Bruce A. Kraemer

Fluctuation in grip and pinch strength among normal subjects

Grip and pinch strength testing are commonly used to evaluate hand strength for disability ratings and to assess responses to various forms of therapy. This study determined the variations in grip and pinch strength in normal individuals. Ninety-five healthy subjects--61 women and 34 men--were examined prospectively by use of a Jamar dynamometer and a Preston pinch gauge. Grip and pinch were measured in the morning and afternoon twice a week for 3 weeks, giving a total of 12 testing periods. Mean grip strength fluctuated between 5.1 and 8.4 kg, or between 19.2% and 23.7%. Mean lateral pinch strength fluctuated between 2.6 and 3.8 pounds, or between 13.8% and 17.6%. There were no differences between the morning and afternoon values. Grip and pinch strength fluctuate over time. Repeat testing is necessary to accurately assess hand strength. Grip and pinch strength do not vary from morning to afternoon.

Complete ear replantation without venous anastomosis.

Traumatic amputation of the entire auricle is a rare occurrence. Management ideally consists of microvascular reconstruction of auricular arterial, venous, and nerve continuity. However, appropriately sized veins are often not available and venous drainage must be accomplished with leech therapy. In occasional cases where leeches are unavailable or cannot be made to attach, mechanical drainage and anticoagulation can give satisfactory drainage. The authors present a case of mechanical wick venous drainage of a complete ear replantation, resulting in virtually normal appearance and function of the ear. In addition, the ear regained normal touch and two‐point sensibility, although the great auricular nerve had not been repaired.

Prevention of spinal cord injury after transient aortic clamping with tissue factor pathway inhibitor

BACKGROUND Lower limb paralysis that occurs in 11% of patients after treatment of thoracic and thoracoabdominal aortic aneurysms is unpredictable and at present not preventable. The proposed cause for the neurologic changes is believed to be spinal cord ischemia combined with ischemia/reperfusion injury. Recombinant tissue factor pathway inhibitor (rTFPI), a multivalent Kunitz-type inhibitor that binds to tissue factor-VIIa complex, was evaluated. METHODS The effectiveness of rTFPI as an agent to limit spinal cord ischemia/reperfusion injury was studied in a rabbit spinal cord made ischemic for 20 minutes. rTFPI or phosphate-buffered saline solution (control) was given in randomized blinded fashion at the onset and conclusion of ischemia. Animals underwent neurologic evaluation at 24 hours in a blinded fashion with a modified Tarlov Scale to rate the lower limb paralysis (score of 4 = normal function, score of 0 = complete paralysis). RESULTS Seventy-five percent of the TFPI-treated animals had Tarlov scores of 3 to 4, whereas only 29% of the animals treated with phosphate-buffered saline solution had such scores (p < 0.0014). Spinal cord histologic findings correlated with the neurologic findings. CONCLUSIONS We believe that TFPI has unique inhibitory properties that make it an effective agent in limiting postoperative paraplegia associated with spinal ischemia.

Dermatofibrosarcoma protuberans of the toe.

Dermatofibrosarcoma protuberans is an unusual soft-tissue tumor with a propensity for local recurrence and occasional metastatic spread. Given its indolent course, it may be mistaken for atypical scarring or a keloid growth. Most lesions are trunkal or on the proximal extremities with digital lesions being extremely rare. There is only one previous reference of the tumor arising on a toe. Early diagnosis and prompt wide local resection of this entity are required to prevent a local recurrence, which would necessitate a wider, more debilitating resection. The management of a patient with a dermatofibrosarcoma protuberans of the second toe is presented along with a review of the literature.

Radiographic features of hand and wrist surgery excluding arthroplasties

The normal and abnormal radiographic appearances of various hand and wrist surgical procedures have been presented. It is hoped that increased familiarity with these procedures and their radiographic features will lead to more meaningful radiographic interpretations by consulting radiologists.

Radiographic features of hand and wrist arthroplasties

The normal and abnormal radiographic appearances of various arthroplasties of the hand and wrist have been presented. It is hoped that increased familiarity with these procedures and their radiographic features will lead to more meaningful radiographic interpretations by consulting radiologists.

Characteristics and management of flexor tendon graft disruption

In order to define the proper management of patients with disruption of a flexor tendon graft, 220 consecutive flexor tendon grafts were reviewed. Patients were divided into two groups--those who did not require a silastic rod prior to tendon grafting (89 grafts) and those who did require a silastic rod prior to tendon grafting (131 grafts). The incidence of tendon graft disruption for these two groups was 1.1% and 7.6%, respectively. Based on an analysis of these 11 graft disruptions, a method of management was devised. The literature is reviewed regarding the incidence and method of management of disrupted flexor tendon grafts.

The Ideal Upper Extremity Flap for Soft Tissue Defects, Radial Artery Perforator Adipofascial Flap

Purpose: The ideal requirements for soft tissue coverage of the upper extremity are a thin, pliable, durable flap with minimal donor site morbidity that allows early functional rehabilitation and protection. Drawbacks of common flaps used for dorsal hand coverage include sacrifice of the radial or ulnar artery, donor site morbidity, bulky flaps requiring secondary thinning, non-aesthetic donor sites, and inability to provide sensate coverage. We report our series of five adipofascial radial artery perforator flaps for the upper extremity. A modification to the proximal forearm fascial flap allows the flap to be harvested as a neurosensory flap. Methods: We present our experience of 5 cases with the adipofascial forearm flap for upper extremity soft tissue defects including dorsal hand or proximally based wounds of the elbow. The proximally based flaps were based 4cm distally to the anticubital fossa while the distally based flap was based 2 cm from the radial styloid. The adipofascial flaps were raised in a retrograde fashion from the pivot point. The flaps were subsequently skin grafted and the donor sites closed primarily. Experience: Two patients had traumatic defects of the elbow which represent the first description of the neurosensory proximally based radial artery perforator adipofascial flap and three patients were treated for dorsal hand coverage. None of the patients needed secondary thinning or flap revisions. Figure 1. Pre-operative dorsal hand injury on the day of presentation. Figure 2. Intra-operative image of adipofascial turnover flap prior to skin graft placement. Conclusion: The forearm fascial flap provides coverage of the upper extremity without sacrificing any major arteries to the hand. Donor site morbidity is minimal as the adipofascial nature of the flap allows primary closure of the donor site. Further benefits include a shorter operative time, no microsurgery requirements, aesthetically pleasing contour for the hand with out the need for secondary procedures and early range of motion for patients. It has become our flap of choice for upper extremity reconstruction.