Should parents accompany pediatric interfacility ground ambulance transports? The parent's perspective.

Parental accompaniment can be a positive experience for the parent and the patient, as perceived by the parent. It can also be accomplished effectively without hindering the delivery of intratransport medical care by a nurse/nurse or nurse/physician transport team. This survey, along with the responses from other parents, led our team to adopt the position that a parent is welcome and encouraged to accompany the transport team if he or she wishes to. The team has recognized the importance of the family unit during the stressful period surrounding an acute medical issue and interfacility transport. The transport team reserves the option to ask that a parent not ride along if they suspect the parent might not function as a supportive team member (ie, the parent is belligerent, inebriated, or hostile). The parent normally rides in the passenger seat of the ambulance, and we encourage him or her to interact with the patient as much as possible. Occasionally parents ride in the back of the ambulance if the patient's situation allows for that option (ie, no anticipated need for potential interventions, number of team personnel, etc.).

Revisitation of the vascular anatomy of the lumbrical and interosseous muscles.

Functional outcome after transmetacarpal replantations and revascularizations is discouragingly poor and often associated with a high incidence of intrinsic-related complications. In order to explore the hypothesis that intrinsic muscle ischemia may play a significant role, we revisited the vascular anatomy of the lumbrical and interosseous muscles. Six fresh-frozen cadaver hands were injected with latex-barium sulfate, and dissections were performed focusing on the contributions of the deep and superficial palmar arches and their branches to the intrinsic muscle vasculature. We found that the lumbrical muscles are supplied from both their volar and dorsal surfaces by both the superficial and deep palmar arches in both axial and segmental fashions. The dorsal and volar interossei receive their major blood supply from the deep arch and metacarpal arteries without any distinct pattern of axial or segmental vessels. These minute vessels cannot be repaired and are not reconstituted even with arch reconstruction. Moreover, with injuries distal to the arch, dissection of the digital arteries further disrupts this blood supply. These anatomic findings may have significant implications in clinical replantation and revascularization.

Severe contractures of the proximal interphalangeal joint in Dupuytren's disease: combined fasciectomy with capsuloligamentous release versus fasciectomy alone.

Severe proximal interphalangeal joint contracture in Dupuytren's disease presents a frustrating problem for hand surgeon. Some surgeons argue for fasciectomy alone, avoiding violation of the proximal interphalangeal joint, which may prolong morbidity and result in permanent limitation of flexion; this loss of flexion can be more disabling than a mild flexion contracture. Others favor capsulotomy in addition to fasciectomy, especially for severe contractures, to obtain additional release, arguing that one cannot completely correct secondary contracture by fasciectomy alone. We performed a retrospective review of severe flexion contractures (60 degrees or greater) involving 42 proximal interphalangeal joints in 28 patients with Dupuytren's disease. Twenty-seven joints in 18 patients underwent fasciectomy alone, and 15 joints in 10 demographically similar patients underwent capsulotomy in addition to fasciectomy. In the noncapsulotomy group, preoperative contracture averaged 78.4 degrees. Postoperative contracture averaged 36.6 degrees, with a 53 percent improvement. In the capsulotomy group, preoperative joint contracture averaged 82.5 degrees. Postoperative contracture averaged 36.8 degrees, with a 55 percent improvement. Intraoperative residual contracture for 21 of the 27 joints in the noncapsulotomy group averaged 7 degrees compared with 8 degrees for 9 of the 15 joints in the capsulotomy group. Preoperative proximal interphalangeal joint flexion averaged 100.6 degrees in the noncapsulotomy group and 98.6 degrees in the capsulotomy group. Postoperative flexion averaged 92.2 degrees in the noncapsulotomy group, which was 91.7 percent of preoperative flexion, and 82.7 degrees, which was 83.9 percent of preoperative flexion, in the capsulotomy group. No statistically significant difference was seen in the percentage of contracture correction in the capsulotomy group compared with the noncapsulotomy group at follow-up. The degree of correction initially obtained at surgery using either method was not maintained during the short follow-up period. There was a significant decrease in postoperative proximal interphalangeal joint flexion compared with preoperative flexion following either surgical approach; however, there was no significant difference between the two groups with respect to the percentage of flexion lost. Complications developed in both groups but tended to occur more commonly in the capsulotomy group. This study failed to show any advantage to capsuloligamentous release in addition to fasciectomy in treating severe proximal interphalangeal joint contracture due to Dupuytren's disease.

An approach to soft tissue sarcomas of the hand and upper limb.

Referral letters and histories of patients seen for sarcomas involving their hands repeatedly describe a serious tumour found during or after shelling out a "lump". Many times these apparently unexpected encounters are followed by an incomplete excision which is, in turn, followed by one or more local recurrences. Repeat operations are often amputations of increasing magnitude, and are not infrequently followed by the death of the patient. The hand is a site in which a patient usually presents for evaluation of a swelling when it is quite small. For the patient with a sarcoma, initial adequate surgery offers the best hope of cure. Why are these relatively uncommon tumours of such interest and importance? They frequently afflict young, productive patients. When treated late or inadequately, they can result in tremendous suffering. In recent years there has been considerable progress made in the treatment of sarcomas. Early and effective treatment often allows local control of the tumour without amputation. In order to accomplish this, the approach to these patients must be cautious and precise.

A surgical approach to melanonychia striata.

Longitudinal pigmented streaks--melanonychia striata longitudinalis--are discussed from the perspective of a difficult diagnostic problem. These must be differentiated as early as possible from melanoma. The history of this subject and evaluation of patients in the context of various populations are reviewed. Difficult decisions and technical aspects of the approach are outlined. Case presentations contrast multiple different subungual pigmented lesions that enter into the differential diagnosis of these tumors. A larger number of lesions that make up this differential diagnosis are also discussed in addition to the cases. Appropriate biopsy is reviewed. The potential deformities from the biopsy are contrasted with dangers that are associated with some subungual pigmented tumors.

Squamous cell carcinoma of the nail bed: a clinicopathological study of 12 cases.

Twelve cases were reviewed of squamous cell carcinoma of the nail bed, with emphasis on the aetiological role of human papillomavirus (HPV) infection and radiation damage. Using a hybridization technique, similar HPV genomes were detected in a uterine cervical neoplasia and a subungual squamous cell carcinoma in the same patient.

Tumors of the perionychium.

Tumors of the nail bed are not as rare as we might imagine. Frequent marked delay in diagnosis or misdiagnosis not only contributes to these problems, but may even, on occasion, threaten a patient's life. Because the characteristics of these tumors in their earliest stages are subtle and their growth insidious they are easily missed by even careful observers. Special discussions on cysts, dermatofibroma, fibrous tissue lesions, glomus tumor, hemangioma, infection, neurofibroma, and sweat gland tumors are included.

The "cap" technique: nonmicrosurgical reattachment of fingertip amputations.

With the exception of children, amputations at the level of the lunula survive poorly by direct reattachment. Microsurgical replantation is costly and often fails because of poor venous drainage. In a series of seven adult patients the severed tip was filleted and replaced as a "cap" over the skeletonized distal phalanx of the stump. A 2 mm remnant of germinal matrix was preserved for nail regrowth. The reconstructed digits, although shortened by an average of 6 mm, give the "illusion" of a normal finger. All were successful with small areas of tip necrosis in two, healing by secondary reepithelialization. Mean static two-point discrimination was 6.5 mm (range, 3 to 10 mm) and pulp pinch was 67% of normal. The "cap" technique of nonmicrosurgical reattachment is a simple, reliable method of functional preservation of pulp tissue, as well as normal esthetic appearance of the nail complex.

The versatile axial pattern digital transposition flap.

The anatomic and clinical basis for a reliable and versatile axial pattern transposition flap for reconstruction of complex distal finger injuries is presented. This is a one-step procedure utilizing the nondominant side digital skin with possible preservation of the nerve to the fingertip. This flap obviates the necessity for a distant donor site and provides nonbulky good quality tissue. In eight patients requiring nine flaps, it has proved valuable in the salvage of severely injured digits. These injuries probably would have required distant flap reconstruction or flaps that might have jeopardized adjacent digits.

Osteoarthritis of the distal interphalangeal joint.

DIP joint arthritis may be painful and interfere with function of a finger or the entire hand. When conservative measures are no longer adequate to control the symptoms, operative intervention may be recommended. Arthrodesis is the procedure of choice in most situations, although specialized functional requirements may justify an attempt to maintain motion. Treatment of mucous cysts requires removal of the offending osteophyte as well as the cyst itself. Technique of skin closure depends on the situation and the surgeon's preference. Careful attention to the indications for surgery, to the education of the patient, to the anatomy, and to the surgical technique will usually lead to a beneficial result and will minimize complications.

Fast axonal transport in amyotrophic lateral sclerosis: an intra-axonal organelle traffic analysis.

Fast transport of intra-axonal organelles was studied in motor nerve from amyotrophic lateral sclerosis (ALS) patients. Organelle traffic in ALS nerves demonstrated a significant increase in anterograde mean speed, while retrograde mean speed was decreased compared with that of controls. Retrograde traffic density (organelles per unit time) was also significantly decreased in the ALS specimens. Anterograde transport machinery is therefore intact and may be responding to the increased physiologic demand of larger motor units. Diminished retrograde speed and organelle traffic density are consistent with a defect in retrograde transport and could impair communication between axon terminals and perikarya.

Tumors involving the skin of the upper extremity.

This review can only introduce the subject of tumors found involving the skin of the upper extremity. Many benign masses as well as some malignant tumors have to be considered when a patient calls to the physician's attention a lump, firm area, color change, ulcer, or other alteration in the skin. In response, the physician must have a high index of suspicion, take a careful history, and carry out a thorough examination in order to develop a safe approach. Thought has to be given to the complex anatomy of this area. Understanding of the pathophysiology of tumors and of possible later additional therapy is needed to plan an appropriate biopsy. In the brief discussions of treatment, the difficulty in choosing margins of resection and assessing the efficacy of lymph node dissection is mentioned. An open mind and assessment of future reports of studies in progress may be helpful. Whatever treatment is applied to the malignant tumors under consideration, it is my opinion that one must persist in this until one obtains tumor-free margins. The surgeon undertaking this responsibility must apply the same tumor techniques including operating room discipline that would be applied to any serious malignancy. Consultation and careful work with colleagues that are able to assess the potential for response to chemotherapy, immunotherapy, and/or radiotherapy, should be sought. Subtle hazards in our environment, such as changing risk of sun exposure, industrial chemicals, and irradiation should be pointed out to our patients. These are a challenge to the student of this subject, just as tobacco products are to those involved with malignancies of the head and neck, respiratory, and other systems. All of the previously mentioned methods must be used in the anatomically complex upper extremity to preserve function while ridding the patient of the burden of a disfiguring or painful benign process, or even a life-threatening malignancy.

Elbow arthrography in the evaluation of posterior interosseous nerve compression in rheumatoid arthritis.

This is a case report of a fifty-nine-year-old rheumatoid arthritic woman who developed lack in finger extension bilaterally. These deficits had two completely different aetiologies, Posterior Interosseous Nerve (PIN) Syndrome and extensor tendon rupture. No previous report in the literature has used elbow arthrography as a diagnostic tool in a patient with PIN Syndrome. Elbow arthrography confirmed the abnormality at this joint and aided in appropriate management.

Rehabilitation after upper extremity burns.

The rehabilitation of the patient with an upper extremity burn begins with the study and understanding of the magnitude of burn problems. The initial care as well as reconstruction of selected chronic deformities is presented to help the physician to develop an approach to some of the more common burn injuries.

Blood supply of the flexor pollicis longus tendon.

The blood supply of the flexor pollicis longus tendon was investigated by arterial injections of india ink--latex-barium-solution in 15 fresh, adult cadaver upper extremities. In the digital area vascularity was by way of two vincula (V1 and V2). V1, located just proximal to the metacarpophalangeal joint and the A1 pulley, originated either from both digital arteries or from the princeps pollicis artery alone. V2, located at the interphalangeal joint level under the A2 pulley, originated from both digital arteries. In the predigital area branches of the median nerve artery supplied the area from the base of the thumb to the musculotendinous junction; in addition, the microvascular network of the mesotendon contributed to this area. Intratendinous vascularization was more abundant in the predigital area.

Modified treatment of thumb ray dysplasia: a case report.

The abnormality of the carpometacarpal joint and lack of opposition are two of the more difficult components to treat in the thumb ray dysplasia syndrome. A trapezium arthroplasty and an extensor indicis proprius opponensplasty were used in a typical case. Active opposition was obtained.