Pilomatrixoma of the forearm: a case report.

Pilomatrixoma is a benign neoplasm derived from hair follicle matrix cells. Involvement of the upper extremities is relatively uncommon and can be mistaken for malignancy. We present the case of a 52-year-old woman with a pilomatrixoma of the forearm, and we review the literature regarding pilomatrixomas in the upper extremity.

Internal fixation of acute, nondisplaced scaphoid waist fractures via a limited dorsal approach: an assessment of radiographic and functional outcomes.

PURPOSE: To evaluate the clinical and radiographic outcomes of a consecutive series of patients who had internal fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach. METHODS: Twenty consecutive patients had surgical fixation of a nondisplaced scaphoid waist (Herbert B2) fracture via a limited dorsal approach. Eighteen patients were available for follow-up evaluation at a mean duration of 98 weeks after surgery (range, 12-272 wk). Fifteen males and 3 females with a mean age of 25 years (range, 16-62 y) were examined. Wrist range of motion; grip strength; visual analog and numeric pain scores; and a Disabilities of the Arm, Shoulder, and Hand (DASH) outcomes questionnaire were assessed. Postoperative radiographs were reviewed in a blinded fashion to assess the fracture union and screw position. RESULTS: Seventeen of 18 fractures healed at a mean duration of 8 weeks. No case of proximal pole avascular necrosis occurred. All patients were satisfied and returned to their pre-injury level of employment. Five of 6 collegiate or professional athletes returned to play without limitations. The mean subjective and visual analog pain scores were 0.3 and 0.4 (maximum of 10 for each scale). The mean DASH score was 6.12 (out of 100), which is consistent with an excellent functional outcome. Central axis screw position was achieved on anteroposterior and lateral radiographs in 17 of 18 patients. CONCLUSIONS: Fixation of an acute, nondisplaced scaphoid waist fracture via a limited dorsal approach is safe and effective. The limited dorsal approach allows for accurate insertion of the screw in the central scaphoid, which is biomechanically advantageous for fracture union and early restoration of function. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Factitious disorders.

Factitious disorders reside under the broad umbrella of dysfunctional syndromes. This article is meant specifically to focus on common patterns of upper extremity factitious illness. It is intended to emphasize recognition, differential diagnosis, and problems related to misdiagnosis. It is not devoted to treatment, which is a separate issue.

Complex regional pain syndrome type I in the upper extremity.

Complex regional pain syndrome (CRPS) remains a challenging condition for physicians to treat since the earliest descriptions dating back to the Civil War. It has been most commonly reported after traumatic injury or fracture; however, many other causes have been documented. This article focuses on CRPS type 1 as it pertains to the upper extremity. In general, patients who have complex regional pain syndrome suffer from pain, sensory changes, edema, sweating, and temperature disturbance in the afflicted extremity. Chronic changes can involve the skin, nails, and bone. The pathophysiology of this condition remains unclear and is probably multifactorial, involving persistent inflammation, the sympathetic nervous system, the central nervous system and external stimuli. Treatment should be based on a multidisciplinary experienced team approach that is focused on functional restoration. Future research will provide insight into pathophysiology and optimal treatment regimens.

Fibromyalgia and myofascial pain syndromes and the workers' compensation environment: an update.

Fibromyalgia and myofascial pain syndromes are terms used to describe a constellation of complaints ranging from generalized aches to specific tender trigger points often accompanied by fatigue, depression, and sleep disturbances. In the past 5 years, research has been directed primarily at determining the pathophysiology of fibromyalgia and myofascial pain syndromes and the treatment of patients' comorbidities to alleviate their symptomatology. Controversy exists as to whether fibromyalgia and myofascial pain syndromes represent a specific pathology or are merely terms to describe clinical conditions that provide patients with the reassurance that their symptoms are real and help clinicians with therapeutic direction. In the occupational health setting, this uncertainty can lead to significant difficulty in determining short- and long-term disability and assigning culpability to an individual's work environment.

Wrist arthrodesis.

Wrist arthrodesis results in a high degree of patient satisfaction and predictable pain relief in most patients. Most patients are able to return to gainful employment, many without impairment. Some patients require restrictions and employment in a less strenuous occupation. Successful fusion rates have been reported in the vast majority of patients overall. Although the functional outcome is acceptable for most patients,some adaptation is necessary, because certain activities such as perineal care and manipulating the hand in tight spaces are difficult. Activities that require forceful gripping with the hand ina fully pronated or supinated position also may be difficult to accomplish. Preoperative counseling of the patient should include a candid discussion of the potential postoperative functional difficulties. The most common indication for a wrist arthrodesis is advanced symptomatic arthritis secondary to a degenerative, post-traumatic, inflammatory, or postinfectious condition. Wrist arthrodesis also may improve function, hygiene,and cosmesis in the patient who has a contracted or flail wrist associated with cerebral palsy, traumatic brain injury, or brachial plexus injury.Various techniques have been described for achieving a successful arthrodesis. The type of operative technique used depends on the underlying condition, quality of bone, presence of bi-lateral disease, condition of the remaining joints of the involved extremity, and surgeon's preference. Intramedullary rod or Steinman pin fixation has been successful in patients who have inflammatory arthritis. Dorsal plate and screw fixation is preferred for patients who have post-traumatic or degenerative arthrosis. Rigid fixation with a dorsal plate is advocated because of the ease of implant application, the high rates of fusion achieved, and the avoidance of prolonged postoperative cast immobilization. Precontoured low profile plates have been developed to position the hand appropriately and to minimize extensor tendon irritation. Controversy still exists as to the ideal position of the hand. Generally the wrist is placed in slight dorsiflexion and ulnar deviation to optimize power grip. In cases of bilateral involvement, the nondominant hand may be placed in 5 degrees -10 degrees of flexion to better assist in such activities as perineal care. Complications are frequent but can be minimized with attention to detail and good surgical technique. Fortunately most complications are amenable to nonoperative treatment. Major complications include nonunion, deep wound infection, neuroma formation, DRUJ arthritis,ulnocarpal impaction, CTS, and painful retained hardware. Minor complications include hematoma formation, partial wound dehiscence, and transient paresthesias involving the radial, ulnar,or median nerves. Donor site morbidity remains a concern when the iliac crest is used. Complications include hematoma formation, infection, injury to the lateral cutaneous femoral nerve, and prolonged discomfort. Successful outcomes have been reported with the use of local autogenous cancellous bone graft from the distal radius metaphyseal region.

The hand in metastatic disease and acral manifestations of paraneoplastic syndromes.

Metastatic tumors to the hand and wrist are rare, accounting for approximately 0.1% of all metastatic lesions to the skeleton. The biochemically mediated pathways of bone metastases, the location of the hand at the distal extremity, and the small amount of marrow in the bones of the hand and wrist account for the low prevalence of acrometastases. More rarely, hand dermatologic and soft tissue changes of paraneoplastic syndromes herald an occult malignancy.