Sonographic diagnosis of subungual intraosseous epidermoid cyst.

Intraosseous epidermoid cyst is an uncommon subungual mass. We report the sonographic findings in a case of intraosseous epidermoid cyst, which showed the characteristic whorled pattern of layers, previously described in other locations and unequivocally clinched the diagnosis in favor of this benign etiology and guided the management to phalangeal-sparing surgery.

Percutaneous fixation of selected scaphoid fractures by dorsal approach.

The aim of our study was to evaluate clinical, radiological and functional outcomes of selected cases of percutaneous fixation of scaphoid fractures via a dorsal approach. Percutaneous fixation by dorsal approach was done in 32 patients (mean age 32.2 years) involving both fresh and late scaphoid fracture presentations (mean 17 days). Fourteen cases of B1 type, ten cases of B2 and eight cases of C type (Herbert's classification) were treated. The patients were prospectively followed up clinically and radiologically for a minimum follow-up of 14 months (mean 16 months), and functional outcome and complications were assessed. All fractures united over an average of nine weeks. There was no avascular necrosis or screw cutout with preservation of wrist movement and grip strength. There were no injuries to any at risk anatomical structures. Percutaneous fixation of scaphoid fractures through dorsal approach gives good clinical and functional outcome in acute and chronic scaphoid fractures of B1, B2 and C types (Herbert's classification).

Diagnosis of post-traumatic complex regional pain syndrome of the hand: current role of sympathetic skin response and three-phase bone scintigraphy.

PURPOSE: To evaluate the role of sympathetic skin response (SSR) and three-phase bone scintigraphy (TPBS) in the diagnosis of complex regional pain syndrome (CRPS). METHODS: 60 patients with CRPS of the hand were recruited. TPBS was performed using a bolus injection of 20 mCi of Tc-99m methylene diphosphonate in an antecubital vein and blood flow (first phase) image, blood pool (second phase) image, and delayed (third phase) image obtained. Patients were considered to have CRPS when the blood pool and blood flow images showed diffuse asymmetric uptake, or when the delayed image indicated increased asymmetric periarticular uptake. SSR was measured simultaneously in the affected and unaffected hands. Standard surface electromyogram disc electrodes were applied to the palm and dorsum of both hands. Electrical stimuli were applied to the skin at the base of little and ring fingers of the unaffected hand. Patients were considered abnormal when response was absent or the peak-to-peak amplitude was <50% of the contralateral hand in at least 2 readings. RESULTS: The delayed phase of TPBS tested positive in all; the first and second phases tested positive in 54 (90%) and 56 (93%) of the patients, respectively. Four of the 6 patients with a negative first phase had had symptoms persisting for more than 6 months, and the other 2 for about 3 to 6 months. No patient presenting within 3 months had a negative scan. SSR was absent in 16 (27%) patients and normal in 44 (73%). 11 (79%) of 14 patients who presented more than 6 months after symptom onset displayed an abnormal SSR, while only 10% of those presenting within 3 to 6 months and 11% of those presenting within 3 months had an abnormal SSR. 12 (75%) of the 16 patients with abnormal SSR had associated decreased sweating, compared with 2 (4.5%) of the 44 patients with a normal SSR. CONCLUSION: TPBS is a very sensitive corroborative test to confirm the clinical suspicion of CRPS during the initial stages, but not in late cases. SSR can be used to document the sympathetic dysfunction in cases having an associated sweating abnormality and may have some diagnostic value in late cases of CRPS, when TPBS is less reliable.

Arthritis associated with tuberculosis.

There has been a resurgence in tuberculosis (TB) worldwide. Approximately 2 billion people have latent infection, 8 million would develop active TB annually, and 2-3 million would die due to TB. With this resurgence, cases with extrapulmonary TB have also shown an increase. Approximately 10-11% of extrapulmonary TB involves joints and bones, which is approximately 1-3% of all TB cases. The global prevalence of latent joint and bone TB is approximately 19-38 million.TB arthritis most commonly manifests as a monoarthritis of weight-bearing joints in the hip or the knee. Oligo- or polyarticular presentation is not rare and may cause diagnostic confusion with inflammatory arthritis. Owing to the low incidence in developed countries, the diagnosis of joint and bone TB is often delayed. A high degree of sensitivity to this diagnosis would prevent delays, permitting prompt institution of anti-TB therapy and preventing irreversible joint damage. Despite advances, confirmation of diagnosis still relies on lengthy microbiological techniques or invasive biopsy. Due to the frequency of isoniazid resistance, initial treatment at present typically includes a combination of four drugs: isoniazid, rifampicin, pyrazinamide and streptomycin or ethambutol. Antimicrobial therapy should be of at least 9 months duration, longer in children and immunocompromised hosts. Surgical procedures should be restricted to joints with severe cartilage destruction, large abscesses, joint deformity, multiple drug resistance or atypical mycobacteria.

Macrodactyly.

We report the results of the treatment of 23 patients with macrodactyly. Eighteen had a two-stage bulk-reducing (defatting) procedure; phalangectomy was used to shorten the digits. At a mean follow-up of nine years (2 to 12), two patients had been lost to follow-up, and three await a second-stage procedure. Good cosmetic correction was achieved in 12 patients, with satisfactory results in seven; two patients had poor results and required amputation.

Giant-cell tumour of the tendon sheath. Is radiotherapy indicated to prevent recurrence after surgery?

Giant-cell tumour of the tendon sheath, also called pigmented villonodular synovitis, is a benign tumour with a high incidence of recurrence. We have tried to identify risk factors for recurrence. Of the 48 patients included in the study, 14 received radiotherapy after surgery. Only two (4%) had a recurrence. This compares favourably with previously reported incidences of between 25% and 45%.

Trapezius transfer for deltoid paralysis.

We have reviewed 26 patients treated by trapezius transfer for deltoid paralysis due to brachial plexus injury or old poliomyelitis. We assessed the power of shoulder abduction and the tendency for subluxation. There were good results in 16 patients (60%); five were fair and five poor. Trapezius transfer appears to give reasonable results in the salvage of abductor paralysis of the shoulder.

Painless destruction of the shoulder joint: a case report.

A case of painless destruction of the shoulder joint is reported for its rarity and unusual presentation as a neuroarthropathic joint with no evidence of neurological disease. A differential diagntosis of Gorham-Stout syndrome and avascular necrosis was discussed.

Vascular malformations in muscles around the knee presenting as knee pain.

Vascular malformations involving the muscles around the knee can be a cause of knee pain. We studied ten such cases. All underwent magnetic resonance (MR) imaging which confirmed the diagnosis. Eight cases underwent wide surgical excision of the lesion, histology of which showed a vascular malformation with predominantly venous element. There was no recurrence in any of the operated cases at the last follow-up. We believe that most of these lesions can be treated successfully by careful preoperative planning aided by MR imaging and a wide-open excision of the lesion.

Aneurysmal bone cyst in the metacarpal of a child: a case report.

An unusual case of aneurysmal bone cyst in the metacarpal of a five-year-old girl is described. The lesion was initially diagnosed and treated as a simple bone cyst. Subsequently the affected metacarpal was excised and replaced by an autogenous fibular graft, with good results. A discussion of the pathogenesis of the lesion is given, with a review of the literature.

Resurfacing of skin in hand injuries.

The Authors discuss their experience with the use of various flaps (radial artery, groin and abdomen) in the primary or delayed cover of skin defect in the hand, in a total number of 20 cases. All the three types of flaps took up well in 3-4 weeks with minimal complications. The Authors preferred the radial artery flap to the groin and abdominal flaps, in that order.

Open reduction and internal fixation of displaced supracondylar fractures of the humerus.

The results of open reduction and internal fixation were analysed in 200 displaced supracondylar fractures of the humerus in children. Overall, excellent results were obtained in 65% of cases, good in 15% and unsatisfactory in 20%. Delay in surgery was found to lead to unsatisfactory results. The operation was performed within 48 hours of injury in 140 cases and gave an excellent result in 120 cases, whereas delayed surgery, in 60 cases, gave an excellent result in only 10 cases. Open reduction provides an accurate, stable reduction, is easy to perform and has been found to give consistently good results.

Cisplatinum neuropathy with Lhermitte's sign.

A case of cisplatinum induced neuropathy is reported because of its unusual presentation. Withdrawal of the drug resulted in improvement.

Reconstruction with fibular autograft and silicone implant arthroplasty after resection of giant-cell tumour of the proximal phalanx: a case report with 18-month follow-up.

Primary giant-cell tumour of phalanx is a rare entity. Only few cases are described in the literature. Giant-cell tumour of hand is reported to have high local recurrence rate. Curettage and bone grafting have been performed by few authors with limited success. Most of the cases have been treated with ray amputation. We report this case as the first reported case in the literature that has been treated with fibular autograft and silicone implant arthroplasty for giant-cell tumour of the proximal phalanx.

Comparison of surgical treatment and nonoperative management for radial longitudinal deficiency.

We compared the radiological and functional outcomes in patients with radial longitudinal deficiency treated surgically with those managed nonoperatively and correlated the ease of performance of activities with radiological and functional parameters in the two groups. A retrospective analysis was done in 446 type 3 and 4 hands (modified Bayne classification) over 20 years comparing the subjective assessment, objective and functional scores in nonoperatively managed hands (Group 1; n = 137) to hands managed with centralization or radialization (Group 2; n = 309). The subjective, objective and functional measures were significantly better in Group 2. Improved alignment, finger and wrist range of motion and grip strength were related to improvement in functional score. Surgical treatment of radial longitudinal deficiency provides improvement in cosmesis, function and ease of performance of activities when compared with nonoperatively managed hands.