Phalangeal osteochondroma: a cause of childhood trigger finger.

Trigger finger is uncommon among children and often caused by various lesions. We report a 5-year old girl who presented with chronic painless triggering of the right ring finger and normal X-ray. She underwent exploration of the finger flexor tendons and release of the A1 pulley. Lack of obvious pathology dictated further wound exploration which revealed a hidden osteochondroma of the proximal phalanx. We believe that adequate surgical wound exposure is necessary if no obvious cause of triggering could be seen in order to rule out an atypical osteochondroma even in the presence of normal X-rays.     

Lower trunk brachial plexus compression neuropathy due to cervical rib in young athletes

Compression by a cervical rib may result in neurologic and/or vascular symptoms. Two patients are reported with thoracic outlet syndrome (TOS) secondary to cervical rib. Both patients had vague shoulder pain as well as neurologic manifestations due to compression neuropathy of the lower trunk of the brachial plexus. One patient was suspected initially to have carpal tunnel syndrome.     

Skin necrosis complicating mallet finger splinting and vascularity of the distal interphalangeal joint overlying skin

Two patients are reported with full-thickness skin necrosis over the dorsum of the distal interphalangeal (DIP) joints after dorsal splint immobilization in hyperextension to treat acute mallet finger. An investigation was carried out to study the relationship of hyperextension to the dorsal circulation of the DIP joint. In 66 digits, the average degree of DIP joint hyperextension at which the skin blanches was 50% of the total passive hyperextension. It is recommended, therefore, when the DIP joint is immobilized to treat acute mallet finger, the degree at which the dorsal skin begins to blanch must be determined, and the amount of hyperextension should not exceed that degree. Excessive localized pressure to the dorsal skin should be avoided by adjusting the angle of the dorsal splint.     

Enzyme-linked immunosorbent assay (ELISA) in the diagnosis of active pulmonary tuberculosis.

This study evaluates the sensitivity and specificity of an enzyme-linked immunosorbent assay (ELISA) for the detection of antibodies against Mycobacterium tuberculosis antigen. Twenty seven of the 35 patients with pulmonary tuberculosis had positive serology with an antibody titre of 10 nineteen of them had positive serology with an antibody titre of 100. All the 27 patients with positive serology were either smear or culture positive or both. Twenty six of the 35 control group had negative serology and 9 had positive serology with an antibody titre of 10. The test has a sensitivity of 77.14% and a specificity of 74.29%.     

Archery-related injuries of the hand, forearm, and elbow.

The five patients reported herein had various archery-related injuries of the upper extremities. Acute injuries included arrow laceration of a digital nerve and artery, contusion of forearm skin and subcutaneous tissue, and compression neuropathy of digital nerves from the bowstring. Chronic injuries included bilateral medial epicondylitis and median nerve compression at the wrist, de Quervain's tenosynovitis, and median nerve compression at the elbow. Essential measures for archery safety include use of archery protective gear, use of a light-weight bow, conditioning of the forearm flexor muscles, and modifications in drawing the bowstring.     

Gouty tenosynovitis and compression neuropathy of the median nerve

Two cases of gouty tenosynovitis were associated with carpal tunnel syndrome. Both patients had carpal tunnel release with good relief of symptoms. In one patient, gout was not suspected before operation; this patient developed wound dehiscence with tophaceous urate crystal drainage that eventually disappeared. Proper preoperative antigout therapy may have prevented this complication. Carpal tunnel syndrome associated with gout is rare. Preoperative investigations for gout may be indicated in patients with carpal tunnel syndrome.     

Wrist arthrodesis

Twenty consecutive patients were treated with wrist arthrodesis. Nine patients had rheumatoid arthritis, and eleven patients had a variety of other arthritic conditions. The average follow-up time was 34 months. Clinical examination and roentgenograms showed that eighteen patients had solid fusion of their wrists, with an average of 11 weeks of immobilization. Two patients had delayed union--one of them removed his cast after the operation. No reason for the delayed union was found in the second patient, who had rheumatoid disease. Ultimately, both patients had solid fusions after a total immobilization time of 20 weeks and 16 weeks, respectively. Solid fusion, pain relief, and satisfactory functional results can be achieved following wrist arthrodesis. Prerequisites for obtaining such results are as follows: First preoperative assessment of the patient's upper extremity level of function and range of motion (ROM) of all other joints of the extremity, and radiographic assessment of wrist and hand deformities. Second, during surgery, rigid fixation should be obtained and wrist deformity if present, as in rheumatoid disease, should be corrected. Third, a postoperative rehabilitation program should include range of motion of other joints, muscle strengthening, and functional activities.     

Congenital Thumb-Index Web Space Deficiency

Background: There are several congenital hand differences that cause thumb-index (TI) web space deficiency. There is a knowledge gap in the literature about the hand differences that are associated with TI web space deficiency. We aimed to identify these congenital differences and the various specific reconstructive surgical procedures that are used for these conditions. Methods: We conducted a retrospective chart review of children treated operatively over a period of 30 years for congenital TI web space deficiency by the senior author (G.M.R.). We gathered data on demographics and associated congenital hand differences and compiled a list of all surgical procedures performed for the web space and the ipsilateral upper extremity. Results: We included 71 patients (77 hands) with 12 congenital hand differences (62 developmental and 9 spastic). The total number of upper extremity operations, (ie), anesthetics performed for these patients was 186, averaging 2.6 settings and 7.5 procedures for each patient. Cutaneous reconstructive procedures included first dorsal metacarpal artery pedicle flaps (49 patients), 4-flap Z-plasties (15), and transposition flaps (13). In addition, 16 different thumb reconstructive procedures were necessary. Ten patients required revision of their TI web space procedures for recurrence. Conclusions: The prevalence of TI web space deficiency is underappreciated. These patients often have multiple musculoskeletal anomalies of the hand and upper extremity that should be ruled out and require surgical treatment to optimize hand function. Consideration should be given to performing more than one procedure in one setting when possible.     

Clinical presentation and types of Dupuytren's disease

The clinical presentation of Dupuytren's disease is discussed with emphasis on dermato-pathology, the nodule, the cord, ectopic manifestations regional and distant, and disease progression. The differential diagnosis also is described with a list of pseudo-Dupuytren's disease cases. Observations by this author suggest that there are two distinct clinical entities responsible for palmar fascial contracture, namely typical Dupuytren's disease and atypical Dupuytren's contracture. These two types seem to differ in presentation, treatment, and prognosis. The characteristic clinical findings of each of these two types are described. The disparity among treatment outcome studies and epidemiologic studies with regard to the prevalence of Dupuytren's disease is probably in part due to lack of distinction between these two clinical types. Accurate diagnosis and satisfactory treatment outcome can be achieved by careful history, thorough physical examination, and keen understanding of the pathophysiology of this enigmatic disease.     

Palmar fascial complex anatomy and pathology in Dupuytren's disease

Familiarity with the normal palmar fascial anatomy of the hand is necessary for understanding the convoluted pathologic changes that take place in Dupuytren's disease. This article includes a literature review and the findings of a study by the author of the fascial anatomy and pathology as related to Dupuytren's disease. Gross and microdissection of the palmar fascial structures were carried out with the aid of the operative microscope and an arthroscope, which allowed examination of the fine and undisturbed retinacular anatomy. The palmar fascial complex of the hand has five components: the radial aponeurosis, ulnar aponeurosis, central (palmar) aponeurosis, palmo-digital fascia, and digital fascia. The subtle constituents of each component are outlined and the transformation from normal to pathologic anatomy is clarified.