Herbert P. von Schroeder

Early but No Long-term Benefit of Regional Compared with General Anesthesia for Ambulatory Hand Surgery

Background:The purpose of this study was to determine whether either regional anesthesia (RA) or general anesthesia (GA) provided the best analgesia with the fewest adverse effects up to 2 weeks after ambulatory hand surgery. Methods:Patients undergoing ambulatory hand surgery were randomly assigned to RA (axillary brachial plexus block; n = 50) or GA (n = 50). Before surgery, all patients rated their hand pain (visual analog scale) and pain-related disability (Pain-Disability Index). After surgery, eligibility for bypassing the postanesthesia care unit (“fast track”) was determined, and pain, adverse effects, and home-readiness scores were measured. On postoperative days 1, 7, and 14, patients documented their pain, opioid consumption, adverse effects, Pain-Disability Index, and satisfaction. Results:More RA patients were fast-track eligible (P < 0.001), whereas duration of stay in the postanesthesia care unit was shorter in the RA group (P < 0.001). Time to first analgesic request was longer in the RA group (P < 0.001), and opioid consumption was reduced before discharge (P < 0.001). In the RA group, the pain ratings measured at 30, 60, 90, and 120 min after surgery were lower (P < 0.001), and patients spent less time in the hospital after surgery (P < 0.001). More GA patients experienced nausea/vomiting during recovery in the hospital (P < 0.05). However, on postoperative days 1, 7, and 14, there were no differences in pain, opioid consumption, adverse effects, Pain-Disability Index, or satisfaction. Conclusions:Despite significant reduction in pain before discharge from the hospital after ambulatory hand surgery, single-shot axillary brachial plexus block does not reduce pain at home on postoperative day 1 or up to 14 days after surgery when compared with GA. However, RA does provide other significant early benefits, including reduction in nausea and faster discharge from the hospital.

Osseous anatomy of the scapula.

Detailed anatomy and morphometry of the scapula were obtained to provide information for surgical procedures such as hardware fixation, drill hole placement, arthroscopic portal placement, and prosthetic positioning. Twenty-six measurements were made in 15 pairs of scapulas from cadavers. The average length of the scapulas from the superior to the inferior angle was 155 ± 16 mm (mean ± standard deviation). The thickness of the medial border 1 cm from the edge was 4 ± 1 mm. The superior border was sharp and thin, and the suprascapular notch was present as a foramen in two scapulas. The distance from the base of the suprascapular notch to the superior rim of the glenoid was 32 ± 3 mm. The length of the spine from the medial edge of the scapula to the lateral edge of the acromion was 134 ± 12 mm. The anteroposterior width of the spine at 1 and 4 cm from the medial edge was 7 ± 1 and 18 ± 3 mm, respectively; the width at the lateral edge (spinoglenoid notch) was 46 ± 6 mm. The acromion measured 48 ± 5 mm × 22 ± 4 mm and was 9 ± 1 mm thick. The acromial shape was flat in 23%, curved in 63%, and hooked in 14% of scapulas. The distance from the glenoid to the acromion was 16 ± 2 mm. The glenoid dimensions were 29 ± 3 mm (anteroposterior) × 36 ± 4 mm (superoinferior) and faced posterior by 8 ± 4°. Anteroposterior thickness of the head of the scapula 1 cm from the surface was 22 ± 4 mm. The thickness of the coracoid was 11 ± 1 mm. The average length of the coracoacromial ligament was 27 ± 5 mm. Scapulas from male cadavers were significantly larger than scapulas from female cadavers in 19 measurements.

The dorsal branch of the ulnar nerve: An anatomic study

The dorsal branch of the ulnar nerve was dissected in 24 cadavers. The nerve arose from the medial aspect of the ulnar nerve at an average distance of 6.4 centimeters from the distal aspect of the head of the ulna and 8.3 centimeters from the proximal border of the pisiform. Its mean diameter at origin was 2.4 millimeters. The nerve passed dorsal to the flexor carpi ulnaris and pierced the deep fascia. It became subcutaneous on the medial aspect of the forearm at a mean distance of 5.0 centimeters from the proximal edge of the pisiform. The nerve gave an average of five branches with diameters between 0.7 and 2.2 millimeters. A better understanding of the anatomy of this nerve may help prevent nerve injury during surgical procedures, and can help in locating the nerve for repair of lacerations or administration of local anesthetics for regional nerve blocks.

Anatomy of the extensor tendons of the fingers : variations and multiplicity

The extensor tendons to the fingers were dissected in 43 adult hands. The most common distribution pattern of the extensor tendons of the fingers was: (1) a single extensor indicis proprius (EIP) tendon that inserted ulnar to the extensor digitorum communis (EDC) of the index; (2) a single EDC-index; (3) a single EDC-long; (4) a double EDC-ring; (5) an absent EDC-small; and (5) a double extensor digiti quinti (EDQ) with a double insertion. Frequent variations included, a double EIP tendon; a double or triple EDC-long tendon; a single or triple EDC-ring tendon; and a single or double EDC-small tendon. The extensor medii proprius was noted in 5 specimens. Increased multiplicity of any tendon was not associated with multiplicity of any other tendon, but was associated with a thinner (type 1) junctura tendinum between EDC-index and EDC-long. An absent EDC-small was related to an increased incidence of a double EDC-ring and the presence of a thick type 3 junctura tendinum between the EDC-ring and the EDQ or dorsal aponeurosis of the small finger. Knowledge of potential tendon multiplicity and variations may help in the identification and repair of these structures.

Redefining the arcade of struthers

PURPOSE To define the anatomy and presence of the arcade of Struthers, its anatomic variations, and potential sites of compression of the ulnar nerve. METHODS In 11 fresh specimen dissections, the ulnar nerve was followed from the brachial plexus through the anterior compartment into the posterior compartment through the intermuscular septum and the arcade of Struthers on to the cubital tunnel. The arcade was identified, dissected, measured, and photographed. All anatomic variations were documented. RESULTS The arcade of Struthers and intermuscular septum were present in all 11 specimens. The arcade was not merely an opening in the septum nor was it a short band as typically described: the arcade was better described as a fibrous canal with an average length of 5.7 cm. Its openings at either end were 3.9 and 9.6 cm proximal to the medial epicondyle. The structural components of the canal consisted of the fibrous tissue of the intermuscular septum, the internal brachial ligament, the deep fascia of the triceps, and the epimysium of the triceps muscle itself. The ulnar nerve was bound tightly within the entire canal in one case. In all specimens the nerve had an hourglass indentation at the proximal opening of the canal between the intermuscular septum and the internal brachial ligament. CONCLUSIONS The arcade of Struthers consists of a fibrous canal. The tightest point is the proximal end of the canal at the intermuscular septum that represents the clinically relevant site of entrapment or compression of the ulnar nerve.

Anatomy and functional significance of the long extensors to the fingers and thumb.

Intrinsic and extrinsic hand muscles power finger extension. These two muscle groups have different anatomy that allows complimentary function at the interphalangeal joints and opposing function at the metacarpophalangeal joints. Independent extension of each finger is not possible because of anatomic constraints including the juncturae tendinum and intertendinous fascia between the extrinsic extensor tendons on the dorsum of the hand. Anatomic variations of the extrinsic extensor tendons are frequent and knowledge is important when assessing the traumatized or diseased hand.

Trigger Finger Treatment: A Comparison of 2 Splint Designs

PURPOSE To compare the effectiveness of 2 splint designs in treating trigger finger. METHODS This prospective, randomized study of 30 subjects evaluated splinting efficacy for trigger finger, comparing 2 splint designs: a custom metacarpophalangeal (MCP) joint blocking splint and a distal interphalangeal (DIP) joint blocking splint. We evaluated range of motion, grip strength, severity and frequency of triggering, functional impact, and performance measure scores. Subjects recorded frequency of splint use, splint comfort, and functional impact of the splint. We undertook statistical analysis of splint effectiveness before and after treatment and of differences between the 2 splint groups. We evaluated qualitative data to identify trends in subjective preference toward splint design. RESULTS Both groups showed quick and significant improvement of triggering; however, the MCP joint blocking splint was successful in providing at least partial relief of triggering and pain in 10 of 13 trigger finger subjects, whereas the DIP joint blocking splint provided at least partial relief of triggering and pain in 7 of 15 subjects after 6 weeks of treatment. Data showed statistically significant improvement in both groups at 6 weeks, which was maintained in a minority of the cohort for 1 year. There was little difference between the 2 splint groups for impact on function. Subjects who wore the MCP joint blocking splint reported higher rates of comfort compared with those who wore the DIP joint blocking splint. CONCLUSIONS Subject comfort with the MCP joint blocking splint allowed for longer periods of usage. Selection of a splint design depends on clinical presentation, vocation, and leisure activities. Initiating conservative treatment with the MCP joint blocking splint has value for patients with trigger finger and positive outcomes in 77% of subjects, whereas use of the DIP joint splint was effective in about half of subjects. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic I.

The Aging Hand and the Ergonomics of Hearing Aid Controls

Objectives: The authors investigated the effects of hand function and aging on the ability to manipulate different hearing instrument controls. Over the past quarter century, hearing aids and hearing aid controls have become increasingly miniaturized. It is important to investigate the aging hand and hearing aid ergonomics because most hearing aid wearers are adults aged 65 years and above, who may have difficulty handling these devices. Design: In Experiment 1, the effect of age on the ability to manipulate two different open-fit behind-the-ear style hearing aids was investigated by comparing the performance of 20 younger (18–25 years of age), 20 young–old (60–70 years of age), and 20 older adults (71–80 years of age). In Experiment 2, ability to manipulate 11 different hearing instrument controls was investigated in 28 older adults who self-reported having arthritis in their hand, wrist, or finger and 28 older adults who did not report arthritis. For both experiments, the relationship between performance on the measures of ability to manipulate the devices and performance on a battery of tests to assess hand function was investigated. Results: In Experiment 1, age-related differences in performance were observed in all the tasks assessing hand function and in the tasks assessing ability to manipulate a hearing aid. In Experiment 2, although minimal differences were observed between the two groups, significant differences were observed depending on the type of hearing instrument control. Performance on several of the objective tests of hand function was associated with the ability to manipulate hearing instruments. Conclusions: The overall pattern of findings suggest that haptic (touch) sensitivity in the fingertips and manual dexterity, as well as disability, pain, and joint stiffness of the hand, all contribute to the successful operation of a hearing instrument. However, although aging is associated with declining hand function and co-occurring declines in ability to manipulate a hearing instrument, for the sample of individuals in this study, including those who self-reported having arthritis, only minimal declines were observed.

Titanemia from total knee arthroplasty: A case resulting from a failed patellar component

The subject of this case report is a patient with elevated serum levels of titanium (77 parts/billion [ppb]; normal, 3.3 ppb) and vanadium (0.38 ppb; normal, 0.17 ppb) resulting from excessive wear of a metal-backed patellar component in a total knee arthroplasty. The patellar component was worn through both its polyethylene and metal backing as a result of abnormal contact between the patellar and femoral components. Scanning electron microscopic examination of the ingrowth surface of the patellar component indicated that particle debonding occurred as a result of overloading of the sintered neck regions at the particle-substrate interface, suggesting a possible damage during initial insertion of the device, which may have predisposed it to loosening and abnormal contact with the femoral component. Wear particles resulted in staining of the tissues within the knee and an inflammatory and immune response in the synovium consisting of giant cells and T lymphocytes. The serum metal levels were reduced 22 weeks after replacing the patellar component; however, the titanium level was still slightly elevated (8 ppb).

The dorsal aponeurosis, intrinsic, hypothenar, and thenar musculature of the hand

The intrinsic muscles of the hand consist of seven interossei and four lumbrical muscles. With the extrinsic long extensors, the intrinsic muscles act via the dorsal aponeurosis to control finger motion. The interossei also control finger abduction and adduction, and flexion of the metacarpophalangeal joints. The lumbricals are the main extensors of the interphalangeal joints. The complex structure of the dorsal aponeurosis allows coordination and individual joint motion. The muscles of the hypothenar and thenar eminences also insert into the dorsal aponeurosis and the skeleton of the small finger and thumb, respectively, and are responsible for the specialized motion. Knowledge of the anatomy is necessary for understanding the function in treating abnormalities and trauma to the intricate structures of the hand.