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Infection associated with a palmar skin pit in recurrent Dupuytren's disease
The Journal of HAND SURGERY
Rose et al,
of a normal digit, although actually shortened in comparison with the adjacent fingers.
REFERENCES I. Elsahy NI. When to replant a fingertip after its complete amputation. Plast Reconstr Surg 1977;60: 14-21. 2. Yamano Y. Replantation of the amputated distal part of the fingers. J HAND SURG 1985;lOA:211-18. 3. Gordon L, Leitner DW, Buncke HJ, Alpert BD. Partial nail plate removal after digital replantation as an alternative method of venous drainage. J HAND SURG 1985;lOA:360-4. 4. Allen MJ. Conservative treatment of fingertip injuries in adults. Hand 1980; 12:257. 5. Kutler W. A new method for fingertip amputations. JAM A 1947;133:29. 6. Moberg B. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg 1964;46A:817 . 7. Atasoy E, lokimiolis B, Kasdan M, et al. Reconstruction of amputated fingertip with a triangular volar flap. J Bone Joint Surg 1970;52(A):921. 8. Sturman M, Duran R. Late results of fingertip injuries. J Bone Joint Surg 1963;45(A):289. 9. Kleinert HB, McAlister CG, MacDonald CJ, et al. A critical evaluation of cross finger flaps. J Trauma 1974;14:756. 10. Flatt AE. The thenar flap. J Bone Joint Surg 1957; 39(B):80.
11. Beasley R. Reconstruction of amputated fingertips. Plast Reconst Surg 1969;44:349. 12. Ma FY, Cheng CY, Chen Y, Leung C. Fingertip injuries-a prospective study on seven methods of treatment on 200 cases. Ann Acad Med Singapore 1982;11:207. 13. Flatt AE. The care of minor hand injuries. 4th ed. St. Louis: The CY Mosby Co, 1979. 14. Douglas B. Successful replacement of completely avulsed portions of fingers as composite grafts. Plast Reconst Surg 1959;23:213-25. 15. Brent B. Replantation of amputated distal phalangeal parts of fingers without vascular anastomoses, using subcutaneous pockets. Plast Reconstr Surg 1979;63:1-8. 16. Rose EH, Norris MS, Kowalski TA. Microsurgical management of complex fingertip injuries: comparison to conventional skin grafting. J Reconstr Microsurg 1988; 4:89-98. 17. Urbaniak JR, Roth JM, Nunley JA, Goldner RD, Koman LA. The results of replantation after amputation of a single finger. J Bone Joint Surg 1985;67A:611-19. 18. May JY, Toth BA, Gardner M. Digital replantation distal to the proximal interphalangeal joint. J HAND SURG 1982;7:161-6. 19. Zook EG. Nailbed injuries. Hand Clinics 1985;1:70116.
Infection associated with a palmar skin pit in recurrent Dupuytren's disease A clinical case of documented hand infection, caused by a skin pit in a patient with. Dupuytren's contracture is described. (J HAND SURG 1989;14A:518-20.)
P. Wylock, MD, and H. Vansteenland, MD, Brussels, Belgium From the Unit of Plastic Surgery, Academic Hospital Vrije Universiteit Brussel, Brussels, Belgium. Presented at the Winter Meetingof the Dutch Association of Plastic and Reconstructive Surgery, Utrecht,The Netherlands, November 7, 1987.
Received for publication Feb. 17, 1988; accepted in revised form July 1, 1988. No benefits in any form have been receivedor will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: P. Wylock, MD, Unitof PlasticSurgery, Academic Hospital Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brossels, Belgium. 518
THE JOURNAL OF HAND
SURGERY
Case report A 55-year-old man was seen initially in October 1983 with throbbing pain in the ulnar part of his right hand. He was known to have bilateral Dupuytren's disease. There are no other members of his family affected. A regional fasciectomy had already been done 2 years earlier for a contracture of the small finger of his right hand. At that operation a Skoog incision in the palm and a Z-plasty over the base of the small finger was used. The extension deficit at the proximal interphalangeal (PIP) joint was reduced from 90 degrees to 40 degrees. Healing was uneventful. The patient returned later in October 1983 with a painful
Vol. 14A, No .3 May 1989
Fig. 1. Redness and swelling in the palm of the right hand proximal to a skin pit.
Infe ction associated with skin pit
519
Fig. 3. Contracture of 100 degree s in the PIP joint and 40 degrees in the MP joint in the small finger and a flexion deformity of the ring finger 6 months after incision of the abscess in the right hand.
Fig. 2. The point of the scis sors penetrates the mouth of the pit in the right hand. right hand and with a flexion deformity of 100 degrees at the PIP joint, the metacarpophalangeal (Me) joint was not affected . A skin pit in the distal palm ar crease was situated just palmar to a red, swollen, painful area (Fig. I). The skin pit, which was 8 mm long was exc ised and pus was evacuated ( Fig . 2). A nodule in the palm ar fasc ia was not remo ved, and afte r the operation the patient was free of pain and the wound healed spontaneously in a few days. When the patient wa s seen 6 month s later the flexion deform ities of the MP, PIP, and distal interphalangeal (DIP) joi nts had increased , and a flexion contracture of the MP joint had developed ( Fig . 3). The physician and patient decid ed the fifth ray was not salvage able and an amputation was done in Jun e 1984. At that operation a regional fasciectomy of the ring finger was also performed ; wound healing after this operation was uneventful . The contralateral left hand had been operated on 4 years ago and a skin pit developed , which was excised with a regional fasciectomy ( Fig . 4). In spite of the surgica l procedu res on this patient's right and left hands, an examination in \988 showed that both hands had flexion contractures identical to their deformities in 1985 ( Fig . 5).
Fig. 4. Recurrence of the disease with a pit in the distal palmar crease and 90 degrees contracture in the PIP joint of the contralateral small finger in the left hand.
Fig. 5 . The postoperative contractures of the right and left hands after multiple operations . The se deformities are identical to their contractures in 1985 .
The Journal of HAND SURGERY
Wylock and Vansteeland
Discussion Mac Grouther' points out that pits are found in welldefined areas, such as the insertion of the longitudinal fibers in the dermis and the distal palmar crease. In this patient two skin pits were observed in the scars at the distal palmar crease after previous surgical fasciectomies in the right and left hands. The pit in the left hand was excised in combination with a fasciectomy and the pit in the right hand was 8 mm in length and difficult to clean and as a result became the origin of a hand infection.
Writers have reported progression of the disease after trauma, and this is the first case report of a patient with infection in a palmar pit that appeared to trigger progression of the Dupuytren's disease.
REFERENCE 1. Mac Grouther. The micro anatomy of Dupuytren's disease. In: Dupuytren's disease. 2nd ed. Hueston JT, Tubiana R, eds. New York: Churchill Livingstone, 1985.
Factors affecting the sensitivity and specificity of the three-phase technetium bone scan in the diagnosis of reflex sympathetic dystrophy syndrome in the upper extremity The three-phase technetium bone scan has been recommended for use in the diagnosis of the reflex sympathetic dystrophy syndrome with a sensitivity and specificity of >90%. A retrospective chart review was conducted of 63 patients who had three-phase technetium bone scan as part of a work-up for unexplained upper extremity pain, to determine the predictive value of the three-phase technetium bone scan in reflex sympathetic dystrophy syndrome, and what factors might affect it. The prevalence of definite or probable reflex sympathetic dystrophy syndrome, as assessed by Kozin's criteria, was 26% in this sample. The 3-hour delayed image demonstrated a sensitivity 50%; specificity 92%; positive predictive value 67%, and negative predictive value 84%. This was not improved using the data from the blood flow or pool phase. The sensitivity of 50% is lower than previous reports. The predictive value of the three-phase technetium bone scan was affected by the duration of symptoms and the age of the patient. Duration of symptoms less than 6 months, or ages more than 50 years substantially increased the sensitivity and positive predictive value of the three-phase technetium bone scan. (J HAND SURG 1989;14A:520-3.)
= =
=
=
Robert Werner, MD, Gary Davidoff, MD, MS, M. David Jackson, MD, Steven Cremer, MD, MS, Carmen Ventocilla, MD, and Laurie Wolf, MD, Ann Arbor, Mich.
From the Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center, Ann Arbor, Mich. Supported by a Clinical Investigator Development Award (G.D.) from the National Institute of Neurological and Communicative Disorders and Stroke (NS 01120·20). Received for publication Feb. 10, 1988; accepted in revised form April 13, 1988.
520
THE JOURNAL OF HAND SURGERY
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Robert A. Werner, MD, Instructor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI 48109·0042.
Rose et al,
of a normal digit, although actually shortened in comparison with the adjacent fingers.
REFERENCES I. Elsahy NI. When to replant a fingertip after its complete amputation. Plast Reconstr Surg 1977;60: 14-21. 2. Yamano Y. Replantation of the amputated distal part of the fingers. J HAND SURG 1985;lOA:211-18. 3. Gordon L, Leitner DW, Buncke HJ, Alpert BD. Partial nail plate removal after digital replantation as an alternative method of venous drainage. J HAND SURG 1985;lOA:360-4. 4. Allen MJ. Conservative treatment of fingertip injuries in adults. Hand 1980; 12:257. 5. Kutler W. A new method for fingertip amputations. JAM A 1947;133:29. 6. Moberg B. Aspects of sensation in reconstructive surgery of the upper extremity. J Bone Joint Surg 1964;46A:817 . 7. Atasoy E, lokimiolis B, Kasdan M, et al. Reconstruction of amputated fingertip with a triangular volar flap. J Bone Joint Surg 1970;52(A):921. 8. Sturman M, Duran R. Late results of fingertip injuries. J Bone Joint Surg 1963;45(A):289. 9. Kleinert HB, McAlister CG, MacDonald CJ, et al. A critical evaluation of cross finger flaps. J Trauma 1974;14:756. 10. Flatt AE. The thenar flap. J Bone Joint Surg 1957; 39(B):80.
11. Beasley R. Reconstruction of amputated fingertips. Plast Reconst Surg 1969;44:349. 12. Ma FY, Cheng CY, Chen Y, Leung C. Fingertip injuries-a prospective study on seven methods of treatment on 200 cases. Ann Acad Med Singapore 1982;11:207. 13. Flatt AE. The care of minor hand injuries. 4th ed. St. Louis: The CY Mosby Co, 1979. 14. Douglas B. Successful replacement of completely avulsed portions of fingers as composite grafts. Plast Reconst Surg 1959;23:213-25. 15. Brent B. Replantation of amputated distal phalangeal parts of fingers without vascular anastomoses, using subcutaneous pockets. Plast Reconstr Surg 1979;63:1-8. 16. Rose EH, Norris MS, Kowalski TA. Microsurgical management of complex fingertip injuries: comparison to conventional skin grafting. J Reconstr Microsurg 1988; 4:89-98. 17. Urbaniak JR, Roth JM, Nunley JA, Goldner RD, Koman LA. The results of replantation after amputation of a single finger. J Bone Joint Surg 1985;67A:611-19. 18. May JY, Toth BA, Gardner M. Digital replantation distal to the proximal interphalangeal joint. J HAND SURG 1982;7:161-6. 19. Zook EG. Nailbed injuries. Hand Clinics 1985;1:70116.
Infection associated with a palmar skin pit in recurrent Dupuytren's disease A clinical case of documented hand infection, caused by a skin pit in a patient with. Dupuytren's contracture is described. (J HAND SURG 1989;14A:518-20.)
P. Wylock, MD, and H. Vansteenland, MD, Brussels, Belgium From the Unit of Plastic Surgery, Academic Hospital Vrije Universiteit Brussel, Brussels, Belgium. Presented at the Winter Meetingof the Dutch Association of Plastic and Reconstructive Surgery, Utrecht,The Netherlands, November 7, 1987.
Received for publication Feb. 17, 1988; accepted in revised form July 1, 1988. No benefits in any form have been receivedor will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: P. Wylock, MD, Unitof PlasticSurgery, Academic Hospital Vrije Universiteit Brussel, Laarbeeklaan 101, 1090 Brossels, Belgium. 518
THE JOURNAL OF HAND
SURGERY
Case report A 55-year-old man was seen initially in October 1983 with throbbing pain in the ulnar part of his right hand. He was known to have bilateral Dupuytren's disease. There are no other members of his family affected. A regional fasciectomy had already been done 2 years earlier for a contracture of the small finger of his right hand. At that operation a Skoog incision in the palm and a Z-plasty over the base of the small finger was used. The extension deficit at the proximal interphalangeal (PIP) joint was reduced from 90 degrees to 40 degrees. Healing was uneventful. The patient returned later in October 1983 with a painful
Vol. 14A, No .3 May 1989
Fig. 1. Redness and swelling in the palm of the right hand proximal to a skin pit.
Infe ction associated with skin pit
519
Fig. 3. Contracture of 100 degree s in the PIP joint and 40 degrees in the MP joint in the small finger and a flexion deformity of the ring finger 6 months after incision of the abscess in the right hand.
Fig. 2. The point of the scis sors penetrates the mouth of the pit in the right hand. right hand and with a flexion deformity of 100 degrees at the PIP joint, the metacarpophalangeal (Me) joint was not affected . A skin pit in the distal palm ar crease was situated just palmar to a red, swollen, painful area (Fig. I). The skin pit, which was 8 mm long was exc ised and pus was evacuated ( Fig . 2). A nodule in the palm ar fasc ia was not remo ved, and afte r the operation the patient was free of pain and the wound healed spontaneously in a few days. When the patient wa s seen 6 month s later the flexion deform ities of the MP, PIP, and distal interphalangeal (DIP) joi nts had increased , and a flexion contracture of the MP joint had developed ( Fig . 3). The physician and patient decid ed the fifth ray was not salvage able and an amputation was done in Jun e 1984. At that operation a regional fasciectomy of the ring finger was also performed ; wound healing after this operation was uneventful . The contralateral left hand had been operated on 4 years ago and a skin pit developed , which was excised with a regional fasciectomy ( Fig . 4). In spite of the surgica l procedu res on this patient's right and left hands, an examination in \988 showed that both hands had flexion contractures identical to their deformities in 1985 ( Fig . 5).
Fig. 4. Recurrence of the disease with a pit in the distal palmar crease and 90 degrees contracture in the PIP joint of the contralateral small finger in the left hand.
Fig. 5 . The postoperative contractures of the right and left hands after multiple operations . The se deformities are identical to their contractures in 1985 .
The Journal of HAND SURGERY
Wylock and Vansteeland
Discussion Mac Grouther' points out that pits are found in welldefined areas, such as the insertion of the longitudinal fibers in the dermis and the distal palmar crease. In this patient two skin pits were observed in the scars at the distal palmar crease after previous surgical fasciectomies in the right and left hands. The pit in the left hand was excised in combination with a fasciectomy and the pit in the right hand was 8 mm in length and difficult to clean and as a result became the origin of a hand infection.
Writers have reported progression of the disease after trauma, and this is the first case report of a patient with infection in a palmar pit that appeared to trigger progression of the Dupuytren's disease.
REFERENCE 1. Mac Grouther. The micro anatomy of Dupuytren's disease. In: Dupuytren's disease. 2nd ed. Hueston JT, Tubiana R, eds. New York: Churchill Livingstone, 1985.
Factors affecting the sensitivity and specificity of the three-phase technetium bone scan in the diagnosis of reflex sympathetic dystrophy syndrome in the upper extremity The three-phase technetium bone scan has been recommended for use in the diagnosis of the reflex sympathetic dystrophy syndrome with a sensitivity and specificity of >90%. A retrospective chart review was conducted of 63 patients who had three-phase technetium bone scan as part of a work-up for unexplained upper extremity pain, to determine the predictive value of the three-phase technetium bone scan in reflex sympathetic dystrophy syndrome, and what factors might affect it. The prevalence of definite or probable reflex sympathetic dystrophy syndrome, as assessed by Kozin's criteria, was 26% in this sample. The 3-hour delayed image demonstrated a sensitivity 50%; specificity 92%; positive predictive value 67%, and negative predictive value 84%. This was not improved using the data from the blood flow or pool phase. The sensitivity of 50% is lower than previous reports. The predictive value of the three-phase technetium bone scan was affected by the duration of symptoms and the age of the patient. Duration of symptoms less than 6 months, or ages more than 50 years substantially increased the sensitivity and positive predictive value of the three-phase technetium bone scan. (J HAND SURG 1989;14A:520-3.)
= =
=
=
Robert Werner, MD, Gary Davidoff, MD, MS, M. David Jackson, MD, Steven Cremer, MD, MS, Carmen Ventocilla, MD, and Laurie Wolf, MD, Ann Arbor, Mich.
From the Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center, Ann Arbor, Mich. Supported by a Clinical Investigator Development Award (G.D.) from the National Institute of Neurological and Communicative Disorders and Stroke (NS 01120·20). Received for publication Feb. 10, 1988; accepted in revised form April 13, 1988.
520
THE JOURNAL OF HAND SURGERY
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: Robert A. Werner, MD, Instructor, Department of Physical Medicine and Rehabilitation, University of Michigan Medical Center, 1500 E. Medical Center Dr., Ann Arbor, MI 48109·0042.