Ghazi M. Rayan

Nonoperative Treatment of Dupuytren's Disease

Many approaches to nonoperative treatment of Dupuytrens disease have been tried since the disease was originally described in 1831, and most have been abandoned. Nonetheless, the appeal for nonoperative methods persists, in pursuit of lower morbidity and lesser complications than may be encountered with open surgical treatment. A number of nonoperative treatment modalities are in current use for Dupuytrens disease, despite lack of high-level clinical studies supporting these methods. Some of these can be utilized as an adjunct to surgical treatment rather than a replacement for it. The most commonly used nonoperative treatment methods are briefly reviewed.

Phalangeal osteochondroma: a cause of childhood trigger finger

Trigger finger is uncommon among children and often caused by various lesions. We report a 5-year old girl who presented with chronic painless triggering of the right ring finger and normal X-ray. She underwent exploration of the finger flexor tendons and release of the A1 pulley. Lack of obvious pathology dictated further wound exploration which revealed a hidden osteochondroma of the proximal phalanx. We believe that adequate surgical wound exposure is necessary if no obvious cause of triggering could be seen in order to rule out an atypical osteochondroma even in the presence of normal X-rays.

Non-Dupuytren's Disease of the Palmar Fascia

The typical Dupuytren’s disease patient is of Northern European descent with bilateral progressive multiple digital contractures and is genetically predisposed, with a family history. Palmar fascial proliferations sometimes present as a different entity without the typical Dupuytren’s disease characteristics. We identified 39 patients (20 women and 19 men) over a 4-year period with “Non-Dupuytren’s palmar fascial disease”, with unilateral involvement, without family history or ectopic manifestations. Twenty-three patients presented with unrelated complaints and were discovered, incidentally, to have the condition. In 28 patients, prior ipsilateral hand surgery or trauma precipitated the condition. Other related factors were diabetes mellitus and cardiovascular disease. Ten patients had skin tethering and subcutaneous thickening akin to Dupuytren’s nodules and 29 had palmar fascial thickening into ill-defined pretendinous cords. The diseased tissue was in the line of the ring finger in 30 patients. The time from insult to onset of contracture averaged 3.6 months and from onset to follow-up averaged 5.3 years. The condition was non-progressive, or partially regressive, in 33 patients. Seven patients had operations for unrelated conditions and underwent simultaneous fasciectomy without recurrence. Environmental factors, especially trauma, surgery and diabetes, are important in the pathogenesis of Non-Dupuytren’s palmar fascial disease, but these patients do not appear to be genetically predisposed for Dupuytren’s disease. Typical Dupuytren’s disease and Non-Dupuytren’s palmar fascial disease are two clinical entities that run different courses and do not share a similar prognosis. This should be taken into account in future epidemiological and outcome studies.

Closing Wedge Osteotomy of Abnormal Middle Phalanx for Clinodactyly

PURPOSEnTo report a series of clinodactyly patients to report clinical and radiographic outcomes after closing wedge osteotomy and K-wire fixation of abnormal middle phalanges.nnnMETHODSnTwenty-five fingers from 17 patients were included in the study. All patients had more than 25 degrees of angulation and were treated with closing wedge osteotomy. Subjective and objective data with radiographic assessment were compared preoperatively and postoperatively.nnnRESULTSnMale gender was predominant in our series (14 of the total 17 patients). Family history was positive for clinodactyly in 4 patients. The appearance of all fingers improved after surgery. Angular deformity was corrected on average from 33 degrees preoperatively to 9 degrees postoperatively. Analysis of radiographs showed deformity correction from 29 degrees preoperatively to 5 degrees postoperatively. Preoperative and postoperative arc of motion measurements were available for 10 patients. Distal interphalangeal joint arc of motion decreased from 84 degrees prior to surgery to 81 degrees after surgery, whereas proximal interphalangeal joint arc of motion was unchanged.nnnCONCLUSIONSnClosing wedge osteotomy of the abnormal middle phalanx for clinodactyly has provided our patients with adequate correction of the deformity, improved hand function, and has provided high satisfaction for parents. This treatment is recommended for moderate (15 degrees to 30 degrees ) and severe (>30 degrees ) deformities.

SURVEY OF UPPER EXTREMITY INJURIES AMONG MARTIAL ARTS PARTICIPANTS

PURPOSEnTo survey participants at various experience levels of different martial arts (MA) about upper extremity injuries sustained during training and fighting.nnnMATERIALSnA 21-s question survey was designed and utilised. The survey was divided into four groups (Demographics, Injury Description, Injury Mechanism, and Miscellaneous information) to gain knowledge about upper extremity injuries sustained during martial arts participation. Chi-square testing was utilised to assess for significant associations.nnnRESULTSnMales comprised 81% of respondents. Involvement in multiple forms of MA was the most prevalent (38%). The hand/wrist was the most common area injured (53%), followed by the shoulder/upper arm (27%) and the forearm/elbow (19%). Joint sprains/muscle strains were the most frequent injuries reported overall (47%), followed by abrasions/bruises (26%). Dislocations of the upper extremity were reported by 47% of participants while fractures occurred in 39%. Surgeries were required for 30% of participants. Females were less likely to require surgery and more likely to have shoulder and elbow injuries. Males were more likely to have hand injuries. Participants of Karate and Tae Kwon Do were more likely to have injuries to their hands, while participants of multiple forms were more likely to sustain injuries to their shoulders/upper arms and more likely to develop chronic upper extremity symptoms. With advanced level of training the likelihood of developing chronic upper extremity symptoms increases, and multiple surgeries were required. Hand protection was associated with a lower risk of hand injuries.nnnCONCLUSIONnMartial arts can be associated with substantial upper extremity injuries that may require surgery and extended time away from participation. Injuries may result in chronic upper extremity symptoms. Hand protection is important for reducing injuries to the hand and wrist.

Hand Injuries During Hand Surgery: A Survey of Intraoperative Sharp Injuries of the Hand Among Hand Surgeons

An e-mail survey comprising 19 questions was directed towards members of the American Society for Surgery of the Hand (ASSH) to investigate the prevalence and nature of intraoperative injuries to hand surgeons during hand surgery. The responses were collected, statistical analysis was done and trends were extrapolated. Two hundred members of the ASSH completed the e-mail survey. A hand surgeon in practice for greater than 10 years has a 97% chance of sustaining an intraoperative “sharps” injury. The injury is self-inflicted (88%) in most cases and the index finger (94%) of the left hand (87%) is the most likely site. The suture needle was the cause in 91% of cases. Awareness of the risks and factors associated with hand injuries during hand surgery and adopting intraoperative measures are important strategies for preventing these potentially serious and life-threatening accidents.

Open extensor tendon injuries: an epidemiologic study.

PURPOSEnTo report the epidemiology, mechanism, anatomical location, distribution, and severity of open extensor tendon injuries in the digits, hand, and forearm as well as the frequency of associated injuries to surrounding bone and soft tissue.nnnMETHODSnRetrospective chart review was conducted for patients who had operative repair of open digital extensor tendon injuries in all zones within an 11-year period. Data was grouped according to patient characteristics, zone of injury, mechanism of injury, and presence of associated injury. Statistical analysis was used to determine the presence of relevant associations.nnnRESULTSnEighty-six patients with 125 severed tendons and 105 injured digits were available for chart reviews. Patients were predominantly males (83%) with a mean age of 34.2 years and the dominant extremity was most often injured (60%). The thumb was the most commonly injured (25.7%), followed by middle finger (24.8), whereas small finger was least affected (10.5%). Sharp laceration was the most common mechanism of injury (60%), and most of these occurred at or proximal to the metacarpophalangeal joints. Most saw injuries occurred distal to the metacarpophalangeal joint. Zone V was the most commonly affected in the fingers (27%) while zone VT was the most commonly affected in the thumb (69%). Associated injuries to bone and soft tissue occurred in 46.7% of all injuries with saw and crush/avulsions being predictive of fractures and damage to the underlying joint capsule.nnnCONCLUSIONSnThe extensor mechanism is anatomically complex, and open injuries to the dorsum of the hand, wrist, and forearm, especially of crushing nature and those inflicted by saws, must be thoroughly evaluated. Associated injuries should be ruled out in order to customize surgical treatment and optimize outcome.

Diagnosis of cubital tunnel syndrome.

THE PATIENT A 51-year-old anesthesiologist complains of intermittent numbness or tingling in the ring and small fingers of his nondominant hand for 1 year with occasional medial elbow pain that radiates to the ulnar side of the hand. The symptoms are worse with activity and have gradually increased in frequency and severity, and in the last 3 months became nocturnal and now constant. He has no history of upper extremity injury and has no systemic disease. Examination shows tenderness in the retro-condylar groove without ulnar nerve instability and decreased light touch in the ulnar 2 digits along with weakness of the ulnar innervated intrinsic muscles without atrophy.

Astley Cooper: his life and surgical contributions.

Sir Astley Paston Cooper (1768-1841) was a successful and influential British surgeon during the early decades of the 19th century. He was a dedicated anatomist, an accomplished researcher, an inspiring teacher, and a skillful surgeon. Cooper published about the cause and treatment of Dupuytrens disease 10 years before Dupuytren. His contributions were widespread and substantially advanced the understanding and treatment of breast disease, vascular aneurysms, and abdominal wall hernias, along with orthopedic, otologic, and hand surgery. His contributions to surgical science have endured and are being used today.

Digital sucking induced trophic ulcers caused by nerve deficit from amniotic constriction band.

Two infants presented with amniotic constriction bands (ACB) in the distal third of the forearm. After teeth eruption they developed recurrent skin ulcerations mainly in the distribution of the median nerve from digital sucking. Both patients underwent reconstruction with multiple Z-plasties, followed by neurolysis of the ulnar nerve and sural nerve grafting of the median nerve. This neurological complication presented late in ACB as ulcerative lesions and secondary infection from digital sucking on the insensate digits. Thorough physical examination of the extremities at an early stage in children with ACB is essential to exclude an occult neurological dysfunction. Exploration of peripheral nerves is warranted in cases of deep forearm ACB during their soft tissue reconstruction.