Pitfalls in diagnosing carpal tunnel syndrome.

The aim of this paper is to point out the differential diagnosis be-tween a thumb hypoplasia type 1/11 and a carpal tunnel syndrome. Both syndromes have symptoms in common. Two children and an adult with hypoplastic thumbs were sent to our department with the diagnosis carpal tunnel syndrome. In both children, the diagnosis was changed after an exact history and examination, and in one child an opponensplasty was done. The adult patient had already been operated unsuccessfully for a carpal tunnel syndrome elsewhere and again at our department. The exact diagnosis was only made after the second operation,when an extended questioning was done. This shows how important a careful history taking, an exact clinical examination, X-ray examinations of both hands, knowledge of type 1/11 hypoplasia, and finally electroneurography and sonography are important for a correct diagnosis.

[Pedicled flap plasty in closure of defects after recurrence of tumors of the back]. / Gestielte Lappenplastiken zum Verschluss von Defekten nach Tumorrezidiven am Rücken.

Resection of recurrent tumors of the back often results in large transmural defects. Sometimes, radiation therapy is applied after the first operation, leading to indurated, badly vascularized skin and surrounding tissue, often complicated by infection. For this reason, it is necessary to remove not only the tumor but also the surrounding tissue. To reconstruct such wide defects, we use large axial pattern flaps with extension through a fasciocutaneous flap. This leads to safe reconstruction of a complex defect with well-vascularized tissue. We report on two patients with recurrent tumors of the back, reconstructed with combined, extended axial pattern flaps.

The lateral thoracic fasciocutaneous island flap for treatment of recurrent hidradenitis axillaris suppurativa and other axillary skin defects.

A series of eight axillary skin defect reconstructions in seven patients using the lateral thoracic island fasciocutaneous flap is presented. The defects originated from wide excision of recurrent hidradenitis axillaris suppurativa and in one case from radical melanoma resection with axillary lymph node clearance. The technique used to cover the resulting large defects is advancement or transposition of an island flap from the lateral thoracic wall, pedicled on two or three nourishing vessels arising from the lateral thoracic or thoracodorsal vessels. No flap complications occurred and the results with respect to donor site morbidity, functional and aesthetic outcome were very satisfactory.

[Preoperative intermittent pneumatic extension treatment stage III and IV Dupuytren contracture]. / Präoperative intermittierende pneumatische Extensionsbehandlung bei Dupuytrenscher Kontraktur im Stadium III und IV.

BACKGROUND: The purpose of this study was the development of a non-invasive preoperative soft-tissue extension device for the treatment of patients with Dupuytren's contracture grade III and IV according to the classification of Tubiana, based on the experience of continuous extension treatment using the external fixator of Messina. METHODS: Intermittent pneumatic distraction (IPD) of soft tissue using a pneumatic extension device was employed for three weeks preoperatively on ten patients. RESULTS: After three weeks the active and passive extension deficit was reduced by 30.02% and 44.64% respectively. Eight months postoperatively an increase of extension on average of 110 degrees was attained. In contrast, a second group of ten patients with Dupuytren's contracture grade III and IV (Tubiana) without preliminary treatment was listed. In these patients, three times a skin graft was needed; in addition, the stay in hospital and time of rehabilitation was longer. CONCLUSIONS: The preoperative reduction of contracture simplifies the surgical treatment and reduces the complication rate. We present a new non-invasive technique for preoperative continuous extension of Dupuytren's contracture yielding at least equal results to the method introduced by Messina. Comparing the two groups of patients, the patients with preliminary treatment had a shorter stay in the hospital and a shorter time of rehabilitation.

Intraneural nerve metastasis with multiple mononeuropathies.

Although cancer is a frequent condition, neoplastic involvement of the peripheral nervous system is rare. The mechanisms are heterogeneous and include lesions within the cerebrospinal fluid (CSF) space, local invasion (e.g. brachial plexus), compression, rarely direct infiltration, perineurial spread and even rarer intranerval metastasis. A 47-year-old woman had been treated for a carcinoid 10 years earlier and had received axillar irradiation. At presentation she suffered from weakness of the biceps brachii and was experiencing pain radiating from the axilla into the forearm and thumb. MR scans of the brachial plexus were negative and her symptoms were primarily considered to stem from a postradiation brachial plexopathy, Because of increasing pain, the brachial plexus was explored and a metastasis in the left musculocutaneous nerve was resected. Several months later, numbness and pain appeared in the ulnar nerve and another intrafascicular metastasis in the ulnar nerve was discovered. Resection with preservation of remaining fascicles was performed. This rare case report demonstrates that multiple mononeuropathies, resembling multiplex neuropathy, may be caused by intranerval metastasis.

[Significance of double crush in carpal tunnel syndrome]. / Die Bedeutung des Double Crush beim Karpaltunnelsyndrom.

From June 1992 to October 1995, 224 patients were operated on carpal tunnel syndrome. We treated 71 male and 153 female patients. During our investigations, we found that one third of the patients suffered from a double crush syndrome. 84% of the patients suffered from one or more predisposing accompanying diseases. In most of them (42%) we found rheumatic diseases, 19% diabetes mellitus, 8% hyperuricaemia, and 6% hypothyreosis. In 33%, we observed a very short history and a bilateral carpal tunnel syndrome. According to the preoperative tests, four different groups of patients regarding electrophysiological parameters and the graduation of thenar atrophy were differentiated. The fourth group was composed of patients with double crush syndrome, who continued to complain of considerable pain despite surgery, the operated hand remaining both weak and awkward in its movements. Inspired by the prospective study by Dellon (1992) and our results, we will perform a retrospective analysis of the longterm effect of carpal tunnel release in diabetic neuropathy.

[Complications of endoscopic carpal tunnel operations]. / Komplikationen bei endoskopischen Karpaltunnel-Operationen.

This report is about four female patients admitted to our hospital because of pain, dysaesthesia and paraesthesia following endoscopic release of the carpal tunnel, who underwent revisional surgery. Intraoperatively, we found a partial lesion of the median nerve in two cases and an incomplete release of the ligament in the remaining two cases. The complete decompression and epineurotomy of the median nerve and a nerve graft in two patients resulted in clinical improvement.

Quantification of functional deficits associated with rectus abdominis muscle flaps.

To evaluate the deficits in trunk flexion due to partial or complete unilateral rectus abdominis muscle flap transfer in reconstructive surgery, 27 patients (11 females, 16 males) with rectus abdominis muscle flap transfer dating back at least 3 years, clinically healthy at the time of testing, and 22 controls (10 females and 12 males), comparable in age and body mass index, were compared. For clinical assessment of power of the straight and oblique abdominal muscles, Janda's test of muscle function was used, and torque (in N.m) of isometric trunk flexion at 0, 5, 10, 20, and 30 degrees was determined with the TEF Modular Component, an auxiliary unit of the Cybex 6000. Results were analyzed for males and females separately. Relative torque (N.m/kg) of operated male and female patients was significantly lower (p < 0.05) as compared with controls. Differences were more pronounced in males than in females. Clinically, there were no significant between-group differences in the power of the straight and oblique abdominal muscles. In conclusion, trunk flexion deficits following rectus abdominis muscle flap transfer can be compensated for satisfactorily in most cases, supporting the use of this muscle in reconstructive surgery, if patients are selected carefully.

[Functional deficits following transfer of rectus abdominis muscle]. / Funktionelle Defizite nach Entnahme des M. rectus abdominis.

Functional deficits after raising of a rectus abdominis muscle flap in reconstructive surgery were evaluated retrospectively in 27 patients (11 female, 16 male) and compared to 22 healthy control individuals. To test the torque of trunk flexion, the Cybex 6000 (TEF modular component) was used and subjects tested in a defined position allowing isolated sagittal flexion. For the rectus and oblique abdominal muscles, the Janda muscle function test was applied. For comparison of patients and controls, the Man and Whitney test was applied, and subgroup analyses were performed for men and women, respectively. The peak torque (relative to bodyweight) was significantly lower in patients as compared to controls, the differences being greater in men than in women, whereas clinical examination did not reveal a significant difference between either group. After autologous transplantation of the rectus abdominis muscle flap, compensation is obviously restricted to a certain degree, although the remaining deficit does not seem to represent a handicap in normal life. Thus the use of rectus abdominis muscle flaps in reconstructive surgery may be beneficial for the patient, provided the indication is precise and long-term control is possible.

[Experiences in the treatment of far advanced primary breast cancers, extensive tumor recurrences and radiation damage (reflections on on the value of surgical therapy)]. / Erfahrungen in der Behandlung weit fortgeschrittener primärer Mammakarzinome, ausgedehnter Tumorrezidive und Strahlenschäden (Uberlegungen zur Sinnhaftigkeit der chirurgischen Therapie).

Ulcerating primary breast cancer, local recurrence with extension to the thoracic wall and skin and ulceration after radiation therapy, sometimes with malignant degeneration, call for interdisciplinary evaluation and treatment. For the benefit of the patient an effective cooperation of the involved specialties seems desirable at an early stage of management. We performed breast tumor resection and immediate coverage of the defect in 25 patients (median age 54 years). In choosing the reconstruction procedure great attention was paid to short hospitalization and the possibility of commencing cytostatic or radiation therapy as soon as possible. We are able in all cases to resect the open and partly infected, ulcerated and bleeding tumors and to close the defects completely by means of various flaps. Among the many flaps at our disposal to reconstruct the thoracic well defects, we prefer the cranial based, ipsi- or contralateral extended rectus abdominis flap.

[Intra- and postoperative nerve lesions and their treatment]. / Intra- und postoperative Nervenläsionen und ihre Behandlung.

Injuries to the central or peripheral nerves caused by medical intervention are called iatrogenic nerve lesions. The caudal relationship between medical intervention and iatrogenic nerve injuries is frequently not very clear. Careful pre- and post-operative examination of the patient, however, will in most instances reveal a nerve lesion in a timely manner. Iatrogenic nerve lesions in the clinical cases available to us were predominantly due to indirect influences, such as pressure, insertion of a retractor or heat; we discovered that only in a few cases a nerve was partially or completely severed or damaged by the material used for osteosynthesis. The pre- and postoperative clinical neurological and electrophysiological examinations of our patients were performed by a neurologist. Nerve-repair was achieved by neurolysis in 19 cases; a primary or secondary suture was performed in three cases. A nerve graft was used in five cases to regain continuity. Those patients (nearly 75%) who underwent restitutive surgery within an six-month period after iatrogenic injury in the primary operation were treated successfully. These results suggest that timely treatment is decisive for good outcome.

Abdominopelvic radiation for stage I-II ovarian cancer. The effect of grade on outcome.

The initial postoperative treatment of 31 patients with stage I-II ovarian cancer of epithelial origin, consisted of abdominopelvic radiotherapy. The 5-year survival was significantly better in stage I as compared to stage II (81.1% vs 36.3%). There was a consistent trend in both stages for better outcome in grades 1-2. This trend, however, reached statistical significance only for PFI. Most of the patients with recurrent disease had grade 3 tumors. While satisfactory treatment results may be achieved with postoperative radiotherapy for stage I-II tumors which are well or moderately differentiated, it is not recommended for undifferentiated tumors.

Castleman's disease. An uncommon computed tomographic feature.

A case of localized intrathoracic Castleman tumor demonstrated, on CT scan, calcifications in a circumferential distribution. The prevalence of calcifications in Castleman's disease and the differential diagnosis of the above unusual CT findings are discussed.

Pure primary ovarian squamous cell carcinoma.

A 65-year-old woman with pure primary ovarian squamous cell carcinoma invading the fallopian tube and the terminal ileum is described. The tumor recurred shortly after surgery in spite of complete resection. No response to chemotherapy was observed and the patient expired 6 months after diagnosis. In order to establish the diagnosis of pure primary ovarian squamous cell carcinoma extragenital and genital tumors containing squamous elements as well as endometriosis have to be excluded.

Spindle cell squamous carcinoma of the lung. Immunocytochemical and ultrastructural study of a case.

A case of squamous cell carcinoma of the lung showing extensive spindle transformation is presented. On light microscopy, the tumour showed sheets and fascicles of elongated fusiform cells resulting in a growth pattern which closely resembled a sarcoma. Immunocytochemistry using tissue-specific antibodies against intermediate filaments demonstrated exclusive labelling of the tumour cells with prekeratin antibodies. Electron microscopy showed well-formed intercellular junctions and thick bundles of tonofilaments within the cytoplasm of the cells further confirming the squamous epithelial nature of the neoplasm. The findings in the present case point to the existence of a non-metaplastic spindle cell variant of squamous carcinoma of the lung. The possible mechanisms which may account for the spindle shape of the cells are reviewed.

Adenosquamous carcinoma of the gallbladder with spindle cell features. A light microscopic and immunocytochemical study of a case.

A case of adenosquamous carcinoma of the gallbladder showing extensive spindle transformation is presented. By light microscopy, areas showing interwoven fascicles of fusiform, poorly differentiated cells closely resembling a sarcoma were seen to merge imperceptibly with areas showing more obvious glandular and squamous cell features. Immunocytochemistry utilizing tissue-specific antibodies against intermediate filaments demonstrated the exclusive presence of prekeratin antibodies in both components of the tumour, thus establishing the epithelial nature of this neoplasm. The importance of immunological phenotyping in the differential diagnosis of epithelial tumours of the gallbladder showing pseudosarcomatous features is underscored.

Sclerosing hemangioma of the lung. Immunohistochemical demonstration of mesenchymal origin using antibodies to tissue-specific intermediate filaments.

A case of pulmonary sclerosing hemangioma of the lung was studied by light microscopy and indirect immunofluorescence using tissue-specific antibodies against intermediate filament subunits. All the tumor cells stained positively and exclusively with antivimentin antibodies thus indicating their mesenchymal origin. In addition, positive staining with cytokeratin antibodies was observed in cells lining cystic spaces and elongated slit-like spaces were occasionally encountered throughout the tumor, disclosing residual epithelial elements. Using brightfield microscopy, the keratin-positive areas were identified as distorted alveolar spaces lined by hyperplastic respiratory epithelium entrapped within the tumor. It is proposed that these entrapped epithelial elements may account for the conflicting results obtained by different investigators in previous attempts to determine the histogenesis of this tumor.