Triggering of the Digits After Carpal Tunnel Surgery.

INTRODUCTION: Carpal tunnel syndrome (CTS) and trigger finger may be seen simultaneously in the same hand. The development of trigger finger in patients undergoing CTS surgery is not rare, but the relationship between these conditions has not been fully established. The aims of this prospective randomized study were to investigate the incidence of trigger finger in patient groups undergoing transverse carpal ligament releasing (TCL) or TCL together with distal forearm fascia releasing and to identify other factors that may have an effect of these conditions. MATERIALS AND METHOD: This prospective randomized study evaluated 159 hands of 113 patients for whom CTS surgery was planned. The patients were separated into 2 groups: group 1 (79 hands of 57 patients) undergoing TCL releasing only and group 2 (80 hands of 56 patients) undergoing TCL and distal forearm fascia releasing together. The age and gender of the patients, dominant hand, physical examination findings, visual analogue scale (VAS), and electromyography (EMG) results were recorded. Follow-up examinations were made at 1, 3, 6, 12, and 24 months for all patients. We noted development of trigger finger in the surgical groups, and its location and response to treatment. RESULTS: The incidence of trigger finger development was statistically significantly different between group 1 and group 2 (13.9% and 31.3%, respectively). The logistic regression analysis of factors affecting the development of trigger finger posttreatment found that the surgical method and severity of EMG were significant, whereas the effects of the other factors studied were not found to have any statistical significance. CONCLUSION: There was an increased risk of postoperative trigger finger development in patients undergoing TCL and distal forearm fascia releasing surgery for CTS compared to those undergoing CTL only. There is a need for further studies to support this result and further explain the etiology.

Wrist tourniquet: the most patient-friendly way of bloodless hand surgery.

BACKGROUND: The literature is scarce on wrist tourniquets. In this study, three well-established locations of tourniquet setting including upper arm, proximal forearm, and wrist were compared on the same limb using both clinical as well as biochemical variables in paramedical volunteers. METHODS: Twenty unmedicated, healthy, paramedical, right-hand dominant volunteers participated in the study. The left upper arms were used for monitoring. Blood pressures and heart rates were monitored and recorded before (baseline) and immediately after the application of the tourniquet, every 5 minutes, and at the time the patient requested deflation. An intravenous cannula (22 G) was placed on the right hand to obtain samples, which were taken at baseline and immediately after deflation of the tourniquet to evaluate the levels of pO2, pCO2, O2 saturation, pH, bicarbonate, blood sugar, lactate, hematocrit, and electrolytes. The tourniquets were applied to the right upper arm, forearm, and wrist of each subject with 5-day intervals between each trial. Subjective discomfort and tourniquet pain levels were recorded. For each trial, tourniquet tolerance and details of discomfort were recorded. Statistical analysis was performed as appropriate. RESULTS: Twenty volunteers aged 20 to 44 years were included. For each trial, in the first 10 minutes after inflation of the tourniquet, the heart rate and systolic blood pressure were increased compared with baseline values. Diastolic blood pressure was elevated immediately after inflation and remained so until deflation in each trial. Diastolic blood pressure values were higher in the upper-arm tourniquet group compared with wrist. Then pH, pO2, and O2 saturation values were decreased and pCO2 and lactate levels were increased compared with baseline values in each trial. Blood sugar was decreased significantly in the arm group. The decrease in pH, pO2, O2 saturation, and blood sugar in the upper arm group was significantly higher compared with wrist and forearm groups. The lactate value was higher in the upper arm group compared with wrist. Visual analog scale and numerical rating scores were lower in the wrist group compared with others at all times. The longest tourniquet tolerance was in the wrist group. In the wrist group, curling was observed in all subjects but the fingers could easily be extended. CONCLUSION: The wrist tourniquet is the most comfortable technique of bloodless surgery for procedures limited to the hand region.

Loading is more effective than posture in lumbar spinal stenosis: a study with a treadmill equipment.

The objective of this study was to assess the correlation between neurogenic intermittent claudication (NIC) in LSS and different positions as well as loading status, using the treadmill device. The study was a prospective clinical trial on lumbar spinal stenosis (LSS) using a treadmill equipment. The study population comprised of 80 LSS patients with a mean age of 61. The equipment included a treadmill, unloading station and loading vests. The patients were instructed to walk in five different positions. The initiation time of symptoms and total walking time were recorded. The examination was stopped after 20 min or at the onset of severe symptoms. In order to obtain pretest demographic data on subjects, visual analog scale, Roland-Morris questionnaire, pain disability index, and Beck depression index were used. The initiation time of symptoms (ITS) and total walking time (TWT) were measured during the test. Unloading provided a longer and loading a shorter ITS and TWT. Decline or incline positions did not affect ITS or TWT. The changes in posture had no correlation with the appearance of symptoms in LSS patients with NIC on a treadmill in this study, rather ITS and TWT were determined by axial loading and unloading.

The pain associated with intraarticular hyaluronic acid injections for trapeziometacarpal osteoarthritis.

Trapeziometacarpal osteoarthritis predominantly affects middle-aged women. Most cases with rhizarthrosis can be managed successfully by conservative means. The purpose of this prospective study was to evaluate pain and tolerability of viscosupplementation therapy with hyaluronic acid (HA) for trapeziometacarpal osteoarthritis. Groups A and B consisted of eight patients each with Eaton stage 3 or 4 rhizarthrosis, who underwent one cycle of three injections of (one per week) 0.3 cm3 sodium hyaluronate. The injections for group A were under fluoroscopy control, but fluoroscopy was not used in group B. Pain and tolerability of both groups A and B were measured and compared. The patients of the groups were also asked to evaluate the tolerability of the treatment. The results suggested that HA injection in the carpometacarpal joint is a tolerable procedure but the patients complained of pain and discomfort during the injections. The pain in group A was much greater than in group B. Viscosupplementation for the treatment of trapeziometacarpal osteoarthritis is a viable treatment option for stages 3 and 4 patients when they do not want to be operated on. It is a tolerable but not a painless procedure especially when it is done without fluoroscopy control. We recommend giving injections under fluoroscopy control.

The concomitant presence of two anomalous muscles in the forearm.

This article describes the concomitant presence of two anomalous forearm muscles in a 20-year-old man, discovered accidentally during an operation for a forearm injury. The first one was similar to a reverse palmaris longus muscle except for its direction to the Guyon's canal. The second one originated from the radial antebrachial fascia, superficial to all other forearm muscles in the lower half of the forearm, then diverged medially and extended into the Guyon's canal and was innervated by the ulnar nerve. The patient had no symptoms related to overcrowding of the Guyon's canal before the injury. A hand surgeon should be well informed about the anatomic variations of the hand to be comfortable during surgical practice.

Closed traumatic avulsion of both flexor tendons in the ring finger.

Traumatic rupture of the deep flexor tendon is a well-recognized entity known as "jersey finger". However, simultaneous traumatic rupture or avulsion of both flexor tendons in a finger without pre-existing disease is extremely rare. Such an injury is presented and discussed here, with regards to the mechanism, location, and treatment in comparison with similar reports in the literature.

Acute thrombosis of inferior vena cava in a pregnant woman presenting with sciatica: a case report.

A 20-year-old pregnant woman was admitted to our department with symptoms of deep venous thrombosis in the left lower extremity and excessive lumbar pain. Low-molecular-weight heparin was administered. She recovered with this treatment, however, severe lumbar pain continued. A lumbar magnetic resonance image showed dilated epidural veins compressing the roots and acute thrombosis of the inferior vena cava extending to renal veins. During the same period she had acute deep venous thrombosis in her right leg. An urgent venous thrombectomy was performed. Sciatica and deep venous thrombosis resolved after the operation. Low-molecular-weight heparin was administered until the end of her pregnancy.

Value of limited hip abduction in developmental dysplasia of the hip.

BACKGROUND: Developmental dysplasia of the hip (DDH) continues to be missed by routine physical examination in up to 50% of cases. Ultrasound (US) supplementation is the best method of screening for DDH, but the resources required should not be underestimated. Limited abduction of the hip (LHA) in an infant triggers suspicion, and often an urge to treat, in most orthopaedic surgeons and pediatricians alike. This study aimed to document the value of unilateral LHA in the diagnosis and decision making of DDH, and the correlation between LHA and US. METHODS: In total, 464 infants referred from the pediatrics clinic with LHA, aged between 30 and 120 days, were included in the study. RESULTS: Physical examination revealed LHA in 186 (41%) infants, 26 of which were unilateral and 160 were bilateral. US examination showed that 13 (8.1%) patients in the bilateral LHA group and 18 (69.2) patients in the unilateral LHA group, had DDH (total number 31, 7%). CONCLUSION: Unilateral limitation of hip abduction was found to be a sensitive sign for developmental hip dysplasia, but US could be defined once again as the best golden standard before initiating treatment.

A lasting solution is hard to achieve in primary hydatid disease of the spine: long-term results and an overview.

STUDY DESIGN: Retrospective evaluation of patients with primary hydatid disease was done, with an overview of the pertinent literature. OBJECTIVES.: To determine the results of surgical decompression and antihelminthic treatment. SUMMARY OF BACKGROUND DATA: Bone involvement in hydatid disease has been reported to be only 0.5 to 4%. Spinal involvement is found in 50% of these cases, with mortality over 50%. Paraplegia is the most serious complication of the disease, caused by compression of the spinal cord by the cysts. Aggressive surgery combined with antihelminthic therapy is recommended to eradicate the disease and prevent recurrence. METHODS: Three patients with primary spinal hydatid disease were operated on several times for multiple recurrences. Combined chemotherapy with either mebendazole or albendazole was also given. The mean age was 52 years, and the mean follow-up time was 92 months. RESULTS: Surgery and chemotherapy improved the symptoms in all cases but could not prevent recurrences and multiple operations. CONCLUSIONS: Primary spinal echinococcosis must be considered in the preoperative differential diagnosis of the atypical presentation of vertebral lesions, especially in patients with risk factors. Early diagnosis and preferably anterior radical surgery combined with antihelminthic therapy of sufficient duration are mandatory to at least halt the progression of symptoms, but these measures could not provide a lasting solution for the patients described here.

Vertebral artery loop formation: a frequent cause of cervicobrachial pain.

STUDY DESIGN: Patients with cervicobrachial pain were examined in detail with special attention to vertebral artery loop formation. OBJECTIVES: To determine the incidence, short-time natural course and response to a conservative approach to vertebral artery loop formation in a group of patients with cervicobrachial pain. SUMMARY OF THE BACKGROUND DATA: Vertebral artery loop formation is reported to be a rare cause of cervicobrachial neuralgia, discovered incidentally during the search for its cause. It can be congenital or acquired, occurring equally in both sexes. Surgical decompression has been the preferred method in the majority of reported cases, with favorable results. METHODS: One hundred seventy-three patients with cervicobrachial pain were examined in a period of 7 months using physical examination, radiography, and magnetic resonance imaging with or without angiography. RESULTS: Thirteen patients with a mean age of 43.9 +/- 13.5 years were diagnosed with vertebral artery loop formation. The most common level was C6-C7. Four patients presented with loop formation at two levels. None of the patients had symptoms attributable to intervertebral disc pathology. The complaints were in accordance with the level of the vascular pathology. Complete relief or decrease in pain was observed in all patients with the conservative approach. CONCLUSIONS: In patients with cervicobrachialgic symptoms and without established discopathy, during the examination of sagittal magnetic resonance images, vertebral artery loop formation should be kept in mind, and in suspected cases, the vertebral artery should be visualized using three-dimensional time of flight magnetic resonance angiography. Vertebral artery-nerve root relation should also be demonstrated using the multiplanar reformatting method from time of flight images. A conservative course of treatment has a favorable outcome.