An angiographic study of congenital hand anomalies (author's transl)

Accurate knowledge of the arterial variations of the anomalous hand is of considerable practical importance not only in the process of reconstructive surgery in hand anomalies but also in the consideration of the classification and the developmental stage of these defects. Between 1970 and 1980, we have performed an angiography on 102 anomalous hands of 97 patients at the Department of Orthopaedic Surgery, Nagoya University Branch Hospital. They consist of 28 cases of polydactyly, 25 of syndactyly, 14 of cleft hand, 13 of radial ray deficiency, 6 of ulnar ray deficiency, 6 of congenital constriction band syndrome, 5 of brachysyndactyly, 3 of macrodactyly and 1 each of monodactyly and aberrant muscle of the forearm. High origin of the radial artery was encountered in 11 out of 95 hands (11.6 per cent). In 5 out of 11 hands, an incomplete volar arch was found. The median artery entered into the formation of the superficial volar arch in about 20 per cent of cases. It occurred most frequently in radial ray deficiency (Table 1). An unusual division and course of the artery in the forearm occurred in 5 hands. The developmental disorders of the radial artery were encountered in 19 of the 102 hands (18.6 per cent). Especially, they were observed frequently in radial ray deficiency, and represented an occurrence in 84.6 per cent of these deficits (Table 2). The superficial volar arch was absent in about 25 per cent of cases. This arterial pattern was seen frequently in cleft hand and syndactyly (Table 3). In 30 of the 39 cases of syndactylism, the common digital artery bifurcated into the proper digital artery much further distally than normal. The digital arterial patterns of the duplicated thumb could be divided into 4 types (Fig. 3). The arterial patterns of cleft hand were quite different from those with radial ray deficiency, but were rather similar to those of syndactyly. The arterial patterns of ulnar ray deficiency tended to fall into two groups: those with the developmental disorders of the radial artery and those without them.     

The Carpus in Congenital Anomalies of the Hand

Congenital anomalies of the carpus associated with congenital hand and upper limb anomalies were investigated from the point of view of the development of the hand. Defects of the carpus were categorized as follows: 1) Radial ray defect: loss of the scaphoid, trapezium and trapezoid. 2) Central ray defect: loss of the capitate and loss of a part of the trapezium and hamate. 3) Ulnar ray defect: loss of the triquetrum, pisiformis and hamate. Deficiencies of the carpus and more distal parts of the hand proved to be secondary to defects of the forearm bones in both the radial and ulnar ray. On the other hand, deficiency of the carpus was secondary to defects of the phalanx and metacarpal of the middle finger in the central ray. Thus, from the standpoint of the development of the carpus, bipolar development of the bones of the hand originates proximally in both the radial and ulnar rays and distally in the central ray.     

The carpus in congenital anomalies of the hand

Congenital anomalies of the carpus associated with congenital hand and upper limb anomalies were investigated from the point of view of the development of the hand. Defects of the carpus were categorized as follows: 1) Radial ray defect: loss of the scaphoid, trapezium and trapezoid. 2) Central ray defect: loss of the capitate and loss of a part of the trapezium and hamate. 3) Ulnar ray defect: loss of the triguetrum, pisiformis and hamate. Deficiencies of the carpus and more distal parts of the hand proved to be secondary to defects of the forearm bones in both the radial and ulnar ray. On the other hand deficiency of the carpus was secondary to defects of the phalanx and metacarpal of the middle finger in the central ray. Thus, from the standpoint of the development of the carpus, bipolar development of the bones of the hand originates proximally in both the radial and ulnar rays and distally in the central ray.     

Epidemiological analysis of deaths caused by burns in Osaka, Japan

By referring to all of the death cards recorded for the year of 1978 in the whole area of Osaka Prefecture, we examined deaths due to burn injuries, electric injury and heatstroke, and obtained the following results.

1. 1. Of the total 41 737 deaths, externally induced death took place in 3207 cases (8 per cent), and death due to burn injuries including electric shock and heatstroke took place in 215 cases (2–60 cases against 100 000 population), accounting for 6.7 per cent of all externally induced deaths. In those aged under 40 years, externally induced death ranked highest as the cause of death, and burn injury was one of the chief causes.

2. 2. The sex ratio of burn-induced death was 3: I for males and females, respectively. However, if burn injuries resulting from social factors and suicide were excluded, the sex ratio was not significantly different at 1-3:1. The causes of injury were work accidents, suicide and other accidents at a rate of I: 2: 3.

3. 3. The monthly incidence of injuries was larger in winter when there were many cases of on-the-spot death due to fire, but there was no significant difference in the monthly incidence of post-treatment death.

4. 4. Of the 215 cases, 158 (73–5 per cent) died on the spot, while only 57 cases died after treatment. There were apparent regional differences in the total casualties. Post-treatment death probably occurred in 30 per cent of the total deaths induced by burn injuries.

5. 5. Medical institutions receiving burn victims could be divided into private and public ones at a nearly equal ratio. Public institutions took a significantly larger proportion of this type of casualty than following road accidents.

6. 6. Supplementary investigations revealed that two to three times as many people died at the scene of the accident than died after treatment from severe burns, this amounted to 140 cases a year in the whole area of Osaka Prefecture.

     

A method for predicting postoperative lung function and its relation to postoperative complications in patients with lung cancer

We predicted the postoperative forced expiratory volume in 1 second (FEV1) with a formula based on the premise that the total number of subsegments was 42: postop FEV1 = [1 - (b - n)/(42 - n)] (preop FEV1), where n and b are the number of obstructed subsegments and total subsegments, respectively, in the resected lobe. It was assumed that b was 6, 4, and 12 in the right upper, middle, and lower lobes, respectively, and 10 each in the left upper and the left lower lobes. The obstructed subsegments, n, were obtained from the findings on bronchography or bronchofiberscopy or both before operation. The linear regression line derived from the correlation between predicted (x) and measured (y) FEV1 was y = 0.850x + 0.286 +/- 0.296 (standard error) (N = 52; r = 0.821; p less than 0.001). We calculated the predicted postoperative FEV1 in 188 patients with primary lung cancer. The predicted values were corrected with the regression equation just mentioned and then normalized by the patient's height and sex (%FEV1(p,c). The correlation between %FEV1(p,c) and the surgical risk was studied. Postoperative respiratory complications were inversely related to %FEV1(p,c), and a significantly high incidence of complications (p less than 0.05) was observed in those whose %FEV1(p,c) was less than 60% of predicted normal. In aged patients (65 years old or more) without complications, %FEV1(p,c) was 67.3 +/- 18.0%; it was 52.2 +/- 12.8% in those with respiratory trouble and 53.3% +/- 9.6% in those with circulatory complications. The difference between groups with and without complications was significant (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Three-phalangeal thumbs

Many teratogenic mechanisms converge to create a three-phalangeal thumb: duplication, fusion and deletion. Fine observation of the position of growth centres and of associated hand malformations suggests that the intermediate delta phalanx of the three-phalangeal thumb results of the fusion of a three-phalanx ray with a two-phalanx thumb. The ulnar or radial side of the deviation is determined by the radial or ulnar position of this three-phalangeal ray fusing with the thumb. An opposable three-phalangeal thumb ulnarly deviated with a radial intermediate delta phalanx is the result of the fusion of a duplicated Wassel VII type thumb composed by a radial three-phalangeal ray and an ulnar two-phalangeal ray. In split hands, the three-phalangeal thumb is most often radially deviated because it presumably results from the fusion of a radial two phalanx thumb with the index, deleted in this fusion. The aligned opposable three-phalangeal thumb is quite uncommon and is probably the result of a fusion of two Wassel VII-type duplicated three-phalangeal rays. Conversely, the five-fingered hand or non-opposable three-phalangeal thumb, usually has no deviation and could result of a thumb deletion associated to an index duplication. This understanding of three-phalangeal thumbs makes usual classifications obsolete, but explains the various pathologic associations found in literature and in our own series. Treatment varies with age and takes in account all fundamental aspects of this congenital hand anomaly: the extraphalanx, the clinodactyly due to a delta phalanx, the thumb duplication or the absence of opposable thumb.     

Triphalangies du pouce

Many teratogenic mechanisms converge to create a three-phalangeal thumb: duplication, fusion and deletion. Fine observation of the position of growth centres and of associated hand malformations suggests that the intermediate delta phalanx of the three-phalangeal thumb results of the fusion of a three-phalanx ray with a two-phalanx thumb. The ulnar or radial side of the deviation is determined by the radial or ulnar position of this three-phalangeal ray fusing with the thumb. An opposable three-phalangeal thumb ulnarly deviated with a radial intermediate delta phalanx is the result of the fusion of a duplicated Wassel VII type thumb composed by a radial three-phalangeal ray and an ulnar two-phalangeal ray. In split hands, the three-phalangeal thumb is most often radially deviated because it presumably results from the fusion of a radial two phalanx thumb with the index, deleted in this fusion. The aligned opposable three-phalangeal thumb is quite uncommon and is probably the result of a fusion of two Wassel VII-type duplicated three-phalangeal rays. Conversely, the five-fingered hand or non-opposable three-phalangeal thumb, usually has no deviation and could result of a thumb deletion associated to an index duplication. This understanding of three-phalangeal thumbs makes usual classifications obsolete, but explains the various pathologic associations found in literature and in our own series. Treatment varies with age and takes in account all fundamental aspects of this congenital hand anomaly: the extraphalanx, the clinodactyly due to a delta phalanx, the thumb duplication or the absence of opposable thumb.     

Congenital clasped thumb: a review of forty-three cases

Over a 10-year period, 43 patients (75 hands) with congenital clasped thumb were seen in our institution. Three groups were identified: group I, 14 patients (24 hands) without contracture; group II, 14 patients (21 hands) with contractures of the palmar side; and group III, 15 patients (30 hands) with arthrogryposis multiplex congenita. Forty-two hands were treated with splinting alone and 16 hands with surgery. The remaining 17 hands were followed conservatively without splinting or surgery. The mean follow-up was 32 months. The results were evaluated by active abduction of the carpometacarpal joint and extension of metacarpophalangeal joint. All patients in group I showed good response to splinting, and the cause of the deformity appeared to be the predominance of the flexor muscles. In groups II and III, 10 patients (16 hands) who had severe deformity or no response to splinting were treated by release of the palmar soft tissues, skin grafts, and reconstruction of the extensors. Satisfactory results were obtained in 12 of 16 hands.     

A clinical study of congenital anomalies of the hand

The author has studied the clinical features of split hand, syndactyly, radial and ulnar ray deficiency, and brachydactyly. Many clinical findings make clear that typical split and is not a result of failure of formation but a result of union of digital rays. If we would try to classify congenital anomalies of the hand on the basis of embryological failure, syndactyly and split hand, and webbed and web free brachydactyly are never classified into other categories, just as constriction band syndrome is not divided by the presence of union of the digital rays.     

Classification and functional management of congenital central defect of the hand

Classification of central defect of the hand includes three general categories--Type I (typical), Type II (atypical), and Type III (two, three, and four digit hand). These three types of central defect have one common denominator--central metacarpal deficiency or absence. Otherwise, these three distinct types differ completely in inheritance pattern, characteristic features, bilaterality, and functional management. Functional management of the Type I central defect combines release of the tethered thumb metacarpal from its adduction contracture and simultaneous closure of the cleft using that redundant skin to fabricate a physiologic thumb-index web. Type II reconstructive procedures should be planned to provide as effective a pinch and grasp as possible between the radial and ulnar columns by deepening the central cleft, excising "digital nubbins" and any impinging skeleton, and performing rotational osteotomies of either metacarpal base or both and, occasionally, transfers to provide active digital flexion. Type III reconstructive procedures should release the adducted thumb and fabricate a physiologic thumb-index web along with appropriate releases of syndactyly. In the two-digit hand, rotational osteotomies may increase function.     

Clinical and experimental study on reconstruction after pancreatectomy--Part II. Myoelectric activity of small intestine after pancreatoduodenectomy

The aim of the study was to investigate the intestinal motility on I-type of reconstruction (e.g. Imanaga procedure) and II-type of reconstruction (e.g. Whipple procedure) following pancreatoduodenectomy in conscious dogs by chronically implanted electrodes along the reestablishing small intestine. During fasting, the interdigestive myoelectric complexes (IMCs) were initiated at a variety of electrode sites in either type of reconstruction. Seventy-six percent of the IMCs which were recorded in I-type dogs were propagated in sequence aborad. On the other hand, in II-type dogs, only 49% of the IMCs was propagated aborad. Furthermore the IMC cycles were more irregular in II-type dogs than in I-type dogs. After a meal, a characteristic fed pattern was induced in I-type dogs, whereas in II-type dogs the response of the small intestine to a meal was suppressed. This study shows that the intestinal myoelectric activity after pancreatoduodenectomy is more markedly disturbed in II-type of reconstruction than in I-type of reconstruction. Such disturbance of the intestinal activity may be a cause of postoperative malnutrition.     

Classification of the pattern of intrauterine amputations of the upper limb in constriction ring syndrome

Twenty patients with congenital upper limb amputations caused by constriction rings were reviewed to classify the pattern of these amputations. In the 20 patients studied, 31 upper limbs had congenital amputations. The pattern of amputation was classified into three types. Proximal upper limb amputation was considered type I and was only seen in one limb. The most common pattern of amputation was digital amputation associated with "coning" or "superimposition" of the digits (type II) and was seen in 20 hands. Type II amputations were subclassified according to the involvement of all, ulnar, radial, or central digits by the constriction ring. In type III amputations (N = 10 limbs), there was no associated coning or superimposition of the digits. This type of amputation was subclassified into type IIIA (multiple-digit amputations within the same hand) and type III B (single-digit amputation). Associated anomalies are reviewed and the pathogenesis of constriction rings is discussed.     

Primary reconstruction with digital ray transposition after resection of malignant tumor

Introduction  Hand reconstruction after wide resection of digital malignant tumors is still very challenging. The technique of adjacent digital ray transposition has been used for digital defects arising from trauma, but few papers have focused on reconstruction following resection of malignant tumors of the finger. The indications, complications and functional outcomes with this approach are discussed. Patients and methods  Four patients underwent primary reconstruction with adjacent digital ray transposition after tumor resection. Two were men and two were women and the median age was 62 years. The malignant tumors were low-grade chondrosarcomas of the metacarpal bone in two cases, epithelioid sarcoma at the fingertip in one case and synovial sarcoma at the base of the thumb in the fourth case. Results  Metacarpal osteotomies were rigidly stabilized with a plate and screws and with an intramedullary bone peg graft. Digit length and rotation were satisfactory and there were no non-unions. Local recurrence was not observed at the final follow-up. The mean musculoskeletal tumor society (MTS) score was 60% (range 48–80%). The results of the disabilities of the arm, shoulder and hand score were similar to the MTS score, with a mean score of 35 points (range 22.5–63.5). The worst result was for index-to-thumb transposition and the best was for index-to-middle. All patients experienced emotional difficulty with acceptance of a three-finger hand. Conclusion  Primary reconstruction with digital ray transposition produces acceptable functional outcomes after resection of malignant tumor. This procedure is best indicated for central single ray amputation but sometimes is associated with esthetical problems.     

Pollicization of Middle Finger in a Cleft Hand Associated with Acrorenal Syndrome

Introduction  Acrorenal syndrome is autosomal recessive inherited disorder commonly associated with congenital renal disorders and ipsilateral hand/foot anomalies. The hand and foot deformities corrections are challenging to achieve a good functional and cosmetic result. We described a case of acrorenal syndrome with suppressed radial elements and absent thumb in whom we were able to reconstruct the hand. Case Report  A 5-year-old girl presented to us with right renal agenesis and right hand/foot deformity. The hand showed a cleft hand with central deficiency, index finger hypoplastic, and syndactylyzed to middle finger, absent thumb. The hand was nonfunctional because of absent thumb. To improve the functions, it was decided to proceed with thumb reconstruction. The middle finger was pollicized to regain tripod grip and thereby the functions was enhanced. Discussion  The cleft hand belongs to “failure of finger ray induction group” in classification by “International Federation of Societies for Surgery of the Hand (IFSSH).” Absence of thumb and first web space makes it a strong indication for surgical reconstruction. In our case, thumb was addressed by pollicization of middle finger and we were able to provide a good tripod grip.     

Myasthenia gravis in elderly patients

The clinical features and the effect of thymectomy were compared between 27 elderly patients (Group 2) and 119 young adult patients (Group 1) with myasthenia gravis (MG). In the elderly group, MG was type I in 3 patients, type IIA in 6, type IIB in 17, and type III in 1; and in the young group, type I in 6, type IIA in 36, type IIB in 73, and type III in 4. The association rate with autoimmune disease in patients without thymoma was 12.5% (1/8) in Group 2 and 21.3% (20/94) in Group 1. Autoimmune diseases were not seen in any patients with thymoma. The clinical stage of thymoma was not significantly different between the two groups. The rates of remission and of palliation at 3 years after thymectomy were 18.2% and 72.7%, respectively, in Group 2 patients with thymoma, 21.4% and 78.6% in Group 1 patients with thymoma, 50% and 100% in Group 2 patients without thymoma, and 50% and 98.1% in Group 1 patients without thymoma.     

Type 0 ulnar longitudinal deficiency

PURPOSE: To describe the characteristics of type 0 ulnar longitudinal deficiency (ULD) in which deficiencies are present in the hand and carpus without involvement of the forearm or elbow. METHODS: A retrospective chart, radiograph, and clinical photograph review (1960-2005) of patients previously diagnosed with ectrodactyly, hand hypoplasia, or ULD was performed to evaluate for a diagnosis of ULD isolated to the hand. RESULTS: Thirteen extremities were identified. Three extremities had complete absence of the small-finger ray (phalanges and metacarpal) and 6 extremities had complete absence of the ring- and small-finger rays. Four hands showed hypoplasia of the small finger, 3 in conjunction with a ring- and small-metacarpal synostosis and 1 in isolation. Three extremities also had radial-sided hypoplasia or aplasia of the rays. Additional common findings included simple syndactyly, delta phalanx, and carpal fusions, most commonly of the capitohamate joint. CONCLUSIONS: Patients with isolated ulnar-sided hand deficiency such as ectrodactyly of the ring and/or small fingers or synostosis of the small metacarpal of the ring finger in the presence of a normal forearm may be diagnosed as having type 0 ULD. We propose that type 0 be added to the current classification systems for ULD representing those extremities with deficiencies isolated to the hand.     

Terminal limb congenital malformations: analysis of 523 cases

A total of 523 Japanese patients with terminal limb congenital malformations were reviewed for the characteristic features, and especially for type correlation between hand and foot anomalies. There were 281 cases of hand involvement alone, 149 cases of foot involvement alone, and 93 cases of combined hand and foot involvement. Polydactyly was commonly preaxial in the hand and postaxial in the foot, in contrast to the well-known postaxial dominance in the hand among whites. Hand anomalies were likely to show the same Swanson type of anomaly as the foot, with the affected digital ray likely to be identical in both hand and foot.     

Congenital cleft-foot deformity treatment.

A retrospective review of congenital cleft foot was done on 16 patients with 32 involved feet. The average age at the time of surgery was 4 years (range, 5 months to 13 years). The average follow-up after surgery was 7.8 years, with a range of 2-45 years. A simple classification based on severity of deficiency was developed. Twenty-three of the 24 procedures performed gave a satisfactory result. Six of the nine untreated feet were satisfactory. Based on our classification, the following treatment is recommended: type I, central partial forefoot cleft was treated by a soft-tissue syndactylism and a partial hallux valgus correction, if needed. Type II, for a complete forefoot cleft to the tarsus, soft-tissue syndactylism with first-ray osteotomy if necessary before age 5 years is recommended. First-ray amputation is advised after age 5 years. Type III: Complete absence of first through fourth ray did not need forefoot surgery.     

The degeneration of adjacent intervertebral discs negatively influence union rate of osteoporotic vertebral fracture: A multicenter cohort study

Background

With the increasing aging population in developed countries, there has been an associated increased prevalence of osteoporotic vertebral fracture (OVF). Many previous reports have attempted to predict the risk of delayed union associated with OVF. However, the role of endplate failure and the degeneration of adjacent intervertebral discs, and their association with delayed union has received little attention. The aim of this study was to evaluate the endplate fracture and disc degeneration rank as risk factors for delayed union.

A child with longitudinal cleavage of the upper extremity: treatment and etiology considerations

We report a 4-year-old boy with a normal right upper extremity and 2 left upper extremities. These extremities included one with radial components including the radius and rudimentary thumb ray extended from the humerus in the more superior extremity, and another with the ulna and ulnar hand elements attached more inferiorly to the thorax. The patient had normal shoulder motion but no other function in the more superior extremity; the inferior extremity had active flexion and extension of the 2 fingers. We excised the nonfunctioning radius and thumb and performed an "on-top-plasty" by mobilizing the inferior extremity on its neurovascular pedicle and fusing the ulna to the distal aspect of the humerus of the superior extremity. This unusual clinical presentation may represent a proximal manifestation of central longitudinal deficiency with early limb bud cleavage affecting the apical ectodermal ridge and underlying mesoderm.