Surgical treatment of carpal tunnel syndrome in patients exposed to vibration from handheld tools.

During 1985 at Sabbatsberg Hospital in Stockholm, carpal tunnel decompression was done for 50 men (58 hands) with carpal tunnel syndrome (CTS). In 1988 2.5 to 3 years after the operations, a questionnaire about their present health was answered by 43 men (50 hands). In 10/17 (59%) hands exposed to vibrations and 26/33 (79%) not exposed, carpal tunnel decompression had resulted in no recurrence of neurological symptoms at follow up. Preoperative signs of neurophysiological dysfunction of the ulnar nerve, which might indicate a more widespread neuropathy, did not correlate with poor postoperative function of the median nerve. We recommend that patients with carpal tunnel syndrome should be operated on, whether or not they have been exposed to vibration.

Is the treatment of enchondroma in the hand by simple curettage a rewarding method?

46 enchondromata of the hand have been treated by simple curettage without bone grafting. 82% healed and 16% were left with only small bone defects. Only one patient had a clear-cut recurrence requiring re-operation. This simple method, performed on out-patient basis, is recommended.

[Surgery cures numbness of the hand. Long-term follow-up of carpal tunnel decompression]. / Operation botar domningar i handen. Långtidsuppföljning av karpaltunnelklyvningar.

One hundred and ninety-one hands with suspected carpal tunnel syndrome (CTS) were treated with surgical decompression of the median nerve. In a retrospective analysis 2.5-3 years later, an inquiry was carried out by questionnaire and the patients' records were examined to evaluate the final outcome. The questionnaire was answered by all 158 still living patients (ie, 175 hands), of whom 91 per cent reported numbness in the hand to have been completely relieved after surgery, while 23 per cent had had a recurrence of numbness, or other hand problems not clearly related to CTS, though just under half of this 23 per cent reported their symptoms to be milder than prior to operation. Thus, 2.5-3 years after surgical intervention, 85 per cent of the patients had recovered completely or improved; and 96 per cent were satisfied with the outcome. To conclude, surgical treatment of CTS is a technically simple operation with good final results.

Weilby tendon interposition arthroplasty for osteoarthritis of the trapezial joints.

Primary osteoarthritis of the trapezial joints has been treated by an interposition tendoplasty according to Weilby in eighty-nine cases. After excision of the trapezium, a strip from the flexor carpi radialis was wound around the main portion of the flexor carpi radialis tendon and the abductor pollicis longus. The abductor tendon was then duplicated over the tendoplasty and reinserted to the first metacarpal base. In 40% of cases, osteoarthritis was present in more than one trapezial joint. 57% had an adduction contracture of the first metacarpal, half of which were relieved postoperatively. 73% of patients were satisfied at follow-up. Complications included four cases with loss of active metacarpal abduction which was regained after reinsertion of the abductor pollicis longus. It is concluded that the Weilby tendoplasty is a useful alternative to Silastic implants, especially in cases of adduction contracture. The risks of implant dislocation and silicone synovitis are eliminated.

Carpal boss.

Carpal boss is an often painful protuberance located dorsally in the region of the second and third carpometacarpal joints. This protuberance, emanating from juxtaarticular bone or consisting of an accessory ossicle, is often misinterpreted as a ganglion. Twenty-one patients with carpal boss were operated on with acceptable results.

Ultrastructural morphometric studies on regeneration of the lateral sural cutaneous nerve in the white rat after transection of the sciatic nerve.

The lateral sural cutaneous nerves of 49 Sprague-Dawley rats 7-76 weeks of age were examined morphometrically in single transverse sections using electron microscopy. The following variables were estimated: the relative proportions of collagen-occupied and collagen-free areas of the extracellular compartment of the endoneurial space, the number and the diameters of axons, the number of myelin lamellae, and the number of different kinds of cell nuclei. The nerve contained on the average 2600 axons of which about 2200 (85%) were unmyelinated. The different variables were computed with regard to the animal-to-animal, side-to-side, and age variations. From these data normal reference diagrams based on the 95% prediction intervals for individual observations were constructed. Animal-to-animal and side-to-side variations were of about the same magnitude except in cases where the variation was age-dependent. Prediction intervals for individual observations that were +/- 50-70% of the mean value were found for the numbers of different types of Schwann cell nuclei. The intervals for the number and mean diameters of unmyelinated axons and myelinated fibres was +/- 20-30%. The g-value showed the narrowest interval +/- 10%. Age-related variation was found for the transverse section area of the nerve, axon diameters, and the number of myelin sheath lamellae. The application of normal values as a reference system to experimental data is discussed.

Glomus tumor in the hand. A clinical and morphological study.

Eighteen patients with a glomus tumor in the hand are reviewed. In five cases the tumor was subjected to light and electron microscopical analysis. This unusual lesion is often quite debilitating. The major symptoms are intense pain with mechanical stimulation of the tumor and temperature hypersensitivity. Careful dissection and complete removal of the tumor is adequate treatment. A possible mechanism in the glomus tumor for the generation of painful sensations is discussed.

Sural nerve biopsies from workers with a history of chronic exposure to organic solvents and from normal control cases. Morphometric and ultrastructural studies.

An ultrastructural and morphometric study was performed on sural nerve biopsies of four industrial spray painters (35-59 years) and 11 controls (6-64 years). No difference could be shown in spray painters and age-matched controls as to the number of myelinated nerve fibres per area, their size distribution, variation of internodal length along single nerve fibres or the ratio between the number of myelin lamellae and the axon circumference. There was marked scattering of the two latter parameters in older exposed and and control individuals. The distribution of NADH2-tetrazolium reductase activity was similar in exposed and control cases. The general ultrastructural appearance of nodal-paranodal regions in controls conformed with that noted in experimental animals. The overall ultrastructural organization and age-related changes of nerves of exposed cases were similar to those of control cases except for a presence of paranodal axonal mitochondria which contained glycogen-like particles in exposed cases. In one exposed case abundant dispersed or clustered glycogen-like particles were seen in the paranodal axoplasm. These findings are suggested to be an effect of chronic exposure to organic solvent vapours. Ageing seems, however, to have a much greater impact on the morphology of the sural nerve fibre than occupational exposure to organic solvent.

Ulnar neuropathy at the elbow treated with decompression. A clinical and electrophysiological investigation.

Forty-four patients with ulnar neuropathy confined to the elbow region were operated with simple decompression. The operation was usually performed more than six months after the debut of symptoms. At follow-up earliest six months postoperatively 89% of the patients had improved and 39% recovered completely. An improvement in EMG activity and/or nerve conduction velocity was seen in 89% of the patients tested pre- and postoperatively. The validity of nerve compression, epineurial fibrosis and other factors of possible prognostic significance such as age, duration of symptoms and electrophysiological findings are discussed. Since the results of simple decompression of the ulnar nerve were similar to those obtained in a previous study of transposition, the former method is recommended as the standard procedure.

Operative treatment of ulnar nerve neuropathy in the elbow region. A clinical and electrophysiological study.

Thirty-three patients with ulnar nerve neuropathy due to a lesion in the ulnar groove were operated upon during a 5-year period. All the patients were analyzed preoperatively. One-third of the patients had a history of alcohol abuse. Twenty-five of the patients were subjected to anterior transposition of the ulnar nerve. The results after transposition have been compiled according to etiology, duration, age and alcohol abuse. All seven patients with only subjective symptoms improved; 11 out of 18 (61 per cent) with motor and/or sensory loss also improved but only six (33 per cent) recovered completely. Overall, 21 patients (84 per cent) were improved by the operation. In 11 of the transposition cases the ulnar nerve was examined electrophysiologically before and after operation and an improvement of the motor conduction velocity within the elbow segment of the nerve was found in 10 cases.

Late synovectomy of the hand in rheumatoid arthritis.

PIP joints, MCP joints and wrists of 80 patients with rheumatoid arthritis were operated on with late synovectomy. The rate of recurrence of local synovitis was about 5%, which contrasted favourably with a considerably higher rate of progression of bony erosions. The loss of range of movement was small to moderate. Pain was alleviated in most cases. The possibility of forecasting the results by preoperative parameters was limited. It was concluded that the main indication for late synovectomy of the hand was alleviation of pain. The prophylactic effect on joint destruction seemed to be both slight and unpredictable.

X-ray changes in connection with late synovectomy of the hand in rheumatoid arthritis.

Eighty-two patients subjected to late synovectomy of the hand were followed up. Late synovectomy was defined as an operation performed after at least 3 years' duration of local synovitis in the type of joint operated on. The minimum follow-up period was 24 months for the fingers joints (IP + PIP and MCP) and 18 months for the dorsal aspect of the wrist (W). The multifocal swelling of joints, preoperatively, was symmetrical in 89% of the patients. The X-ray changes, however, were symmetrical in only 22%, 27%, and 68% for IP + PIP, MCP, and W, respectively. These findings may preclude the use of controlled studies on early synovectomy using the non-operated hand as a control in a long-term assessment of X-ray progression. The rate of X-ray progression during the observation period was 60% for IP + PIP joints. The corresponding figures for MCP and W were 64% and 39%, respectively. Absence of bony lesions prior to synovectomy was favourable sign.