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American Association for Hand Surgery
PROCEEDINGS American Association for Hand Surgery
T
he Thirteenth Annual Meeting of the American Association for Hand Surgery was held October 27 through 30, 1983, in Dallas, Texas, under the presidency of Garry S. Brody, M.D. Papers by Drs. Ryu, Yousif, and Jelalian were awarded prizes in the Annual Resident's Essay Contest. Chemotherapy extravasations: Management of acute and chronic injuries. FREDERICK R. HECKLER, M.D., JOHN C. SCHIMMEL, M.D., and E. WEST JONES, B.S. The authors have treated 32 patients suffering acute extravasation of antineoplastic agents with immediate regional clysis by use of normal saline and hyaluronidase. None of these patients suffered any skin loss, and all maintained full active range of hand motion. A model using ulcerations resulting from subcutaneous injections of doxorubicin hydrochloride (Adriamycin) in distal segments of rabbit extremities was developed. Clyses with saline/hyaluronidase, saline, corticoids, and hyaluronidase alone were then tested for their ability to ameliorate subsequent skin ulceration. The saline/hyaluronidase combination was significantly more efficacious than the other agents, confirming clinical observations. Another series of patients with established extravasation ulcerations were selected prospectively for management without surgical wound closure. The wounds were treated with silver sulfadiazine (Silvadene) and dressings, and the patients were followed as outpatients. Thirty-six patients were available for follow-up and did well without aggressive surgery. Reversing the burn injury in the burned hand. ANTONIO M. CARBONELL, M.D. The early application of an antiprostaglandin-antibiotic cream combination on a partial thickness bum injury of the hand results in painless restoration of the range of motion and functional preservation of the skin and underlying structures without the need for skin grafting or extensive splinting and physiotherapy. The author has treated 50 patients with silver sulfadiazine-methylprednisolone (Silvadene-Medrol) combination. Hand bums treated in this fashion require minimal splinting, are essentially painless, demonstrate little edema, can be mobilized within 24 hours, are aesthetically pleasing, and demonstrate a 50% reduction in overall morbidity; furthermore, the need for skin grafting tangential or enzymatic debridement is eliminated. Peripheral defects after meningitis. JOSEPH AGRIS, 288
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M.D., and JACOB VARON, M.D. It is possible with the pediatric intensive care facilities of today for children to survive meningitis. Morbidity and mortality rate has been reduced 8% to 12%. However, these children are now surviving with normal mental capacity but severe peripheral defects. The authors discussed the physiologic and seriologic changes that take place during the disease process leading to the peripheral vascular compromise. DR. DONALD TEAL, in discussion, noted the similarity to frost bite and suggested that heparin was of therapeutic value in view of the microvascular nature of the lesion. Digitotalar dysmorphism. AVTAR S. DHALIWAL, M.D., and TERRY L. MYERS, M.D. Digitotalar dysmorphism is a rare clinical entity that was first described by Sallis and Beighton in 1972. The syndrome consists of significant ulnar deviation of the phalanges, adduction and flexion deformity of the thumbs, soft tissue webbing, simian lines, vertical tali with "rocker bottom" deformities of the feet, and an apparent short stature. Another family with this inherited genetic disorder was presented including details of clinical findings and their surgical management. In discussion, DR. JOSEPH UPTON also stressed early release of contractures, especially at the first web space. Pre and postaxial polydactyly of the upper extremity: A long-term follow-up study. THOMAS A. McENNERNEY, M.D. Polydactyly of the upper extremity is a common congenital anomaly. The records of 59 patients with upper extremity polydactyly who had been treated at Carrie Tingley Hospital for Crippled Children from 1937 to 1982 were reviewed. A total of 84 supernumerary digits were involved. Long-term follow-up was obtained on 33 patients. Preaxial polydactyly was classified according to the Wassel classification with an additional category for triphalangism. Postaxial polydactyly was classified into four groups on the basis of the location of the origin of the supernumerary digit. Treatment of preaxial polydactyly frequently results in joint instability, decreased strength, and loss of arc of motion. Additional operations for instability were common. Treatment of postaxial polydactyly did not produce functional impairment. Any additional operations were usually done for cosmesis.
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DR. UPTON commented that simple ablation is rarely possible, and reconstructive procedures are often necessary. Distraction augmentation manoplasty: 1983 update. NORMAN J. COWEN, M.D., reported 172 digital lengthenings in 47 patients in whom 94 Matev distraction devices were applied. This series includes eight cases of traumatic amputation of one or more digits and 39 patients with congenital anomalies. The congenital anomalies vary from simple hypoplasia of one ray to shortness of all the fingers, to severe central defect, and eventually to aplasia of the hand. A previous report on 12 infants with severely hypoplastic hands who had surgery before the age of 2 years was updated. In that series, an increase in length of 145% was achieved which means that the average hand was more than doubled and less than tripled in length. There is now a 3-year follow-up on this series. The complications have been many. The technique is very time-consuming and very demanding on both the physician, the nurses, and the patients and their parents. DR. FREDERICK HANSEN, in discussion, emphasized the many complications of the procedure. In an invited paper, ANDREW PALMER, M.D., discussed limited versus complete wrist fusion and emphasized that complete wrist fusions result in absent wrist motion and relief of wrist pain, whereas limited wrist fusions result in decreased (but not absent) wrist motion and decreased (but not absent) wrist pain. The applicability of each of these alternative procedures was discussed in detail. Reperfusion of skeletal muscle after ischemia. ELOF ERIKSSON, M.D., R. C. RUSSELL, M.D., and E. G. ZoOK, M.D. Muscle reperfusion after more than 6 hours of ischemia is unlikely. Various reasons for the vascular occlusion or "no reflow phenomenon" have been suggested. The present study was designed to answer the question: what causes vascular occlusion in skeletal muscle after more than 6 hours of warm ischemia? Twenty-nine cats weighing 2.6 kg were anesthetized with chloralose and the tenuissimus muscle studied in vivo by use of the intravital microscope that is specially equipped for study of the microcirculation in live tissues. This study concluded that even after 10 hours of warm ischemia in muscle, there is an initial reperfusion after release of the tourniquet. Platelet thrombi then occlude the venules causing complete proximal microvascular standstill. The effects of platelet inhibitors such as aspirin or Dextran 40 given before reperfusion
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in muscles occluded for more than 6 hours are presently being studied. Streptokinase therapy for arterial occlusions of the hand. CRHISTINE JELALlAN, M.D., JAMES RICHARDSON, M.D., AUSTIN MEHRHOF, JR., M.D., and WYNDELL MERRITT, M.D. Intra-arterial streptokinase infusion has been successfully used to treat peripheral and coronary arterial occlusions. All patients with angiographically demonstrated occlusions of the radial, ulnar, and/or digital arteries from September 1, 1982, until December 30, 1982, who received intra-arterial streptokinase therapy were reviewed. After angiography, a bolus of 40,000 to 100,000 units of streptokinase was given followed by a continuous infusion of 4000 to 5000 U Ihr administered via an indwelling arterial catheter. Follow-up angiography was performed at 8 to 12 hourly intervals. Six patients with demonstrated arterial occlusion of the hand were treated with intra-arterial streptokinase. In this series, 100% success was achieved when therapy was begun within 24 hours of the onset of signs and symptoms. DR. LEE EDSTROM wondered, in his discussion, about the toxicity of streptokinase and whether placing the catheter closer to the clot would be beneficial. A hemodynamic comparison of interrupted and continuous microarteriorrhaphy techniques. WILLIAM F. BLAIR, M.D., DOUGLAS R. PEDERSEN, B.S.E., KAREN Joos, and DAVID BONDI. Interrupted and continuous techniques in laboratory microarteriorrhaphy were compared. The comparison was based on rat femoral artery hemodynamic parameters, including blood velocities, flow stream cross-sectional geometry, and calculated blood flow. No statistical difference was noted postoperatively between the interrupted and continuous techniques relative to any of the hemodynamic parameters. The average blood flow after the interrupted and continuous techniques was 13.21 cc/min and 13.15 cc/min, respectively. The two microarteriorrhaphy suture techniques, interrupted and continuous, result in statistically similar postoperative vessel performances in a laboratory model. Free deltoid fasciocutaneous transfer for sensate coverage of upper and lower extremity soft tissue defects. R. C. RUSSELL, M.D., R. J. GUY, M.D., C. J. MERREEL, M.D., and E. G. ZoOK, M.D. The ideal tissue transfer should contain skin and subcutaneous tissue, should be thin and hairless, and should provide durable, sensate coverage. The deltoid flap, first described by Franklin, possesses most of these characteristics. The authors have transferred nine free deltoid flaps to
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cover eight extremity defects resulting from trauma and one surgically created by excision of a hemangioma. The patients ranged in age from 1Y2 to 62 years. Four of five foot defects involved the weight-bearing plantar surface. Two hand injuries involved only the dorsum , and two injuries included both dorsal and palmar surfaces. Eight flaps survived completely. A portion of the ninth was lost because an unrecognized proximal bifurcating artery was divided . The ease of transfer, thinness, and ability to provide sensibility makes the free deltoid flap an excellent choice for extremity reconstruction.
Use of cyclosporine A in homotransplantation of rat limbs. S . KIM, M.D ., S . AZIA, M.D., and V.
HENTZ , M.D. Cyclosporine A has been used in animal models for various organ allografts with promising resuits. In this study, the effectiveness of cyclosporine A in prolonging survival of limb allografts in rats was examined and compared to that of other conventional immunosuppressive agents . Two strains of inbred rats, BUF (H-I b, Ag-B6) and LEW (H-I', Ag-BI) were used. All of the animals were male, weighing 180 to 200 gm. The BUF was the donor and the LEW the recipient of the limb allograft. The hind limb on the recipient was amputated at the mid femoral level. The donor limb was similarly amputated and attached to the recipient limb stump. The femoral artery and vein were anastomosed under an operating microscope. The study shows that cyclosporine A is a very effective immunosuppressive agent in preventing rejection of transplanted limbs in rats. It is found to suppress rejection of the homotransplants as long as treatment is continuous. It is superior to the conventional agents such as azathioprine and prednisolone that allow rejection of the limbs while the treatment is in progress. There is a period of immune tolerance after cyclosporine A treatment. However, this period becomes shorter as the length of treatment is increased . This may indicate that cyclosporine A treatment should be continuous and not pulsed at the dose used in this experimental model.
Optimum management of blast injuries to the hand. SAMUEL E. LoGAN, M.D., JURIS BUNKIS, M.D., STEPHEN J. MATHES, M.D., and ROBERT L. WALTON,
M.D. Twenty-four blast injuries to the hand were treated (nine bombs, six firecrackers, nine high velocity bullets) with associated injuries: one ruptured globe, one perforated eardrum, and two abdominal gunshot wounds. The complex hand injuries were characterized by extensive soft tissue trauma and complicated by
The Journal of HAND SURGERY
burns, foreign bodies, fractures, and amputations . This complexity demands optimum care. Although treatment is individualized, a systematic, staged approach is used as a common denominator to ensure maximal functional recovery. Essential initial treatment includes tissue debridement, revascularization, and fracture stabilization. Definitive wound closure is usually delayed as are nerve and tendon repairs . The reparative stage begins at I to 2 days with debridement of residual nonviable tissue and repair of vital structures if wound conditions permit. Wound closure is now a major goal and may include delayed primary closure, skin grafts, or local or distant flaps. In the third reconstructive stage, optimum function is restored by reconstructing tendon, nerve , bones, and joints. Additional skin and soft tissue is often provided at this time. This final stage includes a vigorous physical therapy program and is a key determinant in recovering maximum hand function.
Sports-related injuries to the distal upper extremity. GEORGE A. PRIMIANO, M.D ., and RICHARD LEE, B.S . Ten thousand two hundred twenty-seven patients with sports-related injuries who presented to a rural hospital emergency room for care over 5 years and 7 months were reviewed . Two thousand nine hundred eighteen (28.4%) of the injuries were of the distal upper extremity, including the elbow. Two thousand five hundred and twenty-two (24.5%) of the injuries were distal to the elbow; 53.2% of the injuries occurred in organized activities; 47 .7% of the injuries occurred in recreational sporting activities. The data revealed three groups of injuries. Thumb injuries accounted for 208 of 2606 (8%) of snow skiing injuries (thumb sprains, 108; thumb fractures, 100). This figure is probably too low because of the large transient portion of the snow skiing population. These injuries were all recorded after the introduction of the breakaway ski pole handle. Wrist injuries accounted for 212 of 397 (28%) of skating injuries (fractures, 123; sprains, 90). The authors agree with Kvidera and Frankel that commercial wrist splints should be used while roller skating. Digital injuries accounted for 150 of 932 (16%) of football injuries (83 finger and thumb fractures and 67 finger and thumb sprains). The soft splint as recently popularized by Bergfeld et al. that protects these injuries during the treatment phase but allows continued participation is recommended. THOMAS J. KRIZEK, M.D., in an Invited Paper, discussed the importance of the appearance of the hand in a paper entitled "Aesthetic surgery of the hand."
Skin graft of Hap-A safe, thin, hairless, axial Hap
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for resurfacing the hand. KENNETH M. DIEFFENBACH, M.D. The deltoid pectoral flap popularized in reconstructive surgery of the head and neck has been applied to immediate and delayed coverage of major tissue losses of the hand. The deltoid pectoral flap medially based on the perforating arteries of the internal mammary produces a lengthy tubed pedicle delivering hair-free thin skin to major hand defects. The tubed portion of the pedicle allows free motion of the shoulder, elbow, wrist, and digits without rigid fixation to the chest wall. It allows the hand to be carried in an elevated position. The flap requires no defatting. It provides an ideal cover for the passage of tendon grafts, transfers, or bone work required beneath the area of tissue loss. The safety margin supersedes that of any reported series of free flaps. The disadvantage lies in the fact that it is not capable of supplying sensory innervation to the resurfaced area. This thin, flexible, hairless flap that can be safely elevated within predictable anatomic landmarks has been used in 10 cases to provide flexible and predictable coverage to soft tissue losses in the hand. Fasciocutaneous flap coverage for peri olecranon defects. RICHARD RYu, M.D., JURIS BUNKIS, M.D., ROBERT L. WALTON, M.D., LEONARD I. EpSTEIN, M.D., and LUIS O. VASCONEZ, M.D. Postmortem dissections were performed in 10 cadaver limbs. Anatomic dissections and barium latex injections were used to study the peri olecranon anatomy and to delineate vascular anatomy. Proximally based, forearm fasciocutaneous flaps may be elevated from either flexor or extensor surfaces of the forearm. The excised flaps were x-rayed to study their blood supply. A fine vascular plexus above and below the fascial layer was found to enhance flap vascularity. The study group consisted of 31 patients with soft tissue defects of the peri olecranon region. All patients ultimately enjoyed stable coverage. Potential complications include partial flap or skin graft loss, infections, recurrence of the chronic wound, and, with excessive scarring, damage to the ulnar nerve. Brachioradialis flexor pollicis longus transfer for active lateral pinch in the quadriplegic. STEVEN R. GRABOFF, M.D., KAREN PARIS, O.T.R., and ROBERT WATERS, M.D. Thirteen patients with quadriplegia, the majority caused by gunshot wound and motor vehicle accident, had transfer of the brachioradialis to the flexor pollicis longus tendon, Moberg Screw thumb interphalangeal joint fixation, and tenodesis of the thumb extensors. This provided an active lateral pinch that is not dependent upon tenodesis and decreased the use of orthotic devices.
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Postoperatively all patients were able to actively flex the thumb at the metacarpophalangeal joint. This provided a significant lateral pinch that was strongest in combined elbow and wrist extension and was present in all ranges of wrist and elbow motion. All patients felt improved by the surgery, and most had an increase in functional independence, most notably in fine rather than in gross motor tasks. Tension band arthrodesis in the hand (early results). SUHEIL KAURI, M.D. Since July 1980, 18 proximal interphalangeal and metacarpophalangeal joints in the hand underwent tension band arthrodesis by the author. One patient was lost to follow-up, and it is too recent to evaluate two other patients. The 15 remaining arthrodeses were reviewed. An accurate angle of fusion was achieved by inserting the retrograded parallel pins through the proximal phalanx (metacarpal in a metacarpophalangeal joint) so that the angle between the pins and the proximal phalanx shaft is equal to the desired angle of fusion. Then by driving the pins into the medullary canal of the middle phalanx (proximal phalanx in a metacarpophalangeal joint) that same desired angle is obtained. The author suggested that this is a reliable and predictable method for hand proximal interphalangeal and metacarpophalangeal joint arthrodesis. It has a very high union rate, accurate control of the angle offusion, allows early unprotected mobilization of the adjacent joints, and carries minimal complications. Long step-cut osteotomy in reconstructive handsurgical procedures. LEONARD T. FURLOW, JR., M.D. Osteotomy is a necessary step in many reconstructive procedures in the hand. Joint stiffness and tendon adherence are said to be frequent sequelae of osteotomy. Although bone grafting of the transverse bone junction may reduce the risk of nonunion, it does not allow earlier motion. A number of procedures lend themselves to a long (neck to base) step-cut osteotomy that provides sufficient stability and bony interface to obviate the need for joint immobilization and bone grafting. Motion may be started shortly after surgery, which reduces the risk of joint stiffness and tendon adherence and hastens recovery of function. Functional recovery has been very good in 14 patients. The results have justified the extra exposure and greater precision in bone contouring that is necessary. There have been no nonunions, postoperative fractures, or infections. DR. LUCAS pointed out, in discussion, that with current association of osteosynthesis fixation, transverse
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phalangeal or metacarpal joint osteotomies also have a high union rate while maintaining adjacent joint motion.
Noninvasive pulsed electromagnetic stimulation in the treatment of scaphoid nonunion. ROBERT D. BECKENBAUGH, M.D. Twenty patients with established nonunion of the scaphoid (duration of 6 months to 4 years after fracture) were treated with pulsed noninvasive electromagnetic stimulation for a period of 3 to 61f2 months. The overall union achieved was 70%. Nine of 10 patients treated with a long-arm cast achieved union, whereas only six of 10 patients treated with a short-arm cast achieved union. In patients in whom established nonunion of a nondisplaced fracture of the scaphoid was encountered, pulsed external electromagnetic stimulation resulted in a healing rate of 90%. The author feels this should be the primary treatment of choice in these patients.
Replacement of the proximal portion of the scaphoid with a spherical implant for posttraumatic carporadial arthritis. KENNETH G. JONES, M.D. Subsequent to 1967, 18 patients with necrosis and collapse of the proximal portion of the scaphoid (six right, 12 left) that resulted from trauma have been treated by resection of the un salvageable proximal bone segment and replacement with a spherical implant (11 to 20 mm diameter). A spherical implant has significant advantages over an implant that exactly duplicates anatomy. It does not require resection of significant normal bone, and it requires only entrapment in an adequate enclosure of bone, capsule, and fibrous tissue where it is free to rotate. Anatomic contouring is not needed. The most satisfactory surgical approach has been demonstrated to be from the dorsal surface with tight closure of the capSUle. All wrist and forearm motion present before surgery has been retained or increased after surgery . The same is considered to be true for strength. Pain has been markedly reduced or eliminated in all cases.
The Journal of HAND SURGERY
spot view and were followed at biweekly intervals. Out of 380 patients with wrist injuries, 17 patients were diagnosed immediately as having scaphoid fractures. All 17 patients had maximum tenderness in the snuffbox. Of the 42 patients in this group, 17 patients had fractures resolved within two weeks, were mobilized, and had no recurrence of the symptoms. Thirteen fractures were resolved after 4 weeks, and at the 4-week follow-up, motion views of the wrist revealed no evidence of instability or abnormal carpal alignment. Two patients, however, required 6 weeks and two required 8 weeks of casting because of persistent snuffbox pain and tenderness. Only one scaphoid fracture was not revealed in the acute x-ray. Undisplaced fractures may be healing undetected, and ligamentous injuries require time to heal as well. The algorithm works effectively in providing pain relief and allowing soft tissue injuries to heal with a minimum of immobilization while supporting and following the more severe soft tissue injury out to a suitable clinical recovery. Leonardo da Vinci: On the human hand. JOSEPH C. CREMONE, JR., M.D., and FRANOS G. WOLFORT, M.D. Leonardo da Vinci's anatomic studies of the upper extremity are of special interest to those surgeons who practice surgery of the hand . Leonardo's representations of the osseous structures of the hand were the first to show these structures with any degree of accuracy. His detailed studies of the flexor tendons illustrate both their anatomic structure and the mechanical basis of their function. Leonardo's remarkable studies of the brachial plexus, drawn to help those who "treat wounds in this area," are especially intriguing to surgeons who perform brachial plexus reconstructions. He displayed superbly the distribution of the median and ulnar nerves in the hand as well as the sensory distribution of radial and ulnar nerves to the dorsum of the hand.
Wrist sprain-The significance of snuftbox tenderness. DAVID A. LABOSKY, M.D. An injury to the
Giant cell tumor of distal radius: A reconstructive dilemma. HOUSAND SERADGE, M.D. Giant cell tumor
wrist presenting with pain in the anatomic snuffbox is considered, in spite of negative x-rays, as a possible scaphoid fracture because of the potential for this fracture to be missed on the acute film. Most textbooks suggest cast immobilization for these patients. The authors followed all patients who. presented to the emergency ward after an acute injury with pain localized to the anatomic snuffbox. They constructed an algorithm to provide a standardized approach to the problem. All patients were evaluated radiographically with posteroanterior and lateral views of the wrist and a scaphoid
of bone is an invasive tumor. About 10% of these tumors develop in the distal end of the radius with a 1% incidence of distant metastasis. Replacement of the excised distal radius can be done by translocating the distal portion of the ipsilateral ulna. The blood supply to this segment of ulna is preserved by translocating the ulna without detaching its soft tissue attachments.
Eosinophilic granuloma of the hand: Case report. RONALD E. PALMER, M.D . A previously undescribed solitary lesion of eosinophilic granuloma of the proximal phalanx of the hand of an II-month-old child was
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presented including the x-ray findings, histologic picture, electron micrographs of the pathologic specimen , and review of the treatment. The history of the disorder and a review of the clinical implications was included. Hand injuries associated with parenteral propylhexedrine abuse. H. R. MANCUSI-UNGARO, JR., W. J. DECKER, V. R. FORSHAN, S. J. BLACKWELL, and S. R. LEWIS. Propylhexedrine, the active ingredient in Benzedrex Inhalers, is extracted from the wicks of the inhalers by drug abusers for intravenous injection to provide a "desirable high." Injection of this potent vasoconstrictor produces local injury at the site of injection as well as distal injuries secondary to its arterial vasoconstrictive effect. Six representative cases treated over a I-year period are presented. The scope of complications from the abuse of propylhexedrine included loss of digits, sensory deficits, abscess formation, and simple cellulitis. Hand surgery applications of the low intensity x-ray imaging device. WILLIAM J. TANSEY, M.D. In 1978 the National Aeronautics and Space Administration developed an instrument for use in x-ray astronomy. This instrument contained a low-level gamma source to provide single proton imaging in x-ray astronomy . This low-dose, low-yield, radioactive fluoroscopic machine was basically a low intensity x-ray imaging process. The gamma ray source converts an image to a visible-light image by converting the electrons in the scope itself through a scintillator plate. A primary application of this instrument has been in the field of hand surgery. Mycobacterium marinum infection: A disease endemic in southwest Louisiana fisherman. R. DALE BERNAUER, M.D. Mycobacterium marinum infection is very common in southwest Louisiana fisherman, especially crab and shrimp fisherman. The natural history of the disease, treatment , and clinical presentation as well as examples from the author's personal experience was discussed. The need for proper bacteriologic techniques was emphasized. Digital nerve compression in tennis players. STEPHEN J. NASO, JR., M.D. Over the past few years the author has noticed a complex of symptoms peculiar to amateur tennis players. Such symptoms consist in numbness and tingling of the index finger, tenderness over the head of the second metacarpal, and thickening of the palmar skin at the base of the index finger. Surgical exploration in two patients revealed marked perineural fibrosis and scarring of the radial digital nerve that was similar to that found in a "bowler's thumb . " Operative treatment consisting in the excision of the thickened nerve sheath and neurolysis was found
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to be most successful. One patient with early symptoms was treated conservatively with excellent results. Pyridoxine as an adjunct to the treatment of carpal tunnel syndrome. PETER C. AMADIO, M.D. Recent publications in both the lay and scientific press have suggested that pyridoxine may be useful in the treatment of carpal tunnel syndrome and other peripheral neuropathies. To evaluate this possibility, 15 consecutive patients with clinical findings consistent with carpal tunnel syndrome were studied . Each of the 15 patients was treated by the following protocol : a printed information sheet describing the positive effects of pyridoxine for carpal tunnel syndrome was provided after the clinical diagnosis was established and a prescription for pyridoxine, 200 mg/ day, was administered. The patients were reevaluated in 1 month. No patient improved on pyridoxine alone. Six patients had sufficient symptomatic release after splinting, and anti-inflammatory medication was added to return to full activity . Treatment was gradually stopped over the next few months without recurrence of symptoms . The other nine patients continued to have symptoms . Repair of syndactylism in the newborn infant. ELMER E. RAUS, M.D . With increased knowledge and awareness of the physiology of the newborn infant and the use of microsurgical techniques and advances in anesthesia, the stage has been set for elective surgery in the newborn infant. The author discussed the advantages and technique of repair of syndactylism in the newborn infant, the unique physiology of the newborn infant, and the importance of the timing of the surgery. A straight line separation of the fingers is performed. Direct closure is used with no undermining or defatting . Dorsal and palmar flaps are used to form the web space. The results are soft, minimal scars with excellent finger function and appearance. It appears that shortly after birth may be the optimal age for the repair of syndactylism. Silicone rubber ball and socket arthroplasty of the thumb. WALTER M. BRAUNOHLER, M .D. Twenty silicone rubber ball and socket arthroplasties were performed between 1980 and 1983 with a 3- to 33-month follow-up period. This procedure creates a crater in the base of the first metacarpal and trapezium through a ligament-splitting approach at the interval between the abductor pollicis longus and brevis . Minimum ligament detachment, the distraction effect, and the elasticity of the silicone rubber elastomer provide immediate stability. Indications, technique, and results are comparable to other procedures. Morbidity is decreased because of a short immobilization time of 3 weeks. Postoperative
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complications of shortening and subluxation, common in other arthroplasty techniques, are eliminated.
Silicone rubber arthroplasties of the metacarpophalangeal joints in rheumatoid arthritis. ROBERT H. BRUMFIELD, JR., M.D. Two hundred sixty-four rheumatoid arthritic patients treated with 901 Swanson silicone rubber arthroplasties of the metacarpophalangeal joints by the Arthritis Service at Rancho Los Amigos Hospital (Downey, Calif.) from 1967 to 1981 were evaluated after a minimum of 2 years (average 8 years). Pain was relieved in all patients except in those patients who had complications. Active motion was increased by 20% while passive motion increased by 25%. By use of the Rancho Los Amigos Hospital functional analysis, 5% of the patients were classified as excellent, 60% were classified as good, 28% were classified as fair, and 7% were classified as poor.
The Journal of HAND SURGERY
forearm and hand were described. These fibers have a similar appearance and orientation to those fibers that make up the extensor retinaculum and are located in the same fascial plane proximal and distal to the extensor retinaculum.
Vascular anatomy of the proximal interphalangealjoint. N. JOHN YOUSIF, M.D., JAMES R. SANDER,
FORST E. BROWN, M.D. Ulnar drift and metacarpophalangeal (MP) joint subluxation are hand deformities frequently observed in rheumatoid arthritis. In an attempt to reduce the deforming forces responsible for MP ulnar drift, a static splint incorporating threepoint pressure was evaluated for the last 3 years. The pathogenesis of MP ulnar drift appears to be multifactorial: (1) synovial damage to the MP joint and weakening of ligament support, (2) intrinsic muscle tightness, (3) weakness of the radial interossei muscles, (4) the moment of action of the intrinsic muscle-tendon complexes, and (5) the zigzag effect of carpal collapse and wrist radial deviation. The static splint used for rheumatoid arthritis patients with ulnar drift has been designed to correct the radial deviation at the wrist while also aligning the fingers at the MP joints. The three points of pressure are the ulnar border of the small finger, the radial border of the second metacarpal head, and the ulnar side of the forearm. This splint puts the intrinsic muscles on stretch, blocks the extrinsic muscle action, and corrects the intercalated system zigzag effect.
M.D., MARSHALL WADE CUNNINGHAM, M.D., RUEDI P. GINGRASS, M.D., and HANI S. MATLOUG, M.D. Three methods were used to identify the general vascular branches that supply the joint, bone, and cartilage of the proximal interphalangeal joint. These methods include intraarterial injection of radiopaque cinnabar, intraarterial injection of liquid latex followed by microscopic dissection of the arterial system, and selective injection with India ink of specific branches followed by sectioning of the joints and examination of the areas stained. The studies demonstrate that the major branches of the digital artery to the joint arise from the dorsal surface, whereas smaller branches that run to the soft tissue and palmar branch arise from the palmar side. Three branches supply the proximal interphalangeal joint. Ruptures of the palmar plate. R. JOHN BROVES, M.D., and HARVEY SHAPIRO, M.D. The authors presented a retrospective analysis of 10 patients who presented with proximal interphalangeal joint hyperextension and instability. The presenting symptoms were pain, instability on extension developing into hyperextension, and locking in hyperextension. Locking proved to be the most disabling complaint. DR. ROBERT CHASE'S Keynote Address traced the recent developments in hand surgery including the various new flaps and tissue transfers, skin expansion, electrical stimulus to bone healing, implants and prosthesis, internal fixation devices, and prostheses both cosmetic and functional. DR. CHASE concluded by describing the importance of biomedical engineering to hand surgery such as imaging devices, 3-D television, and the robotic hand.
The extensor retinaculum: Anatomic and biomechanical observations. DAVID BOLAND, M.D. None
Bennett's fracture: An anatomic and clinical study. J. R. HARRIS, M.D., J. O. EDMUNDS, M.D., D.
of the well respected texts of anatomy or hand surgery gives an in-depth description of the extensor retinaculum. The author described the origin and insertion of the retinaculum, frequent subdivision of the first compartment, unique restraining mechanisms for the extensor pollicis longus and extensor carpi ulnaris tendons, gross and histologic appearance of this ligamentous tissue, and vascular supply of this structure. "Accessory retinacular fibers" of the dorsal fascia of the distal
RIORDAN, M.D., and R. J. HADDAD, M.D. The authors have found the method of closed reduction of Bennett's fracture as is advocated in current texts to be ineffective in producing an anatomically reduced fracture. The Wagner method of reduction involves radial abduction of the thumb metacarpal with distal traction placed upon the thumb and pressure applied to the base of the thumb metacarpal to bring the thumb metacarpal into alignment with the palmar beak fragment. The authors
Three-point splinting for the rheumatoid hand with ulnar drift. JOANNE C. CASSIDY, O.T.R., and
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feel this method is incorrect. The unique anatomy of the carpometacarpal joint determines the correct rationale for reduction of a Bennett's fracture. The saddleshaped carpometacarpal joint has no inherent bony stability. It is reinforced by four ligaments. The strongest of these is the ulnar or palmar ligament, which is thick and wide and runs from the trapezial crest up to the ulnar beak of the first metacarpal. According to Eaton and Littler this ligament is the primary stabilizer of the thumb. It is this palmar ligament that avulses the ulnar beak of the thumb metacarpal in a Bennett's fracture. The neutral position of "position of rest" of the trapezium metacarpal axis is in opposition. In this position the palmar ligament is relaxed. As the thumb is brought into radial abduction, this ligament becomes taut. It is for this reason that radial abduction displaces the metacarpal away from the palmar fragment and that opposition and internal rotation brings the metacarpal into correct alignment with the palmar fragment held by the palmar ligament. Opposing the thumb brought the thumb metacarpal into correct alignment with the palmar fragment, but an imperfect reduction was obtained. It was only when they internally rotated and "screwed home" the opposed metacarpal that they obtained an anatomically reduced fracture that was reduced on both anteroposterior view and the Robert's view. Clinically, the authors have found this to be the only effective method of obtaining an anatomically reduced fracture by closed means. Augmentation of skin flap survival with dazoxiben hydrochloride, a selective thromboxane synthetase inhibitor: Clinical and laser Doppler assessment in rats. W. C. BRENDER, M.D., E. T. DICKINSON, B.A., and R. H. MCSHANE, M.D. Skin flaps provide essential coverage in difficult hand problems. Exogenous prostacyclin (PGI2 ) has been shown to improve skin flap survival but has limited clinical applicability. Dazoxiben hydrochloride, a selective thromboxane (TX2 ) inhibitor, can elevate prostacyclin levels for 6 to 8 hours. The authors have demonstrated that systemic perioperative dazoxiben hydrochloride treatment can augment skin flap survival and may have clinical applicability. Twenty-four Sprague-Dawley rats had modified McFarland flaps elevated and replaced. Twelve rats were treated with 100 mg/kg of dazoxiben hydrochloride peri operatively in 3 ml of normal saline (1 ml administered at 2 hours before surgery, 1 ml administered at 6 hours before surgery, and 1 ml administered at 12 hours after surgery). Twelve rats were treated similarly with 3 ml of normal saline alone. A postoperative study
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was then undertaken with 12 rats. After elevating and replacing flaps, six rats received 100 mg/kg of dazoxiben hydrochloride per day over a 3-day course every 8 hours, and six rats were treated similarly with 3 ml of normal saline per day. In the perioperative (preoperative and postoperative) treatment study, the control groups had a 31. 8 ± 9.6% flap survival, whereas the dazoxiben hydrochloride groups were noted to have a 45.2 ± 12.5% flap survival. There was a significant difference between the control and experimental groups (p < 0.005). No bleeding complications were noted. In the postoperative study there was no significant difference between dazoxiben hydrochloride and control groups. DR. FRED HECKLER, in discussion, pointed out that the modified McFarland flaps have a highly variable survival, and the control group of flaps is thus compromised. Occupational hand disorders in musicians. F. J. BEJJANI, M.D., MICHAEL S. GROSS, M.D., and PAUL W. BROWN, M.D. A study of five parameters of hand function in musicians is underway: clinical, psychologic, electromyographic, thermographic, and ergonomic. The authors reported preliminary findings for the clinical part in 71 professional musicians (36 males and 35 females, mean age 35 ± 11 years): violinists (11), violists (15), cellists (8), bassists (5), harpists (11), pianists (13) and guitarists (8). Of the 71 musicians, 77.5% have had or still have some type of upper extremity disorder serious enough to impair performance or to prevent playing, at least temporarily. These conditions included neurologic symptoms (26.7%); painful finger joints (33% of the pianists and 28.6% of the female violinists); inflammatory syndromes (tendonitis, trigger finger, bursitis) in 36.6% who had one or more of these conditions that represented the most common cause of cessation of performing; and muscle tension or spasm (28%). The early findings of this study demonstrate that the development of hand disorders in musicians is fairly specific to the type of instrument played and related to the age at which the musician began, whether he also developed neck problems, the fluctuations in his playing routine, and various subjective factors. DR. LEE DELLON believed this was a very useful study that will give us information about a group of individuals who place maximal demands on their hands. Nerve regeneration through synthetic nerve guides-Importance of the distal stump. B. R. SECKEL, M.D., E. W. HENRY, M.D., and R. L. SIDMAN, M.D. Five millimeter, 10 mm, and 20 mm sec-
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tions were excised from the sciatic nerve of adult rats. Ten millimeter and 20 mm biodegradable polyester nerve guides were used to bridge the nerve gap by suturing the proximal and distal nerve stump into the respective ends of the guides. Controls with no distal stump in the guide were also prepared. Light microscopic and computerized axon-counting analyses were done to evaluate the success of nerve regeneration. In both the lO mm and 20 mm guide groups, a regenerated nerve was consistently obtained that was growing down the lumen of the guide and innervating the distal nerve stump in all cases when the nerve gap was 10 mm or less and the distal nerve stump was present. Approximately 40% of the fibers were myelinated at 3 months. In contrast, if the nerve gap was greater than 10 mm or if no distal stump was present, there was striking failure of regeneration. Scar response to the nerve guide was minimal.
Facilitation of axillary block anesthesia by use of the electrical nerve stimulator. LARRY G. LEONARD, M.D., CHARLES A. FEAGIN, M.D., and CLIFFORD C. SNYDER, M.D. Regional conduction anesthesia that is well-suited to surgery of the hand offers certain distinct advantages to the patient over general anesthesia including exposure to fewer and less toxic agents and less physiologic strain on the cardiorespiratory system. Its use is frequently limited, however, by the nonavailability of an anesthesiologist skilled in the necessary techniques, the length of time required to administer the block and allow it to take effect, and the spe ''!r of occasional failure of a block even under the best circumstances. Many of the disadvantages of axillary block anesthesia have been obviated by the routine use of lowvoltage electrical stimulation to precisely and rapidly locate the axillary sheath or individual cords within the sheath. A rapid, reliable means of achieving upper extremity
The Journal of HAND SURGERY
anesthesia allows the surgeon a degree of independence not otherwise achievable. The intent should not be to eliminate the need for an anesthesiologist but rather to allow one more option in the planning of surgery. This, for example, allows a trauma case to be done more expeditiously when the anesthesiologist is occupied with other emergencies, and for selected patients, it allows greater convenience and reduction of cost by opening a broader spectrum of cases for outpatient or office surgery with the elimination of anesthetic and possibly hospital charges. The traumatic neuroma. CLIFFORD C. SNYDER, M.D., JAMES E. PICKENS, M.D., and LARUE PICKENS, R.N. As is usual in most therapeutic measures, prevention of a traumatic neuroma is the better approach, but once the painful condition exists, there must be a method to prevent recurrence of the annoying lesion. Studies have been carried out in the laboratory on the animal and in the operating room on the human. Controls were compared with the treated subjects histologically and clinically. The sciatic nerve of the rat was the site of study in the laboratory subjects. The median, ulnar, radial, proper digital, and palmar digital nerves were those treated in the human subjects. The authors report a study of 264 laboratory subjects and 39 human nerves. The methods used to prevent or inhibit neuroma formation were grouped into chemical, physical, and surgical treatment. The chemical approach was segregated into nonfixatives, temporary fixatives, and permanent fixatives. The physical modes used were electrical, irradiation, freezing, and burning. The surgical means included excision, crushing, ligation, diversion, capping, grafting, and transferring. Medically, excellent prevention of a recurrent neuroma was achieved with triple deionized water. Surgical prevention was achieved by implanting the central stump of the severed nerve into a treated homograft vein.
T
he Thirteenth Annual Meeting of the American Association for Hand Surgery was held October 27 through 30, 1983, in Dallas, Texas, under the presidency of Garry S. Brody, M.D. Papers by Drs. Ryu, Yousif, and Jelalian were awarded prizes in the Annual Resident's Essay Contest. Chemotherapy extravasations: Management of acute and chronic injuries. FREDERICK R. HECKLER, M.D., JOHN C. SCHIMMEL, M.D., and E. WEST JONES, B.S. The authors have treated 32 patients suffering acute extravasation of antineoplastic agents with immediate regional clysis by use of normal saline and hyaluronidase. None of these patients suffered any skin loss, and all maintained full active range of hand motion. A model using ulcerations resulting from subcutaneous injections of doxorubicin hydrochloride (Adriamycin) in distal segments of rabbit extremities was developed. Clyses with saline/hyaluronidase, saline, corticoids, and hyaluronidase alone were then tested for their ability to ameliorate subsequent skin ulceration. The saline/hyaluronidase combination was significantly more efficacious than the other agents, confirming clinical observations. Another series of patients with established extravasation ulcerations were selected prospectively for management without surgical wound closure. The wounds were treated with silver sulfadiazine (Silvadene) and dressings, and the patients were followed as outpatients. Thirty-six patients were available for follow-up and did well without aggressive surgery. Reversing the burn injury in the burned hand. ANTONIO M. CARBONELL, M.D. The early application of an antiprostaglandin-antibiotic cream combination on a partial thickness bum injury of the hand results in painless restoration of the range of motion and functional preservation of the skin and underlying structures without the need for skin grafting or extensive splinting and physiotherapy. The author has treated 50 patients with silver sulfadiazine-methylprednisolone (Silvadene-Medrol) combination. Hand bums treated in this fashion require minimal splinting, are essentially painless, demonstrate little edema, can be mobilized within 24 hours, are aesthetically pleasing, and demonstrate a 50% reduction in overall morbidity; furthermore, the need for skin grafting tangential or enzymatic debridement is eliminated. Peripheral defects after meningitis. JOSEPH AGRIS, 288
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M.D., and JACOB VARON, M.D. It is possible with the pediatric intensive care facilities of today for children to survive meningitis. Morbidity and mortality rate has been reduced 8% to 12%. However, these children are now surviving with normal mental capacity but severe peripheral defects. The authors discussed the physiologic and seriologic changes that take place during the disease process leading to the peripheral vascular compromise. DR. DONALD TEAL, in discussion, noted the similarity to frost bite and suggested that heparin was of therapeutic value in view of the microvascular nature of the lesion. Digitotalar dysmorphism. AVTAR S. DHALIWAL, M.D., and TERRY L. MYERS, M.D. Digitotalar dysmorphism is a rare clinical entity that was first described by Sallis and Beighton in 1972. The syndrome consists of significant ulnar deviation of the phalanges, adduction and flexion deformity of the thumbs, soft tissue webbing, simian lines, vertical tali with "rocker bottom" deformities of the feet, and an apparent short stature. Another family with this inherited genetic disorder was presented including details of clinical findings and their surgical management. In discussion, DR. JOSEPH UPTON also stressed early release of contractures, especially at the first web space. Pre and postaxial polydactyly of the upper extremity: A long-term follow-up study. THOMAS A. McENNERNEY, M.D. Polydactyly of the upper extremity is a common congenital anomaly. The records of 59 patients with upper extremity polydactyly who had been treated at Carrie Tingley Hospital for Crippled Children from 1937 to 1982 were reviewed. A total of 84 supernumerary digits were involved. Long-term follow-up was obtained on 33 patients. Preaxial polydactyly was classified according to the Wassel classification with an additional category for triphalangism. Postaxial polydactyly was classified into four groups on the basis of the location of the origin of the supernumerary digit. Treatment of preaxial polydactyly frequently results in joint instability, decreased strength, and loss of arc of motion. Additional operations for instability were common. Treatment of postaxial polydactyly did not produce functional impairment. Any additional operations were usually done for cosmesis.
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DR. UPTON commented that simple ablation is rarely possible, and reconstructive procedures are often necessary. Distraction augmentation manoplasty: 1983 update. NORMAN J. COWEN, M.D., reported 172 digital lengthenings in 47 patients in whom 94 Matev distraction devices were applied. This series includes eight cases of traumatic amputation of one or more digits and 39 patients with congenital anomalies. The congenital anomalies vary from simple hypoplasia of one ray to shortness of all the fingers, to severe central defect, and eventually to aplasia of the hand. A previous report on 12 infants with severely hypoplastic hands who had surgery before the age of 2 years was updated. In that series, an increase in length of 145% was achieved which means that the average hand was more than doubled and less than tripled in length. There is now a 3-year follow-up on this series. The complications have been many. The technique is very time-consuming and very demanding on both the physician, the nurses, and the patients and their parents. DR. FREDERICK HANSEN, in discussion, emphasized the many complications of the procedure. In an invited paper, ANDREW PALMER, M.D., discussed limited versus complete wrist fusion and emphasized that complete wrist fusions result in absent wrist motion and relief of wrist pain, whereas limited wrist fusions result in decreased (but not absent) wrist motion and decreased (but not absent) wrist pain. The applicability of each of these alternative procedures was discussed in detail. Reperfusion of skeletal muscle after ischemia. ELOF ERIKSSON, M.D., R. C. RUSSELL, M.D., and E. G. ZoOK, M.D. Muscle reperfusion after more than 6 hours of ischemia is unlikely. Various reasons for the vascular occlusion or "no reflow phenomenon" have been suggested. The present study was designed to answer the question: what causes vascular occlusion in skeletal muscle after more than 6 hours of warm ischemia? Twenty-nine cats weighing 2.6 kg were anesthetized with chloralose and the tenuissimus muscle studied in vivo by use of the intravital microscope that is specially equipped for study of the microcirculation in live tissues. This study concluded that even after 10 hours of warm ischemia in muscle, there is an initial reperfusion after release of the tourniquet. Platelet thrombi then occlude the venules causing complete proximal microvascular standstill. The effects of platelet inhibitors such as aspirin or Dextran 40 given before reperfusion
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in muscles occluded for more than 6 hours are presently being studied. Streptokinase therapy for arterial occlusions of the hand. CRHISTINE JELALlAN, M.D., JAMES RICHARDSON, M.D., AUSTIN MEHRHOF, JR., M.D., and WYNDELL MERRITT, M.D. Intra-arterial streptokinase infusion has been successfully used to treat peripheral and coronary arterial occlusions. All patients with angiographically demonstrated occlusions of the radial, ulnar, and/or digital arteries from September 1, 1982, until December 30, 1982, who received intra-arterial streptokinase therapy were reviewed. After angiography, a bolus of 40,000 to 100,000 units of streptokinase was given followed by a continuous infusion of 4000 to 5000 U Ihr administered via an indwelling arterial catheter. Follow-up angiography was performed at 8 to 12 hourly intervals. Six patients with demonstrated arterial occlusion of the hand were treated with intra-arterial streptokinase. In this series, 100% success was achieved when therapy was begun within 24 hours of the onset of signs and symptoms. DR. LEE EDSTROM wondered, in his discussion, about the toxicity of streptokinase and whether placing the catheter closer to the clot would be beneficial. A hemodynamic comparison of interrupted and continuous microarteriorrhaphy techniques. WILLIAM F. BLAIR, M.D., DOUGLAS R. PEDERSEN, B.S.E., KAREN Joos, and DAVID BONDI. Interrupted and continuous techniques in laboratory microarteriorrhaphy were compared. The comparison was based on rat femoral artery hemodynamic parameters, including blood velocities, flow stream cross-sectional geometry, and calculated blood flow. No statistical difference was noted postoperatively between the interrupted and continuous techniques relative to any of the hemodynamic parameters. The average blood flow after the interrupted and continuous techniques was 13.21 cc/min and 13.15 cc/min, respectively. The two microarteriorrhaphy suture techniques, interrupted and continuous, result in statistically similar postoperative vessel performances in a laboratory model. Free deltoid fasciocutaneous transfer for sensate coverage of upper and lower extremity soft tissue defects. R. C. RUSSELL, M.D., R. J. GUY, M.D., C. J. MERREEL, M.D., and E. G. ZoOK, M.D. The ideal tissue transfer should contain skin and subcutaneous tissue, should be thin and hairless, and should provide durable, sensate coverage. The deltoid flap, first described by Franklin, possesses most of these characteristics. The authors have transferred nine free deltoid flaps to
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cover eight extremity defects resulting from trauma and one surgically created by excision of a hemangioma. The patients ranged in age from 1Y2 to 62 years. Four of five foot defects involved the weight-bearing plantar surface. Two hand injuries involved only the dorsum , and two injuries included both dorsal and palmar surfaces. Eight flaps survived completely. A portion of the ninth was lost because an unrecognized proximal bifurcating artery was divided . The ease of transfer, thinness, and ability to provide sensibility makes the free deltoid flap an excellent choice for extremity reconstruction.
Use of cyclosporine A in homotransplantation of rat limbs. S . KIM, M.D ., S . AZIA, M.D., and V.
HENTZ , M.D. Cyclosporine A has been used in animal models for various organ allografts with promising resuits. In this study, the effectiveness of cyclosporine A in prolonging survival of limb allografts in rats was examined and compared to that of other conventional immunosuppressive agents . Two strains of inbred rats, BUF (H-I b, Ag-B6) and LEW (H-I', Ag-BI) were used. All of the animals were male, weighing 180 to 200 gm. The BUF was the donor and the LEW the recipient of the limb allograft. The hind limb on the recipient was amputated at the mid femoral level. The donor limb was similarly amputated and attached to the recipient limb stump. The femoral artery and vein were anastomosed under an operating microscope. The study shows that cyclosporine A is a very effective immunosuppressive agent in preventing rejection of transplanted limbs in rats. It is found to suppress rejection of the homotransplants as long as treatment is continuous. It is superior to the conventional agents such as azathioprine and prednisolone that allow rejection of the limbs while the treatment is in progress. There is a period of immune tolerance after cyclosporine A treatment. However, this period becomes shorter as the length of treatment is increased . This may indicate that cyclosporine A treatment should be continuous and not pulsed at the dose used in this experimental model.
Optimum management of blast injuries to the hand. SAMUEL E. LoGAN, M.D., JURIS BUNKIS, M.D., STEPHEN J. MATHES, M.D., and ROBERT L. WALTON,
M.D. Twenty-four blast injuries to the hand were treated (nine bombs, six firecrackers, nine high velocity bullets) with associated injuries: one ruptured globe, one perforated eardrum, and two abdominal gunshot wounds. The complex hand injuries were characterized by extensive soft tissue trauma and complicated by
The Journal of HAND SURGERY
burns, foreign bodies, fractures, and amputations . This complexity demands optimum care. Although treatment is individualized, a systematic, staged approach is used as a common denominator to ensure maximal functional recovery. Essential initial treatment includes tissue debridement, revascularization, and fracture stabilization. Definitive wound closure is usually delayed as are nerve and tendon repairs . The reparative stage begins at I to 2 days with debridement of residual nonviable tissue and repair of vital structures if wound conditions permit. Wound closure is now a major goal and may include delayed primary closure, skin grafts, or local or distant flaps. In the third reconstructive stage, optimum function is restored by reconstructing tendon, nerve , bones, and joints. Additional skin and soft tissue is often provided at this time. This final stage includes a vigorous physical therapy program and is a key determinant in recovering maximum hand function.
Sports-related injuries to the distal upper extremity. GEORGE A. PRIMIANO, M.D ., and RICHARD LEE, B.S . Ten thousand two hundred twenty-seven patients with sports-related injuries who presented to a rural hospital emergency room for care over 5 years and 7 months were reviewed . Two thousand nine hundred eighteen (28.4%) of the injuries were of the distal upper extremity, including the elbow. Two thousand five hundred and twenty-two (24.5%) of the injuries were distal to the elbow; 53.2% of the injuries occurred in organized activities; 47 .7% of the injuries occurred in recreational sporting activities. The data revealed three groups of injuries. Thumb injuries accounted for 208 of 2606 (8%) of snow skiing injuries (thumb sprains, 108; thumb fractures, 100). This figure is probably too low because of the large transient portion of the snow skiing population. These injuries were all recorded after the introduction of the breakaway ski pole handle. Wrist injuries accounted for 212 of 397 (28%) of skating injuries (fractures, 123; sprains, 90). The authors agree with Kvidera and Frankel that commercial wrist splints should be used while roller skating. Digital injuries accounted for 150 of 932 (16%) of football injuries (83 finger and thumb fractures and 67 finger and thumb sprains). The soft splint as recently popularized by Bergfeld et al. that protects these injuries during the treatment phase but allows continued participation is recommended. THOMAS J. KRIZEK, M.D., in an Invited Paper, discussed the importance of the appearance of the hand in a paper entitled "Aesthetic surgery of the hand."
Skin graft of Hap-A safe, thin, hairless, axial Hap
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for resurfacing the hand. KENNETH M. DIEFFENBACH, M.D. The deltoid pectoral flap popularized in reconstructive surgery of the head and neck has been applied to immediate and delayed coverage of major tissue losses of the hand. The deltoid pectoral flap medially based on the perforating arteries of the internal mammary produces a lengthy tubed pedicle delivering hair-free thin skin to major hand defects. The tubed portion of the pedicle allows free motion of the shoulder, elbow, wrist, and digits without rigid fixation to the chest wall. It allows the hand to be carried in an elevated position. The flap requires no defatting. It provides an ideal cover for the passage of tendon grafts, transfers, or bone work required beneath the area of tissue loss. The safety margin supersedes that of any reported series of free flaps. The disadvantage lies in the fact that it is not capable of supplying sensory innervation to the resurfaced area. This thin, flexible, hairless flap that can be safely elevated within predictable anatomic landmarks has been used in 10 cases to provide flexible and predictable coverage to soft tissue losses in the hand. Fasciocutaneous flap coverage for peri olecranon defects. RICHARD RYu, M.D., JURIS BUNKIS, M.D., ROBERT L. WALTON, M.D., LEONARD I. EpSTEIN, M.D., and LUIS O. VASCONEZ, M.D. Postmortem dissections were performed in 10 cadaver limbs. Anatomic dissections and barium latex injections were used to study the peri olecranon anatomy and to delineate vascular anatomy. Proximally based, forearm fasciocutaneous flaps may be elevated from either flexor or extensor surfaces of the forearm. The excised flaps were x-rayed to study their blood supply. A fine vascular plexus above and below the fascial layer was found to enhance flap vascularity. The study group consisted of 31 patients with soft tissue defects of the peri olecranon region. All patients ultimately enjoyed stable coverage. Potential complications include partial flap or skin graft loss, infections, recurrence of the chronic wound, and, with excessive scarring, damage to the ulnar nerve. Brachioradialis flexor pollicis longus transfer for active lateral pinch in the quadriplegic. STEVEN R. GRABOFF, M.D., KAREN PARIS, O.T.R., and ROBERT WATERS, M.D. Thirteen patients with quadriplegia, the majority caused by gunshot wound and motor vehicle accident, had transfer of the brachioradialis to the flexor pollicis longus tendon, Moberg Screw thumb interphalangeal joint fixation, and tenodesis of the thumb extensors. This provided an active lateral pinch that is not dependent upon tenodesis and decreased the use of orthotic devices.
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Postoperatively all patients were able to actively flex the thumb at the metacarpophalangeal joint. This provided a significant lateral pinch that was strongest in combined elbow and wrist extension and was present in all ranges of wrist and elbow motion. All patients felt improved by the surgery, and most had an increase in functional independence, most notably in fine rather than in gross motor tasks. Tension band arthrodesis in the hand (early results). SUHEIL KAURI, M.D. Since July 1980, 18 proximal interphalangeal and metacarpophalangeal joints in the hand underwent tension band arthrodesis by the author. One patient was lost to follow-up, and it is too recent to evaluate two other patients. The 15 remaining arthrodeses were reviewed. An accurate angle of fusion was achieved by inserting the retrograded parallel pins through the proximal phalanx (metacarpal in a metacarpophalangeal joint) so that the angle between the pins and the proximal phalanx shaft is equal to the desired angle of fusion. Then by driving the pins into the medullary canal of the middle phalanx (proximal phalanx in a metacarpophalangeal joint) that same desired angle is obtained. The author suggested that this is a reliable and predictable method for hand proximal interphalangeal and metacarpophalangeal joint arthrodesis. It has a very high union rate, accurate control of the angle offusion, allows early unprotected mobilization of the adjacent joints, and carries minimal complications. Long step-cut osteotomy in reconstructive handsurgical procedures. LEONARD T. FURLOW, JR., M.D. Osteotomy is a necessary step in many reconstructive procedures in the hand. Joint stiffness and tendon adherence are said to be frequent sequelae of osteotomy. Although bone grafting of the transverse bone junction may reduce the risk of nonunion, it does not allow earlier motion. A number of procedures lend themselves to a long (neck to base) step-cut osteotomy that provides sufficient stability and bony interface to obviate the need for joint immobilization and bone grafting. Motion may be started shortly after surgery, which reduces the risk of joint stiffness and tendon adherence and hastens recovery of function. Functional recovery has been very good in 14 patients. The results have justified the extra exposure and greater precision in bone contouring that is necessary. There have been no nonunions, postoperative fractures, or infections. DR. LUCAS pointed out, in discussion, that with current association of osteosynthesis fixation, transverse
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phalangeal or metacarpal joint osteotomies also have a high union rate while maintaining adjacent joint motion.
Noninvasive pulsed electromagnetic stimulation in the treatment of scaphoid nonunion. ROBERT D. BECKENBAUGH, M.D. Twenty patients with established nonunion of the scaphoid (duration of 6 months to 4 years after fracture) were treated with pulsed noninvasive electromagnetic stimulation for a period of 3 to 61f2 months. The overall union achieved was 70%. Nine of 10 patients treated with a long-arm cast achieved union, whereas only six of 10 patients treated with a short-arm cast achieved union. In patients in whom established nonunion of a nondisplaced fracture of the scaphoid was encountered, pulsed external electromagnetic stimulation resulted in a healing rate of 90%. The author feels this should be the primary treatment of choice in these patients.
Replacement of the proximal portion of the scaphoid with a spherical implant for posttraumatic carporadial arthritis. KENNETH G. JONES, M.D. Subsequent to 1967, 18 patients with necrosis and collapse of the proximal portion of the scaphoid (six right, 12 left) that resulted from trauma have been treated by resection of the un salvageable proximal bone segment and replacement with a spherical implant (11 to 20 mm diameter). A spherical implant has significant advantages over an implant that exactly duplicates anatomy. It does not require resection of significant normal bone, and it requires only entrapment in an adequate enclosure of bone, capsule, and fibrous tissue where it is free to rotate. Anatomic contouring is not needed. The most satisfactory surgical approach has been demonstrated to be from the dorsal surface with tight closure of the capSUle. All wrist and forearm motion present before surgery has been retained or increased after surgery . The same is considered to be true for strength. Pain has been markedly reduced or eliminated in all cases.
The Journal of HAND SURGERY
spot view and were followed at biweekly intervals. Out of 380 patients with wrist injuries, 17 patients were diagnosed immediately as having scaphoid fractures. All 17 patients had maximum tenderness in the snuffbox. Of the 42 patients in this group, 17 patients had fractures resolved within two weeks, were mobilized, and had no recurrence of the symptoms. Thirteen fractures were resolved after 4 weeks, and at the 4-week follow-up, motion views of the wrist revealed no evidence of instability or abnormal carpal alignment. Two patients, however, required 6 weeks and two required 8 weeks of casting because of persistent snuffbox pain and tenderness. Only one scaphoid fracture was not revealed in the acute x-ray. Undisplaced fractures may be healing undetected, and ligamentous injuries require time to heal as well. The algorithm works effectively in providing pain relief and allowing soft tissue injuries to heal with a minimum of immobilization while supporting and following the more severe soft tissue injury out to a suitable clinical recovery. Leonardo da Vinci: On the human hand. JOSEPH C. CREMONE, JR., M.D., and FRANOS G. WOLFORT, M.D. Leonardo da Vinci's anatomic studies of the upper extremity are of special interest to those surgeons who practice surgery of the hand . Leonardo's representations of the osseous structures of the hand were the first to show these structures with any degree of accuracy. His detailed studies of the flexor tendons illustrate both their anatomic structure and the mechanical basis of their function. Leonardo's remarkable studies of the brachial plexus, drawn to help those who "treat wounds in this area," are especially intriguing to surgeons who perform brachial plexus reconstructions. He displayed superbly the distribution of the median and ulnar nerves in the hand as well as the sensory distribution of radial and ulnar nerves to the dorsum of the hand.
Wrist sprain-The significance of snuftbox tenderness. DAVID A. LABOSKY, M.D. An injury to the
Giant cell tumor of distal radius: A reconstructive dilemma. HOUSAND SERADGE, M.D. Giant cell tumor
wrist presenting with pain in the anatomic snuffbox is considered, in spite of negative x-rays, as a possible scaphoid fracture because of the potential for this fracture to be missed on the acute film. Most textbooks suggest cast immobilization for these patients. The authors followed all patients who. presented to the emergency ward after an acute injury with pain localized to the anatomic snuffbox. They constructed an algorithm to provide a standardized approach to the problem. All patients were evaluated radiographically with posteroanterior and lateral views of the wrist and a scaphoid
of bone is an invasive tumor. About 10% of these tumors develop in the distal end of the radius with a 1% incidence of distant metastasis. Replacement of the excised distal radius can be done by translocating the distal portion of the ipsilateral ulna. The blood supply to this segment of ulna is preserved by translocating the ulna without detaching its soft tissue attachments.
Eosinophilic granuloma of the hand: Case report. RONALD E. PALMER, M.D . A previously undescribed solitary lesion of eosinophilic granuloma of the proximal phalanx of the hand of an II-month-old child was
Vol. 9A, No.2 March 1984
presented including the x-ray findings, histologic picture, electron micrographs of the pathologic specimen , and review of the treatment. The history of the disorder and a review of the clinical implications was included. Hand injuries associated with parenteral propylhexedrine abuse. H. R. MANCUSI-UNGARO, JR., W. J. DECKER, V. R. FORSHAN, S. J. BLACKWELL, and S. R. LEWIS. Propylhexedrine, the active ingredient in Benzedrex Inhalers, is extracted from the wicks of the inhalers by drug abusers for intravenous injection to provide a "desirable high." Injection of this potent vasoconstrictor produces local injury at the site of injection as well as distal injuries secondary to its arterial vasoconstrictive effect. Six representative cases treated over a I-year period are presented. The scope of complications from the abuse of propylhexedrine included loss of digits, sensory deficits, abscess formation, and simple cellulitis. Hand surgery applications of the low intensity x-ray imaging device. WILLIAM J. TANSEY, M.D. In 1978 the National Aeronautics and Space Administration developed an instrument for use in x-ray astronomy. This instrument contained a low-level gamma source to provide single proton imaging in x-ray astronomy . This low-dose, low-yield, radioactive fluoroscopic machine was basically a low intensity x-ray imaging process. The gamma ray source converts an image to a visible-light image by converting the electrons in the scope itself through a scintillator plate. A primary application of this instrument has been in the field of hand surgery. Mycobacterium marinum infection: A disease endemic in southwest Louisiana fisherman. R. DALE BERNAUER, M.D. Mycobacterium marinum infection is very common in southwest Louisiana fisherman, especially crab and shrimp fisherman. The natural history of the disease, treatment , and clinical presentation as well as examples from the author's personal experience was discussed. The need for proper bacteriologic techniques was emphasized. Digital nerve compression in tennis players. STEPHEN J. NASO, JR., M.D. Over the past few years the author has noticed a complex of symptoms peculiar to amateur tennis players. Such symptoms consist in numbness and tingling of the index finger, tenderness over the head of the second metacarpal, and thickening of the palmar skin at the base of the index finger. Surgical exploration in two patients revealed marked perineural fibrosis and scarring of the radial digital nerve that was similar to that found in a "bowler's thumb . " Operative treatment consisting in the excision of the thickened nerve sheath and neurolysis was found
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to be most successful. One patient with early symptoms was treated conservatively with excellent results. Pyridoxine as an adjunct to the treatment of carpal tunnel syndrome. PETER C. AMADIO, M.D. Recent publications in both the lay and scientific press have suggested that pyridoxine may be useful in the treatment of carpal tunnel syndrome and other peripheral neuropathies. To evaluate this possibility, 15 consecutive patients with clinical findings consistent with carpal tunnel syndrome were studied . Each of the 15 patients was treated by the following protocol : a printed information sheet describing the positive effects of pyridoxine for carpal tunnel syndrome was provided after the clinical diagnosis was established and a prescription for pyridoxine, 200 mg/ day, was administered. The patients were reevaluated in 1 month. No patient improved on pyridoxine alone. Six patients had sufficient symptomatic release after splinting, and anti-inflammatory medication was added to return to full activity . Treatment was gradually stopped over the next few months without recurrence of symptoms . The other nine patients continued to have symptoms . Repair of syndactylism in the newborn infant. ELMER E. RAUS, M.D . With increased knowledge and awareness of the physiology of the newborn infant and the use of microsurgical techniques and advances in anesthesia, the stage has been set for elective surgery in the newborn infant. The author discussed the advantages and technique of repair of syndactylism in the newborn infant, the unique physiology of the newborn infant, and the importance of the timing of the surgery. A straight line separation of the fingers is performed. Direct closure is used with no undermining or defatting . Dorsal and palmar flaps are used to form the web space. The results are soft, minimal scars with excellent finger function and appearance. It appears that shortly after birth may be the optimal age for the repair of syndactylism. Silicone rubber ball and socket arthroplasty of the thumb. WALTER M. BRAUNOHLER, M .D. Twenty silicone rubber ball and socket arthroplasties were performed between 1980 and 1983 with a 3- to 33-month follow-up period. This procedure creates a crater in the base of the first metacarpal and trapezium through a ligament-splitting approach at the interval between the abductor pollicis longus and brevis . Minimum ligament detachment, the distraction effect, and the elasticity of the silicone rubber elastomer provide immediate stability. Indications, technique, and results are comparable to other procedures. Morbidity is decreased because of a short immobilization time of 3 weeks. Postoperative
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complications of shortening and subluxation, common in other arthroplasty techniques, are eliminated.
Silicone rubber arthroplasties of the metacarpophalangeal joints in rheumatoid arthritis. ROBERT H. BRUMFIELD, JR., M.D. Two hundred sixty-four rheumatoid arthritic patients treated with 901 Swanson silicone rubber arthroplasties of the metacarpophalangeal joints by the Arthritis Service at Rancho Los Amigos Hospital (Downey, Calif.) from 1967 to 1981 were evaluated after a minimum of 2 years (average 8 years). Pain was relieved in all patients except in those patients who had complications. Active motion was increased by 20% while passive motion increased by 25%. By use of the Rancho Los Amigos Hospital functional analysis, 5% of the patients were classified as excellent, 60% were classified as good, 28% were classified as fair, and 7% were classified as poor.
The Journal of HAND SURGERY
forearm and hand were described. These fibers have a similar appearance and orientation to those fibers that make up the extensor retinaculum and are located in the same fascial plane proximal and distal to the extensor retinaculum.
Vascular anatomy of the proximal interphalangealjoint. N. JOHN YOUSIF, M.D., JAMES R. SANDER,
FORST E. BROWN, M.D. Ulnar drift and metacarpophalangeal (MP) joint subluxation are hand deformities frequently observed in rheumatoid arthritis. In an attempt to reduce the deforming forces responsible for MP ulnar drift, a static splint incorporating threepoint pressure was evaluated for the last 3 years. The pathogenesis of MP ulnar drift appears to be multifactorial: (1) synovial damage to the MP joint and weakening of ligament support, (2) intrinsic muscle tightness, (3) weakness of the radial interossei muscles, (4) the moment of action of the intrinsic muscle-tendon complexes, and (5) the zigzag effect of carpal collapse and wrist radial deviation. The static splint used for rheumatoid arthritis patients with ulnar drift has been designed to correct the radial deviation at the wrist while also aligning the fingers at the MP joints. The three points of pressure are the ulnar border of the small finger, the radial border of the second metacarpal head, and the ulnar side of the forearm. This splint puts the intrinsic muscles on stretch, blocks the extrinsic muscle action, and corrects the intercalated system zigzag effect.
M.D., MARSHALL WADE CUNNINGHAM, M.D., RUEDI P. GINGRASS, M.D., and HANI S. MATLOUG, M.D. Three methods were used to identify the general vascular branches that supply the joint, bone, and cartilage of the proximal interphalangeal joint. These methods include intraarterial injection of radiopaque cinnabar, intraarterial injection of liquid latex followed by microscopic dissection of the arterial system, and selective injection with India ink of specific branches followed by sectioning of the joints and examination of the areas stained. The studies demonstrate that the major branches of the digital artery to the joint arise from the dorsal surface, whereas smaller branches that run to the soft tissue and palmar branch arise from the palmar side. Three branches supply the proximal interphalangeal joint. Ruptures of the palmar plate. R. JOHN BROVES, M.D., and HARVEY SHAPIRO, M.D. The authors presented a retrospective analysis of 10 patients who presented with proximal interphalangeal joint hyperextension and instability. The presenting symptoms were pain, instability on extension developing into hyperextension, and locking in hyperextension. Locking proved to be the most disabling complaint. DR. ROBERT CHASE'S Keynote Address traced the recent developments in hand surgery including the various new flaps and tissue transfers, skin expansion, electrical stimulus to bone healing, implants and prosthesis, internal fixation devices, and prostheses both cosmetic and functional. DR. CHASE concluded by describing the importance of biomedical engineering to hand surgery such as imaging devices, 3-D television, and the robotic hand.
The extensor retinaculum: Anatomic and biomechanical observations. DAVID BOLAND, M.D. None
Bennett's fracture: An anatomic and clinical study. J. R. HARRIS, M.D., J. O. EDMUNDS, M.D., D.
of the well respected texts of anatomy or hand surgery gives an in-depth description of the extensor retinaculum. The author described the origin and insertion of the retinaculum, frequent subdivision of the first compartment, unique restraining mechanisms for the extensor pollicis longus and extensor carpi ulnaris tendons, gross and histologic appearance of this ligamentous tissue, and vascular supply of this structure. "Accessory retinacular fibers" of the dorsal fascia of the distal
RIORDAN, M.D., and R. J. HADDAD, M.D. The authors have found the method of closed reduction of Bennett's fracture as is advocated in current texts to be ineffective in producing an anatomically reduced fracture. The Wagner method of reduction involves radial abduction of the thumb metacarpal with distal traction placed upon the thumb and pressure applied to the base of the thumb metacarpal to bring the thumb metacarpal into alignment with the palmar beak fragment. The authors
Three-point splinting for the rheumatoid hand with ulnar drift. JOANNE C. CASSIDY, O.T.R., and
Vol. 9A, No.2 March 1984
feel this method is incorrect. The unique anatomy of the carpometacarpal joint determines the correct rationale for reduction of a Bennett's fracture. The saddleshaped carpometacarpal joint has no inherent bony stability. It is reinforced by four ligaments. The strongest of these is the ulnar or palmar ligament, which is thick and wide and runs from the trapezial crest up to the ulnar beak of the first metacarpal. According to Eaton and Littler this ligament is the primary stabilizer of the thumb. It is this palmar ligament that avulses the ulnar beak of the thumb metacarpal in a Bennett's fracture. The neutral position of "position of rest" of the trapezium metacarpal axis is in opposition. In this position the palmar ligament is relaxed. As the thumb is brought into radial abduction, this ligament becomes taut. It is for this reason that radial abduction displaces the metacarpal away from the palmar fragment and that opposition and internal rotation brings the metacarpal into correct alignment with the palmar fragment held by the palmar ligament. Opposing the thumb brought the thumb metacarpal into correct alignment with the palmar fragment, but an imperfect reduction was obtained. It was only when they internally rotated and "screwed home" the opposed metacarpal that they obtained an anatomically reduced fracture that was reduced on both anteroposterior view and the Robert's view. Clinically, the authors have found this to be the only effective method of obtaining an anatomically reduced fracture by closed means. Augmentation of skin flap survival with dazoxiben hydrochloride, a selective thromboxane synthetase inhibitor: Clinical and laser Doppler assessment in rats. W. C. BRENDER, M.D., E. T. DICKINSON, B.A., and R. H. MCSHANE, M.D. Skin flaps provide essential coverage in difficult hand problems. Exogenous prostacyclin (PGI2 ) has been shown to improve skin flap survival but has limited clinical applicability. Dazoxiben hydrochloride, a selective thromboxane (TX2 ) inhibitor, can elevate prostacyclin levels for 6 to 8 hours. The authors have demonstrated that systemic perioperative dazoxiben hydrochloride treatment can augment skin flap survival and may have clinical applicability. Twenty-four Sprague-Dawley rats had modified McFarland flaps elevated and replaced. Twelve rats were treated with 100 mg/kg of dazoxiben hydrochloride peri operatively in 3 ml of normal saline (1 ml administered at 2 hours before surgery, 1 ml administered at 6 hours before surgery, and 1 ml administered at 12 hours after surgery). Twelve rats were treated similarly with 3 ml of normal saline alone. A postoperative study
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was then undertaken with 12 rats. After elevating and replacing flaps, six rats received 100 mg/kg of dazoxiben hydrochloride per day over a 3-day course every 8 hours, and six rats were treated similarly with 3 ml of normal saline per day. In the perioperative (preoperative and postoperative) treatment study, the control groups had a 31. 8 ± 9.6% flap survival, whereas the dazoxiben hydrochloride groups were noted to have a 45.2 ± 12.5% flap survival. There was a significant difference between the control and experimental groups (p < 0.005). No bleeding complications were noted. In the postoperative study there was no significant difference between dazoxiben hydrochloride and control groups. DR. FRED HECKLER, in discussion, pointed out that the modified McFarland flaps have a highly variable survival, and the control group of flaps is thus compromised. Occupational hand disorders in musicians. F. J. BEJJANI, M.D., MICHAEL S. GROSS, M.D., and PAUL W. BROWN, M.D. A study of five parameters of hand function in musicians is underway: clinical, psychologic, electromyographic, thermographic, and ergonomic. The authors reported preliminary findings for the clinical part in 71 professional musicians (36 males and 35 females, mean age 35 ± 11 years): violinists (11), violists (15), cellists (8), bassists (5), harpists (11), pianists (13) and guitarists (8). Of the 71 musicians, 77.5% have had or still have some type of upper extremity disorder serious enough to impair performance or to prevent playing, at least temporarily. These conditions included neurologic symptoms (26.7%); painful finger joints (33% of the pianists and 28.6% of the female violinists); inflammatory syndromes (tendonitis, trigger finger, bursitis) in 36.6% who had one or more of these conditions that represented the most common cause of cessation of performing; and muscle tension or spasm (28%). The early findings of this study demonstrate that the development of hand disorders in musicians is fairly specific to the type of instrument played and related to the age at which the musician began, whether he also developed neck problems, the fluctuations in his playing routine, and various subjective factors. DR. LEE DELLON believed this was a very useful study that will give us information about a group of individuals who place maximal demands on their hands. Nerve regeneration through synthetic nerve guides-Importance of the distal stump. B. R. SECKEL, M.D., E. W. HENRY, M.D., and R. L. SIDMAN, M.D. Five millimeter, 10 mm, and 20 mm sec-
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tions were excised from the sciatic nerve of adult rats. Ten millimeter and 20 mm biodegradable polyester nerve guides were used to bridge the nerve gap by suturing the proximal and distal nerve stump into the respective ends of the guides. Controls with no distal stump in the guide were also prepared. Light microscopic and computerized axon-counting analyses were done to evaluate the success of nerve regeneration. In both the lO mm and 20 mm guide groups, a regenerated nerve was consistently obtained that was growing down the lumen of the guide and innervating the distal nerve stump in all cases when the nerve gap was 10 mm or less and the distal nerve stump was present. Approximately 40% of the fibers were myelinated at 3 months. In contrast, if the nerve gap was greater than 10 mm or if no distal stump was present, there was striking failure of regeneration. Scar response to the nerve guide was minimal.
Facilitation of axillary block anesthesia by use of the electrical nerve stimulator. LARRY G. LEONARD, M.D., CHARLES A. FEAGIN, M.D., and CLIFFORD C. SNYDER, M.D. Regional conduction anesthesia that is well-suited to surgery of the hand offers certain distinct advantages to the patient over general anesthesia including exposure to fewer and less toxic agents and less physiologic strain on the cardiorespiratory system. Its use is frequently limited, however, by the nonavailability of an anesthesiologist skilled in the necessary techniques, the length of time required to administer the block and allow it to take effect, and the spe ''!r of occasional failure of a block even under the best circumstances. Many of the disadvantages of axillary block anesthesia have been obviated by the routine use of lowvoltage electrical stimulation to precisely and rapidly locate the axillary sheath or individual cords within the sheath. A rapid, reliable means of achieving upper extremity
The Journal of HAND SURGERY
anesthesia allows the surgeon a degree of independence not otherwise achievable. The intent should not be to eliminate the need for an anesthesiologist but rather to allow one more option in the planning of surgery. This, for example, allows a trauma case to be done more expeditiously when the anesthesiologist is occupied with other emergencies, and for selected patients, it allows greater convenience and reduction of cost by opening a broader spectrum of cases for outpatient or office surgery with the elimination of anesthetic and possibly hospital charges. The traumatic neuroma. CLIFFORD C. SNYDER, M.D., JAMES E. PICKENS, M.D., and LARUE PICKENS, R.N. As is usual in most therapeutic measures, prevention of a traumatic neuroma is the better approach, but once the painful condition exists, there must be a method to prevent recurrence of the annoying lesion. Studies have been carried out in the laboratory on the animal and in the operating room on the human. Controls were compared with the treated subjects histologically and clinically. The sciatic nerve of the rat was the site of study in the laboratory subjects. The median, ulnar, radial, proper digital, and palmar digital nerves were those treated in the human subjects. The authors report a study of 264 laboratory subjects and 39 human nerves. The methods used to prevent or inhibit neuroma formation were grouped into chemical, physical, and surgical treatment. The chemical approach was segregated into nonfixatives, temporary fixatives, and permanent fixatives. The physical modes used were electrical, irradiation, freezing, and burning. The surgical means included excision, crushing, ligation, diversion, capping, grafting, and transferring. Medically, excellent prevention of a recurrent neuroma was achieved with triple deionized water. Surgical prevention was achieved by implanting the central stump of the severed nerve into a treated homograft vein.