A METHOD OF ARTHRODESIS OF THE WRIST

808

angiomata, and spinal deformities all occur in members of the family bearing the characteristic triad. Congenital cataract, appearing in the eldest of the seven brothers

A METHOD OF

ARTHRODESIS OF THE WRIST

(111 2), affects his two daughters (iv 5 and 7) who are otherwise normal; it may appear by chance, and will not be included further in the discussion of the main abnormalities. Two explanations

of the

Y

.

pedigree

then

seem

possible. 1. That the

numerous and diverse congenital anomalies due to the action of a single, rather versatile gene, which shows variations in penetrance for particular characteristics. 2. By analogy with the recent theories concerning the blood-group genes (Fisher 1949), it is possible that several genes, closely associated on the same chromosome, may be responsible. These loci may be so near together that crossing-over hardly ever occurs and they act as a unit in inheritance. are

.

DAVID F. THOMAS F.R.C.S. ORTHOPÆDIC SURGEON, SCUNTHORPE AND DISTRICT WAR MEMORIAL HOSPITAL AND LINDSEY COUNTY COUNCIL

With illustration on plate THE operation described here has been designed to promote a more certain arthrodesis of the wrist in a good position than is generally achieved. It has advantages over the usual methods, and consists essentially in fusion of the joint by a diamond-shaped inlay graft.

CONTUSION

A type of renal dysplasia is described which presents the same clinical picture as chronic glomerular nephritis. Thus there is persistent albuminuria with casts of all types and occasional red blood-cells. Renal function is slightly diminished and radiography shows kidney shadows of normal size and shape. AUroselectan ’ Four (iodoxyl) study excludes polycystic disease. definite cases are recorded and two probable ones, both the latter having died with generalised oedema. This form of dysplasia may account for the so-called familial congenital nephritis described by previous writers. When such families are discovered in future a careful search may reveal other hereditary anomalies. No opportunity has arisen in the present family for detailed pathological study ; but, if the analogy with congenital nephritis is correct, there is probably nothing to distinguish the final picture from acquired chronic glomerular nephritis. The course of this developmental renal lesion may, however, be more benign than the acquired disease. The general condition of the patients was good and hypertension was found in only one. A child aged 8 years showed normal physical development with no sign of renal rickets. The oldest living person was 45, and the two thought to have died from the condition lived to 64 and 47 years. The Y family also possess a great number of congenital abnormalities affecting tissues both of ectodermal and mesodermal origin. The commonest trait involves the fingernails, elbow-joints, and patellae and is known by the family to have been inherited from distant

THE METHOD

A posterior, midline incision is made from the base of the third metacarpal to a point about 2 in. proximal to the lower end of the radius. The extensor retinaculum is divided and reflected on each side, and the extensor tendons are separated between the extensor digitorum communis on the one hand and the extensor proprius indicis and longus pollicis on the other hand. The whole of the posterior surface of the lower 2 in.

of the radius is cleaned, and the posterior surfaces of the semilunar, scaphoid, and os magnum, as well as the base of the third metacarpal, are also A diamondcleaned. shaped bed is now cut (fig. 1). The wrist must be in moderate dorsiflexion when this is done. The most distal corner of the diamond-shaped bed is bed includes the base of Fig.—The cut from the lower part of the the radius, greater part of the the third metacarpal. The semounar, scaphoid, and os most proximal corner is base of the third metacarpal bones. the same distance from Both apices of the bed are the lower margin of the for slotting of the graft after the radius as this margin is manner of Brittain’s operation. .. the base of the from the t111rd third At the medial angle of the diamond care is taken to avoid line metacai’pal; and the encroaching on the inferior i the i and ....LT_ ,) distal radio-ulnar joint. joining proximal angles should bisect the line joining the medial and lateral angles (fig. 2). The medial angle is just lateral to the medial angle of ancestors. the lower end of the radius and the outer angle a little who have this triad also show other Many changes medial to the tip of the styloid process of the radius. affecting the skin, vertebral column, and pelvis. A The saw-cut is about 3/8 in. deep throughout its extent. particular study has been made of iliac horns, because these have hitherto had scant attention and have not DR. HAWKINS: REFERENCES been demonstrated as a hereditary characteristic. It is Aitken, J. (1909) Lancet, ii, 444. Attlee, W. H. W. (1901) St Bart’s Hosp. J. 9, 41. thought that the detailed analysis of so many widely )ickinson, W. H. (1875) Diseases of the Kidney. London; vol. I, scattered developmental errors may in the distant p. 379. Eason, J., Smith, G. L. M., Buchanan, G. (1924) Lancet, ii, 639. future be of some value in preparing a map of the human Fisher, R. A. (1949) Adcanc. Sci. 5, 20. chromosome. Fong, E. E. (1946) Radiology, 47, 517. I am very grateful to Dr. F. Parkes Weber for his enthusiastic encouragement, and also to Prof. Lancelot Hogben, F.R.S., and Dr. A. A. Osman for their helpful advice. Acknowledgment is made to Dr. Harold Black for permission to reproduce the radiographs ; and the investigation would not have been possible without the ready cooperation of Sister Le Gallais and the staff of the X-ray department. Grateful appreciation is expressed to Dr. A. A. Cunningham and Dr. Ian MacCallum for help with cases in their area, and I would like to thank Prof. P. C. P. Cloake for permission to study the original case which was discovered in his indebted to the Medical Research Council for to cover the expenses of this work. am

tunnelled so as to allow

Fracer, F. C. (1948) Personal communication, from the British Museum (Natural History), South Kensington, London. Guthrie, L. G. (1902) Lancet, i, 1243. Herxheimer, G. (1908) Frankfurt Z. Path. 2, 138. HHurst, A. F. (1923) Guy’s Hosp. Rep. 73, 368. Johnston, T. B. (1948) Personal communication. Little, E. M. (1897) Lancet, ii, 781. Mino, R. A., Mino, V. H., Livingstone, R. G. (1948) Amer. J. Roentgenol. 60, 633. Montant, R., Eggermann. A. (1937) Pr. med. 45, 770. Nicholson, G. W. (1931) J. Path. Bact. 34, 711. Osman, A. A. (1927) Brit. med. J. i, 938. (1949) Personal communication. Paget, J. (1882) Lancet, ii, 1017. Parkes Weber, F. (1927) Trans. med. Soc. Lond. 50, 107. (1933) Lancet, ii, 1472. —

—

outpatient department. I

magnum, and from the

—

a

grant

(1949)

Personal communication.

Senturia, H. R., Senturia, B. D. (1944) Amer. J. Roentgenol. 51, 352. Smith, E. C., Orkin, L. A. (1945) J. Urol. 53, 11. Tobias, N. (1925) J. Amer. med. Ass. 84, 1568. Turner, J. W. (1933) Ibid, 100, 882.

809 The bone enclosed within the diamond-shaped cut is removed by a small gouge; it includes the posterior half of almost the whole width of the lower radial articular surface and the greater part of the articular surfaces of the scaphoid, semilunar, and os magnum. The length and breadth of the diamondshaped bed are now measured, and a graft is cut. from the lower part of the medial surface of the tibia of a size to fit tightly into it. This is not difficult : the area is defined by marking out on the bone the transverse and longitudinal diagonals of the diamond " so that they bisect each other at right-angles, and joining their extremities (fig. 3). If the graft is cut from the appropriate part of the tibia, its cortical surface will be concave and its cancellous surface convex (figs. 4 and 5). It should be so cut that its greatest width corresponds the to the summit of

at the level of the joint ; the greatest width of the graft is at joint level ; cancellous-bone is used as well as cortical bone ; and fixation is secure. 2. Stable fixation is achieved by fixing the graft at both ends by means of the method of slotting ; using the inlay method when applying the graft, and having the

.

I

convexity. The graft

is now transthe wrist and into the bed made for it, the

ferred to

punched already proximal pointed angle being slotted under the cor-

width of the

in

profile. ,

,

at the site of the greatest at the radio-carpal joint level). As the shape of the graft naturally fits dorsiflexion of the wrist, no attempt is made to strain the graft out of

greatest possible

movement

graft

(i.e.,

its normal shape (fig. 5). Being curved, the graft fits down into the bed throughout its length. 3. No bulky mass is laid on the back of the radius and carpal bones. The extensor tendons will lie back evenly in place because the bony contour is little altered -except of course, that Liston’s tubercle is removed when the graft bed is excised. 4. The movements of pronation and supination are preserved. In dealing with a joint in which these movements are already destroyed the lower end of the ulna can be removed in the course of operation with a view to restoring them. I wish to thank Miss Jean Evison for her help with the illustrations and preparation of this, article.

BASILAR INVAGINATION IN PAGET’S DISEASE

tical surface of the upper corner of the bed, and (traction being applied to the wrist) the lower pointed angle slotted into the third metacarpal in the manner used for Brittain’s arthrodesis. It is not necessary to cut steps in the proximal and distal angles of the graft : cutting steps in the ends of a graft always weakens it. If the graft is made with pointed ends, and so can be slotted into the metacarpal and radius, the necessity for steps is avoided. With this method, in contrast to Brittain’s, the graft is laid with its cancellous surface downwards and not directed to the radial or ulnar sides. I believe that any drawbacks to placing the graft in such a way are offset by the fact that the maximum width of the graft corresponds to the site of the maximum strain, and that the actual width of the graft at this site is much greater than the width of Brittain’s graft. When the graft is being fitted the wrist must be put in a position of dorsiflexion neither too little nor too great ; and if the long axis of the graft is made to run truly from the central axis of the radius to the base of the third metacarpal there will be neither undue radial nor undue ulnar deviation. Cancellous-bone chips taken from the donor area are packed around the graft. After the extensor retinaculum has been sutured and the wound closed, the wrist is immobilised in plaster for at least two months (fig. 6). ADVANTAGES

1. Union is promoted because the greatest amount of bone is removed

:Fig. 4-The

Fig. 5-Graft

lower part of the medial surface of the tibia is

concave

forwards. A graft can be cut from this portion to fit the dorsiflexed wrist. Furthermore, removing the graft from this portion of the

tibia makes cancellous bone chips available.

R. A. GOODBODY M.B. Lond. REGISTRAR IN

PATHOLOGY,

LEWISHAM GROUP LABORATORY

L. V. ROBERTS M.D. Edin. PHYSICIAN,

LEWISHAM HOSPITAL

With illustration

on

plate

BASILAR invagination (syn. basilar impression, platybasia) is a rare craniovertebral deformity due to the foramen magnum and surrounding bone being pushed up into the posterior fossa by the atlas. The upper cervical vertebral are thus displaced upwards, and usually forwards. In the majority of cases a congenital developmental anomaly of the basi-occiput, atlas, and axis is responsible ; in the remainder the condition is almost always the result of Paget’s disease. Neurological symptoms are common in the congenital but rare in the acquired type. They are significant of pressure on : (1) the hind brain and lower cranial nerves by the invaginated bone, accentuated by the correspondingly smaller posterior fossa ; (2) the medulla and upper cervical cord by a narrowed foramen magnum, and distorted upper cervical canal, aggravated perhaps by the frequent, usually unequal, herniation into them of the cerebellar tonsils. Syndromes produced may simulate syringomyelia, disseminated sclerosis, tumour of the posterior fossa, motor neurone disease, and other disorders. Internal hydrocephalus is likely to complicate the severer degrees of deformity. In only one of the cases secondary to Paget’s disease so far published has involvement of the central nervous system been noted (Ray 1942). A second case is reported here. CASE-RECORD

The patient, an obese woman of 56, was brought to hospita late one evening in a state of coma. History.-She had developed during the preceding fortnight an unusual habit of dozing in her chair of an evening. On the previous afternoon she had fallen deeply asleep and could not