Disseminated histoplasmosis presenting as an acute tenosynovitis.

Disseminated histoplasmosis is usually a multifocal process with a wide variety of clinical presentations. Despite frequent bone marrow involvement, overt bone and joint disease is uncommon and isolated synovial involvement is extremely rare. We describe in this report an unusual case of disseminated histoplasmosis presenting as acute tenosynovitis. To our knowledge, this is only the second reported case of synovial involvement by H. capsulatum without a concomitant osseous lesion.

Post-traumatic palmar carpal subluxation. Report of two cases.

Traumatic carpal instability can be difficult to detect and may present complicated management problems. Post-traumatic palmar carpal subluxation has been previously described only as a theoretical ligament instability. Such a condition implies disruption of the normal ligament attachments either within or around the carpus, or both, which very often results in altered intercarpal relationships and in disturbed kinematics. Post-traumatic palmar carpal subluxation is a form of carpal ligament instability that we could not find in any previous reports. We are reporting the cases of two patients who were followed for three years after such an injury. After closed reduction and non-operative management, both patients had a satisfactory functional result.

Radiographic features of hand and wrist surgery excluding arthroplasties.

The normal and abnormal radiographic appearances of various hand and wrist surgical procedures have been presented. It is hoped that increased familiarity with these procedures and their radiographic features will lead to more meaningful radiographic interpretations by consulting radiologists.

Radiographic features of hand and wrist arthroplasties.

The normal and abnormal radiographic appearances of various arthroplasties of the hand and wrist have been presented. It is hoped that increased familiarity with these procedures and their radiographic features will lead to more meaningful radiographic interpretations by consulting radiologists.

Three-dimensional wrist imaging: evaluation of functional and pathologic anatomy by computer.

The wrist has been studied morphologically and functionally using advanced technology. The osseous morphology of the wrist was investigated by computed tomography and surface reconstruction software. The functional behavior of the wrist in motion was studied using electromagnetic tracker technology. Three-dimensional imaging from CT scans is emerging as a research tool for the study of gross surface morphology, especially for osseous structures. One of the most demanding applications of this technology lies in the human wrist, because of its small size and inherent complexity. We have demonstrated some of the potential of computer graphics and three-dimensional surface reconstructions in the wrist for patients with osseous abnormalities. Acquisition of six-degree-of-freedom kinematic data to describe carpal motion has been made possible by new electromagnetic tracker technology. Analysis of these data in human wrist experiments revealed that the instantaneous center of rotation was not fixed in the head of the capitate, as was previously thought.

A cause of wrist pain: non-specific tenosynovitis involving the flexor carpi radialis.

We describe 4 patients who complained of pain over the course of the flexor carpi radialis tendon at the wrist, and who presented with point tenderness there. These 4 patients presented a spectrum of non-specific tenosynovitis involving the flexor carpi radialis tendon at the wrist, ranging from slight tenderness and swelling to complete disruption of the tendon. Their clinical course and treatment is presented.

Traumatic pseudoaneurysm in an ulnar artery vein graft.

Ulnar artery thrombosis is well reported but treatment recommendations still vary. We report the 10-year follow-up of a vein graft used to treat a patient with ulnar artery thrombosis. The graft remained patent until the tenth year, when the patient sustained a blunt hyperextension injury to the involved wrist and developed a pseudoaneurysm of the vein graft. The pseudoaneurysm was found to be in the graft itself and not at the anastomosis. The vein graft thrombosed and was successfully treated with resection of the thrombosed vessel, embolectomy of the superficial palmer arch, and replacement with a new vein graft.

Lateral-volar finger flap for the treatment of burn syndactyly.

To completely open the web space in burn syndactyly and provide tissue that is pliable and elastic, we describe a flap from the lateral and volar surfaces of an adjacent finger which will completely cover the opened defect. The results of this procedure in 24 web spaces are reported.

Median nerve compression and trigger finger in the mucopolysaccharidoses and related diseases.

Patients with Hurler's syndrome (MPS-1H), I-cell disease (ML-II) and pseudo-Hurler's syndrome (ML-III) had median nerve compression and triggering of the fingers which limited finger extension. To our knowledge, this combination has not been reported previously in patients with mucopolysaccharidoses and related disorders. In all of our 3 cases the median nerve was compressed by thickened flexor tenosynovium. Synovectomy and resection of the volar carpal ligament improved the hand function in all, including the mentally retarded patient with Hurler's syndrome. Release of the fibroosseous tunnel in two patients was followed by an increased range of motion (but not full extension). A fourth patient, without a mucopolysaccharide storage disorder, also had the combination of trigger finger and carpal tunnel syndrome.

Experimental study of the optimal time for tenolysis.

We have attempted to define the optimal time for tenolysis by evaluating the blood supply, the rupture rate, and the tensile strength of tenolysed and control tendons. In 128 chickens tenolysis was performed 1, 3, 6, 12, 16, and 24 weeks after primary tendon repair. Tenolysis at 1 and 3 weeks resulted in devascularization, weak tendons, and high rupture rates. Tenolysis at 6 weeks after the primary repair had mixed effects on the blood supply but weakened the tendon. Tenolysis at 12 weeks after the tendon repair did not weaken the tendon and resulted in an increased blood supply. Tenolysis at 16 and 24 weeks did not weaken the tendon, but had varied effects on the blood supply. We recommend an interval of 12 weeks between primary tendon repair and tenolysis.

The results of non-operative management of stiff joints in the hand.

We selected 500 patients randomly from a total of 1300 patients seen in our Hand Rehabilitation Center between 1971 and 1975; 212 of the 500 presented with a chief complaint of stiff hand joints. Of the 212 patients treated non-operatively, 173 responded sufficiently to this treatment alone. Of the 789 stiff joints, 686 responded sufficiently to this treatment alone. The results of this regime of non-operative treatment of stiff joints provide excellent functional improvement in most patients, with a large saving of money through the reduction in disability payments required.

Clinical treatment of partial tendon lacerations without suturing and with early motion.

Partial lacerations of flexor tendons in chickens come out the strongest and glide best if they are not sutured and not immobilized. We treated 17 patients with 20 partial flexor tendon lacerations by not suturing the tendon and by early mobilization of the digit. These partial tendon lacerations varied from 25 to 95 percent of the cross-sectional area. Sixteen of obtained excellent function of the digit, and one obtained good to excellent function. This technique should be used only in cooperative patients.

Plastic surgery applicants in 1992.

All the applicants to plastic surgery residency programs who participated in the residency matching program for 1992 were reviewed. Data were collected on age, sex, race, nationality, place of birth, undergraduate education, medical education, postgraduate training, research activity, and evaluation scores. Findings indicate that applicants interested in academic careers are significantly more likely to have published research and are generally rated higher in categories of intellectual curiosity, performance, and intelligence by evaluators. Women and some minorities were underrepresented when compared with recent medical school graduating classes. We recommend a longitudinal study of applicants to correlate career achievement with applicant characteristics. We also recommend some changes in the application and evaluation process and in efforts to interest women and minorities in the specialty.

The Byars hypospadias repair. A review of 253 consecutive patients.

Of 253 consecutive hypospadias repairs by various surgeons, using the Byars technique, 57 (22 percent) had postoperative fistulae; 41 required one operation, 9 required two operations, and 7 required more than two operations for closure of these fistulae. Other complications were infrequent. When performed either by attending or resident physicians, the Byars hypospadias repair produced complete correction of the chordee, a urethra of satisfactory length and caliber, normal penile appearance, and a fistula rate comparable to that reported after other procedures.

Spontaneous regression of the primary lesion of a metastatic maligvant melanoma.

An atypical elderly patient with spontaneous regression of a primary lesion of malignant melanoma is presented. The 12 previously reported cases are also reviewed. The histological diagnosis of spontaneous regression of a melanoma can still be made after the regression appears to be grossly complete. All localized areas of depigmentation, or of scarring, should be biopsied when searching for an "occult" primary.

Factors influencing final range of motion in the fingers after fractures of the hand.

We evaluated 123 patients in which we treated 150 fractured fingers primarily. Sixty-seven percent of these fractured fingers required open reduction with internal fixation; the remainder had closed reduction with internal or external fixation, or immediate arthrodeses. Active and passive range-of-motion (ROM) exercises were usually begun within 3 days after injury. The active and passive ROM of all joints of each finger in the involved hand were measured at regular intervals until no further change in ROM occurred. An associated crush injury, a flexor or extensor tendon injury, or a skin loss (each) caused a significantly more frequent decrease in the final ROM of the unfractured fingers of the same hand. An associated joint injury, more than one fracture per finger, a crush injury, a flexor or extensor tendon injury, or a skin loss (each) caused a significant decrease in the ROM of the fractured fingers. After treatment of a simple fracture, the ROM in both the fractured and the unfractured fingers was essentially normal.

Flexible-implant arthroplasty and finger replantation.

We performed flexible-implant arthroplasty in three metacarpophalangeal joints in two patients at the time of finger replantation. We believe flexible-implant arthroplasty is preferable to permanent arthrodesis for most patients.

Management of synovial sarcoma of the median nerve at the elbow.

Synovial sarcoma is a high-grade malignancy with a marked propensity for local recurrence and a moderate rate of regional lymph node involvement. It usually causes death from massive pulmonary metastases. Despite its aggressive biologic behavior, en bloc wide local resection of small extremity tumors rather than amputation may be indicated if removal of all gross disease is possible. Extremity morbidity from resection of vessels, nerves, and soft-tissue bulk can be minimized by the use of composite reconstruction techniques currently available. A case report is presented to illustrate aggressive limb-sparing surgical therapy of a small, favorably located synovial sarcoma with immediate neurovascular and soft-tissue reconstruction. The literature is reviewed to aid subsequent surgeons faced with management of this uncommon tumor.

Digital ischemia of the upper extremity: a systematic approach for evaluation and treatment.

Symptomatic upper extremity digital ischemia is an uncommon disorder reflecting diverse etiologies. Herein we present an algorithm to aid in evaluation and treatment of digital ischemia. This approach seeks to establish the diagnosis and lead to appropriate treatment while minimizing testing and therapy. Practical application of the algorithm is demonstrated through illustrative cases.

The surgical management of stiff joints in the hand.

Significant and lasting improvement in stiff MP and PIP joints can be achieved by operative management. Operative intervention should be considered only after persistence of stiffness after a vigorous program of nonoperative therapy. In our series of 135 such stiff finger joints, capsulotomy increased the range of motion in MP joints by more than 30 degrees in 68 percent of the patients, more than 50 degrees in 57 percent, and more than 70 degrees in 32 percent. The increased range of motion for the PIP joints was more than 30 degrees in 63 percent of the patients, more than 50 degrees in 41 percent, and more than 70 degrees in 25 percent.