Effects of motor imagery on hand function during immobilization after flexor tendon repair.

OBJECTIVE: To determine whether motor imagery during the immobilization period after flexor tendon injury results in a faster recovery of central mechanisms of hand function. DESIGN: Randomized controlled trial. SETTING: Tertiary referral hospital. PARTICIPANTS: Patients (N=28) after surgical flexor tendon repair were assigned to either an intervention group or a control group. INTERVENTION: Kinesthetic motor imagery of finger flexion movements during the postoperative dynamic splinting period. MAIN OUTCOME MEASURES: The central aspects of hand function were measured with a preparation time test of finger flexion in which subjects pressed buttons as fast as possible following a visual stimulus. Additionally, the following hand function modalities were recorded: Michigan Hand Questionnaire, visual analog scale for hand function, kinematic analysis of drawing, active total motion, and strength. RESULTS: After the immobilization period, the motor imagery group demonstrated significantly less increase of preparation time than the control group (P=.024). There was no significant influence of motor imagery on the other tested hand function (P>.05). All tests except kinematic analysis (P=.570) showed a significant improvement across time after the splinting period (P

What to do with non-replanted hands?

We describe a method for the preparation of amputated limbs to obtain a specimen for anatomical study of the arteries and the skeleton. The procedure is particularly applicable to hands, and prevents the destruction of a perfect hand that cannot be replanted.

Postoperative hand therapy in Dupuytren's disease.

BACKGROUND: Postoperative hand therapy in patients after surgery for Dupuytren's contracture is common medical practice to improve outcomes. Until now, patients are referred for postoperative hand rehabilitation on an empirical basis. PURPOSE: To evaluate whether referral criteria after surgery because of Dupuytren's disease were actually adhered to, and, to analyse differences in outcomes between patients who were referred according to the criteria (correctly referred) and those who were not referred but should have been (incorrectly not referred). METHODS: Referral pattern was evaluated prospectively in 46 patients. Total active/passive range of joint motion (TAM/ TPM), sensibility, pinch force, Disability Arm Shoulder Hand questionnaire (DASH) and Michigan Hand outcomes Questionnaire (MHQ) were used as outcome measures preoperatively and 10 months postoperatively. RESULTS: In total 21 patients were referred correctly and 17 patients were incorrectly not referred. Significant improvements on TAM/TPM, DASH and MHQ were found at follow-up for the total group. No differences in outcomes were found between patients correctly referred and patients incorrectly not referred for postoperative hand therapy. CONCLUSION: Referral criteria were not adhered to. Given the lack of differences in outcomes between patients correctly referred and patients incorrectly not referred, postoperative hand therapy in Dupuytren's disease should be reconsidered.

Bell's palsy before Bell: Cornelis Stalpart van der Wiel's observation of Bell's palsy in 1683.

Bell's palsy is named after Sir Charles Bell (1774-1842), who has long been considered to be the first to describe idiopathic facial paralysis in the early 19th century. However, it was discovered that Nicolaus Anton Friedreich (1761-1836) and James Douglas (1675-1742) preceded him in the 18th century. Recently, an even earlier account of Bell's palsy was found, as observed by Cornelis Stalpart van der Wiel (1620-1702) from The Hague, The Netherlands in 1683. Because our current knowledge of the history of Bell's palsy before Bell is limited to a few documents, it is interesting to discuss Stalpart van der Wiel's description and determine its additional value for the history of Bell's palsy. It is concluded that Cornelis Stalpart van der Wiel was the first to record Bell's palsy in 1683. His manuscript provides clues for future historical research.

Rehabilitation strategy using enhanced housing environment during neural regeneration.

The influence of an enriched environment on the recovery of nerve function was studied after a sciatic nerve lesion and repair. A sciatic nerve gap of 15 mm was bridged in 12 rats using autologous nerve grafts. The rats were housed either in an enriched environment or in standard cages. In the enhanced housing environment, the rats were forced to move by dissociating food and water sources, including wire for foot gripping instead of flat plastic floors, and wooden play toys. Locomotor behavior was recorded on tape with a digital videorecorder and behavioral data were compared with those of a group of six unoperated rats. The video-recordings were analyzed for the stance factor (SF) as well as several other aspects of the rat's walking pattern. Walking was evaluated between 10 and 21 weeks after the operation. Differences in walking behavior between rats raised in an enriched environment and rats raised in standard cages could not be demonstrated. Differences in walking behavior between male and female rats were not found either. But data differed significantly at all ages with rats of the control group. Automutilation of parts of the denervated foot revealed a significant difference in both experimental groups, occurring less often in the enriched environment group.

Was Thomasz Drobnik really the first to operate on the facial nerve?

Thomasz Drobnik is considered to have been the first to operate on the facial nerve. The original report of this operation has unfortunately never been found. Because Drobnik's procedure has generally been considered to be the first documented facial nerve repair in history, it is interesting to explore Drobnik's background and the veracity of this claim. Three sources were studied: (1) literature on facial nerve repair; (2) L'état actuel de la chirurgie nerveuse, the oldest known reference to Drobnik's operation; and (3) some biographies of Drobnik. It is concluded that Thomasz Drobnik was not the first to operate on the facial nerve in 1879. Instead, the first was Sir Charles Balance, of London, England, in 1895.

Bilateral macrodystrophia lipomatosa of the upper extremities with syndactyly and multiple lipomas.

Macrodystrophia lipomatosa is a rare disease that causes congenital local gigantism of part of an extremity, which is characterised by an increase in all mesenchymal elements, particularly fibroadipose tissue. This is the first report to our knowledge of a case of histologically confirmed bilateral macrodystrophia lipomatosa of the upper extremities with syndactyly and multiple lipomas.

The osmotic tissue expander: a three-year clinical experience.

Closure of defects after trauma or excision of neoplasms is a basic skill in plastic surgery. Local, regional and distant flaps lead to additional scars. Skin recruitment by serial excision or skin expansion is a less damaging option for defects that must be closed. Advantages of tissue expansion include good colour and texture match. Disadvantages are the need for a second operation, use of an implant with the attendant risk of infection, time needed for inflation of the device, repeat visits to the clinic, and punctures to inflate the expander. To overcome the last disadvantage, an osmotic expander was developed in Germany in 1999 by OSMED GmbH (Ilmenau).

Plexiform malignant peripheral nerve sheath tumour of infancy and childhood of the index finger: Surgical treatment.

We describe a rare case of plexiform malignant peripheral nerve sheath tumour (MPNST) of infancy and childhood in a 3.5-year-old girl. The tumour was located in the proximal phalanx of the left index finger. After initial excisions and a ray amputation, exarticulation of the third and fourth rays was required.

Sound-induced facial synkinesis following facial nerve paralysis.

Facial synkinesis (or synkinesia) (FS) occurs frequently after paresis or paralysis of the facial nerve and is in most cases due to aberrant regeneration of (branches of) the facial nerve. Patients suffer from inappropriate and involuntary synchronous facial muscle contractions. Here we describe two cases of sound-induced facial synkinesis (SFS) after facial nerve injury. As far as we know, this phenomenon has not been described in the English literature before. Patient A presented with right hemifacial palsy after lesion of the facial nerve due to skull base fracture. He reported involuntary muscle activity at the right corner of the mouth, specifically on hearing ringing keys. Patient B suffered from left hemifacial palsy following otitis media and developed involuntary muscle contraction in the facial musculature specifically on hearing clapping hands or a trumpet sound. Both patients were evaluated by means of video, audio and EMG analysis. Possible mechanisms in the pathophysiology of SFS are postulated and therapeutic options are discussed.

Sir Charles Alfred Ballance (1856-1936) and the introduction of facial nerve crossover anastomosis in 1895.

Sir Charles Ballance (1856-1936) was the first surgeon in history to perform a facial nerve crossover anastomosis in 1895. Although, recently, several papers on the history of facial nerve surgery have been published, little is known about this historically important operation, the theoretical reasoning behind the operation or the surgical perspective in which Ballance developed this method. An original document on the operation, dated in 1895, is not known. The earliest report of the operation is a paper by Ballance, published in 1903. Study of this 1903 paper reveals that Ballance stopped performing the operation after his first attempt in 1895 until he resumed in December 1901. What was the reason for this interruption? Why did Ballance start doing it again in 1901? Between 1895 and Ballance's 1903 paper, several other surgeons had published the results of their facial nerve crossovers. Were they inspired by Ballance's operation from 1895 to do the same or did they invent the method independently? To enhance our knowledge about the early history of facial nerve surgery, the original manuscripts by Ballance and his contemporaries have been studied. Ballance's first facial nerve crossover from 1895 is described in the surgical perspective of the end of the 19th century. The theoretical reasoning for the operation is discussed. It was discovered that Ballance's operation was first recorded in St. Thomas's Hospital Report of 1895, which was published in 1897. However, this report was probably hardly known by Ballance's contemporaries and consequently could not have stimulated them to perform the operation themselves. Jean Louis Faure (1863-1944), from France, appears to have been the first to have performed the operation until Ballance's 1903 paper was published. In 1903, after Ballance's paper had been published, many other accounts of this method were reported in the literature. At that moment facial nerve crossover seems to have been widely regarded as a potential successful technique, a technique which, a century later, is still part of our repertoire.

On the surgical treatment of facial paralysis in the early nineteenth century.

The treatment of facial paralysis is generally considered to have been nonsurgical until the end of the nineteenth century. However, the authors discovered recently that already in the 1840s the celebrated German facial reconstructive surgeons Dieffenbach and von Langenbeck applied the technique of subcutaneous myotomy to healthy facial muscles to reestablish balance in the chronically paralyzed faces of their patients. They performed their operations at a time when anesthesia, asepsis, antisepsis, and antibiotics had not yet been introduced into surgery. It is concluded that Dieffenbach and von Langenbeck were the first, in recorded history, to develop a surgical way to treat irreversible facial paralysis. As their principles are still being used in surgical practice, they cannot be regarded as antiquated, which illustrates the difficulties that reconstructive surgeons still experience in the treatment of irreversible facial paralysis.

Kinematic analysis of hand movements after tendon repair surgery: a new assessment using drawing movements.

OBJECTIVE: Although several hand outcome tests exist to judge skill level after hand injury, currently none give insight into how tasks are performed by looking at kinematic parameters. In this article, the clinical value of analyzing kinematic parameters related to the drawing of a triangle on a graphics tablet by healthy subjects and patients with hand injury is discussed. DESIGN: In a first experiment 10 healthy subjects drew the triangles as accurately as possible at various speeds. In a second experiment, 67 healthy subjects and 12 patients with flexor tendon injury were measured repeatedly. RESULTS: In the first experiment, the analysis showed a high linear correlation between speed and accuracy for each individual (Pearson correlation coefficient >/=0.762, P

Does surgical management of the hand in children with spastic unilateral cerebral palsy affect functional outcome?

The aim of this review was to examine the literature on the effects of surgery of the spastic hand in children with cerebral palsy on functional outcome and muscle coordination. We performed a search of the relevant literature in Medline, Embase, and Biological Abstracts from 1966 to June 2006. The search resulted in eight studies on the effect of surgery on functional outcome and three studies on the effect of surgery on muscle coordination. Heterogeneity in outcome measures precluded meta-analysis. The studies revealed that -- at the level of impairment -- surgery has a positive effect on supination and dorsiflexion of the wrist. At the level of function, surgery might improve grip strategy and induce an increase of the repertoire of grips and spontaneous use of the hand. The evidence for the functional effects is, however, limited. Whether the possibly improved function is mediated by alterations in muscle coordination patterns remains unclear. The muscle coordination studies provided inconclusive results. We concluded that surgery improves the position of the hand and there are indications that it might improve hand function. Future research should address the question: does surgery improve hand function and, if so, is this due solely to a better hand position or does change in muscle coordination play an additional role?

Secondary digital nerve repair in the foot with resorbable p(DLLA-epsilon-CL) nerve conduits.

Nerve guides are increasingly being used in peripheral nerve repair. In the last decade, much preclinical research has been undertaken into a resorbable nerve guide composed of p(DLLA-epsilon-CL). This report describes the results of secondary digital nerve reconstruction in the foot in a patient with post-traumatic neuromas of the common plantar digital nerves II-III and III-IV. The neuromas were resected and reconstruction of the nerves was carried out with resorbable Neurolac nerve guides. The Pressure Specified Sensory Device was used to measure the static (s) and moving (m) 1- and 2-point discrimination (PD). Fourteen months after nerve repair, the m1-PD returned in all digital nerves. The s1-PD returned only on the lateral side of the second toe. The m2-PD and s2-PD did not return in any of the toes originally innervated by the reconstructed nerves. According to the British Classification System, the sensory nerve recovery was poor. However, there were no complaints of painful neuromas after this procedure. In conclusion, this report shows no beneficial effects of Neurolac nerve guides in terms of return of sensibility after repair of common plantar digital nerves. Painful neuromas, however, could be well-treated.

In vivo three-dimensional reconstruction of human median nerves by diffusion tensor imaging.

The in vivo assessment of axonal projections of the peripheral nervous system has been severely limited by the lack of noninvasive techniques. We examined whether MR diffusion tensor imaging with fiber tracking of the human median nerve is feasible. The median nerve was examined with a 3-T MRI scanner in wrists of three healthy volunteers and the wrist of a patient after median nerve repair. In vivo three-dimensional (3D) reconstruction of axonal projections of the median nerve could be achieved in healthy volunteers with intact median nerves and a patient with a transected median nerve using diffusion tensor imaging combined with fiber tracking. The median nerve could be visualized and correlated well to the expected location on T1-weighted images in the patient and all volunteers. The transected median nerve in the patient could be detected up to the site of repair one month postoperatively, whereas the nerve could not be detected more distally immediately after repair. Two months postoperatively, it could clearly be tracked more distally, indicating nerve regeneration. Diffusion tensor imaging can detect the median nerve in healthy individuals as well as up to the lesion site in a patient with a complete transection of the median nerve.

The anatomy lesson of Dr. Nicolaes Tulp by Rembrandt (1632): a comparison of the painting with a dissected left forearm of a Dutch male cadaver.

Rembrandt's The Anatomy Lesson of Dr. Nicolaes Tulp (1632) is considered a masterpiece and is a group portrait of the Amsterdam Guild of Surgeons in the form of an anatomy lesson. Dr. Nicolaes Tulp, Doctor of Medicine and Praelector Anatomiae to the Amsterdam Guild of Surgeons, showed an anatomic dissection of a forearm on the corpse of an executed criminal. The anatomic accuracy in Rembrandt's famous painting has been discussed in the literature for decades without any general consensus. In 2006, on the 400th anniversary of Rembrandt's birth, a forearm dissection of a cadaver and a comparison with the anatomy in the painting are presented to analyze the anatomic accuracy of Rembrandt's famous painting.