Radial Tunnel Syndrome: Case Report and Comprehensive Critical Review of a Compression Neuropathy Surrounded by Controversy.

Radial tunnel syndrome (RTS) is an uncommon controversial entity thought to cause chronic lateral proximal forearm pain due to compression of the deep branch of the radial nerve, without paralysis or sensory changes. Diagnostic confusion for pain conditions in this region results from inconsistent definitions, terminology, tests, and descriptions in the literature of RTS and "tennis elbow," or lateral epicondylitis. A case of bilateral RTS with signs discordant with traditionally used clinical diagnostic tests was successfully relieved with surgical decompression and led us to perform a comprehensive critical review of the condition. We delineate the controversy surrounding its diagnosis and aim to facilitate appropriate management and identify other areas for further study in this controversial condition. Clinical validity and evidence of anatomical rationale for the traditionally used Maudsley's provocative test is unclear in diagnosis of RTS or in chronic lateral elbow pain, if at all. Neither imaging nor electrophysiological studies contribute to a clinical diagnosis which is supported by short-term improvement after an injection with long-acting local anesthetic and corticosteroid. Accurate diagnosis and treatment of RTS can significantly improve quality of life, but validity and evidence for traditional clinical tests and definitions must be clarified.

Long-term impact of saliva control surgery in children with disability.

Sialorrhea is a common problem in children with disability, often negatively affecting socialization, self-esteem, and burden of care. Saliva control surgery is an available option to manage this problem, particularly when other conservative methods have failed. As little is known about the long-term impact of surgery, we followed up 62 patients who had combined bilateral submandibular duct translocation and bilateral sublingual gland excision at our pediatric hospital between 1994 and 2014. Eligible individuals were identified through a search of ICD procedure codes. When families of patients were contacted successfully, they were invited to complete a 14-item questionnaire designed specifically for this study. The results indicated that long-term outcomes of surgery were very good; 13/62 (21%) individuals no longer had a drooling problem and another 30 (48%) experienced only mild to moderate drooling. Although 84% families reported some or major improvement in drooling, 9 families reported that they would not go through the experience again because of a difficult recovery period, lack of effectiveness of the intervention, changes in saliva consistency that caused coughing and gagging, and dental decay. None of the collected variables were predictive of good or poor outcome. The study indicated that surgical intervention is effective in the long term in the majority of cases and can be recommended to other families who attend our saliva control clinic.

The Acutely Blue Finger: Cause for Concern?

An acutely blue finger may cause concern, with both ischaemic and non-ischaemic aetiologies. Achenbach syndrome is a rare condition involving spontaneous haematoma of the finger. We present a case with distinct histological findings and a family history.

The "Trigger" Thumb Locked in Extension - An Unusual Presentation of a Common Paediatric Condition.

BACKGROUND: We report a variant of paediatric trigger thumb which is locked in extension rather than flexion. METHODS: Eleven children with 14 trigger thumbs (three bilateral) locked in extension were reviewed retrospectively over a 12-year period. The number of flexed trigger thumbs encountered over this period was established from the operating room database. RESULTS: All children were treated with release of the A1 pulley. Nine children achieved a full range of motion at the interphalangeal joint. One child with bilateral extended trigger thumbs required bilateral dorsal capsulotomy and another child developed temporary mild triggering in flexion. CONCLUSIONS: Approximately 1% of trigger thumbs treated operatively at this institution presented as the extended variant. Trigger thumb locked in extension should be considered in a child presenting with inability to flex the thumb.

Spinal accessory nerve transfer outperforms cervical root grafting for suprascapular nerve reconstruction in neonatal brachial plexus palsy.

BACKGROUND: The authors evaluated long-term shoulder function in patients with neonatal brachial plexus palsy undergoing suprascapular nerve reconstruction with cervical root grafting or spinal accessory nerve transfer. METHODS: A retrospective review was performed on all infants presenting with neonatal brachial plexus palsy between 1994 and 2010. Functional outcomes were compared by type of suprascapular nerve reconstruction. RESULTS: Seventy-four patients met the inclusion criteria (46 transfers, 28 grafts). Both groups presented with an active movement scale score of 2.0 for shoulder abduction and 0.0 for external rotation. Postoperative follow-up was 9.0 years for the graft group and 6.7 years for the transfer group. Both groups achieved an active movement scale score of 5.0 for shoulder abduction at 12, 24, and 36 months postoperatively. Active movement scale scores for shoulder external rotation were 1.0, 2.0, and 2.5 for the graft group versus 2.0, 2.0, and 3.0 for the transfer group at 12, 24, and 36 months postoperatively. None of these differences reached statistical significance. Composite Mallet scores were 13.0 for the graft group versus 15.0 for the transfer group at 3 years (p = 0.06) and 13.0 for the graft group versus 16.0 for the transfer group at 5 years postoperatively (p = 0.07). Secondary shoulder surgery was performed on 57.1 percent (16 of 28) of patients with grafts compared with 26.1 percent (12 of 46) of patients with transfers (OR, 3.17; p = 0.02). CONCLUSION: Suprascapular nerve reconstruction by cervical root grafting results in poorer shoulder function and a two-fold increase in secondary shoulder surgery compared with spinal accessory nerve transfer. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Lipoblastoma: An important differential diagnosis of tumours of the hand in children.

Lipoblastoma is a rare benign neoplasm of infancy and childhood with the potential for locally invasive, rapid growth. It has an excellent prognosis, and does not metastasise. An important differential diagnosis for these rapidly-enlarging tumours is liposarcoma. Ultrasound, magnetic resonance imaging, fine needle aspiration, and cytogenetics are important diagnostic tools for this rare tumour. We present two cases of lipoblastoma of the hand that were excised within a three month period with no evidence of recurrence at 14, and 12, months respectively.

Cemented versus uncemented surface replacement arthroplasty of the proximal interphalangeal joint with a mean 5-year follow-up.

PURPOSE: To retrospectively compare the long-term results of cemented and uncemented surface replacement arthroplasties of the proximal interphalangeal (PIP) joint in a single surgeon's experience. METHODS: A cemented prosthesis was used on 18 patients for 27 PIP joints between February 1997 and September 2000. An uncemented prosthesis was used on 18 patients for 21 PIP joints between September 2000 and June 2003. The preoperative and postoperative pain score (0-10) during activities of daily living and the active range of motion for each digit as well as radiographs were assessed. Patients with less than 2 year of follow-up were excluded unless the short follow-up was due to prosthesis removal. Mean follow-up was 5 years. RESULTS: Data were available for 28 patients who collectively received 24 cemented implants and 19 uncemented implants. The average length of follow-up was 4 years for the uncemented group and 6 years for the cemented group. The average pain score decreased by 5.5 units after the operation, and the average arc of motion increased by 13 degrees after the operation. No evidence was found for any association between implant type and postoperative pain and motion measurements. Very strong evidence was found for an association between implant type and subsidence, with 1 cemented implant subsiding compared with 13 uncemented implants. There was no evidence for an association between implant type and joint failure. CONCLUSIONS: There was no difference in the postoperative pain scores or the postoperative arc of motion for the cemented versus the uncemented group. There were significantly more cases with radiologic evidence of loosening in the uncemented group (p < .001). Revision rate was higher in the uncemented group (26%) compared with that of the cemented group (8%), but this was not a significant difference (risk difference, -0.18; 95% confidence interval, -0.040 to 0.05).

Intraoperative nerve stimulation: a simple, effective, and inexpensive alternative to standard devices.

Many surgical procedures require intraoperative stimulation of peripheral nerves. Using a pair of conventional bipolar forceps and an anesthetic impulse generator (Stimlocator, Model SL3, B. Braun Australia Pty Ltd, Australia), we have developed a simple, effective, and inexpensive alternative to standard nerve stimulation devices that enables the accurate localization of motor fascicles intraoperatively. Bipolar forceps provide better control than a monopolar electrode, as the current generated across the nerve fibers generates an action potential that is then propagated down the axon. This inexpensive and reusable device is routinely used at Royal Children's Hospital, Melbourne, and its efficacy and ease of use has been demonstrated over a long period.

Brachial artery thrombosis in infants: an algorithm for limb salvage.

BACKGROUND: Arterial occlusion in infants, although uncommon, is usually an iatrogenic event associated with arterial vascular access. Most common in the upper limb, the consequences of iatrogenic arterial occlusion may be gangrene and limb loss. Even if there is adequate collateral flow and limb loss is avoided, long-term growth disturbances may be seen. There are few published data to guide the management of arterial occlusion in premature or sick infants. In general, there is agreement regarding the importance of early diagnosis and the reestablishment of limb perfusion with the fewest risks, but the optimal choice and timing of treatment modalities remain unknown. METHODS: This article examines the authors' experiences at the Royal Children's Hospital, Melbourne, and provides their algorithm for the management of this complex iatrogenic disease. RESULTS: The management algorithm has successfully treated 11 limbs in 11 patients with arterial vascular access-associated thrombosis over the period 1995 to 2003, with no instances of limb loss. Five of these patients required surgical intervention. CONCLUSIONS: The authors recommend a multidisciplinary approach involving plastic surgeons and hematologists for all cases of suspected or confirmed arterial thrombosis. A consensus algorithm that determines the role of heparin, thrombolysis, and acute surgical interventions, and the sequence of such interventions, is useful in providing the framework of therapy. The early recognition of the limb at risk is a key factor in obtaining a successful outcome.

Prospective analysis of the outcome of surgical management of drooling in the pediatric population: a 10-year experience.

BACKGROUND: Sialorrhea is a common problem in the neurologically impaired pediatric patient and surgery is the mainstay of treatment for severely affected patients refractory to conservative or medical treatment. METHODS: The results of the surgical protocol used since 1993 at the Royal Children's Hospital in Melbourne, Australia, are reported. Seventy-two patients underwent bilateral submandibular duct transposition combined with bilateral sublingual gland excision. Patients were analyzed prospectively and reviewed at 1, 6, and 12 months, then at 2 and 5 years postoperatively. RESULTS: Of 67 patients with 2 years of complete follow-up, the median score for the frequency of drooling fell from 4.0 to 2.9 (p < 0.001) and the median severity-of-drooling score decreased from 4.8 to 3.0 (p < 0.001). There was a fall in the number of clothing/bib changes from a median of four per day to zero (p < 0.0001). Of 41 patients followed to 5 years, both the median frequency and severity of drooling scores remained at 3. Overall the majority of patients benefited from surgery. Thirteen patients (18 percent) experienced complications which were major in 9 percent. CONCLUSION: We have found bilateral sublingual gland excision in combination with bilateral submandibular duct transposition to be superior to bilateral submandibular duct transposition plus parotid duct ligation. The surgical treatment of sialorrhea continues to be a rewarding experience for our multidisciplinary team.

Management of the upper limb in cerebral palsy.

The management of the upper limb in cerebral palsy is often complex and challenging. Effective treatment requires a multidisciplinary approach involving paediatricians, occupational therapists, physiotherapists, orthotists and upper extremity surgeons. Interventions are generally aimed at improving function and cosmesis by spasticity management, preventing contractures and correcting established deformities. Treatment objectives vary according to each child and range from static correction of deformities to ease nursing care, to improvements in dynamic muscle balance to augment hand function. Botulinum toxin A therapy has been shown to relieve spasticity and improve function in the short term. Surgery is also effective but requires careful patient selection, as many children with cerebral palsy are not candidates for surgery. Occupational therapy and physiotherapy have small treatment effects alone but are essential adjuncts to medical and surgical management.

Genes and nerves.

The unpredictability of a brachial plexus graft, a median nerve repair, or a facial-nerve reconstruction is well known. No matter how precise the technical skills, a perfect recovery from a peripheral-nerve lesion is elusive. To resolve this problem, understanding of the normal development of the peripheral nervous system is needed. Presently, the development of the innervation in the upper limb is complex and not fully understood. However, many of the genes involved in this process are now known, and the link between anatomy and genetics is becoming clearer. This short review aims to acquaint the clinical surgeon with some of the main genes. The principal steps in the establishment of neural circuits will be summarized, in particular, the specification and development of neurons and glia, the pathfinding of cells and axons towards their target, and the downstream molecules that control the circuitry of these neurons.

Toe-to-hand transfer in symbrachydactyly.

Symbrachydactyly, or central atypical cleft, is classified as a failure of formation. For the adactylous or monodactylous forms, free toe transfer is the treatment of choice. We present 18 free toe transfers in 13 patients for symbrachydactyly. Despite abnormal anatomy, the functional building blocks have always been available and transfer technically possible. The result has been improved function and high levels of parental satisfaction.

Functional and cosmetic outcome of surgery for cerebral palsy in the upper limb.

Function, cosmesis, hygiene, and ability to dress can be improved by appropriate surgery. This frequently involves multiple simultaneous procedures and addresses the muscles, their tendons, and the joints they pass over. The improvement in cosmesis is most profound in hemiplegic patients. Overall, patients are satisfied with the results of surgery.