Veterinary waste disposal: practice and policy in Durban, South Africa (2001-2003).

In South Africa, until recently, veterinary waste has not been included in definitions of health care waste, and so has been neglected as a contributor to the hazardous waste stream. Despite the application of, for example, the "Polluter Pays" principle in South African environmental legislation, to generators of waste, which would include veterinarians, there appears to be little awareness of and even less enforcement of the legislation in this regard. This paper reports on a 2001-2003 survey of management practices of the five waste contractors servicing just over half of the veterinarians in Durban, South Africa's second largest city. Some of their activities, when evaluated in terms of the legislation, guidelines and policies relating to waste handling and disposal, were found to be non-compliant. Since any discussion on waste management should take cognisance of waste from generation to final disposal, the responsibility of veterinarians as waste generators is also discussed in the light of the recent developments in health care waste management in South Africa. This study presents a review of past and current policies, legislation and guidelines that have application to veterinary waste. This is the first study to address veterinary waste disposal in any South African city.

Evaluating short-term pain after steroid injection.

Steroids are injected into joints for various indications. All steroid preparations relieve pain similarly over the long term. Therefore, decisions about which preparation to use are often arbitrary. We evaluated methylprednisolone acetate and a combination of betamethasone diproprionate and betamethasone sodium phosphate for short-term pain and the predictive value of short-term pain. Eighty-five patients were injected in prospective double-blind randomized fashion. Pain was evaluated by visual analog scale (1 = no pain, 10 = severe pain) at baseline, 3 days, and 3 weeks. No patient had joint pain immediately after injection. Three days after injection, mean (SD) pain levels were 5.1 (2.9) for methylprednisolone and 5.2 (2.6) for betamethasone (P = .97); 3 weeks after injection, they were 4.0 (2.8) and 3.7 (2.5), respectively (P = .57). Short-term pain increased from baseline for both preparations and decreased from 3 days to 3 weeks. Pain at 3 days and 3 weeks was positively correlated. This study does not support a difference in short-term pain between preparations. The significant correlation between short- and long-term pain may justify early decisions regarding treatment, especially in patients with high levels of initial pain.

Ulnar dysmelia.

Eleven patients with hypoplasia and partial or complete aplasia of the ulna (examples of a complex spectrum of postaxial forearm and hand abnormalities) were reviewed. Three types of ulnar deformity were observed: (1) hypoplasia, (2) partial aplasia (ossification of the proximal part of the ulna present at birth); and (3) total aplasia (ossification not development). The roentgenographically "absent" segment of the ulna may be a large fibrocartilaginous anlage attached distally to the distal radial epiphysis or the ulnar side of the carpus, or both. The tethering effect of this band may cause ulnar deviation of the wrist (and hand) and dislocation of th badial head in utero as well as progression of these deformities after birth. Resection of the distal end of the fibrocartilaginous anlage during the first to second year of life is recommended, since the results of this procedure suggest that it reduces the angular growth deformities. It is also suggested that if the one-bone-forearm operation is indicated, it should be deferred until a later age, since complications may be less likely to occur then than at the time that the anlage is resected.

Limited triscaphoid intercarpal arthrodesis for rotatory subluxation of the scaphoid.

Rotatory subluxation of the scaphoid is a well known lesion that is relatively common and results in instability of the wrist. It has been well accepted that because of the subluxation of the scaphoid, degenerative changes in the wrist may develop rapidly, and for that reason correction of the subluxation in its early stages is indicated. Over the past thirteen years, many cases of rotatory subluxation of the scaphoid in various stages of the pathological process have been successfully treated with a triscaphoid arthrodesis of the wrist (fusion of the scaphoid, trapezium, and trapezoid) at the Connecticut Combined Hand Surgery Service. A follow-up of thirty patients with an average length of follow-up of three years and eleven months is described. From this experience, a classification system and treatment plans for each type of rotatory subluxation of the scaphoid have evolved.

Degenerative disorders of the carpus.

Degenerative arthritis of the human wrist follows specific patterns. The patterns do not change with time. Degenerative arthritis progresses within the framework of these patterns. Specific therapeutic approaches have been developed for the treatment of degenerative arthritis of the wrist, with an emphasis on maintaining painless range of motion and power function capability.

The palmar approach for the visualization and release of the carpal tunnel. An analysis of 429 cases.

A review of 429 cases of carpal tunnel syndrome in 329 patients confirms the prevalence of this entity among disorders of the hand. Three symptoms are almost diagnostic--daytime numbness, nighttime pain, and morning stiffness of the fingers. The diagnosis is confirmed by findings on physical examination. A relatively simple technique is presented for the exposure and release of the median nerve, using a longitudinal incision in the palm and stopping short of the wrist skin. Limiting the incision to the palmar skin results in an inconspicuous scar, while still providing adequate exposure for a complete anatomical release. An epineural neurolysis of the median nerve was performed in each case, resulting in improvement in the symptoms in all but 4 of these 429 patients.

The carpal boss: surgical treatment and etiological considerations.

We report on 30 symptomatic cases of carpal boss which were treated surgically. The condition represents a highly localized degenerative arthritis at the base of the middle metacarpal, and is seen primarily in relatively young patients. Symptomatic relief was obtained by excision of degenerated tissue in all these patients.

Simultaneous carpal tunnel release and Dupuytren's fasciectomy.

Simultaneous operations for carpal tunnel syndrome and Dupuytren's disease have been reported in only one study which recommended staged treatment because there was an 87% complication rate with simultaneous treatment. The present study reviewed simultaneous treatment of 30 patients during a 20-year period. Complications and unfavourable results were compared to similar groups of patients who underwent either Dupuytren's fasciectomy or carpal tunnel release as sole procedures. Early complications (13%) were far less than in previous studies and were easily corrected. The incidence of recurrence and extension (20%) was lower than in the Dupuytren's fasciectomy group and much lower than in previous reports. Simultaneous carpal tunnel release and Dupuytren's fasciectomy are strongly recommended when these conditions are both present in the same hand.

Modified arthroplasty of the distal radio-ulnar joint.

We report a modified arthroplasty technique for limited degenerative arthritis of the distal radio-ulnar joint, in which the proximal hyperemic portion of the joint is resected with preservation of the unaffected distal portion. The charts of ten patients, one bilateral, were retrospectively reviewed and all 11 wrists were examined after an average of 30 months. All patients reported decreased pain and increased joint function. Grip strength, supination and pronation were comparable to the opposite, unaffected side.

Triquetral impingement ligament tear (tilt).

Ulnar-wrist pain is a complex problem whose cause often remains elusive. A diagnostic triad of localized triquetral pain, history of a wrist hyperflexion injury, and normal radiographs, accompanied by ulnar wrist swelling and limited wrist motion, is often attributable to a syndrome we have termed triquetral impingement ligament tear (TILT). The mechanism of injury causes a cuff of fibrous tissue to be displaced distally from the ulnar sling mechanism, resulting in chronic impingement on the triquetrum that causes hyperaemia, loss of articular cartilage, and softening of the bone. Surgical repair consists of simply excising the impinging fibrous cuff. The outcome of 44 patients treated for TILT over a 6-year period is reviewed. In all cases, TILT repair resulted in improved wrist motion and strength. Ninety-five percent of patients reported a significant improvement in pain both at rest and with activity.

The carpal boss. A 20-year review of operative management.

Between 1969 and 1989, 116 patients were evaluated and treated surgically for symptomatic carpal boss. Their mean age was 32 years and male and female patients were equally affected. 28 patients gave a history of previous injury. Surgical treatment consisted of excision of the localized bony abnormality and the associated degenerative arthritic process to the level of normal articular surfaces and normal adjacent cancellous bone. The mean follow-up period for the patients in this study was 42 months. Complete symptomatic relief was observed in 94% of the patients undergoing surgical treatment. Recurrence or persistence of symptoms developed in seven surgical patients. Six had a second operation with more extensive removal of sclerotic bone and degenerate cartilage, and all patients had relief of symptoms.

Madelung's deformity. A surgical technique.

15 wrists with Madelung's deformity were operated on between 1972 and 1990, constituting the largest series of radial osteotomies reported for this deformity to date. The technique that evolved is described in detail, as are the preliminary follow-up results. All patients reported symptomatic relief and return to normal activity levels.

Bone compression technique for arthrodesis and nonunion in the hand.

We present a simple compression technique for treatment of difficult nonunions and joint fusions in the hand. This technique utilizes only K-wires and small vessel loops. The results of 44 consecutive cases were studied retrospectively. Union was achieved in 37/44 cases. The average time to union was 7 weeks and our results were comparable to those of other studies. We found this technique useful, especially in complicated cases.

One thousand intercarpal arthrodeses.

Limited wrist arthrodesis is a useful method for treating specific carpal disorders that maximizes residual wrist motion and strength while eliminating pain. Selective fusion of specific carpal units can be used in degenerative arthritis, rotary subluxation of the scaphoid, midcarpal instability, scaphoid nonunion, Kienbock's disease, and congenital synchondrosis or partial fusion of specific carpal joints. This report presents our experience with more than 1000 limited wrist arthrodeses, and provides a review of the indications and technical considerations for specific intercarpal fusions, and subsequent results. To date this is the largest series of intercarpal arthrodeses and the study has demonstrated that these techniques are reliable and effective in dealing with a wide range of wrist disorders.

ECG effects of aerobic dance: a study of five exercise-conditioned young women.

Monitoring of the heart rate of five healthy well-conditioned women during an aerobic dance routine showed that maximum rates were within acceptable limits for exercise tachycardia except in one subject, who had paroxysmal supraventricular tachycardia that subsequently converted to sinus tachycardia. Thus, although aerobic dance seems a benign form of exercise, it can be intense enough to trigger dysrhythmias. Before recommending or approving it for any patient, the physician should take into consideration the person's age, health, and physical fitness level.

Pathologic anatomy.

The typical case shows one or more thickened bands overlying the flexor tendons in the palm that connect with one another via the transverse palmar fascia. Vertical septae fix the bands securely to the underlying fascia and transverse metacarpal ligaments. These septae pass deep between the tendon and neurovascular tunnel. Bands running into the fingers represent thickening and fibrosis of the natatory ligaments. Typically, a central band continues into the finger, forks, and dissipates just distal to the PIP joint. This dissipation occurs with bifurcation of the central band into two thickened bundles that pass deep to the neurovascular bundle and attach to the flexor sheath of the middle phalanx. There are also thickenings of Grayson's ligaments that run from the central cord laterally and dorsally. Understanding the anatomy of the palmar aponeurosis is essential to the effective treatment of Dupuytren's contracture. Because the cause is unknown, treatment is best directed at anatomic deformities. Although not systemic or lethal, poorly treated Dupuytren's contracture can lead to significant morbidity and long-term disability. The palmar aponeurosis and its substructures are more than just passive barriers. They integrate hand parts and when pathologically fibrosed can contract joints, deform skin, and deviate neurovascular structures. The best treatments are recognition of the contracture, meticulous dissection, and local radical fasciectomy. Special attention is directed toward protecting spiralling neurovascular bundles. Difficult releases are enhanced by judicious release of checkreins, tendon sheath attachments, and disease on the radial side of the hand.

Dystrophy, recurrence, and salvage procedures in Dupuytren's contracture.

Postoperative complications can jeopardize the results of surgery. These can be avoided by Y-V plasties that allow for efficient skin "lengthening" and wound healing. Proper dressing techniques can prevent hematoma formation. The patient must be started on early active motion to prevent stiffness, and the physician must monitor for reflex sympathetic dystrophy. If RSD should occur, the dystrophile program is the most effective means of treatment. Fasciectomy alone is not always successful in correcting Dupuytren's contracture, especially in longstanding cases. The surgeon should be prepared to correct other entities such as checkreins, sheath fibrosis, and tendon adhesions. Occasionally, a severely compromised finger is not amenable to correction. In this case, salvage procedures are available, such as the concentric arthrodesis that preserves the length of the volar structures. Only when all other attempts fail should one resort to amputation.

Physical examination of the wrist.

A complete examination of the wrist requires both an accurate history and a thorough understanding of carpal anatomy, biomechanics, and pathology. A thorough examination may necessitate evaluation of the radial and ulnar aspects of the carpus as well as potential extra-articular causes of wrist pain. A carefully obtained history is essential to focus the examination. Our standard approach to the examination of radial wrist pain consists of five maneuvers: (1) ANA, (2) scaphotrapezial trapezoid (STT), (3) DWS, (4) SS, and (5) FET. Additional diagnostic tests, as described, are indicated by ulnar wrist or extra-articular symptomatology. Substitution maneuvers serve to distinguish between actual and fictitious findings on examination.

Instabilities of the wrist.

Carpal instability is the result of ligamentous injury to the wrist. Although any ligament may be injured, certain recurring patterns are frequently seen. Common to the treatment of all instability patterns is the need to transfer load from the capitate to the radius: reliably, without stressing normal joints, and while preserving functional motion. Limited wrist arthrodesis fulfills these needs. The radius and carpal bones are shaped so that in their "normal" position, they are preloaded. Were it not for complex ligamentous systems, the bones would immediately assume unloaded "neutral anatomic" positions. Because the shape of the wrist bones tends to displace them with significant forces, current ligamentous reconstructions are inadequate. Common radial side instabilities invariably lead to degenerative arthritis.

The natural progression of scaphoid instability.

Wrist injury or repeated wrist sprains probably result in injury to the scapholunate ligament more commonly than previously recognized, which may allow abnormal scaphoid skid under load. This results in a common clinical entity termed DWS. Scaphoid instability is a spectrum condition ranging from minor, asymptomatic findings (seen in 20% of normal adults) through symptomatic findings in patients with normal radiographs to abnormal instability on radiographs, to degenerative change, and, ultimately, to SLAC wrist (see Fig. 1). Appropriate diagnosis and management of each of these wrist disorders are highly dependent upon a keen understanding of normal periscaphoid anatomy as well as the anatomic derangements that occur within the wrist that predispose a given patient to subsequent degenerative changes. With that understanding, the appropriateness of conservative therapy, SL exploration and arthroplasty, ligament repair, triscaphe arthrodesis, or SLAC reconstruction can be readily determined in each case.