Venous aneurysms of the wrist.

We describe 2 cases of primary atraumatic venous aneurysm affecting the wrist. Both aneurysms were in branches of the cephalic vein in close proximity to the radial artery. The definitive treatment for these venous aneurysms was surgical excision. There was no recurrence after 9 years in case 1 and after 11 years in case 2. Modern diagnostic modalities were used, including physical examination, Doppler ultrasonography, aspiration, magnetic resonance imaging, and venography. The pathologic analysis was consistent with those venous aneurysms reported in other parts of the body. The hand surgeon should be aware of this rare condition when formulating a differential diagnosis for soft tissue masses of the wrist.

Enzyme injection as nonsurgical treatment of Dupuytren's disease.

Surgical fasciectomy is the currently accepted treatment of Dupuytren's disease. The goal of this study was to test the clinical safety and efficacy of clostridial collagenase injection as a nonsurgical treatment of Dupuytren's disease in a phase II open-label trial. Thirty-five Dupuytren's disease patients entered the study (32 men and 3 women). The mean age was 65 years. The first 6 patients were treated following a dose escalation protocol and received 300, 600, 1,200, 2,400, 4,800, and 9,600 U collagenase injected into the cord that was causing contracture of the metacarpophalangeal (MCP) joint. There were no beneficial clinical effects of these injections. The remaining 29 patients had collagenase injections at a dose level of 10,000 U, causing contractures of 34 MCP joints, 9 proximal interphalangeal (PIP) joints, and 1 thumb. Twenty-eight of the 34 MCP joint contractures corrected to normal extension (0 degrees ) and 2 of the 34 MCP joint contractures corrected to 5 degrees of normal extension, with full range of motion, within 1 to 14 days of injection. In the patients with PIP joint contractures, 4 of the 9 joints corrected to normal (0 degrees ). One PIP joint corrected to within 10 degrees of normal and 2 corrected to within 15 degrees of normal. There were 2 failures; these patients will require surgery. The mean follow-up period was 20.0 +/- 5.6 months for the MCP joints and 14.1 +/- 6.6 months for the PIP joints. Clostridial collagenase injection of Dupuytren's cords causing MCP and PIP joint contractures appears to have merit as nonsurgical treatment of this disorder. Pending further placebo, double-blind studies, collagenase injection to treat Dupuytren's disease may be a safe and effective alternative to surgical fasciectomy.

The biochemistry of Dupuytren's disease.

The molecular biochemical aspects of Dupuytren's disease have been studied for decades. This article summarizes biochemical influences on myofibroblast contractility, endogenous and exogenous chemical regulation, the influence of growth factors, and the biochemistry of collagen. A clear insight into the biochemistry of Dupuytren's disease may provide a foundation for future clinical interventions.

Nonoperative treatment of Dupuytren's disease.

Many nonoperative therapies have been investigated for the treatment of Dupuytren's disease. These include needle fasciotomy, continuous slow skeletal traction, radiation, dimethyl sulfoxide, vitamin E, allopurinol, physical therapy, ultrasound therapy, steroid injections, radiation, interferon, splinting, and enzymatic fasciotomy. Most of these therapies have not proven to be clinically useful. However, recent investigation of enzymatic fasciotomy using collagenase injection has shown encouraging results.

Scapholunate dissociation: an experimental kinematic study of two types of indirect soft tissue repairs.

Indirect soft tissue repairs of scapholunate dissociation (SLD) address the pathophysiology but have been criticized for significantly limiting wrist flexion and altering wrist kinematics. This study was designed to analyze and compare the kinematics of a normal cadaveric wrist to those of 2 types of soft tissue repairs performed for SLD. Ten uninjured fresh cadaver arms were evaluated by cineradiography and standard x-rays. The average scapholunate (SL) gap was 0.9 mm, with a SL angle of 50 degrees. A model of SLD was produced by sectioning the SL ligaments resulting in an average SL gap of 3.9 mm and SL angle of 66 degrees. The wrists were randomized to a dorsal capsulodesis repair and a distally based split extensor carpi radialis longus (ECRL) repair. The average SL gap after repair was 1.0 mm and the average SL angle was 47 degrees. The split ECRL repair and dorsal capsulodesis reduced scaphoid flexion with only a 10 degree and 18 degree decrease in wrist flexion, respectively. Both repairs reduced the SLD and restored normal wrist kinematics.

Collagenase in the treatment of Dupuytren's disease: an in vitro study.

The effects of clostridial collagenase on the tensile strength of Dupuytren's cords was studied in vitro to assess its potential efficacy as an agent for clinical enzymatic fasciotomy. Collagenase was injected into Dupuytren's cords from patients undergoing fascioctomy. Following a pilot experiment, in which a 3,600-unit dose of collagenase induced a 93% decrease in tensile modulus as compared with control cords, groups of five cords each were injected with 150, 300, and 600 units. These cords and a control group of five cords were tested by loading to failure in tension. The ultimate stress and strain to failure were recorded by a video capture technique. All specimens were stained for histologic examination with hematoxylin and eosin for collagen typing with sirrius red. Comparison of the ultimate stress values obtained with published values of extensor forces obtainable by the individual fingers of 40 normal hands indicated that a 300-unit dose of collagenase was sufficient for cord rupture within the average maximum force limits of the extensors of the index, long, ring, and small fingers (p < .02). All samples were in the residual disease stage histologically and contained type I collagen by sirrius red staining. These results indicate that collagenase may be effective in enzymatic fasciotomy of residual-stage Dupuytren's disease.

The role of transforming growth factor beta in Dupuytren's disease.

This study was undertaken to mark immunologically intracellular and extracellular sites of two common transforming growth factor beta (TGF-beta) isoforms, TGF-beta1 and TGF-beta2, in the proliferative, involutional, and residual stages of Dupuytren's disease. The effect of TGF-beta on myofibroblast proliferation was also studied using explant cultures from Dupuytren's nodules in the proliferative or involutional stage. TGF-beta1, TGF-beta2 and the combination of both isoforms were studied at low and high myofibroblast plating densities to simulate respectively proliferative or involutional disease stage conditions. Our results indicate that TGF-beta1 showed an intense intracellular marking pattern associated with fibroblasts, myofibroblasts, and capillary endothelial cells in all Dupuytren's samples, regardless of disease stage. TGF-beta2 showed an intense intracellular localization within myofibroblasts in the proliferative and involutional stages. Fibroblasts in the residual stage did not contain TGF-beta2. Neither isoform was present in the extracellular matrix. Results of cell culture indicate that compared with control myofibroblasts, the addition of TGF-beta1, TGF-beta2 and TGF-beta1 + beta2 had significant effects on myofibroblast proliferation, especially at higher plating densities. However, TGF-beta2 had the most significant proliferative effect.

Neuromuscular recovery after peripheral nerve repair: effects of an orally-administered peptide in a primate model.

Oral delivery of the tripeptide calpain inhibitor, leupeptin, after median nerve transection and epineural nerve repair in primates (Cebus apella) was studied for its potential benefits to neuromuscular recovery. Results of a controlled, dose-response study indicated that leupeptin was absorbed into plasma by the oral route of administration. When plasma leupeptin concentrations were 3 micrograms/ml or greater, morphologic and functional motor recovery were facilitated after nerve repair. Serial testing in hematology, clotting, and serum biochemistry showed that there were no adverse effects, when leupeptin was administered twice daily for 6 months following nerve repair. These data indicate that leupeptin is an effective and safe pharmaceutic adjunct to nerve repair and may have clinical benefits in humans, where the oral route is a much preferred method of delivery.

Recovery after delayed nerve repair: influence of a pharmacologic adjunct in a primate model.

Inhibition of calpains in skeletal muscle by the tripeptide, leupeptin, after median-nerve transection in the mid-forearm and a delayed nerve repair of 3-weeks duration, was studied in a primate (Cebus apella) model. Results indicated that leupeptin facilitates axon regrowth and neuromuscular recovery after delayed nerve repair. Toxicologic testing showed that leupeptin, administered at 18 mg/kg intramuscularly, twice daily for 24 weeks after delayed nerve repair, did not adversely affect hematology, clotting, blood chemistry, or echocardiogram profiles. These data indicate that leupeptin is an effective and safe adjunct to delayed nerve repair.

Platelet-derived growth factor in Dupuytren's disease.

This study investigated whether platelet-derived growth factor, a potent inducer of cell proliferation, was identifiable in association with myofibroblasts in Dupuytren's disease. Myofibroblasts in the hypercellular disease stages showed a strong reaction to platelet-derived growth factor antibody using light and electron microscopic immunochemical labels. Platelet-derived growth factor may play a role as a cellular signal for myofibroblast proliferation in the formation of the pathognomonic nodule in Dupuytren's disease.

The use of a passive motion machine in the postoperative rehabilitation of Dupuytren's disease.

The purpose of this study was to prospectively compare the postoperative use of passive motion (PM) and standard hand therapy after surgical treatment of Dupuytren's disease for extent and rate of recovery of joint motion. Our data indicate that metacarpophalangeal joint contractures improved completely to a mean of 0 degrees, regardless of the postoperative protocol. Contractures at the proximal interphalangeal joint showed incomplete recovery in both study groups, with a mean residual contracture of 28 degrees for PM patients and 38 degrees for control patients. Contractures of the metacarpophalangeal-proximal interphalangeal joints in the same finger showed complete metacarpophalangeal joint recovery to a mean of 0 degrees but incomplete proximal interphalangeal joint recovery with a mean residual contracture of 30 degrees in PM patients and 22 degrees in control patients. We conclude that the use of a PM machine in the rehabilitation of Dupuytren's disease does not offer an advantage in the postoperative management of this condition.

Pathobiology of the human A1 pulley in trigger finger.

Eighty-nine A1 pulleys from 65 patients with trigger digits and 20 control A1 pulleys from fresh-frozen cadavers were studied comparatively with histology, immunohistochemistry, and transmission electron microscopy. In both normal and pathologic specimens, the A1 pulley was composed of two layers: an outer, vascularized, convex layer and an inner, concave, friction, flexor tendon gliding layer. In the latter, the cells and adjacent matrix had several characteristics of fibrocartilage, including chondrocytes. In trigger digits, the number of chondrocytes and adjacent extracellular matrix was significantly increased when compared with controls. There was no evidence of a synovial cell layer on the surface of the A1 pulleys in either normal or trigger digits. We conclude that the underlying pathobiological mechanism for triggering at the A1 pulley is characterized by a fibrocartilage metaplasia.

Partial lacerations of median and ulnar nerves.

Twelve patients with sharp distal partial median and ulnar nerve lacerations were treated within 2 weeks of injury by end-to-end repair of the lacerated fascicular groups. After an average follow-up of 21 months, the results, based on the British Medical Research Council Rating Scale, were good: S = 3.81 and M = 4.0 (normal: S = 4.0 and M = 5.0). The function of the originally intact fascicular groups did not deteriorate. We suggest that nerve repair of partially lacerated fascicular groups is a reliable treatment method that results in good return of sensory and motor function and does not harm adjacent intact fascicular groups.

Herpetic whitlow with bacterial abscess.

The herpetic whitlow should be treated nonoperatively. However, a difficult therapeutic dilemma occurs when a whitlow is seen with an established bacterial abscess. We report a case of an adult whose first herpetic whitlow was complicated by secondary periungual abscesses that progressed despite intravenous antimicrobial therapy. Surgical drainage of these periungual abscesses was successfully done in conjunction with intravenous acyclovir with no adverse effects.

Neuromuscular recovery using calcium protease inhibition after median nerve repair in primates.

Inhibition of calcium-activated neutral protease, in muscle and nerve, by the tripeptide leupeptin after median nerve transection and epineural repair in monkeys (Cebus apella) was studied. Results indicate that inhibition of the protease after nerve repair facilitates morphologic recovery in denervated thenar muscles and in distal thenar nerve branches. In addition, functional recovery was facilitated in leupeptin-treated animals after nerve repair as measured by sensory and motor conduction velocities. Toxicologic testing showed that leupeptin, administered at 18 mg/kg, intramuscularly, twice daily, for 6 months did not adversely affect hematology, clotting, or plasma complement component C3 profiles. These data indicate that leupeptin is an effective and safe adjunct to peripheral nerve repair.

Dupuytren's contracture.

Dupuytren's contracture can be controlled by surgery and hand function can be markedly improved. Surgery is not, however, a definitive cure and patients should be so advised, especially when the disease starts in the younger age group.

Prostaglandins influence myofibroblast contractility in Dupuytren's disease.

This study investigated if the vasoactive prostaglandins, PGE2, and PGF2 alpha, were identifiable in association with nodular myofibroblasts of patients with Dupuytren's disease. Immunocytochemic studies, using antibodies specific for these prostaglandins, have confirmed their association with myofibroblasts. Radioimmunoassay was used to quantitate the prostaglandins. Our results indicate a significant increase of both prostaglandins, especially PGF2 alpha, in Dupuytren's palmar fascia when compared with control fascia. These endogenous prostaglandins may influence the contractile behavior of myofibroblasts in Dupuytren's disease to contribute to the pathobiology of this disorder.

Another calendar savant.

A 38-year-old patient, who can give the day of the week of any day this century, is described. He is believed to have been autistic in early childhood. The relationship of the autistic child and the adolescent idiot savant is discussed and brief reference made to the patient's method.

Localization and inhibition of calcium-activated neutral protease (CANP) in primate skeletal muscle and peripheral nerve.

Localization of calcium-activated neutral protease in normal monkey (Cebus apella) skeletal muscle and peripheral nerve was studied by application of the indirect immunofluorescent and peroxidase-antiperoxidase techniques for light and electron microscopy. In muscle, the protease was demonstrated in association with endomysial collagen fibrils, basal lamina, sarcolemma, and Z-bands and also at neuromuscular junctions. In nerve, the enzyme was demonstrated in association with endoneurial collagen fibrils, basal lamina, axolemma, and neurofilaments of both myelinated and unmyelinated axons. Intramuscular injections of the thiol protease inhibitor, leupeptin, abolished Ca-activated neutral protease immunoreactivity in both muscle and peripheral nerve. These data suggest that the protease is localized both intracellularly and extracellularly in normal primate muscle and peripheral nerve. Inhibition of basal lamina associated neutral protease by leupeptin after denervation may hold significance for protecting this structure against degradation and preserving it as a neurotrophic lattice for axon regeneration.