Modified matched ulnar resection for arthrosis of distal radioulnar joint in rheumatoid arthritis.

The pain of distal radioulnar arthrosis in rheumatoid patients is often due to disease largely confined to the radioulnar rather than the ulnocarpal articulation. This is a retrospective study of 14 patients (14 wrists) who underwent selective shaving of the radial articulation of the ulnar head leaving the ulnocarpal articulation intact. The ulnar head is reduced to the circumference of its shaft and a dorsal retinacular flap is interposed between it and the distal radius. Average age of the patients and follow-up were 63.5 years and 31 months, respectively. All patients had rheumatoid arthritis. Pain improved in 14 out of 15 wrists. Overall results were 67% good to excellent and 33% fair based on the modified Mayo's wrist score. This novel procedure for DRUJ arthrosis produces predictable pain relief in low demand rheumatoid patient.

Tenodesis of the extensor carpi ulnaris for chronic, post-traumatic lunotriquetral instability.

We describe a technique of soft-tissue reconstruction which is effective for the treatment of chronic lunotriquetral instability. Part of extensor carpi ulnaris is harvested with its distal attachment preserved. It is passed through two drill holes in the triquetrum and sutured to itself. This stabilises the ulnar side of the wrist. We have reviewed 46 patients who underwent this procedure for post-traumatic lunotriquetral instability with clinical signs suggestive of ulnar-sided carpal instability. Standard radiographs were normal. All patients had pre-operative arthroscopy of the wrist at which dynamic lunotriquetral instability was demonstrated. A clinical rating system for the wrist by the Mayo clinic was used to measure the outcome. In 19 patients the result was excellent, in ten good, in 11 satisfactory and in six poor. On questioning, 40 (87%) patients said that surgery had substantially improved the condition and that they would recommend the operation. However, six (13%) were unhappy with the outcome and would not undergo the procedure again for a similar problem. There were six complications, five of which related to pisotriquetral problems. The mean follow-up was 39.1 months (6 to 100). We believe that tenodesis of extensor carpi ulnaris is a very satisfactory procedure for isolated, chronic post-traumatic lunotriquetral instability in selected patients. In those with associated pathology, the symptoms were improved, but the results were less predictable.

Multiple plexiform schwannoma of the hand and forearm: a long-term follow-up.

We present a case report to illustrate the differential diagnosis and management of a multiple plexiform schwannoma involving the main nerve trunks of the upper limb in a 4 year-old boy. The tumour was diagnosed by MRI scan and histological examination. A 12 year follow-up is presented in which, despite multiple recurrences, the condition has been controlled by surgical means and the limb salvaged.

Bizarre parosteal osteochondromatous proliferation with cortical invasion.

A 15-year-old male presented with an 18-month history of increasing swelling on the radial aspect of his left forearm. Radiographs and MR images showed a partly calcified mass on the lateral border of the radius with erosion of the underlying cortex. Following a CT-guided needle biopsy, the mass was excised by segmental resection of the radial shaft with replacement by a vascularised fibular graft. Histological examination of the resected specimen showed many features typical of a bizarre parosteal osteochondromatous proliferation (BPOP) but with destruction of the underlying cortical bone by cellular spindle cell tissue. Although there were no cytological signs of malignancy, we believe that this unusual disease should be regarded as a particularly aggressive form of BPOP and treated by wide excision. Clinical follow-up of our patient at 2 years shows no sign of local recurrence or metastasis.

The value of crossed intrinsic transfer after metacarpophalangeal silastic arthroplasty: a comparative study.

Seventy three hands in patients with rheumatoid arthritis undergoing primary index to small finger metacarpophalangeal joint replacements were studied retrospectively. In twenty eight hands a crossed intrinsic transfer was performed and in forty five hands it was not. A similar splintage and rehabilitation programme was followed in each group. The two treatment groups had similar preoperative ulnar drift (crossed intrinsic transfer group mean 27 degrees, comparative group 29 degrees). At a mean follow up of 50 months the crossed intrinsic transfer group had statistically less ulnar drift (crossed intrinsic transfer group mean 6 degrees, comparative group mean 14 degrees, P=0.01). There were no other significant differences at follow up.

Lower limb trauma: a review of 40 cases treated at the regional burns and plastic surgery unit, Merseyside, England.

This is a review of 40 patients with lower limb trauma that required reconstruction, treated at Mersey Regional Plastic Surgery and Burns Centre during the year 1989. 73% had bone involvement while there was soft tissue injury only, in 27%. Seven patients (18%) had the affected limb amputated. Of the rest, 6 were treated with skin grafts only, 13 with local flaps and 14 with free flap reconstruction. The soft tissue healing time was least in patients who had free flaps. The time taken by skin and bone to heal and the average duration of hospitalisation was also less in cases that had early management compared to those who had delayed and late treatment. Early reconstruction in severe lower limb trauma is desirable and cost effective.

Use of silastic sheet in Apert's syndactyly.

Patients with Apert's syndrome usually have severe complex syndactyly affecting both hands. Surgical separation of the distal digital bony fusion often exposes bone and cartilage which can cause problems with graft take. A case is presented where the bare divided bone between two digits was kept apart with a silastic sheet. On its removal 4 weeks later, the previously bare bone was covered with a membrane. This was covered with a full thickness skin graft with a complete graft take.

Partial flexor tendon injuries: to repair or not.

The correct management of partially divided flexor tendon injuries is still in dispute. This study compares the results of repair with non-repair in zone 2 injuries. We conclude that tendons divided by 60% or less in cross-sectional area should not be repaired.

Flexor tendon injuries: the result of primary management: a retrospective review of 50 cases treated at Whiston Hospital, England.

A retrospective review of 50 cases treated over a 12-month period with 95 tendon injuries was carried out. Post-operative management utilising a modified Kleinert method was used for cases over eight years of age, while those under eight were immobilised in plaster cast. Our results after a mean follow up period of 14 weeks compared well with other series using the Kleinert method. Zone II injuries gave an unexpected better results than those in other zones.

The management of the complete ring avulsion injury.

The complete ring avulsion injury presents a difficult choice between microvascular repair and further amputation. The former is technically difficult and the latter leaves an undesirable result. We describe an alternative method whereby a thinned groin flap is applied to volar surface and sides of the finger and a full-thickness skin graft covers the dorsum. This provides good quality cover to the volar aspect and avoids bulk on the dorsum.

Cross-arm dermis flaps for repair of dorsal finger defects.

Two cross-arm dermis flaps were successfully used to cover distal defects on the finger where tendon reconstruction was needed. Division after five days allowed early mobilisation.

Shock absorbing finger cap.

We describe the use of a custom-made cap or sleeve made of a visco-elastic polymer offering protection for the tip of the hypersensitive finger or thumb. Of 35 digits treated, relief of symptoms was achieved in 83%. In many cases, cold intolerance was also relieved.

The distally-based brachioradialis muscle flap.

We describe the brachioradialis muscle flap based distally on the radial artery. It is quickly raised and provides excellent cover for soft tissue defects of the hand. In the two clinical cases the brachioradialis tendon has also been used for extensor tendon reconstruction.

The use of the reverse latissimus dorsi flap in the closure of lower spinal defects.

Described is the distally based or reverse latissimus dorsi flap. Its use in closing lower spinal defects in four patients with five flaps is presented. With its predictable blood supply, which is rarely damaged by previous surgery, the flap can provide versatile and reliable cover to the lower back.

Repair of chronic subluxation of the distal radioulnar joint (ulnar dorsal) using flexor carpi ulnaris tendon.

Chronic dislocation of the distal radio-ulnar joint is usually treated conservatively or by resection of the ulnar head (the Darrach procedure). Recently there has emerged a trend towards reconstructive stabilization procedures, based on modifications of old methods. This article describes a stabilization procedure for correction of chronic subluxation of the distal radio-ulnar joint (ulnar-dorsal) using the flexor carpi ulnaris tendon. A series of five patients is presented together with a historical review of the development of reconstructive approaches in this area.

The vascular features of plexiform neurofibroma with some observations on the importance of pre-operative angiography and the value of pre-operative intra-arterial embolisation.

The presence of abnormal feeding vessels in plexiform neurofibromata of the head and neck has been demonstrated by angiography in three patients. Attention is drawn to the possibility of dangerous bleeding in the treatment of these lesions. Two other patients presented with a similar lesion over the trunk: in one patient there was excessive bleeding during surgical excision but not in the other, despite their very similar clinical appearances. It is suggested that two varieties of plexiform neurofibromata exist which are distinguishable only by angiography: those with a normal vasculature and those with a plethora of abnormal vessels forming an integral part of the lesion along with the neural and fibrous elements (haemangioneurofibroma). A method of treatment is proposed based on pre-operative embolisation followed by complete surgical excision. The futility of pre-operative vessel ligation is confirmed.

A major burn in early pregnancy with maternal survival and pregnancy progressing to term.

A case is presented of a 65% burn occurring in early pregnancy with maternal survival and a pregnancy progressing to term. This would appear to be only the third such case recorded in the literature. Maternal and foetal prognosis are discussed and the guidelines proposed by Stage (1973) for the management of pregnancy complicated by a major burn are restated.