Synovial cyst of the pulp of the little finger--origin from the wrist joint.

Synovial cysts of the pulp of the little finger in three elderly patients were shown by arthrography to arise from leakage of synovial fluid from the wrist joint into the ulnar bursa and thence into the flexor synovial sheath in the digit. Distant as well as local sources of the contents of synovial cysts should be considered when the local anatomy permits communication between a degenerate joint and an adjacent tendon sheath.

Phenotypic characterization of mononuclear and multinucleated cells of giant cell reparative granuloma of small bones.

Four cases of giant cell reparative granuloma (GCRG) of small bones were analysed in order to determine the pathogenesis of the lesion and the nature of the component mononuclear and multinucleated cells. In cell cultures, giant cells formed a non-proliferating homogeneous population which expressed features characteristic of the osteoclast phenotype, including leucocyte common antigen, CD68, vitronectin receptor, and tartrate-resistant acid phosphatase. The giant cells were capable of lacunar resorption and their activity was inhibited by calcitonin. In addition to numerous macrophage-like cells, some of which expressed osteoclast phenotypic characteristics, there were also mononuclear stromal cells which proliferated in culture and were alkaline phosphatase-positive; these cells expressed receptor activator of NF-kappaB ligand (RANKL) and were capable of supporting human osteoclast formation from circulating precursors in vitro. These findings suggest that the osteoclast-like giant cells in GCRG of small bones are formed from monocyte/macrophage-like osteoclast precursors which differentiate into osteoclasts under the influence of mononuclear osteoblast-like stromal cells.

Intraosseous ganglion of the trapezium in communication with the flexor carpi radialis tendon sheath.

We report a case of an intraosseous ganglion of the trapezium that communicated with the flexor carpi radialis tendon sheath. The findings support the hypothesis that intraosseous ganglia arise from penetration of bone by synovial tissue or fluid.

Surgery for rheumatoid arthritis of the elbow: a comparison of radial-head excision and synovectomy with total elbow replacement.

The results of total elbow replacement (TER) in 45 elbows of 38 patients with rheumatoid arthritis were compared with results of radial head excision with synovectomy (RHES) in 45 age-matched patients treated in the same unit. The groups were similar with respect to duration of disease and preoperative clinical status, although pain was of longer duration and slightly more severe in the TER group. Failure was defined as the onset of moderate or severe pain after surgery or revision surgery for any reason. Reduction in pain was greater after TER than after RHES (P < .05). Recurrence of pain was common after RHES but was not seen after TER. Movement increased by a similar amount in each group. Complications were more frequent and more serious after TER (4 dislocations, 4 ulnar nerve dysfunctions, 1 significant wound breakdown) than after RHES (2 ulnar nerve dysfunctions, 1 transient wound discharge). Complications after TER were most common in patients who had previous RHES. On survival analysis, TER results were better than RHES results in each successive year. Cumulative survival rates at 10 years were 85% for TER and 69% for RHES, but the difference in rates was not statistically significant. In the medium term, TER relieves pain more reliably than RHES and its use is justified despite the greater risk of complications. In view of the paucity of long-term results for TER, RHES may retain a role in younger patients or in those whose symptoms are related mainly to the radiohumeral joint.

Synovectomy of the elbow and radial head excision in rheumatoid arthritis. Predictive factors and long-term outcome.

We carried out a survival analysis of elbow synovectomy (ES) and excision of the radial head (RHE) performed on 171 rheumatoid elbows. The failure criteria were revision surgery (performed or desired) and/or the presence of significant or severe pain. The cumulative survival was 81% at one year which thereafter decreased by an average of 2.6% per year. The strongest predictor for success was a low preoperative range of supination-pronation when corresponding survival curves were compared. A low range of flexion-extension also predicted failure. Combining both factors gave better prediction (failure: 6.3% v 67%), but a long duration of elbow symptoms before surgery predicted failure (72%, p = 0.04). At review, there was a mean gain of 50 degrees in supination-pronation and 11 degrees in flexion-extension; both correlated with success. Failure correlated with recurrence of synovitis, elbow instability, ulnar neuropathy, poor general mobility and poor upper-limb function. The last was independently affected by the severity of RA in the ipsilateral shoulder. Our findings show that although the short-term result of ES and RHE in rheumatoid arthritis is good, the long-term outcome is poor except in a subgroup with more than 50% limitation of forearm rotation.

Genetic influences in end-stage osteoarthritis. Sibling risks of hip and knee replacement for idiopathic osteoarthritis.

From a prospective, cross-sectional survey of 402 patients who had a total hip (THR) or a total knee (TKR) replacement for idiopathic osteoarthritis (OA) at a major centre, we determined the prevalence of these replacements for idiopathic OA in their 1171 siblings and 376 spouses. Using spouses as controls, the relative risk of THR in siblings was 1.86 (95% CI 0.93 to 3.69). The relative risk for TKR in siblings v spouses was 4.8 (95 % CI 0.64 to 36.4) whereas the risk for the combined outcome measure of THR or TKR was 2.32 (95% CI 1.22 to 4.43) when siblings and spouses over 64 years of age were compared. Using a threshold liability model (Falconer), the heritability of end-stage OA of the hip was estimated at 27%. The increased risks of joint replacement for severe, idiopathic OA which we found in siblings suggest that genetic influences are important in end-stage OA of the hip and knee.

The role of magnetic resonance imaging in the management of peripheral nerve tumours.

Fourteen cases of peripheral nerve tumour which had been examined by MRI were reviewed. T1-weighted images showed the tumours to be of intermediate signal and T2-weighted images showed a high signal with some heterogeneity. These appearances are not specific to peripheral nerve tumours, although the diagnosis may be suggested if the lesion arises from a major nerve trunk. The association with a nerve trunk may be defined by MRI, thus assisting with surgical planning. Neurilemmomas, neurofibromas and malignant nerve sheath tumours could not be differentiated with certainty using MR alone. The MR features of lipofibromatous hamartoma are reported.

Compression of the common peroneal nerve by a cyst of the lateral meniscus. A case report.

Ganglion cysts that compress the common peroneal nerve frequently arise from the proximal tibiofibular joint. In a 60-year-old man, the nerve was compressed by a cyst that arose from the lateral meniscus and extended around the posterolateral aspect of the fibular neck. The origin and extent of the lesion, which could not be determined by clinical examination, was seen through magnetic resonance imaging. Cysts arising from the lateral meniscus should be considered in the differential diagnosis of compression of the common peroneal nerve.

Vascularized pedicle graft of the lower trunk for reconstruction of the branchial plexus.

The middle trunk of an injured brachial plexus was reconstructed using a vascularized graft of the lower trunk, which was expendable because of irreparable damage to the C8 and T1 nerve roots. The graft was transferred on a vascular pedicle of mesoneurium. Useful recovery was achieved at 3 years. This technique helps to overcome the problems of limited supply and secondary sensory deficit of grafts from peripheral nerves, but is possible only if the plexus is explored early, before mobilization and transfer of nerve trunks is precluded by scarring.

Initial treatment of closed metacarpal fractures. A controlled comparison of compression glove and splintage.

A prospective clinical trial compared two forms of initial management for closed stable fractures of the shaft of the finger metacarpals. Patients were randomized to treatment with a compression glove and early mobilization (21 patients) or to immobilization in a plaster splint (21 patients). The mean loss of total active flexion (MP+PIP+DIP) in the second week after injury was 56 degrees in the glove group and 84 degrees in the splint group (P = 0.0036). In the third week, the mean loss of flexion was 23 degrees and 46 degrees respectively (P = 0.0010). Hand volume and PIP joint circumference were significantly smaller in the glove group in the second week but not in the third and fourth weeks. Within each group, however, there was no correlation between range of motion and swelling, suggesting that these were independent variables in this study. The support of the glove helped to relieve pain. Use of a compression glove avoided the loss of function imposed by splintage and was associated with a greater range of movement during the second and third weeks.

Haemostasis during carpal tunnel release under local anaesthesia: a controlled comparison of a tourniquet and adrenaline infiltration.

A randomized controlled comparison of tourniquet and local adrenaline infiltration for control of bleeding was performed in patients undergoing bilateral carpal tunnel release under local anaesthesia. Visual analogue scores for intra-operative pain were substantially greater for tourniquet (mean score 4.7) than for adrenaline (2.2). Incomplete control of bleeding was responsible for longer operating time and for the surgeons' perception of slightly greater operative difficulty with the use of adrenaline. There were no complications attributable to the use of adrenaline. The use of adrenaline-containing local anaesthesia for carpal tunnel release avoids tourniquet pain and is preferred by patients.

Rupture of extensor tendons due to osteoarthritis of the distal radio-ulnar joint.

Extensor tendons ruptured in 12 patients as a result of osteoarthritis of the distal radio-ulnar joint. Rupture occurred without warning in ten cases and was sequential in five. Perforation of the dorsal capsule of the distal radio-ulnar joint, allowing contact between the roughened ulnar head and extensor tendons, was present in every case. The capsular performation was demonstrated by arthrography, which may be used to identify patients who are at risk of extensor tendon rupture. Loss of independent extension of the little finger is a valuable clinical sign because rupture of extensor digiti minimi may be masked by a powerful contribution from the extensor tendon of the ring finger.

Rupture of the flexor carpi radialis tendon associated with scapho-trapezial osteoarthritis.

A case of rupture of the flexor carpi radialis tendon in association with scapho-trapezial osteoarthritis is reported. The symptoms of pain and swelling contrast with the loss of function which characterizes rupture of other tendons in the hand and wrist.

Retropharyngeal abscess, airway obstruction, and tetraplegia after hyperextension injury of the cervical spine: case report.

A retropharyngeal abscess resulted from perforation of the posterior pharyngeal wall by an anterior marginal osteophyte at the time of hyperextension injury of the cervical spine. The abscess communicated with the epidural space via the disrupted intervertebral disk, leading to the delayed onset of upper airway obstruction and tetraparesis.

Elastic band mobilisation after flexor tendon repair; splint design and risk of flexion contracture.

Elastic band mobilisation of repaired flexor tendons in zone 2 may be complicated by flexion contracture of the P.I.P. joint. The mechanics of three types of elastic band mobilisation were analysed from lateral video-recordings of finger movement and the flexion moment at the P.I.P. joint was derived at every 10 degrees of flexion. The conventional forearm attachment of the elastic band produced a steep rise in P.I.P. joint flexion moment during extension; this effect was greatest when the M.P. joint was at 70 degrees and least at 20 degrees. Flexion moments for attachments around the dorsum of the hand or under a palmar pulley were lower, uniform throughout the range of P.I.P. joint motion and independent of the position of the M.P. joint. The effort needed to extend the P.I.P. joint is strongly influenced by the method of elastic band attachment; consideration should be given to both tension and moment arm in application of elastic band mobilisation.

Vibratory detection thresholds following a digital nerve lesion.

Vibratory detection thresholds were measured at a number of frequencies between 5 and 320 Hz following a lesion of the lateral digital nerve innervating the terminal phalanx of the left index finger. Thresholds measurements began approximately 4 weeks after the nerve was repaired. A staircase method was used to determine thresholds on both the injured fingerpad and the intact fingerpad of the opposite hand. There was a large increase in thresholds on the injured fingerpad in the lower range of frequencies (5-40 Hz) while at higher frequencies (80-250 Hz) there was no significant difference between the thresholds on the injured fingerpad and those on the intact fingerpad. It is suggested that the differential effect of the nerve lesion on vibratory thresholds reflects the spread of the vibratory stimulus through the skin and the spatial characteristics of functionally intact receptor/afferent groups innervating neighbouring skin.

Ischaemic contracture of the intrinsic muscles of the hands. A hazard of physical restraint.

A case is described of bilateral ischaemic contracture of the intrinsic muscles of the hands, presenting in a mentally-disturbed patient one year after a reported period of immobilisation in a physical restraint device. Involvement of the deep thenar muscles and the interossei on the radial side of the hand can be explained by consideration of the anatomy of the deep palmar arch. Division of the tendons of the contracted interosseous muscles proximal to the metacarpophalangeal joints and release of the left first web improved hand function. Those who supervise the use of physical restraint devices should be aware of the risk of intrinsic muscle ischaemia and of the need for prompt diagnosis and treatment.