Spontaneous Rupture of the Extensor Pollicis Longus with the Extensor Pollicis Brevis Deformity.

This paper examines three cases of spontaneous ruptures of the extensor pollicis longus (EPL) with the extensor pollicis brevis (EPB) deformity. The patients ranged from 39 to 71 years old. Non-dominant hands were involved in all three cases. There were no trauma nor pathological cause of EPL ruptures. A tendon transfer using the extensor indicis proprius was performed in each case. Intraoperative findings showed hypoplastic EPB in one case and EPB defects in two cases. A weak or defective EPB puts an excessive load on the EPL, which might be one of the causes of spontaneous EPL rupture.

The radial nerve palsy caused by embedding in the humeral shaft fracture - a case report.

This paper examines a case of radial nerve palsy in a 13-year-old girl caused by nerve embedded in a humeral shaft fracture. An X-ray showed a mild angular-displaced humeral shaft fracture. Two weeks later, an intramedullary Ender nailing was performed. Because of brain injury due to traffic accident, the patient lost consciousness for one month. Once she regained consciousness, radial nerve palsy was discovered and closely observed. As the radial nerve palsy had not healed after five months, the radial nerve was explored and found to be interposed between fracture sites and totally entrapped in the fracture callus. During surgery, both the proximal and distal ends of the radial nerve were cut at the surface of the humeral bone. Then, the radial nerve stumps were end-to-end sutured because of their enough length. One year after surgery, the radial nerve palsy had completely recoverd.

Fixation of an ulnodorsal fragment when treating an intra-articular fracture in the distal radius.

If fixation of an ulnodorsal fragment in an intra-articular fracture of the distal radius is not stable, it is sometimes caused by dorsal displacement after surgery. Hence, we recommend the volar plate fixation with an additional dorsal approach and fixation of irreducible ulnodorsal fragments using a low-profile dorsal mini plate. The details of the surgical procedure and indications are discussed in this article.

A large extraskeletal chondroma in the hand of an elderly patient--a case report.

This paper examines a case of extraskeletal chondroma in the hand of an 82-year-old female, first noticed about two years ago. Magnetic resonance imaging showed a mass in the carpal tunnel which extended from the wrist to the palm. The tumor was located between the thenar area and the hypothenar area at the palm level. There was no continuity to the carpal bone or radius bone. The entire size of the tumor was 120 mm × 45 mm × 42 mm. Although extraskeletal chondroma is sometimes seen, a large one in the hand is extremely rare. Since the tumor was too large to excise totally because median nerve entrapped it, it was divided into two parts and excised. After the operation, there was no neurological deficit or pain in the median nerve lesion.

Ossified median nerve schwannoma: a case report.

A case of ossified median nerve schwannoma in the left arm, first noticed about 40 years ago is examined. Although calcification of old schwannoma is sometimes seen, new bone formation in a schwannoma is extremely rare. Since there was a strong adhesion between the tumour and the median nerve in this case, the tumour could not be enucleated easily. The tumour was excised under a surgical microscopy without any neurological deficit.

The bilateral ulnar artery involvement in Type IV Ehlers-Danlos syndrome - a case report.

Ehlers-Danlos syndrome Type IV, the vascular type, is a rare hereditary condition. Major arteries are often affected in this type. In this paper, we present the first case report in the world in which forearm compartment syndrome caused by the bilateral ulnar artery rupture in this type. Successful treatment such as incision of the forearm fascia and ligation of the ulnar artery was performed.

Median nerve palsy: a complication of brachial artery cardiac catheterization.

The patient, an 83-year-old male with ischemic cardiac disease, was examined using a periodical left brachial artery cardiac catheterization. Six hours after the examination, complete median nerve palsy appeared. Four months later, the median nerve was explored and found to be compressed by a hematoma in the brachial artery. The location of the hematoma was at 6 cm proximal to the puncturing point, because the catheter may have penetrated the brachial artery from the lumen. The median nerve was released and the hematoma removed. One year after surgery, the median nerve palsy had disappeared.

Trigger finger at the A2 pulley in children--two case reports.

Trigger fingers, especially trigger at the A2 pulley, are extremely rare. We experienced two cases of the trigger finger at the A2 pulley and treated them surgically. A flexor digitorum profundus (FDP) nodule was located at the distal entry zone of the A2 pulley in case 1; therefore, the digit could not be flexed. The FDP nodule was located at the proximal entry zone of the A2 pulley in case 2, so the digit could not been extended. The surgical treatment was successful in removing the triggering in both the cases.

Percutaneous screw fixation without bone graft for cystic-type scaphoid fractures.

BACKGROUND: The most controversial problem in treating scaphoid fractures is whether bone grafts are necessary for cystic-type fractures. METHODS: We treated 105 scaphoid fractures using Herbert screws (1988-1997), AO 3.0 mm cannulated screws (1998-2002), and Acutrak screws (2003-2006). The patients ranged in age from 14 years to 67 years (average, 26 years). Our classifications were based on the radiographic findings: linear type (51 cases); cystic type (24 cases); and sclerotic or displaced type (30 cases). Linear and cystic types did not have any displacement more than 2 mm. If the fracture line had a sclerotic zone thicker than 1 mm, it was classified as sclerotic or displaced. The length of time before surgery did not affect the classification. Osteosynthesis was performed--without bone graft in all linear cases, with a bone graft in 7 and without a bone graft in 17 cases in cystic type, and with all bone graft in sclerotic or displaced type. RESULTS: Bone union was achieved in all cases in linear type. There were one failure (AO) in 7 cases with bone graft and 3 failures (1 Herbert and 2 AO) in 17 cases without bone graft in cystic type. All 10 cases achieved bone union without bone graft in cystic type using Acutrak screw. There were two failure cases (2 AO) in sclerotic or displaced type. CONCLUSIONS: Screw fixation without bone graft using Acutrak screws was a reliable strategy for the treatment of cystic-type scaphoid fractures.

Relative longitudinal motion of the finger flexors, subsynovial connective tissue, and median nerve before and after carpal tunnel release in a human cadaver model.

PURPOSE: The normal gliding environment in the carpal tunnel is complex. The median nerve and flexor tendons are surrounded by a multilayered subsynovial tissue. To date, observations of the relative motions of the flexor tendon, median nerve and multilayered subsynovial tissue have been through a surgically released open carpal tunnel. The purpose of this study was to compare the motions of these tissues in an intact and open carpal tunnel. METHODS: We measured the relative motion of the middle finger flexor digitorum superficialis tendon, its surrounding subsynovial connective tissue (SSCT) and the median nerve in 8 human cadavers. The flexor retinaculum was used as a fixed reference point. The motions were compared for simulated isolated middle finger and simulated fist motion as measured fluoroscopically in the closed carpal tunnel and directly in the open carpal tunnel. RESULTS: While the simulated isolated finger motion produced significantly less SSCT and median nerve motion (p<.05), there was no difference in flexor digitorum superficialis, SSCT, or nerve motion when comparing the fluoroscopic measurements in the closed carpal tunnel with the direct visual measurements in the open carpal tunnel. CONCLUSIONS: Relative motion of the flexor tendons, SSCT, and median nerve within the carpal tunnel follows a certain pattern, which may indicate the physiological state of the SSCT. This relative motion pattern was not affected by flexor retinaculum release.

The mechanical properties of the rabbit carpal tunnel subsynovial connective tissue.

The rabbit model is commonly used to study carpal tunnel syndrome (CTS). It has been proposed that the subsynovial connective tissue (SSCT) in the carpal tunnel may play a role in the etiology of CTS, but the material properties of the rabbit SSCT are unknown. The purpose of this study was to develop a method to measure the shear properties of the rabbit SSCT. In six rabbit cadaver forepaws, the excursion of the third digit flexor digitorum superficialis (FDS) and load to failure of the SSCT were measured in a custom device. The mean excursion to full flexion in this model was 7.08mm (S.D. 0.77). The mean shearing force at full flexion was 317 mN (S.D. 166). At full flexion percentage of maximum shear force in the SSCT was 54.5% (S.D. 19.4). The mean energy absorbed at full flexion was 0.29mJ (S.D. 0.31). The mean excursion needed to reach 5% of the maximum shear force was 3.04mm (S.D. 0.99). The testing model presented in this study demonstrates structural parameters to evaluate the shear properties of the SSCT in a rabbit model. The data presented could be used for estimating sample sizes in a more comprehensive study of the effect of CTS on the SSCT properties.

Evaluation of the material properties of the subsynovial connective tissue in carpal tunnel syndrome.

BACKGROUND: The purpose of this study was to determine the material properties of the normal carpal tunnel subsynovial connective tissue in response to shear stress. METHODS: The shear modulus and maximum shear strength were measured with a custom-made micro-tester in 10 specimens of subsynovial connective tissue from 10 wrists in eight patients with idiopathic carpal tunnel syndrome and in 10 specimens from five fresh frozen cadavers without a history of carpal tunnel syndrome. FINDINGS: The mean shear modulus was 22.8 (SD 15.4)kPa for the patient group and 2.7 (SD 1.8)kPa for the control group. The mean maximum shear strength was 54.6 (SD 20.3)kPa for the patient group and 23.3 (SD 10.7)kPa for the control group. The values for the patient group were significantly higher than the control group (P<0.05). INTERPRETATION: The material properties of subsynovial connective tissue are altered in patients with idiopathic carpal tunnel syndrome. The impact, if any, of these altered properties on carpal tunnel syndrome remains to be elucidated.

Giant cell tumour in the tendon sheath of the hand: importance of the type of lesion.

There are more diffuse giant cell tumours of the tendon sheath than we had expected, and we recommend excising them microscopically. We have treated 18 patients since 1988. They had two types of tumour: 10 nodular, and eight diffuse. We used a microscope to excise diffuse tumours. In the only case in which we did not use a microscope for a diffuse tumour, the tumour recurred. It spread to an adjacent joint in six diffuse tumours, but no nodular tumours. The detection of diffuse lesions was difficult without a microscope.

Permeability of the subsynovial connective tissue in the human carpal tunnel: a cadaver study.

BACKGROUND: The purpose of this study was to determine the permeability of the normal carpal tunnel subsynovial connective tissue. METHODS: Subsynovial connective tissue samples (10mm(2)) were obtained from 10 fresh frozen human cadavers without a history of carpal tunnel syndrome. The thickness of the sample was measured using a charge-coupled device laser displacement system. Each specimen was tested for permeability in a closed pressure chamber at 13.8, 41.3, 68.9 and 96.5 kPa. FINDINGS: Since permeated flow was very low in all specimens, the permeability could be calculated only for eight specimens at 96.5 kPa pressure and for three specimens at 68.9 kPa. The mean permeability at 96.5 kPa was mean 0.89 (SD 0.93)x10(-14)m(4)/Ns and at 68.9 kPa was mean 1.04 (SD 1.54)x10(-14)m(4)/Ns. INTERPRETATION: The subsynovial connective tissue is the most characteristic tissue in the carpal tunnel; it is found in no other location in such abundance. It is well known that carpal tunnel syndrome is the result of increased pressure within the carpal tunnel. This lack of permeability in the subsynovial connective tissue may explain the predisposition of this region for pressure buildup and subsequent neuropathy.

Detection of differential gliding characteristics of the flexor digitorum superficialis tendon and subsynovial connective tissue using color Doppler sonographic imaging.

OBJECTIVE: The subsynovial connective tissue (SSCT) is the most characteristic structure in the carpal tunnel and is substantially affected in cases of carpal tunnel syndrome. We investigated the usefulness of Doppler sonography for measuring velocity differences between the flexor tendon and its associated SSCT in the carpal tunnel of cadaver hands. METHODS: Six human cadaver wrists were used in this study (mean age of death, 82.2 years). The velocity difference between the middle finger flexor digitorum superficialis tendon and its corresponding SSCT was measured on a sonography machine equipped with a fingertip 13-MHz linear probe. RESULTS: At tendon velocities of greater than 2.5 cm/s, the tendon velocity was significantly greater than the SSCT velocity (P < .05). At less than 2.5 cm/s, there was no significant difference between tendon and SSCT velocities. CONCLUSIONS: Color Doppler imaging can identify and track SSCT motion separately from that of its associated tendons. Analysis of SSCT motion characteristics by color Doppler imaging may be useful for studying its function clinically.

Gliding characteristics between flexor tendons and surrounding tissues in the carpal tunnel: a biomechanical cadaver study.

The purpose of this study was to investigate the gliding characteristics of flexor tendons within the carpal tunnel with varied wrist positions and tendon motion styles, which may help us to understand the relationship between carpal tunnel syndrome (CTS) and repetitive hand motion. Eight fresh human cadaveric wrists and hands were used. The peak (PGR) and mean (MGR) gliding resistance of the middle finger flexor digitorum superficialis tendon were measured with the wrist in 0, 30, and 60 degrees of flexion and extension. While moving all three fingers together, the PGR at 60 degrees flexion was significantly higher than that at 0, 30, or 60 degrees extension. While moving the middle finger alone, the PGR at 60 and 30 degrees flexion was significantly higher than the PGR at 60 degrees extension. The PGR moving the middle finger FDS alone was significantly greater than that for all three digits moving together in 0, 30, and 60 degrees flexion. Differential finger motion with wrist flexion elevated the tendon gliding resistance in the carpal tunnel, which may be relevant in considering the possible role of wrist position and activity in the etiology of CTS.

Segmental carpal canal pressure in patients with carpal tunnel syndrome.

PURPOSE: To clarify which part of the median nerve is the most compressed and to compare carpal canal pressure with the latency of the sensory nerve potential and the duration of symptoms. METHODS: Fifteen patients with idiopathic carpal tunnel syndrome were studied using a pressure guidewire system to record canal pressure. The wire was introduced from the distal end of the carpal canal to 2 cm proximal to the distal wrist crease (DWC) and then retracted in 5-mm increments using an image intensifier to guide the progress. A nerve conduction study was performed, and all patients were asked how long the symptoms lasted. RESULTS: Carpal canal pressure was significantly higher 5 to 15 mm distal to the DWC. The most compressed point was 10 mm distal to the DWC, with a pressure of 44.9 +/- 26.4 mm Hg. The correlation coefficient between the highest canal pressure and the latency was 0.393 and between highest canal pressure and duration of symptoms was 0.402. CONCLUSIONS: Our study showed that the most compressed part of the median nerve in the carpal canal is 10 mm distal to the DWC. The carpal canal pressure was related to the latency and to the duration of symptoms.

Induction of interleukin-6 in dorsal root ganglion neurons after gradual elongation of rat sciatic nerve.

In the reconstruction of a segmental defect in injured peripheral nerves, gradual nerve elongation has become an important alternative to nerve grafting. To clarify biochemical responses in peripheral sensory neurons after nerve elongation, we examined the expression of cytokines and neurotrophins related to nerve regeneration. We first established rat elongation models by lengthening left femurs up to 20.0 mm at the rate of 1.0, 2.0, or 20.0 mm/day. In toluidine blue staining, the acutely elongated, 20-mm/day group showed nuclear eccentricity in the nerve cell body in L5 dorsal root ganglion (DRG) and axonal degeneration in the sciatic nerves; in contrast, the gradually elongated, 1- and 2-mm/day groups remained intact, indicating adaptation. Reverse transcription-polymerase chain reaction analysis revealed that interleukin-6 (IL-6) mRNA was induced in ipsilateral L4-6 DRG in an elongation rate-dependent manner. In contrast, none of the elongated groups exhibited a significant change in mRNA levels for interleukin-1beta, tumor necrosis factor-alpha, nerve growth factor, brain-derived neurotrophic factor, neurotropnin-3, and neurotrophin-4/5. Levels of IL-6 mRNA in all the elongated groups reached the maximum level at day 4 after 20-mm lengthening, while the axotomized group showed a decrease from the maximum level at day 1. Induction of IL-6 mRNA was also detected in the contralateral L4-6 DRG of all the elongated groups, but not detected in the axotomized group. In histochemical analysis, IL-6-immunoreactivity was predominant in neurofilament-positive, medium to large DRG neurons. Application of IL-6 to cultured Schwann cells increased mRNA for peripheral myelin protein 22 (PMP22), a major myelin component. These results suggest that IL-6 plays a key role in biochemical responses in peripheral sensory neurons after gradual nerve elongation.