Surgery of the spastic hand in cerebral palsy. Improvement in stereognosis and hand function after surgery.

Thirty-six patients with hemiplegic cerebral palsy had surgical treatment for the upper limb and were followed up for 18 months postoperatively. Various operations were done. A striking finding was a significant improvement of stereognosis (ability to describe and recognize objects without vision). Most patients had improvement in different functional grasps following surgical reconstruction. Range of movement in the forearm and wrist also increased in most patients. The thumb-in-palm deformity was completely corrected in 31 of the patients and improved in the other five. Most patients had some or all of their expectations of the procedure fulfilled.

Carpal tunnel syndrome in pregnancy. A prospective study.

In this prospective study, 56 women (2.3%) of 2,358 (47% nulliparous and 53% multiparous) delivered during a 12-month period at the Department of Obstetrics and Gynecology, Malmö General Hospital, had symptoms of carpal tunnel syndrome during pregnancy. All (33 nulliparous and 23 multiparous women) were examined, at the outpatient's maternity care unit and within 4-5 weeks from the time of debut of symptoms, by a specialist in hand surgery. At that time the most common symptoms were paresthesia and nocturnal pain. Twenty-nine had signs of reduced sensibility and 14 of them had a positive two-point discrimination test. All had generalized edema. Conservative treatment with splinting of the wrist at night made 46 out of 56 symptom-free. Of the remaining 10 women, 3 had to be operated on, whereas 7 received only conservative treatment, as the expected time for parturition was very close. One of them had to be operated on after delivery. In conclusion, carpal tunnel syndrome during pregnancy is most common in primiparas with generalized edema. Conservative treatment is sufficient for symptom relief in most women (80%) but a few cases need operative intervention to abolish the severe pain and to avoid disturbances of hand function.

Flap coverage for post-traumatic nerve pain in the arm.

14 patients with painful neuroma, skin hyperesthesia or neuralgic rest pain were followed up (mean 20 months) after excision of skin and scar, neurolysis and coverage with pedicled or free flaps. Painful neuroma had improved in 3 of 7 patients. Skin hyperesthesia had been eliminated in 8 of 11 patients, and had improved in 3. Neuralgic rest pain had been eliminated in 5 of 6 patients, and was partially relieved in one. It is concluded that painful neuroma in continuity is not relieved by flap coverage, whereas skin hyperesthesia and neuralgic rest pain are appropriate for this type of treatment.

Restoration of the digital tendon sheath. A new concept of tendon grafting.

The repair of flexor tendons which have been divided within the digital sheath remains an unsolved problem. Adhesions occur at would sites and points of tendon trauma. It is well known that an intact digital canal prevents formation of adhesions. Previous studies in chickens have shown that autologous tendon sheath tissue can successfully be transplanted from one digit to another with preserved vitality and that by this technique the continuity of an injured tendon sheath can be restored. The present series represent a clinical application of this new concept. 40 patients with flexor tendon injuries within the critical zone in the finger were treated by the use of a two-stage tendon grafting procedure. In the first stage operation the continuity of the tendon sheath was restored by transplantation of autologous synovial tissue. In the second procedure 3 months later a conventional tendon grafting was performed. Using the criteria of Boyes & Stark (1971) successful results were obtained in 88%. It can be concluded that the present method of tendon grafting provides a favourable recipient bed and improved gliding conditions.

Ulnar tunnel syndrome caused by anomalous muscles. Case report.

Two cases of ulnar tunnel syndrome at the wrist are described. In both cases an anomalous hypothenar muscle, flexor digiti minimi brevis accessorius, was in part the causative factor. Contributing to the symptoms of nerve compression was swelling associated with rheumatoid disease and Colles' fracture, respectively. Decompression of the nerve including subtotal removal of the anomalous muscle effected complete recovery. Its phylogeny, morphology and clinical significance are discussed in relation to previously described anomalies of the hypothenar muscles.

Volar tenosynovectomy in the rheumatoid hand.

Rheumatoid involvement on the flexor aspect of the hand is common, but is easily overlooked because of difficulty in clinical examination. It is our experience that this localization of the disease process is extremely important and that surgical treatment should be given high priority. In this study a series of 235 operations on the flexor aspect of the hand performed on 139 patients are presented. The results are very gratifying as far as tenosynovectomy in the carpal tunnel and the pain is concerned. When performed on the fingers, however, varying degrees of postoperative flexion contractures developed in no less than 44%. It was found that this problem arose when the synovectomy was extended beyond the level of the middle flexion crease of the finger being caused by excessive postoperative scar formation in the region volar to the proximal interphalangeal joint between the tails of the superficial tendon. It is concluded that less extensive surgery should be aimed at in this particular area.

Assessment of surgery of the rheumatoid wrist.

A series of 314 wrist operations performed on 227 patients with rheumatoid arthritis is presented. In 266 hands various wrist operations were undertaken with the object of synovial debridement and in 48 hands the wrist was also arthrodesed. The mean age at the time of surgical treatment was 51 years and the mean period of observation 4.2 years. This study shows that the main benefits of synovectomy are related to a constant and marked pain relief and prevention of tendon ruptures. The hope that synovectomy might arrest or prevent skeletal destruction was not realized and progression of X-ray changes was found in 74%. The very low recurrence rate in the present series as judged by clinical signs is probably not very significant and it is concluded that the X-ray findings are the most reliable criteria reflecting the real activity in a rheumatoid joint. In several wrists where prophylactic ulnar head resection had been performed through a small ulnar incision, an active dorsal tenosynovitis with tendon invasion developed later. These and other findings at the operation indicate that the erosive effect of the distal end of the ulna is certainly not the sole cause of tendon rupture in this area and that a complete exposure and decompression of the tendons should regularly be performed. Finally, arthrodesis of the wrist was so successful that it can be highly recommended.