Finger deformities in rheumatoid arthritis.

Swan neck and boutonniere deformities describe the two most common afflictions of the interphalangeal joints attributable to rheumatoid arthritis. Two separate classifications have been described, with an emphasis on practical treatment. The complications that can occur are very significant and the decision to perform reconstructive surgery in these patients must be made with full consideration of the patient's disease process, careful functional evaluation of the patient, specific adjacent joint involvement, and the overall treatment plan for improving the patient's function. The timing of hand, foot, and large joint surgery is complex and requires excellent communication among the patient and all the treating specialists, including the primary internist, rheumatologist, orthopaedic surgeon, and hand surgeon. The care for these patients is served best by a coordinated team approach.

Intrinsic muscle flaps: the treatment of painful neuromas in continuity.

Treatment of the pain that is caused by neuroma in continuity in a digital nerve on the palmar surface of the hand is a challenging problem. Eight digital nerves were covered with intrinsic muscle flaps after neurolysis to obtain relief of symptoms in eight patients. Four of the cases involved intrinsic muscles for digital nerves in the thumb. Four patients had digital nerves in the palm covered by lumbrical muscle flaps, two of which were distally based. All patients had significant relief of their symptoms. This report describes the techniques used and their application.

Pisiform-hamate coalition with ulnar neuropathy.

Two cases of pisiform-hamate coalition with compression of the ulnar nerve at the wrist are reported. Pisiform-hamate coalition is a rare entity previously thought to be exclusive to West Africans and without clinical significance. These cases occurred in white patients. This is the first description of a carpal coalition resulting in ulnar neuropathy at the wrist.

Wafer distal ulna resection for triangular fibrocartilage tears and/or ulna impaction syndrome.

Partial resection of the distal ulna (wafer resection) has been used to treat patients with symptomatic tears of the triangular fibrocartilage complex or mild ulna impaction syndrome. In this procedure, the distal 2 to 4 mm of the distal ulnar head is resected while preserving the ulnar styloid process and the ligaments attached to it. The triangular fibrocartilage is debrided, repaired, or partially excised as necessary. The procedure is contraindicated if there is more than 4 mm of positive ulnar variance. Thirteen wafer resections of the distal ulna were performed in 12 patients. All had good to excellent results after a minimum follow-up of 1 year. Wafer resection has specific advantages and avoids many of the potential complications of distal ulna recession and ulnar head resection for patients with the conditions described. The procedure is not indicated if instability or degenerative arthritis of the distal radioulnar joint is present or if there is carpal instability.

The "wafer" procedure. Partial distal ulnar resection.

A technique of partial resection of the distal ulna ("wafer" procedure) for the treatment of patients with symptomatic tears of the triangular fibrocartilage complex or mild ulnar impaction syndrome or both is described. The distal 2-4 mm of the distal ulna is resected while preserving the distal radioulnar joint and the styloid process of the ulna and the ligaments attached to it. The triangular fibrocartilage can be debrided, repaired, or partially excised. The wafer procedure has several advantages and avoids some of the potential complications of other treatment methods.

Psoriatic arthritis in the hand.

Psoriatic arthritis is a polyarthropathy distinct from rheumatoid arthritis and associated with onychodystrophy and skin lesions. Patients present with stiffness, flexion and extension contractures, digital swelling, or painful joints. Psoriatic arthritis mutilans is a rapidly progressive osteolysis resulting in severe deformity. Radiographs reveal widened joint spaces with interphalangeal joint destruction, resorption of the distal tufts, and frequently spontaneous fusion. Surgery involves mainly salvage procedures to relieve pain or improve position, as the increase in motion obtained usually is limited.

Degenerative diseases of the metacarpophalangeal joints.

Degenerative arthritis of the finger metacarpophalangeal joints is uncommon and, when seen, a specific etiology should be sought. MP joint arthritis in the absence of a history of trauma may signal an underlying systemic disease. The clinical and radiographic findings may be subtle. Once degenerative changes occur, the usual treatment is arthroplasty using a flexible silicone rubber (Swanson) finger joint implant that should provide a relatively stable and painless joint with a functional range of motion. Degenerative arthritis of the thumb MP joint is more common following injuries that damage the ligaments on the ulnar or radial side of the MP joint and which result in lateral instability of the joint. Arthritis of the MP joint also may occur following infection or direct joint injury. Secondary MP arthritis may result from thumb CMC joint disease and must be attended to at the time CMC joint reconstruction is performed. Degenerative disease of the thumb sesamoid bones must be considered in patients with persistent MP joint pain after either trauma or MP joint fusion.

Double level amputation: should it be replanted?

Multiple level amputation has been described as a contraindication to replantation. This is a case report of a patient with a double level amputation through the palm and forearm that was successfully replanted. Because of the need for multiple stages of reconstructive surgery, it was not clear until the end result that the replantation was worthwhile. The patient developed an acute respiratory distress syndrome that was probably caused by the reperfusion phenomenon. The stages of reconstruction are described in detail, as are the problems encountered. The final result included a reasonably functional hand that was far superior to the prosthetic alternative.

Osteoid osteoma of the hand.

A review of all cases of osteoid osteoma of the hand seen by four hand surgeons over the last 10 years was performed. Seven cases were documented. Average follow-up was 28.3 months. Average age of the patients was 21.1 years. Five men and two women participated. Six lesions were in the right and one in the left upper extremity. Delay from presenting symptoms to definitive treatment averaged 13.5 months with a range of 7 to 30 months. Surgical excision was curative in all cases. We concluded that although a very unusual occurrence, osteoid osteoma of the hand should be considered in the differential diagnosis of pain in the hand.

The natural history of scaphoid non-union. A review of fifty-five cases.

We reviewed the cases of fifty-six scaphoid non-unions in fifty-five patients, none of whom had received treatment of any kind before examination. In the thirty-two patients who had been injured five years or more earlier, arthritis developed in thirty-one (97 per cent). The one patient in whom osteoarthritis developed less than four years after injury also had avascular necrosis of the scaphoid. The incidence of osteoarthritis increased with time after injury. We concluded that patients with established scaphoid non-union should be advised that osteoarthritis will most likely develop.

Closed reduction and internal fixation of proximal phalangeal fractures.

Displaced fractures of the shaft of the proximal phalanx can lead to marked deformity and disability when poor results are obtained. Despite the attention popular concepts of open reduction and internal fixation have received, a less invasive technique has been our standard approach. A prospective study of closed reduction and percutaneous Kirschner wire fixation in 100 consecutive fractures yielded good or excellent results in 90% of cases when treated within 5 days of injury.

Experience with epigastric free flap transfer in the rat: technique and results.

We have described the advantages and disadvantages of using the rat epigastric free flap as a means of studying transplantation phenomena. The study comprises 20 epigastric free flap autografts in rats. After 1 1/2 years of working on the model, we achieved a 75% success rate in the last 20 consecutive procedures. From our experience with this model, we feel that the rat epigastric flap has a place in the study of transplantation phenomena in the experimental laboratory. In addition, we feel that this is an excellent technical exercise for maintaining proficiency in performing microvascular anastomoses.

Hand involvement in psoriatic arthritis.

From a population of 105 patients with confirmed psoriatic arthritis, 25 patients required hand surgery. These 25 surgical patients were evaluated retrospectively both clinically and radiographically. The patterns of hand and wrist involvement as well as the results of surgery differed from those typically seen in rheumatoid disease. Spontaneous fusion of the wrist in a functional position, severe proximal interphalangeal involvement often with marked flexion contractures, severe erosion of the distal interphalangeal joint with spontaneous fusions, and generalized stiffness characterize these hands. Minimal improvement in motion and a significantly increased incidence of infection following arthroplasty were noted.

Bowler'S thumb in a baseball player: a case report.

A professional baseball player presented with a tender, painful and clinically enlarged ulnar digital nerve to the thumb which prevented him from batting. Thumb sensation was normal. At surgery, a 1.5 cm-length of the digital nerve was found to be thickened and enlarged. His condition was cured by detaching the adductor tendon and transplanting the nerve dorsal to the adductor muscle.

Solitary osteochondroma of the cervical spine.

Solitary osteochondroma of the cervical spine is extremely rare. We reviewed the literature on this disorder, studied a case of an osteochondroma arising from the bony margin of the foramen transversarium of the sixth cervical vertebra, and concluded that osteochondroma should be considered in the differential diagnosis of a palpable mass in the neck. Despite the benign histologic nature of osteochondromata, those located in the cervical spine in proximity to vital vascular and neurologic structures should be excised surgically.