Curtis M. Steyers

Recurrent carpal tunnel syndrome

Persistent or recurrent symptoms following carpal tunnel release surgery are an infrequent but challenging clinical problem. A thorough evaluation of these patients is mandatory and must confirm the accuracy of the original diagnosis and rule out the presence of concurrent conditions or disorders that may cause persistent symptoms that mimic carpal tunnel syndrome. If an alternative explanation of the patients symptoms cannot be identified, and if conservative care is ineffective, then surgical treatment should be considered. Adequate exposure of the median nerve and carpal tunnel are mandatory. The general approach should include gentle mobilization of the nerve from adherent scar tissue and interposition of a biologic barrier between the nerve and surrounding tissues. No published data conclusively demonstrate that internal neurolysis provides superior results. Postoperative care should include early mobilization to encourage tendon and nerve gliding.

Infections in open fractures of the hand

We reviewed one forty-six consecutive cases of patients with open fractures of the hand to identify factors that predict infection and poor outcome. The incidence of infection was 11%. The infection rate in type 1 open fractures was 0%; in type 2, 9%; and in type 3, 14%. Infection occurred in 20.5% of grossly contaminated wounds (p less than 0.02), and was most common in patients with extensive soft tissue and skeletal injury. Delay in treatment did not increase the incidence of infection or affect outcome. Functional outcome was highly correlated with the initial fracture type and with the presence of infection. Preoperative wound cultures were of no value in predicting the risk of infection or the nature of the likely pathogen. Patients with severe open fractures should be warned of the risk of infection, prolonged convalescence, and permanent impairment.

Rehabilitation of the Hand and Upper Extremity. 5th ed.

Evelyn J. Mackin, Anne D. Callahan, Terri M. Skirven, Lawrence H. Schneider, and A. Lee Osterman, editors; and James M. Hunter, editor emeritus. St. Louis: Mosby; 2002. 2109 pages.

The effects of graded compression of the median nerve in the carpal canal on grip force

229.00. nnThe fifth edition of Rehabilitation of the Hand and Upper Extremity is a two-volume tome produced in an effort to share the advances that have been made in hand therapy and hand surgery since the last published edition. The 163 contributors to this book represent varied disciplines, including industrial and biomedical engineering, neurology, electrophysiology, hand surgery, hand therapy, prosthetics, rehabilitation medicine, and rheumatology. Together these contributors have produced 129 chapters and more than 2000 …

Outcome after free flap reconstruction of the heel.

Abstract. The relationship between tactile hypoesthesia and precision grip force was examined using compression of the median nerve in healthy adults. Hypoesthesia was graded by varying the pressure that an external clamp exerted over the carpal canal. Electrical stimulation of the median nerve in the forearm evoked a compound sensory nerve action potential (SNAP) that we recorded from the digital nerves of the index finger. Clamp pressure was varied to achieve SNAPs that were 75%, 50%, and 25% of precompression amplitude (100%). Grip force and tactile sensibility (Semmes-Weinstein filaments, cotton wisps, sharp/dull) did not change in parallel with reductions of the SNAP. Subjects reported paresthesias at the thumb and index finger at 75% SNAP. Tactile pressure thresholds increased to the clinical range of diminished light touch, but subjects detected cotton wisps stroked along the finger. At 75% SNAP grip force did not change compared to 100% SNAP. Simple prehension can proceed efficiently despite these modest reductions in tactile signals. At 50% SNAP the digits remained sensate, but were reported to feel thick, like cardboard. No subject could detect cotton wisps and tactile thresholds increased by one filament. Sharp/dull distinctions remained. Grip force increased by 55% compared to grip force at SNAPs of 100% and 75%. There were no changes in skin slipperiness, so the increased grip force represented elevated safety margin (grip force exceeding that needed to prevent slip). At 25% SNAP subjects described the skin innervated by the median nerve as feeling numb, but grip force increased little compared to 50% SNAP. Grip force continued to reflect changes in grip surface friction, and mechanical transients from setting the object on the table triggered coordinated reductions in grip force. We suspect that the loss of information from SAxa0I and FAxa0I, but not FAxa0II, tactile afferents provoked the increased grip force.

Tendon Ruptures With Scaphoid Nonunion: A Case Report

We reviewed six free flap reconstructions of the weightbearing surface of the heel. Patients were seen for clinical evaluation at a mean follow-up of 4.7 years (range 2.7–6.0 years). Functional results using a modified Boston Childrens Hospital Ankle Score were 33% excellent, 33% good, 17% fair, and 17% poor. The excellent functional results were related to the absence of chronic draining flap ulcers. All flaps lacked protective sensation by Semmes-Weinstein monofilament testing. Weightbearing plantar pressures in the flaps were elevated in all patients. Sequential radiographs from the time of flap coverage revealed the development of a bony protuberance (stalactite) projecting from the undersurface of the calcaneus in all patients with injuries to the plantar cortex of the calcaneus. In patients with flap ulceration, these stalactites projected into the ulcer at the site of maximum plantar pressure. A combination of loss of plantar calcaneal integrity, elevated pressure concentrations, and flap insensitivity appear causally related to the development of heel free flap ulceration and outcome.

Osteosarcoma of the hand: A case report and review of the literature

Intratendinous ruptures of flexor tendons about the hand and wrist are rare. Flexor pollicis longus and index flexor digitorum profundus tendon ruptures, most commonly seen in patients with rheumatoid arthritis, occurred in a nonrheumatoid 48-year-old man with an asymptomatic scaphoid nonunion. This rare injury may simulate an anterior interosseous nerve syndrome. The absence of prior symptoms does not preclude tendon rupture secondary to scaphoid nonunion. Restoration of power pinch provides good function despite limited range of motion.

A role delineation study of hand surgery.

A 6%year-old mentally retarded, institutionalized man with a documented seizure disorder presented to the University of Iowa Hand Surgery Service with a 2-week history of pain in his right hand. The pain began abruptly without a history of trauma or known seizure. Physical examination revealed diffuse erythema and swelling over the dorsum of his right hand with marked tenderness to palpation over the third metacarpal. No fluctuance or drainage was observed. X-ray films (Fig. 1) demonstrated destruction of the shaft of the third metacarpal and dense calcification in the adjacent soft tissue. Serum alkaline phosphatase was 325 IU/L (normal range: 30-l 15). and chest x-ray films and computed tomography scans of the chest revealed no evidence of metatstatic disease. An incisional biopsy revealed osteosarcoma, and a below-elbow amputation was performed. The resection specimen contained a 5.5

Localization of dominantly inherited isolated triphalangeal thumb to chromosomal region 7q36.

In 1986, The American Association for Hand Surgery and the American Society for Surgery of the Hand jointly sponsored a Role Delineation Study of Hand Surgery. The purpose of this study was to define the knowledge and skills necessary for competent hand surgery practice and to determine the responsibilities and activities of hand surgeons. Eight hundred thirty-eight hand surgeons returned a self-report questionnaire. This questionnaire was designed to collect information relative to the demographic characteristics of the respondents, the importance of 38 surgical procedures, and 60 categories of knowledge related to hand surgery, and to elicit respondents opinions regarding certification in hand surgery. This study is a first attempt to define the domain of hand surgery. The data collected in this study provide the basis for designing residency fellowship and continuing education programs and may also be used to study manpower needs, regional variations in practice patterns, and to identify the educational needs of the profession of hand surgery.