Malignant cystosarcoma phylloides. Treatment and prognosis.

Twenty-six cases of malignant cystosarcoma phylloides treated at The Charity Hospital of Louisiana were reviewed. No metastases to axillary lymph nodes was observed. The lesion appears to metastasize seldom, if ever, to lymphatics, and axillary dissection is seldom required. Local recurrence was common, however, and justifies wide resection of the primary. Mortality was related more to the size of the lesion than to other findings such as skin or muscle involvement. No lesion with less than three mitoses per ten high power fields and minimal stromal atypia proved fatal. Associated neoplasia was common, particularly in the opposite breast.     

The clinical use of a tubular compression bandage, Tubigrip, for burn-scar therapy: a critical analysis

Control of burn-scar hypertrophy remains a priority in the care of the burn patient. However, because of the problems associated with traditional compression therapy methods a study of the clinical utility of a tubular compressive bandage (TCB) was initiated. The clinical effectiveness of TCB was determined by studying 210 separate anatomic burn sites in 88 burn patients with a mean age of 25 years and a mean burn size of 21 per cent of the total body surface area (TBSA). To facilitate analysis of the results the patients were divided into two groups, the first group consisted of 71 patients who received prophylactic pressure therapy and a second group of 17 patients who received therapeutic pressure therapy after the establishment of hypertrophic scars. Mean follow-up of the entire group of patients was 11 months. The anatomic area involved by the burn was the most important factor in determining the effectiveness of TCB in this study. Failures primarily occurred at sites of mobility where pressure could not be consistently delivered or maintained, including the digits of the hand, axilla, groin and the head/neck regions. Overall, 85 per cent of the anatomic sites treated had good or satisfactory results. Based on the results of this study, we use TCB on all burn patients, who are at risk of developing burn-scar hypertrophy, immediately after the burn wound has healed or been surgically closed.     

Tendon transfers for radial nerve palsy: use of superficialis tendons for digital extension.

Since 1959, 22 patients have had wrist extension restored by transfer of the pronator teres to the extensor carpi radialis longus and brevis, common finger extension by transfer of the superficialis of the long finger, independent thumb and index finger extension by transfer of the superficialis of the ring finger, and abduction of the thumb by transfer of the flexor carpi radialis at the wrist joint level. Twenty-one of 22 patients have been evaluated from 8 months to 15 years after operation, with an average follow-up of 4.5 years. By our new system of evaluation, there were 10 excellent results, six good results, five fair results, and all patients improved. Sixteen patients obtained full, independent thumb-index finger extension, three had fair function, and two obtained thumb-index extension by tenodesis of the transfer. This procedure allows full metacarpophalangeal extension independent of wrist position, provides thumb-index finger extension independent of the ulnar three digits, and maintains the dorsal-radial-to-volar-ulnar plane of functional motion of the wrist by retaining the flexor carpi ulnaris.     

Acute acalculous cholecystitis: Ultrasonic diagnosis

Ultrasonography is an effective and accurate diagnostic test for acalculous cholecystitis. Until recently, however, little attention was focused on the gallbladder wall as an indicator of disease. By accurately visualizing and measuring the gallbladder wall, ultrasonography can be used to screen patients in whom acute acalculous cholecystitis is suspected. If the gallbladder wall measures 3.5 mm or greater, in the absence of ascites, a diagnosis of acalculous cholecystitis can be made safely with a specificity greater than 98 percent. Four of our five patients with acute acalculous cholecystitis had ultrasonically measured gallbladder walls 3.5 mm or greater in width. We have found ultrasonography useful in any clinical situation, even in the face of ileus, jaundice or pancreatitis. In addition, with the use of the portable real-time ultrasound machine, postoperative, traumatized and other critically ill patients can be examined at the bedside.     

Ultrasound in elective biliary tract surgery

The background, technique and ultrasonic criteria used in the diagnosis of biliary tract disease are reviewed and illustrative case histories and sonograms presented. The results in 100 prospective patients undergoing both biliary tract ultrasound and oral cholecystography are presented with surgical follow-up in 53 patients. Ultrasound was technically adequate in 96 percent of the patients examined and was accurate in 51 of the 53 patients who came to surgery. The gray scale ultrasound examination was more accurate than oral cholecystography, especially in the subgroup of patients with nonvisualizing oral cholecystograms. The current role of elective biliary tract sonography is discussed and gray scale ultrasound is recommended as the initial screening test in all patients with suspected biliary tract disease.     

A policy of early excision and grafting in elderly burn patients shortens the hospital stay and improves survival

Early excision and grafting of the burn wound appears to shorten the hospital stay and decrease mortality in children and adults. However, whether an early surgical approach is safe in elderly burn patients has not been resolved. To answer this question we carried out a prospective study of early surgery in 114 consecutive patients over the age of 50 years. Patients were generally operated on between post-burn days 2 and 5. The mean age of the patients was 68 years, with a burn size of 22 per cent, of which 13 per cent was full thickness skin loss. The mean hospital stay of the surviving patients was reduced by 40 per cent compared to national averages (P less than 0.001). The mortality rate for the entire group of patients was 17 per cent, with 2 deaths in the 65 patients with burns less than 20 per cent total body surface area (TBSA). Although the mortality rate for patients with burns greater than 20 per cent TBSA was 35 per cent, this was less than predicted (P less than 0.05). The improvement in survival appeared to be due to a decrease in the incidence of lethal burn wound infections.     

Malignant fibrous histiocytoma of the forearm: report of a case and review of the literature.

The tissue histiocyte can give rise to a variety of lesions, either benign or malignant, and the latter often is confused with other sarcomas. The multipotential nature of the histiocyte results in the presence of at least five different cell types in these tumors, and all may be derived from a common precursor cell. The anaplasia of elements which differentiate as fibroblasts appears to correlate with survival. The tumors may be highly malignant, and the 10 year survival rate approximates 40%. Aggressive surgical management of these tumors is mandatory, with either wide en bloc resection or primary amputation of the involved extremity. Should the tumor recur locally after a wide resection and there be no detectable metastases, prompt amputation is indicated.     

Spontaneous retrocarpal radial artery thrombosis: a report of two cases

Two patients with spontaneous retrocarpal radial artery thrombosis are reported. Both patients had numbness and cold intolerance of the thumb and index finger and one patient had splinter hemorrhages. Angiography revealed identical occlusions of the radial artery over a 2.5 cm segment dorsal to the wrist. Both patients had complete palmar arches. Flow from the ulnar artery was sufficient to prevent frank necrosis of the thumb but not to prevent ischemic symptoms. Both patients were successfully treated by resection of the area of thrombosis and interpositional vein grafting by use of microsurgical techniques. Symptoms resolved after operation in both cases. Follow-up examinations 3 months and 5 1/2 years later revealed continued graft patency.     

Von Frey's method of measuring pressure sensibility in the hand: an engineering analysis of the Weinstein-Semmes pressure aesthesiometer

The development of microsurgical techniques has generated a resurgence of interest in estimating local pressure sensibility as a measure of sensory improvement. Because our experience with Weinstein's modification of Von Frey's probes yielded variable and poorly understood results, we measured two sets of probes and examined them in the light of the engineering principles on which their behavior is based. The mechanical behavior of the nylon monofilaments can be described as buckling with one end built in and the other end pinned. The probes are relatively uniform and consistent. However, no loss in sensitivity would accompany division of the set into two or three equivalent sets. Variations in the buckling stress as high as a factor of eight are difficult to avoid. Gross errors arise from careless application, variations in the elastic modulus due to changes in temperature and humidity, and variations in the attachment of fibers to handles and differences in the ends of the filaments. Interpreting results for this instrument requires an understanding of the factors which can influence those results. The rpobes are simple to use but easy to misinterpret.     

High-pressure water jet injury of the hand

A rare case of high-pressure injection injury to the thumb with water is reported. The problem was managed without surgical exploration despite subsequent involvement of the small finger.     

Glomus tumor of the metacarpophalangeal joint: a case report

A case of a glomus tumor of the head of the third metacarpal bone is described. The metacarpophalangeal joint had to be opened to allow excision of the tumor.     

Posttraumatic sesamoid arthritis of the metacarpophalangeal joint of the thumb

The articular interface between the radial sesamoid and the radial condyle of the metacarpal head, which is the radial subsesamoid joint, is the most frequently involved area of abnormality in the metacarpophalangeal joint complex. More than 85% of all adult cadavers demonstrate degenerative arthritis of the radial subsesamoid joint. Confusing this condition with degenerative arthritis of the metacarpophalangeal joint may lead to unnecessary joint fusions. The predisposition of the radial subsesamoid to degenerative arthritis is related to the asymmetry of the palmar condyles of the metacarpal. The ulnar sesamoid has a flatter and broader condyle compared with the radial sesamoid, which rides on a high, narrow ridge. Thirty-six patients with symptomatic sesamoiditis have been treated by sesamoidectomy since 1978. Twenty-one of these patients were available for follow-up examination between 1 and 5 years after surgery, and 19 had relief of proximal thumb pain after sesamoidectomy.