Hereditary neuropathy with liability to pressure palsies is not a major cause of idiopathic carpal tunnel syndrome.

BACKGROUND: Carpal tunnel syndrome is a debilitating neuropathy affecting millions of individuals. Although there are published reports of familial associations of carpal tunnel syndrome, the molecular mechanisms are unknown. OBJECTIVE: To determine the prevalence and potential role of the chromosome 17 microdeletion associated with hereditary neuropathy with liability to pressure palsies in patients diagnosed as having carpal tunnel syndrome. DESIGN: Prospective study. PATIENTS AND METHODS: Since hereditary neuropathy with liability to pressure palsies may present as carpal tunnel syndrome, we evaluated 50 patients with idiopathic carpal tunnel syndrome for hereditary neuropathy with liability to pressure palsies. RESULTS: No hereditary neuropathy with liability to pressure palsies deletions were detected. CONCLUSION: Molecular genetic testing for hereditary neuropathy with liability to pressure palsies in patients with idiopathic carpal tunnel syndrome is of limited value.

A case study of a patient with closed avulsion rupture of a single slip of the flexor digitorum superficialis tendon.

A case of a closed rupture of a single slip of flexor digitorum superficialis to the little finger is described. Closed rupture injuries of the flexor digitorum profundus tendon are quite common, but closed injuries to the superficialis tendon have been rarely reported. A single slip avulsion rupture of this tendon would seem to be very uncommon. The clinical presentation is reviewed.

Rectus abdominis muscle flaps used successfully for median sternotomy wounds after ipsilateral internal mammary artery ligation.

Use of the rectus abdominis muscle for reconstruction based on its superior blood supply has been said by some to be contraindicated if the ipsilateral internal mammary artery (IMA) has been divided for reasons such as coronary artery bypass grafting. The authors describe 5 patients in whom either both IMAs were used for coronary revascularization or in whom there was a contralateral subcostal incision, and they were thus compelled to perform sternal reconstruction using at least one rectus abdominis muscle ipsilateral to prior IMA ligation. In all patients the muscle flap was used to reconstruct an open median sternotomy wound successfully. An injection study as well as a fresh cadaveric dissection revealed rich collateral circulation to the superior epigastric vascular pedicle through the musculophrenic artery as well as through the lower intercostal arteries. This case report and the series of 5 patients indicate that if elevation of the rectus muscle and division of the lateral segmental vessels is done only up to the costal margin, one can reliably maintain a viable rectus muscle flap, even in the face of prior ipsilateral IMA ligation. This enables useful reconstruction to the lower half of a sternal wound using the rectus abdominis muscle, requiring a pectoralis major muscle flap for the superior part of the wound.

Upper limb salvage with microvascular bone transfer for major long-bone segmental tumor resections.

A series of 14 young, active patients who underwent vascularized bone graft reconstructions of large (9-15 cm) segmental skeletal defects of the upper extremity resulting from resection of a variety of bony tumors is presented. Eight defects involved the proximal humerus and required shoulder joint reconstruction, two were mid humeral and four involved the distal radius. Surgical techniques for both distal radius reconstruction with vascularized iliac crest and vascularized fibular head and glenohumeral reconstruction using the vascularized fibula are described. Several cases are discussed in detail, including achievement of bony union, postoperative range of motion and pain, and each patient's ability to resume activities. The literature is reviewed, and other reconstructive options for large bony defects of the upper extremity after tumor resection are discussed: nonvascularized bone grafts, allograft transfer, and custom prosthetic devices. The authors think that vascularized bone grafting offers the most favorable method of upper extremity salvage with preservation of joint function, especially at the shoulder.

Comparison of carpal canal pressure in paraplegic and nonparaplegic subjects: clinical implications.

The purpose of this study was to evaluate the pressure within the carpal tunnel that was generated with certain tasks in paraplegic versus nonparaplegic subjects. Four groups of subjects were evaluated: 10 wrists in six paraplegic subjects with carpal tunnel syndrome, 11 wrists in six paraplegics without the syndrome, 12 wrists in nine nonparaplegics with the syndrome, and 17 wrists in 11 nonparaplegics without the syndrome. Carpal canal pressures were measured in the wrists in three positions (neutral, 45-degree flexion, 45-degree extension) and during two dynamic tasks [wheelchair propulsion and RAISE (relief of anatomic ischial skin embarrassment) maneuver]. External force resistors were placed over the carpal canal and correlated with internal tunnel pressures. At each wrist position, paraplegics with carpal tunnel syndrome consistently had higher carpal canal pressure than did the other groups at the corresponding wrist position; statistical significance was evident with regard to the neutral wrist position (p < 0.05). Within each group of subjects, wrist extension and wrist flexion produced a statistically significant increase in carpal canal pressure (p < 0.05), compared with the neutral wrist position. Dynamic tasks (wheelchair propulsion and the RAISE maneuver) significantly elevated the carpal canal pressure in paraplegics with carpal tunnel syndrome, compared with the other groups (p < 0.05). Lastly, there is a linear positive correlation between carpal canal pressure and external force resistance.

Infantile myofibromatosis: case report of a solitary hand lesion with emphasis on differential diagnosis and management.

Infantile myofibromatosis, both solitary and multicentric types, is discussed with emphasis on the importance of diagnosing this condition correctly. Its distinctive clinical and histological characteristics are described, as are the hazards of overhasty and overly ambitious surgical intervention. Other similarly presenting fibromatous diseases of infancy and childhood are discussed, including aplasia cutis, infantile fibrosarcoma, recurring infantile digital fibromatosis, and juvenile aponeurotic fibromatosis. A case of infantile myofibromatosis, solitary type, is reported, and the two surgical procedures carried out over a 4-year period are described. The importance of histological and immunohistochemical evaluation of lesions present during the neonatal period is stressed.

Physical and psychosocial symptoms among 88 volunteer subjects compared with patients seeking plastic surgery procedures to the breast.

In an investigation of the relationship between macromastia and physical and psychosocial symptoms, 88 female university students, 21 augmentation mammaplasty patients, and 31 breast reduction patients graded somatic and psychosocial symptoms. The intent of the study was to discover which complaints were most common among women presenting for reduction mammaplasty and to determine whether height/weight index and brassiere chest measurement and cup size might affect their symptoms. Both the student group and the augmentation mammaplasty patients differed significantly from the breast reduction patients. Eighty-one percent of the reduction patients complained of neck and back pain. Seventy-seven percent complained of shoulder pain, 58 percent complained of chafing or rash; 45 percent reported significant limitation in their activity; and 52 percent were unhappy with their appearance (p < 0.001 compared with augmentation and student groups). Physical symptoms were related to height/weight index and bra chest and cup sizes in each of the three participating groups. It was found that patients who present for symptom-related reduction mammaplasty have a disease-specific group of physical and psychosocial complaints that are more directly related to large breast size than to being overweight.

Quality of life and disease-specific functional status following microvascular reconstruction for advanced (T3 and T4) oropharyngeal cancers.

In an effort to evaluate quality-of-life benefits of ablative head and neck cancer surgery and microvascular reconstruction, a longitudinal study was undertaken in which patients with T3 or T4 oropharyngeal cancers without systemic metastases at presentation were administered both general and disease-specific quality-of-life instruments preoperatively and postoperatively. In an initial prospective pilot study, 17 cancer patients were evaluated both preoperatively and postoperatively using the Medical Outcomes Short-Form Health Survey questionnaire (SF-36) and the Performance Status Scale for Head and Neck Cancer Patients. In the second part of the study, the need was recognized for a different disease-specific measure, for more frequent intervals of longitudinal follow-up (rather than be limited by a single data collection point), and for a noncancer control group. Since then, 17 more cancer patients were evaluated in the second part of the study and were compared with patients who had similar reconstructions after suffering head and neck trauma and also with age-matched controls. Instead of the performance status scale, the University of Washington Head and Neck Quality of Life questionnaire was substituted. Interval assessments were done at 1, 3, 6, and 12 months and preoperatively. Whereas many of the general and disease-specific quality of life subclasses initially worsened following extensive surgery and radiation therapy, most returned to the preoperative baseline by 6 months following conclusion of treatment and surpassed pretreatment values at 1 year. It can be concluded, based on this study, that large resections and reconstructions for head and neck cancer patients are justified in terms of outcome; the resection controls the local disease, and the microvascular reconstruction restores quality of life and functional status.

Sensory recovery of innervated and non-innervated radial forearm free flaps: functional implications.

Findings reported in the literature on the sensation provided by intraorally applied innervated vs. non-innervated radial forearm free flaps differ. In an effort to understand these differences in sensory recovery, the authors carried out sensory evaluations in 12 patients who had undergone radial forearm free flaps. Seven patients had innervated flaps for defects of the tongue and floor of mouth; five had non-innervated flaps to various sites. Flap sensitivity to temperature, light touch, dull touch, and sharpness and two-point discrimination was assessed at the donor site and contralaterally, and at the recipient site and contralateral mirror-image oral mucosa. Patients subjectively rated post-reconstruction sensation and provided quality of life (QOOL) data. The innervated flaps demonstrated better sensory recovery than the non-innervated flaps, although the latter did restore reasonable sensation. This paper describes the results, compares the study to other similar studies, and discusses various factors in the sensory recovery of both innervated and non-innervated intraoral radial forearm free flaps. The authors conclude that, although the trend in this study is toward improved function with the innervated flaps, these flaps do not appear to offer major intraoral functional advantage over the non-innervated flaps, which attain reasonably effective sensory recovery from neural ingrowth, if the lingual nerve is intact.

Neural anatomy of the radial forearm flap.

Typically the lateral antebrachial cutaneous nerve alone is used to innervate the radial forearm free flap when a sensate flap is required. The authors desired, by means of fresh cadaveric microdissections and by means of local anesthetic injections in living subjects, to map the sensory nerve territories of this flap. Eight radial forearm flaps were elevated and the medial antebrachial cutaneous nerve (MABC), lateral antebrachial cutaneous nerve (LABC), and superficial radial sensory nerve (SRSN) were dissected with the aid of an operating microscope (2.5-10x) and traced to their dermal insertions. In the injection study, the MABC, LABC, and SRSN in eight forearms of 4 subjects were blocked sequentially with 2% lidocaine injections. The resulting sensory deficit from each injection was mapped on the skin and superimposed on the marked radial forearm flap territory. Distribution of the three dissected nerve regions and the sensory deficit after injection were determined by digital images and computer analysis. During flap dissections, mean nerve distributions of total flap area were as follows: LABC, 61.8% (range, 48.3-71.6%); MABC, 33.8% (range, 30.5-38.9%); and SRSN, 34.6% (range, 26.8-44.1%). After nerve block the mapped sensory areas were as follows: LABC, 62.3% (range, 44.5-88.5%); MABC, 19.6% (range, 8.0-35.8%); and SRSN, 19.5% (range, 9.9-26.3%). At least 40% of the total flap area was not innervated by the LABC as identified both by nerve dissection and sensory local anesthetic blockade. By including the LABC, MABC, and SRSN in the radial forearm flap, both the theoretical and the clinically determined useful sensory innervation of the radial forearm flap potentially would be increased.

Reconstruction of oncologic torso defects: emphasis on microvascular reconstruction.

A large variety of pedicle flaps centered at the shoulder girdle or pelvic girdle, or derived from the epigastric axis, are generally available to reconstruct defects of the torso. However, microvascular free flap reconstruction may occasionally be required for: 1) locations that are difficult to reach with pedicle flaps (the posterolateral iliac crest region, epigastrium, lower lumbar and sacral, and upper back and lower central); 2) locations in which muscles or their vascular pedicles have been destroyed by surgical ablation or irradiation; 3) a large-volume "dead space" or a large surface area that may be inadequately covered by available regional flaps; and 4) a combination of factors. Whether using a pedicle or free flaps, the reconstructive requirements of torso reconstruction must be met: 1) to restore chest wall or abdominal wall integrity, 2) to fill "dead space," 3) to cover vital exposed structures, 4) to maintain skeletal stability of the thoracic cage and minimize respiratory compromise, and 5) to buttress visceral repairs. Semin. Surg. Oncol. 19:255-263, 2000.

Reconstruction of fingertip amputations with full-thickness perionychial grafts from the retained part and local flaps.

The treatment of fingertip amputations distal to the distal interphalangeal joint when the amputated part is saved is difficult and controversial. Both reattachment of the amputated portion as a composite graft and microvascular anastomosis are prone to failure in this distal location. The authors have evolved a reconstructive plan that uses the nail matrix, perionychium, and hyponychium of the amputated fingertip as a full-thickness graft when the amputation is between the midportion of the nail bed andjust proximal to the eponychial fold. Various flaps are used to lengthen and augment the finger pulp, and skeletal pinning is carried out as necessary. The charts of 15 patients who underwent this procedure over a 38 month period were evaluated retrospectively. Seven returned to the office for examination at least 1 year after the fingertip reconstruction described above; four others were interviewed by telephone. Nail deformity, fingertip sensation, and joint range of motion were evaluated, and the reconstructed fingertips were photographed in standardized views. In six of the seven patients seen in the office, aesthetic and functional results were judged as good by both patient and physician; one of the six had minimal nail curvature. The seventh patient had no nail growth, although finger length was retained and there was no functional disability. The four patients interviewed by phone reported normal fingertip use with no dysesthesias or cold intolerance; all had nail growth, although three patients described slight nail curvature that required care in trimming. The authors favor salvage of all perionychial parts when a distal fingertip amputation occurs. Reconstruction of the fingertip with grafting of the hyponychium, perionychium, and nail matrix from the amputated part combined with local flaps can provide a very satisfactory functional and aesthetic result.

Treatment of acute neonatal vascular injuries--the utility of multiple interventions.

BACKGROUND/PURPOSE: Vascular injuries in neonates are a rare complication of the varied invasive procedures performed in these small children. Unfortunately there remains a reluctance to repair these injuries early, often because of the relative small size of the affected vessels and the nature of the patient's underlying medical condition. The authors report a consecutive series of patients treated for arterial and venous injuries early in their course using a variety of microsurgical techniques. METHODS: A retrospective chart review was performed of consecutive patients (n = 7) treated over a 2-year period. All had injury as a result of invasive procedures performed in the neonatal period. Both arterial and venous injuries that required some form of intervention were included. RESULTS: Five arterial and two venous injuries were identified. Surgical thrombectomy and microvascular repair was required in two patients. Primary healing occurred despite prolonged (>13 hours) warm ischemia time. Pseudoaneurysms of the brachial artery and radial artery were controlled with surgical ligation, and one patient required bilateral fasciotomies for compartment syndromes related to severe spasm of the common femoral arteries. Phlegmasia cerulea dolens of the lower extremity (n = 2) was treated with leech therapy. All patients healed without tissue loss or functional deficit. CONCLUSIONS: A variety of microvascular interventions have application to the treatment of acute vascular injuries in neonates. Early, aggressive use of these techniques can provide effective therapy for these potentially devastating injuries and allow for complete limb recovery without tissue loss.

Evaluation of results and treatment variables for pressure ulcers in 48 veteran spinal cord-injured patients.

This retrospective study of 48 spinal cord-injured patients with pressure ulcers seen at a tertiary referral Veterans Hospital spinal cord injury unit between 1992 and 1997 correlates a number of variables (co-morbid conditions, nutritional status, smoking history, type of repair performed, type of bed used postoperatively, ulcer location and severity, duration of postoperative antibiotic therapy, time elapsed before sitting rehabilitation began, and length of hospital stay) with ulcer repair outcome measures, including postoperative systemic and wound-healing complications, recurrence rates, and the development of new ulcers at different sites. Surgical complication rates were high, occurring in 19 patients (39.6%), and ulcer recurrence or new ulcer development occurred in 38 patients (79.2%). Correlations were found between ulcer location and postoperative wound separation and the length of hospitalization. The hospital course was shorter if the ulcer was new rather than recurrent. Other than the finding that chronic smokers had longer courses of antibiotic therapy, smoking did not correlate statistically with other outcome variables, including wound-healing complications. No significant correlations were found between any postoperative systemic or wound complications, ulcer recurrence, or new ulcer development and patient age, level of spinal cord injury, number of ulcers and grade, laboratory values, mental status, cardiac or pulmonary disease, diabetes, and presence or absence of osteomyelitis.

The life span of silicone gel breast implants and a comparison of mammography, ultrasonography, and magnetic resonance imaging in detecting implant rupture: a meta-analysis.

Because of the growing concern surrounding the integrity and life span of silicone gel breast implants and the reported variations in the diagnostic accuracy of various imaging techniques in identifying ruptured implants, the authors undertook a meta-analysis of articles in the scientific literature to examine these concerns. They were able to include reports from the literature that detailed the condition and removal of 1,099 breast implants during the past 7 years. The median life span of a silicone gel implant was estimated to be 16.4 years. Of the implants, 79.1% were intact at 10 years, falling to 48.7% by 15 years. The sensitivities and specificities of three imaging modalities used in the diagnosis of implant rupture (mammography, ultrasonography, and magnetic resonance imaging [MRI]) were also evaluated and compared statistically in an effort to discover which of the three techniques might serve as the most reliable screening tool in the diagnosis of gel implant rupture. The sensitivity of mammography for finding a ruptured implant is 28.4% with a specificity of 92.9%. Ultrasonography has a sensitivity and specificity of 59.0% and 76.8% respectively compared with MRI, which was 78.1% and 80.0% respectively. For implants in place for 10 years, one would need to image 3.3 implants by ultrasound to identify a single possible rupture. However, because of the 76.8% specificity, 8.1 implants would need to be imaged to find a confirmed intraoperative rupture. This was similar to MRI, in which 3.1 implants would need to be imaged to detect one suspected rupture, and 6.1 implants would need to be imaged to find one intraoperatively confirmed rupture. The authors do not recommend either ultrasound or MRI as a screening tool based on their meta-analysis.

Division of the transverse carpal ligament and flexor tendon excursion: open and endoscopic carpal tunnel release.

Ten fresh cadaver upper extremities from 10 different subjects were used in this study of the effect of both open and endoscopic carpal tunnel release on flexor tendon excursion. The amount of excursion necessary to bring each finger from the fully extended to the fully flexed position with the fingertip just touching the palm was measured with the extremity mounted in a device that moved the wrist from extension through flexion. Endoscopic carpal tunnel release, open release, and transverse carpal ligament reconstruction were performed with tendon excursion measurements made in each of four wrist positions after each procedure. Fingertip to palm distance was also measured. The measurements of flexor tendon excursion in neutral wrist position with intact transverse carpal ligament served as the norm for each finger and as the denominator in the ratio of postoperative to preoperative excursion distances. The study confirmed the importance of the transverse carpal ligament as a flexor pulley; transection of the ligament increased the amount of flexor tendon excursion necessary to achieve finger flexion and fingertip-to-palm contact. Tendon excursion/digital flexion improved after transposition flap repair. Neither open nor endoscopic carpal tunnel release conferred any particular benefit to flexor tendon excursion postoperatively. The proximal palmar aponeurosis does not seem to have the same pulley effect as the transverse fibers of the distal palm.

Ulnar nerve entrapment at the wrist: cases from a hand surgery practice.

BACKGROUND: Eight patients with 11 instances of wrist-level ulnar nerve entrapment, a fairly uncommon compression syndrome, were identified in a hand surgery practice from 1992 through 1996. METHODS: Presentations, causes, and surgical outcomes were examined, and the pertinent literature was reviewed. RESULTS: All eight patients had extrinsic, nonidiopathic compression of the ulnar nerve caused by tumor, vascular disease, anomalous muscle development, or a tight fibrous arch at the origin of the flexor digiti minimi. In all cases, sensory symptoms resolved with removal of the cause of ulnar nerve compression. CONCLUSIONS: These cases serve to remind physicians that not every instance of numbness and tingling in the hand represents carpal tunnel syndrome. Careful clinical examination may not only localize compression of the ulnar nerve at wrist level but also may reveal its etiology. Some causes of ulnar compressive neuropathy, however, are apparent only with surgical exploration.