healthy subjects during sleep, but the relationship between nasal resistance measured during wakefulness and obstructive sleep apnoea syndrome (OSAS) is weak. It was postulated that if the subjects could not breathe through the nose, the oral airway must be used, but if this airway is narrowed as well, then it could precipitate sleep-disordered breathing (SDB). Nasal patency, Mallampati score (MS), neck circumference and body mass index were measured in 202 subjects referred to the authors' hospital to undergo a full-night polysomnography for suspicion of SDB. A significant correlation was found between the MS and apnoea/hypopnoea index measured during sleep. However, the relationship between these parameters was only significant in patients with nasal obstruction. The relative risk of having OSAS with a MS of III or IV was 1.95 for the whole group and 2.45 in patients with nasal obstruction. In conclusion, a high Mallampati score represents a predisposing factor for obstructive sleep apnoea syndrome, especially if it is associated with nasal obstruction. These patients merit special attention from both the sleep physician and the anaesthetist.

[Trapeziometacarpal denervation. Description of surgical technique and preliminary results from a prospective series of 14 cases]. / Dénervation trapézométacarpienne. Description de la technique chirurgicale et résultats préliminaires dans une série prospective de 14 cas.

INTRODUCTION: The main goal of first carpometacarpal arthritis surgical treatment is to relieve pain. The main disadvantages of the usual techniques (trapeziectomy, implant arthroplasty) are loss of strength or presence of a prosthetic device. It is difficult to propose such extensive surgery at an early stage of the disease. Selective denervation of the first carpometacarpal joint seems to be an interesting choice. We propose a new technique of denervation based on our previous anatomical investigations. TECHNIQUE: Two incisions are needed to cut all the articular branches derive from the superficial branch of the radial nerve, the palmar cutaneous branch of the median nerve, the thenar branch of the median nerve and the lateral ante brachial cutaneous nerve. MATERIAL: Fourteen patients were prospectively included in our study with a mean follow-up of 5 months. RESULTS: Pain relief was very satisfying in 12 cases (mean decrease 84%). An increase in grip and key pinch strength was noted. Complications were uncommon, excepted temporary paresthésia in the radial nerve area. DISCUSSION: This technique seems to be promising and a good indication for patients with no disabling deformity, but only long-term results will confirm the place of denervation in the treatment of first carpometacarpal arthritis.

[Wedge excision: a new reconstructive technique after longitudinal nail biopsy]. / L'excision cunéiforme: une nouvelle technique de reconstruction après biopsie unguéale longitudinale.

A biopsy is needed when a solitary melanonychia striata in a white patient remains unexplained after careful clinical examination in order to rule out the development of a malignant melanoma. The ideal biopsy has to excise entirely the lesion and to provide enough tissue for pathological examination. The authors describe a new method of excisional biopsy based on primarily closure using a longitudinal closing wedge osteotomy of the distal phalanx. The longitudinal elliptical resection extended from the distal interphalangeal joint to the hyponychium with en bloc resection of the entire thickness of the nail complex, including the periosteum. A longitudinal closing wedge osteotomy was then performed in the distal phalanx allowing primarily closure with precise alignment of the nailbed edges. After suture of the nailbed, a tension band nail synthesis was performed. Four consecutive melanonychia striata of 2 to 3 mm were consecutively operated on using this technique. Postoperative cares were uneventful in all the cases. The pathological examination confirmed the diagnosis of melanoma in one case, Bowen's disease in one and junctional nevus in two. Cosmetic and functional assessment at a mean follow-up of 12 months evidenced light nail dystrophy in all the cases. Our method offers to the pathologist enough tissue with preserved architecture for precise pathological examination. The technically simple closing wedge osteotomy never complicated the postoperative course. These preliminary results are encouraging and allow us to recommend this technique for the diagnosis of all suspect melanonychia striata between 2 and 3 mm wide.

Sleep fragmentation: comparison of two definitions of short arousals during sleep in OSAS patients.

The measurement of arousals during sleep is useful to quantify sleep fragmentation. The criteria for electroencephalography (EEG) arousals defined by the American Sleep Disorders Association (ASDA) have recently been criticized because of lack of interobserver agreement. The authors have adopted a scoring method that associates the increase in chin electromyography (EMG) with the occurrence of an alpha-rhythm in all sleep stages (Université Catholique de Louvain (UCL) definition of arousals). The aim of the present study was to compare the two scoring definitions in terms of agreement and repeatability and the time taken for scoring in patients with obstructive sleep apnoea syndrome (OSAS) of varying severity. Two readers using both ASDA and UCL definitions scored twenty polysomnographies (PSGs) each on two occasions. The PSGs were chosen retrospectively to represent a wide range of arousal index (from 6-82) in OSAS patients. There was no difference in the arousal indices between readers and between scoring methods. The mean+/-SD difference between the two definitions (the bias) was 1.1+/-3.76 (95% confidence interval: -0.66-2.86). There was a strong linear relationship between the arousal index scored with the two definitions (r=0.981, p<0.001). Mean+/-SD scoring duration was significantly shorter for UCL than for ASDA definitions (18.5+/-5.4 versus 25.3+/-6.6 min, p<0.001). In conclusion, it has been found that in obstructive sleep apnoea syndrome patients, the American Sleep Disorders Association and Université Catholique de Louvain definitions were comparable in terms of agreement and repeatability.

[Nail recession emergency treatment: a new technique for the repair of fingertip amputations]. / Recul unguéal en urgence: nouvelle technique de prise en charge des amputations digitales distales.

INTRODUCTION: In spite of the recent advances made in microsurgery, the reconstruction of oblique fingertip amputations remains problematical. In cases where reimplantation is technically impossible, the surgeon can utilize a number of different flaps to preserve digital length. METHODS: In certain cases, instead of local flap repair using an advancement flap, the nail complex can be recessed so that after bone shortening of the distal phalanx the free edge of the nail can be stitched to the skin without resulting tension. Two longitudinal incisions are made, and a flap including the nail complex is obtained from the distal phalanx. The dissection is made as far as the base of the middle phalanx, and is superficial so that it does not affect the distal branches of the middle phalangeal arteries. This technique was used consecutively in three cases of oblique fingertip amputations. RESULTS: The average shortening required was 10 mm. In all three cases, the nail was preserved, and pulp sensitivity was excellent (mean static two-point discrimination of 5 mm, Semmes-Weinstein monofilaments of 2.83-3.61). The mean period before return to work was 5 weeks. No proximal interphalangeal joint stiffness was noted. However, all the patients complained of pain upon exposure to cold. DISCUSSION: This technique is simple to use, and combines the advantages of bone shortening with the esthetic aspect of preserving the nail complex. No palmar dissection is necessary, and the standard risks associated with advancement flap techniques are thus avoided. Although this reconstruction method results in a shorter finger, good functioning and good immediate sensitivity are maintained.

Expiratory flow limitation in awake sleep-disordered breathing subjects.

Increased upper airways (UA) collapsibility has been implicated in the pathogeny of sleep-disordered breathing (SDB). An increased UA instability during expiration has recently been shown in healthy subjects. The present study assessed UA collapsibility in SDB patients by applying negative pressure during expiration. Full-night polysomnography was performed in 16 subjects (all snorers) with a wide range of SDB, and in six healthy control subjects. Physical examination, spirometry, and maximal inspiratory and expiratory flow rates were within normal limits for all 22 subjects. Negative expiratory pressure (NEP) (-5 cmH2O) was applied during quiet breathing in seated and supine position. Flow limitation (FL) during NEP was expressed as the percentage of tidal volume during which expiratory flow was less than or equal to the flow recorded during quiet breathing (%FL). The mean desaturation index (DI) of the 16 subjects was 27.3+/-26.4 (+/-sD) and the average FL in supine position was 38.4+/-37.9%. A close correlation between %FL supine during wakefulness and DI during sleep (r=0.84, p<0.001) was found. All obstructive sleep apnoea subjects had >30%FL supine. There was no FL in the six control subjects. In conclusion, negative expiratory pressure application during expiration appears to be a useful, noninvasive method for the evaluation of subjects with sleep-disordered breathing. Present results suggest that upper airway collapsibility can be detected in these subjects during wakefulness.

Conservative versus operative treatment for Kienböck's disease. A retrospective study.

In this retrospective study on Kienböck's disease, a comparison was made between 21 cases operated on by various techniques and 22 cases treated conservatively, with a mean follow-up of 65 months. Operative management of the disease did not show any superiority over conservative treatment. Moreover, surgery was responsible for a loss of mobility of 24%, and for a change in social activities in about a quarter of the patients, while grip strength was only slightly improved. Surgical indications for Kienböck's disease should be carefully considered, keeping in mind their side-effects, and the relative benignity in some cases of the natural course of the disease.

Effects of Breathe Right on snoring: a polysomnographic study.

The nasal vestibule is a major site of resistance to airflow in healthy subjects. A high nasal resistance may increase snoring. Activation of the alae nasi and alar retraction reduce resistance to airflow and improve ventilation. The Breathe Right (BR) device has been proposed to reduce or eliminate snoring by improving nasal breathing. We assessed the efficacy of BR on sleep quality and snoring during 2 full-night polysomnographies, the first without and the second with BR. Ten non-apnoeic snorers were studied. Snoring was present during 22-98% of total sleep time during the control night. Ear-nose-throat examination disclosed a nasal valve anomaly in five subjects, objectivated by anterior and posterior rhinomanometry. Quality of sleep and snoring were not influenced by BR, even when different sleep stages were analysed separately. No difference in snoring index was found between snorers with or without nasal valve anomaly. We conclude that BR is ineffective in relieving snoring in non-apnoeic snorers.

Effectiveness of controlled and spontaneous modes in nasal two-level positive pressure ventilation in awake and asleep normal subjects.

STUDY OBJECTIVES: The purpose of the present study was to compare in awake and asleep healthy subjects, under nasal intermittent positive pressure ventilation (nIPPV) with a two-level intermittent positive pressure device (two-level nIPPV), the efficacy of the controlled and spontaneous modes, and of different ventilator settings in increasing effective minute ventilation (VE). PARTICIPANTS: Eight healthy subjects were studied. SETTING: In the controlled mode, inspiratory positive airway pressure (IPAP) was kept at 15 cm H2O, expiratory positive airway pressure (EPAP) at 4 cm H2O, and the inspiratory/expiratory (I/E) time ratio at 1. The respirator frequencies were 17 and 25/min. In the spontaneous mode experiment, IPAP was started at 10 cm H2O and progressively increased to 15 and 20 cm H2O; EPAP was kept at 4 cm H2O. MEASUREMENTS AND RESULTS: We measured breath by breath the effective tidal volume (VT with respiratory inductive plethysmography), actual respiratory frequency (f), and effective VE. Using the controlled mode, effective VE was significantly higher on nIPPV than during spontaneous unassisted breathing, except in stage 2 nonrapid eye movement sleep at 17/min of frequency; increases in f from 17 to 25/min led to a significant decrease in VT reaching the lungs, during wakefulness and sleep; effective VE was higher at 25 than at 17/min of frequency only during sleep; periodic breathing was scarce and apneas were never observed. Using the spontaneous mode, with respect to awake spontaneous unassisted breathing, two-level nIPPV at 10 and 15 cm H2O of IPAP did not result in any significant increase in effective VE either in wakefulness or in sleep; only IPAP levels of 20 cm H2O resulted in a significant increase in effective VE; during sleep, effective VE was significantly lower than during wakefulness; respiratory rhythm instability (ie, periodic breathing and central apneas) were exceedingly common, and in some subjects extremely frequent, leading to surprisingly large falls in arterial oxygen saturation. CONCLUSIONS: It appears that two-level nIPPV should be used in the controlled mode rather than in the spontaneous mode, since it seems easier to increase effective VE with a lower IPAP at a high frequency than at a high pressure using the spontaneous mode. We suggest that the initial respirator settings in the controlled mode should be an f around 20/min, an I/E ratio of 1, 15 cm H2O of IPAP, and EPAP as low as possible.

Determinants of effective ventilation during nasal intermittent positive pressure ventilation.

Our aim was to verify in healthy subjects submitted to nasal intermittent positive pressure ventilation (nIPPV) with a volumetric ventilator on controlled mode, whether changes in ventilator settings (delivered tidal volume (VT), respiratory frequency (fR) and inspiratory flow (V'I) could influence effective minute ventilation (V'E), thus allowing identification of the settings resulting in the highest V'E during nIPPV. We then compared these experimentally obtained "best" settings to those obtained retrospectively in a group of patients submitted to long-term nIPPV for clinical reasons. We studied 10 healthy subjects awake and asleep, and 33 patients with restrictive ventilatory disorders. Changes in delivered V'I (for a constant delivered VT and fR) led to significant changes in V'E. V'E was significantly higher when a given delivered V'E was obtained using higher fR and lower VT than when it was obtained using lower delivered fR and higher VT. Increases in fR generally resulted in increases in V'E. The "best" settings derived from these results were: VT: 13 mL.kg-1 of body weight; fR: 20 breaths.min-1 and V'I: 0.56-0.85 L.s-1. The corresponding average values found in the patient group were: delivered VT: 14 mL.kg-1; fR: 23 breaths.min-1 and delivered V'I: 0.51 L.s-1. Changes in minute ventilation resulting from modifications in ventilator settings can be attributed to the glottic response to mechanical influences. This leads to "ideal" settings quite different from the standard ones in intubated patients. Values derived from nasal intermittent positive pressure ventilation in healthy subjects seem to apply to patients submitted to long-term nasal intermittent positive pressure ventilation.

Residual effect of nCPAP applied for part of the night in patients with obstructive sleep apnoea.

The aim of the present study was to assess whether nasal continuous positive airway pressure (nCPAP) treatment, applied for only a few hours at the beginning of the night, has any residual effect on sleep and breathing during the ensuing hours of unassisted sleep in patients with obstructive sleep apnoea syndrome (OSAS). In 27 patients with newly-diagnosed OSAS, effective nCPAP was applied during the first part of the night and then withdrawn. Polysomnographic parameters after nCPAP withdrawal were compared with those of the corresponding part of the diagnostic polysomnography performed a few days or weeks before and with those of the first part of night on nCPAP. After 255+/-63 (mean+/-SD) min of sleep with normalization of sleep and breathing parameters under nCPAP, there was partial improvement of OSAS severity during the remaining 124+/-56 min of nocturnal sleep without treatment; mean oxygen saturation, desaturation index (equivalent to the apnoea/hypopnoea index) and movement arousal index all improved significantly with respect to the diagnostic night (p=0.001). This improvement was not accounted for by a change in sleep architecture. We conclude that there is an improvement in severity of obstructive sleep apnoea syndrome after only 4 h of nasal continuous positive airway pressure. This carryover effect could explain why a number of patients with obstructive sleep apnoea syndrome apply nasal continuous positive airway pressure for only part of the night or not every night.

Glottic aperture and effective minute ventilation during nasal two-level positive pressure ventilation in spontaneous mode.

Our goal was to verify glottic behavior and its effects on effective minute ventilation during intermittent positive pressure ventilation applied at increasing inspiratory pressure levels through a nasal mask (nIPPV) using a two-level positive pressure ventilator (two-level IPPV) in spontaneous mode. Ten subjects were studied while awake. The spontaneous mode was used at three levels of inspiratory positive airway pressure (IPAP): 10, 15, and 20 cm H2O. The expiratory pressure was kept at 4 cm H2O. Records of spontaneous breathing without nIPPV were also performed. The glottis was continuously monitored through a fiberoptic bronchoscope. We measured, breath by breath, the widest inspiratory angle formed by the vocal cords at the anterior commissure, the corresponding tidal volume (with respiratory inductive plethysmography), the respiratory frequency and other indices. Our data during wakefulness show that inspiratory pressures of 10 and 15 cm H2O did not result in increases in effective minute ventilation with respect to spontaneous breathing. Only at 20 cm H2O of IPAP did effective minute ventilation increase. This was due essentially to a decrease in respiratory frequency with increasing pressures, offsetting increases in tidal volume at 10 and 15, but not at 20 cm H2O of inspiratory pressure. Changes in end-tidal CO2 suggest that alveolar ventilation increased due to the change in breathing pattern. Contrary to what we observed previously with either two-level IPPV used in the controlled mode, or nIPPV performed with volumetric ventilators, the glottis did not play any noticeable role in the control of effective minute ventilation.

Movement arousals and sleep-related disordered breathing in adults.

Sleep fragmentation (an increase in the number of short EEG arousals) is considered a major determinant of excessive daytime sleepiness but is seldom quantified in sleep studies, and reference values are scarce at best. We present data on the movement arousal index (MAI) in five groups of subjects: normals, simple snorers, patients with the sleep apnea-hypopnea syndrome (SAHS), and patients with sleep-related oxygen desaturations due to chronic obstructive pulmonary disease or neuromusculoskeletal disorders. In normal subjects, the MAI was 13 +/- 7 (mean +/- SD). MAI was distinctly increased in most patients with SAHS and was strongly correlated with the apnea-hypopnea index and loss of both slow wave and REM sleep. It was corrected to normal by nasal continuous positive airway pressure (CPAP). There was some overlap of MAI between SAHS patients and snorers, suggesting that a minority of nonapneic snorers may suffer from daytime sleepiness due to upper airway dysfunction. Sleep fragmentation is not a feature of sleep-related hypoventilation due to COPD or neuromusculoskeletal disorders, and an increase of the number of movement arousals (MA) is very suggestive of upper airway dysfunction and of potential success of CPAP. Quantification of sleep fragmentation is feasible and clinically useful; it should be included in the assessment of sleep-related breathing disorders.