Multifocal neurilemomas in different nerves of the same upper extremity

We report a case of multifocal neurilemomas originating from different nerves in the same upper extremity. In the excision of all seven tumors care was taken not to damage the nerves involved. The common features of multifocal neurilemomas that originated from different nerves of the same upper extremity are outlined and the consequent risk of potential nerve damage during the operation is discussed. We recommend intracapsular excisions of multifocal neurilemomas.     

Multiple neurilemomas in the upper extremity: a series of three cases

Neurilemomas are the most frequently arising benign nerve tumors of the upper extremity and are also called Schwannomas. Generally, they present as solitary tumors, although multiple tumors are common. Regardless of number, they are usually found on the lexor surface of the forearm and hand, and multiple tumors are almost always located within a single major nerve, its branches, or both. We present three patients who had multiple neurilemomas; two patients had tumors within a single major nerve and its branches, and the third patient had an unusual occurrence of one tumor in the ulnar nerve and a second tumor in a branch of the median nerve.     

A case of thoracic neurilemoma with neurilemomas of the upper limb and sacrum

A 64-year-old male was admitted in February 24, 1988 because of an abnormal shadow on chest X-ray. The tumor in the thoracic wall was removed at the thoracotomy and histology showed neurilemoma. Aspiration biopsy of tumors on the left upper limb and sacrum revealed the typical histopathologic appearance of neurilemomas. The possibility of malignant transformation and sequential appearance of tumors in patients with a neurilemoma indicates that complete resection and thorough follow-up examination are important.     

Microsurgery of the upper extremity

In the past 50 years, hand surgeons have made considerable contributions to microsurgery. The unique demands of complex upper extremity care have driven many of the technical and scientific advances of this discipline, including functional muscle transfers, nerve transfers, and composite tissue allotransplantation. The purpose of this article was to review the current applications of microsurgery to the upper extremity.     

Frostbite of the upper extremity

Human capacity for physiologic adaptation to cold is minimal; we survive by insulating ourselves with protective clothing. In addition to the irreversible direct injury caused by ice crystallization, the authors have outlined four possible mechanisms by which indirect injury may damage tissue. Other than rapid rewarming, there is no uniformly accepted protocol for the treatment of frostbite injury. Attempting to sort out the world's literature on frostbite in an effort to present a comprehensive treatment protocol is a daunting task. In addition to the probably irreversible direct injury caused by ice crystallization, the authors have outlined at least four possible mechanisms by which indirect injury may damage tissue. The literature is full of various treatment protocols that allegedly are beneficial despite addressing different mechanisms. Mills described 10 different categories of medications, each addressing one of four possible mechanisms, used in the clinical treatment of frostbite injury over a 30-year period. Analyzing this information is even more confusing when one realizes that there is little uniformity in animal models employed to generate these data. This is further complicated by the lack of clinical correlation with the most common experimental model--liquid nitrogen rapid freezing. The risk of frostbite is highest when psychiatric disturbance, intoxication, or unplanned circumstances lead to cold exposure without adequate protective clothing. As tissue freezes, both direct and indirect factors cause injury. Most therapies have been aimed at limiting indirect injury, in an attempt to limit progressive tissue loss. Rapid rewarming is universally accepted, but the benefits of other modalities are still controversial. Traditionally, observation and delayed amputation have been employed to manage frostbite. More recently, triple-phase bone scans have been used to distinguish between tissue that is irreversibly destined for necrosis and tissue that is at-risk for necrosis, but potentially salvageable. Early operation can be used to provide at-risk tissue with a new blood supply and preserve both function and length in the upper extremity.     

Aneurysms of the upper extremity

Thirty aneurysms in the upper extremity in 28 patients over the last 10 years are reviewed. Analysis showed that false aneurysms develop from penetrating trauma, while true aneurysms tend to arise in parts of the arterial tree exposed to blunt trauma. Penetrating injury to vessels should be thoroughly explored and repaired. Arterial aneurysm should be included in the differential diagnosis of masses in the upper extremity, especially after trauma. Three-phase radionuclide scanning is a useful tool for evaluating lesions of the distal arterial tree. When an aneurysm is suspected, early treatment is advised. Treatment options of resection and ligation versus reconstitution of vessel flow should be based on preoperative and intraoperative evaluation of circulatory status.     

Phleborheography of the upper extremity

Phleborheography is a well-established technique for the noninvasive diagnosis of deep venous thrombosis of the lower extremity. For ten years we have used phleborheography in the diagnosis of axillary and subclavian venous thrombosis. We developed modifications in technique and interpretation that are necessary for accurate application of phleborheography to the upper extremity. When compared with venography, the sensitivity and specificity of this technique approached 90%. Therefore, phleborheography appears to be a useful screening examination for deep venous thrombosis of the upper extremity.     

Resympathectomy of the upper extremity

Resympathectomy was performed in 27 patients (eight bilaterally) with ischaemic hand phenomena. An extended operative technique, resecting parts of the second and third intercostal nerves and their surrounding tissue, was used. In all 35 procedures the posterior extrapleural approach was used. Follow-up was from 3 to 12 years. Only the sympathetic ganglia had been removed during the previous surgery by the axillary approach (67 per cent of these patients had had a transient response for between 6 months and 2 years; 33 per cent had had no response at all). A direct subjective improvement was seen after 27 of the 35 reoperations (77 per cent). In 14 patients continuous wave Doppler ultrasound studies were available and showed a significant increase in peak forward frequency after operation (P less than 0.001). From these data it may be concluded that it is possible to obtain a resympathectomy effect, but reoperation should be reserved for special cases for whom survival of digits is essential.     

Neurofibrosarcomas of the upper extremity

A retrospective review of all malignant hand tumors seen at the University of Michigan from 1950 to 1987 demonstrated six biopsy-proven cases of neurofibrosarcoma involving the upper extremity. There were four male and two female patients; average age at presentation was 37 years and ages ranged from 15 to 63 years. All patients had a history of von Recklinghausen's disease. Three patients were seen initially with painful enlarging masses, one with a painful mass with a neurological deficit, and two with painless enlarging masses. Three patients had radical excisions requiring upper extremity or forequarter amputation, and three patients received limited or no surgical treatment. Five patients died of metastases an average of 3 years after diagnosis. One patient remains alive 18 years after upper extremity amputation despite an early local recurrence. Early diagnosis and radical surgical excision offer the best chance of long-term survival from this highly lethal cancer.     

Schwannomas of the upper extremity

This study presented the clinical characteristics, MRI features and postoperative results of 20 schwannomas in the arms of 13 patients. Twelve tumours had a positive Tinel's sign, one caused weakness of the wrist and another in Guyon's canal caused hypothenar muscle atrophy. Of the nine cases which underwent magnetic resonance imaging preoperatively, six were correctly diagnosed as schwannomas. All masses were excised using microsurgical techniques and two transient neurological complications occurred.     

Replantation of the upper extremity

In recent years, the functional results after replantation surgery have improved with increased experience. Stiffness remains as the single greatest postoperative problem. Improvements in this area are now possible with aggressive and closely supervised postoperative hand therapy and splinting. The efficiency of the replantation effort itself has increased dramatically in the hands of a number of surgeons experienced in replantation working together as a team. Once vascular flow to an amputated part has been reestablished, the injury is converted to a complex upper extremity injury that would be treated aggressively by many surgeons trained in this discipline. The stigma associated with the amputated part as being one to which function may never be restored has largely been eliminated. One thing is certain ... missing digits never function.     

Extravasation injuries in the upper extremity

Fourteen patients with intravenous extravasations of chemotherapeutic medications, radiographic contrast agents, vasopressors, fluorescein, or albumin/potassium phosphate were evaluated with regard to function and cosmesis. The average follow-up period was 8.4 months (range, one-24 months). Five patients initially were managed conservatively and, after demarcation of the necrotic area, had surgical procedures for skin coverage. Four of these patients had poor functional and cosmetic results. The remaining patient had an excellent final result. Because of the generally poor results observed in the aforementioned patients, a program of early recognition and surgical intervention in selected extravasation cases was instituted. Following this change, eight of nine patients had good or excellent results. Early surgical involvement in the evaluation of extravasations, with and early surgical drainage and irrigation in selected severe cases, appears to improve the outcome of these iatrogenic injuries.     

Nerve transfers in the upper extremity

Restoration of extremity function following nerve injury is often unpredictable. Nerve transfers in the upper extremity are important techniques in the management of many types of peripheral nerve injury. The physiologic principles of nerve transfer lead to the indications for use. The elements of planning and execution of common nerve transfers are presented in this article.