Dupuytren’s disease of the radial side of the hand

Dupuytren’s disease with involvement of the radial aspect of the hand is a clinical entity, which affects the thumb, the first web space, and the index finger. It can be primary or secondary. The palmar fascia anatomy and the clinical aspects of radial Dupuytren’s disease are described. The authors propose a new classification, which has the advantage in requiring only a clinical evaluation. One hundred and fifteen patients were examined for Dupuytren’s disease with radial involvement, primary or secondary, in the Hand Surgery Unit of the University of Modena between 1985 and 1994. Eighty-two (68.3%) of them were treated surgically as hand function was compromised by first web retraction. The most commonly used incisions of the first commissure are straight-line with Z-plasties or the Hirschowitz incision; either a zigzag incision or a Bruner incision is made over the thumb or index finger; Z-plasties described by Iselin are reserved for patients with severe contraction of the index finger. Results were assessed by improvement coefficient, calculated as the ratio of the difference between preoperative and postoperative scores to postoperative scores. Generally, Dupuytren’s disease with radial prevalence is not aggressive and progresses slowly and may be exclusively radial or associated with ulnar disease. In other patients, as the disease progresses, loss of function becomes apparent owing to retraction in adduction of the first commissure and flexion contracture of the thumb or index finger.     

Patients’ preferences regarding the delivery of health care in a hand surgical practice

Background

The Patient Protection and Affordable Care Act of 2010 includes patient satisfaction scores in the calculation of reimbursement for services provided. The Medicare and Medicaid Electronic Health Care Record Incentive Program mandate that physicians provide electronic communication with patients. Little data exists regarding patient preferences that might guide the physician adhering to these guidelines. We performed a survey study to examine patients’ attitudes regarding the delivery of their health care.

Methods

We provided an anonymous survey to all outpatient hand surgery patients within a 1-month period at our level I academic center. The survey was structured to ascertain patients’ attitudes toward outpatient wait times as well as delivery of patient-specific healthcare-related information. One-hundred and ninety-six surveys were available for review.

Results

Of the 196 patients surveyed, 106 (54 %) were between the ages of 45 and 64. Patients aged 25 to 44 were the least willing to wait for an initial outpatient appointment. The majority of patients in all age groups demonstrated unwillingness to wait more than 1 week for evaluation of a new problem. One hundred and forty patients (71 %) were willing to wait longer for an appointment with an upper extremity specialist rather than have an earlier appointment with a non-upper extremity specialist. Wait times of 30 min after arrival in the office were acceptable to 174 patients (89 %) while 40 patients (20 %) were willing to wait an hour or more. Patients preferred a typed handout detailing their specific problem as opposed to referral to a website or an e-mail containing information.

Conclusions

The results of our study indicate that patients prefer typed information as opposed to e-mail or websites regarding their health care. Our study also suggests that patients are willing to endure longer wait times if they can be given a sooner appointment, and most prefer a specialist for their problems. These results will provide some guidance to the physician regarding what patients find most appealing.     

Angiomyoma of the hand: a post-traumatic tumor?

A 69-year-old woman presented with a tumor of the lateral aspect of the proximal phalanx of the little finger of the right hand. The finger was injured by a ring during a handshake. Excision and histopathological examination revealed the diagnosis of angio-myoma, a benign vascular tumor originating from the smooth muscle cells of arterial or venous walls. Angiomyomas belong to the family of leiomyomas and rare, small tumors (less than one centimeter), preferentially occurring in women between the ages of 40 and 60 years. They may be painful. Only one case of sarcomatous degeneration has been described in the literature. Trauma has never been previously reported as a cause of angio-myoma, but in this case the traumatic origin of the tumor was not in doubt.     

Burn on the buttocks caused by gel wheelchair cushion left on driver’s seat of hand control car

Context: Nowadays, people with paraplegia and quadriplegia have greater opportunities to venture into the general public. However, there is also an increased risk of associated hazards.

Findings: This report describes a 42-year-old man with paraplegia, who was insensate below the T7 level and sustained burns from sitting on a gel wheelchair cushion that had been left on the driver-side seat of a hand control car on a sunny day. Physical examination revealed deep partial-thickness burns on both his buttocks. He underwent surgical debridement and received an autologous split-thickness skin graft, and healed well.

Conclusion In modern times, the lives of people with paralysis are no longer restricted to the bed and wheelchair. Active people with spinal cord injuries inevitably diversify the use of wheelchair cushions in many ways; therefore, there is a greater possibility for the occurrence of associated hazards. This is a preventable issue, so both the user and manufacturers should recognize this potential hazard of gel wheelchair cushions.     

Eating out of the hand,maggots – Friend or foe?

The presence of maggots (fly larvae) in an open wound is a repelling sight to many and documented cases of myiasis in the literature are scant due to the rarity of such infestation in live patients. A unique case of such a presentation is elaborated in a patient who sustained a crush injury to the hand. This case serves to highlight the unique challenges faced in treating such injuries and to raise the profile of maggots and their untapped potential use in biodebridement and management of open wounds in modern day wound care practices.     

Chondrosarcoma of the hand: is a wide surgical resection necessary?

Chondrosarcomas of the hand are rare and generally treated with surgical resection. Thirteen patients with Grade 1 chondrosarcoma of the small bones of the hand were followed up for a mean of 99.8 months (range, 26-293 months). In eight patients (Group 1) curettage and reconstruction with cancellous bone was done and in five patients (Group 2) a wide resection was done. No patient experienced relapse in Group 2. In Group 1 one patient had a local relapse 18 months after intralesional resection. Using the Musculoskeletal Tumor Society score for evaluation, the clinical results showed an average of 98% and 95% of the normal function in Groups 1 and 2, respectively. None of the patients had evidence of systemic spread of the disease. With a relapse rate of 12.5% and no distant metastases after curettage, intralesional resection is the preferred method of treatment in Grade 1 chondrosarcoma of the hand, allowing the patient to avoid amputation and major loss of function.     

Nodular giant cell tumour of the tendon sheath of the hand: analysis of eighty-four cases—diagnostic decisions and outcome

Introduction

The giant cell tumour of the tendon sheath (GCTTS) of the hand is a benign tumour of unknown origin. The clinical diagnosis is supported by preoperative imaging. But the ideal imaging methods necessary for the diagnosis, preoperative planning and total tumour resection are still debated. Standard treatment is surgical resection with histological confirmation.

Methods

We followed up 84 patients who were operated upon for a histologically confirmed nodular type GCTTS for an average of 4.7 years (range four to eight). The preoperative symptoms and radiological findings of X-ray, ultrasound and MRI were reviewed and the surgeon asked for their impact on the surgical procedure.

Results

The average age at operation was 50.9 years, 65.5 % of the patients were female and 61.9 % of the lesions were located on the palmar aspect. Most tumours were found on the first three fingers. Two patients had tumours at two separate sites (2.4 %). After an average follow up of 31.5 months two recurrences were observed (2.4 %). In addition to X-ray and ultrasound, the preoperative findings of the MRI had no influence on the surgical procedure.

Conclusion

Our data on the nodular GCTTS are in accordance with published data concerning the age distribution, gender distribution, and localisation. No soft-tissue imaging method is superior for the diagnosis of nodular GCTTS or for the preoperative planning. A preoperative MRI may not be necessary as clinical and ultrasound examination are sufficient. To exclude bony erosions, a preoperative X-ray is necessary.     

Evaluation of the possibility to assess bone age on the basis of DXA derived hand scans—preliminary results

The classical method of skeletal age assessment is based on the recognition of changes in the radiographic appearance of the maturity indicators in hand-wrist radiographs by comparison with a reference atlas. The purpose of this study was the evaluation of the possibility to assess bone age using a less invasive method such as dual-energy X-ray absorptiometry (DXA). Bone ages of 50 children free of any chronic diseases (5–18 years old) and ten with multihormonal pituitary deficiency (MPD) (8–20 years old) were assessed using an Expert-XL densitometer. Hand scans and classical hand-wrist radiographs were evaluated by two independent observers for bone age by visual comparison with reference standards of skeletal development published in the atlas. The precision errors of duplicate bone age ratings were low both for radiographs (<1%) and DXA hand scans (<0.9%). A high degree of agreement between bone age ratings done by two observers was assessed by intraclass correlation coefficients. The same bone age based on radiographs and DXA hand scans was assessed in 44 of 60 cases (73.3%); in 16 cases the differences between bone age were no higher than 0.5 year. No significant difference between mean bone age based on radiographs and DXA hand scans was observed (P>0.05). Moreover, there was a very strong correlation between bone age results (r=0.998; r ²=0.996; P<0.0001), indicating agreement of bone age assessments based on DXA and radiographic images. Remarkable differences (up to 3 years) between bone age and chronological age were observed in healthy subjects, probably reflecting the effect of the secular trend towards earlier maturation or alterations in pubertal development. The study indicates that evaluation of skeletal maturity using DXA images is less invasive (up to 8 µSv) than radiography, giving results comparable to the classical method.     

Use of dermal substitute Matriderm® in severe injuries of the hand: about one case

Restoring function after hand burns is still a great surgical challenge. Reconstitution of elasticity and pliability are of utmost importance for hand function and aesthetics results. Dermal substitutes have been developed and have been used for many years. The dermal substitute Matriderm^® is an acellular three-dimensional matrix composed of native structurally intact collagen fibrils coated with elastin obtained from bovine dermis. The possibility of a one-stage procedure is profitable in treatment of hand burns. The authors report the case of a 43-year-old man admitted for severe burn by flames to 18% of his total body surface area with complete full thickness injury of left hand. After debridement incisions in emergency, early excision and skin graft using Matriderm^® were performed. Physical therapy was established at Day 10. At six weeks follow-up, full range of motion was achieved and the patient was able to use his hand in daily activities.     

The oldest reported mirror hand? The curse of the coal-house frog!

Despite being one of the rarest congenital upper limb abnormalities, a wide spectrum of the typical mirror hand has been described in the literature. We report a very interesting case of a new variant of mirror hand presenting in a 78-year-old man. The unique features of the case include the age at diagnosis, the anatomical features present and the acquired function despite no form of reconstructive surgery.