James H. House

Sensibility deficiencies in the hands of children with spastic hemiplegia

We evaluated 40 children with spastic hemiplegia due to cerebral palsy for sensory function and relative limb size in the affected and unaffected upper extremities. Sensory function of each limb was evaluated with respect to stereognosis (12 objects), two-point discrimination, and proprioception. Four size measurements of each limb were made: arm and forearm circumference and forearm and forearm-hand length. This study showed that 97% of the spastic limbs had a stereognosis deficit, 90% had a two-point discrimination deficit, and 46% had a proprioception deficit. Thus sensory deficits are the rule rather than the exception in children with spastic hemiplegia. Those children with severe stereognosis deficits had significantly smaller limbs in all four measurement parameters than the children with mild or moderate stereognosis deficits. In the preoperative evaluation of children with spastic hemiplegia, severe size discrepancy is a physical examination tool that can be used as a predictor of severe sensory deficits. This information is helpful for the hand surgeon in establishing realistic surgical goals.

Surgical treatment of carpal tunnel syndrome and trigger digits in children with mucopolysaccharide storage disorders.

The role of surgical intervention for carpal tunnel syndrome (CTS) and trigger digits in children with mucopolysaccharide storage disorders (MPSDs) has not been clearly defined, particularly as the treatment of the underlying disease has advanced to include bone marrow transplantation. This study reviews our experience in the treatment of CTS and trigger digits in 22 children with MPSDs who were evaluated for CTS by electromyographic (EMG)/nerve conduction velocity (NCV) testing. Seventeen children were diagnosed with CTS by EMG/NCV testing and were treated with bilateral open surgical release with or without flexor tenosynovectomy. The EMG/NCV testing revealed normal results in 5 patients who are subsequently being monitored. Forty-five digits in 8 children were diagnosed clinically with trigger digits. Nineteen digits were treated by annular pulley release alone. Twenty-six digits were treated by annular pulley release with partial flexor digitorum superficialis tendon resection. The average age at the time of hand surgery was 6.3 years, and at the time of follow-up, 9.6 years. Postoperative EMG/NCV testing in 7 children showed 1 with improvement and 6 with normalization. None of the patients undergoing carpal tunnel release went on to develop thenar atrophy or absent sensibility, as has been reported in untreated cases. Patients were evaluated for triggering digits both by preoperative tendon palpation and by intraoperative flexor tendon excursion at the time of open carpal tunnel release. All patients undergoing trigger release had improved active digital flexion seen at the final follow-up visit. Because of the very high incidence of CTS and trigger digits in this population, the authors currently recommend routine screening of EMG/NCV for all children with MPSDs. Early surgical intervention for nerve compression and stenosing flexor tenosynovitis can maximize hand function in these children.

Rehabilitation and surgical reconstruction of the upper limb in tetraplegia: An update☆

13. Freeland AE, Sparks DR. Hand injury: repair and reconstruction with an external minifixator. Hosp Phys 1985;6:19-23. Freeland AE. External fixation for skeletal stabilization of severe open fractures of the hand. Clin Orthop 1987;214:93-100. Buchler U, McCollam SM, Oppikofer C. Comminuted fractures of the basilar joint of the thumb: combined treatment by external fixation, limited internal fixation, and bone grafting. J HAND SIJRG 1991;16A:555-60. 14. Allieu Y, Guinouves P, Gomis Gr, Jacoulet P. Le fixateur exteme dans le traitement des infections osteo-articulaires de la main. Ann Chir Plast Esthet 1987;32:64-9. 15. Seitz WH, Gomez W, Putnam MD, Rosenwasser MP. Management of severe hand trauma with a mini external fixateur. Orthopedics 1987;10:601-10. 16. Stuchin SA, Hummer FJ. Stiffness of small-bone external fixation methods: an experimental study. J HAND SURG 1984;9A:718-24.

One-stage key pinch and release with thumb carpal-metacarpal fusion in tetraplegia

One-stage key pinch and release with carpal-metacarpal fusion, extensor pollicis longus tenodesis, and motor transfer to flexor pollicis longus were analyzed for functional results in tetraplegic patients. Eighteen patients (21 hands)--all with International Classification OCu:4 hand function or worse--were studied. Average follow-up was 42 months. All patients experienced significant increase in functional ability and thought the surgery was highly beneficial. Average pinch strength was 3.3 kg, whereas it had been nonmeasurable preoperatively. Both activities of daily living and pinch strength correlated with tetraplegic functional level. The patients with higher preoperative functional level had better postoperative activities of daily living scores and pinch strength. Sixteen hands had solid fusions, and patients with fibrous nonunions showed no decrease in pinch strength, pain, or functional limitations when compared with the patients who had solid fusions. Six hands showed degenerative changes at one or more adjacent joints, but this was not related to results.

Entrapment neuropathy of the infrapatellar branch of the saphenous nerve A new peripheral nerve entrapment syndrome

This paper describes a syndrome of entrap ment of the infrapatellar branch of the saphe nous nerve attributable to its anatomical rela tionship to the sartorius muscle and justifies its identification as a distinct entity. Surgery was performed on four knees in three pa tients for localized pain and tenderness. The infrapatellar nerve was found entrapped be hind the sartorius tendon against the promi nent edge of the medial femoral condyle and sharply angulated while passing around the sartorius in two knees. Entrapment during passage of the nerve through a slit in the musculotendinous portion of the sartorius was observed in the others. All patients had complete relief of symptoms after transloca tion of the nerve away from the site of entrap ment. The characteristic findings demon strate the need to be aware of the possibility of entrapment of the infrapatellar branch of the saphenous nerve when evaluating pa tients with pain on the medial aspect of the knee.

Intrinsic balancing in reconstruction of the tetraplegic hand

This article reviews 183 hand reconstructions in 135 consecutive tetraplegic patients. Comparisons were made between 103 extrinsic reconstructions with intrinsic balancing procedures and 80 extrinsic reconstructions without intrinsic balancing procedures. Extrinsic reconstructions (tendon transfers and tenodesis in the forearm muscles) were augmented by intrinsic reconstructive procedures (tendon transfers or tenodesis to improve the intrinsic balance of the fingers) in patients exhibiting digital imbalance. Intrinsic procedures included primarily the flexor digitorum superficialis (FDS) lasso procedure or the intrinsic tenodesis procedure. The patients were stratified by level of spinal cord injury and by type of extrinsic and intrinsic reconstruction. Hands reconstructed with intrinsic balancing versus without intrinsic balancing, as well as intrinsic balancing using a FDS lasso procedure versus an intrinsic tenodesis procedure, were compared with patients with the same level of spinal cord function. Patients who underwent reconstructions with intrinsic balancing had more grip strength, by an average of 13-26 N, than those who did not undergo intrinsic balancing. When different intrinsic procedures were compared, there was improvement in grip strength and function in activities of daily living for all hands, but there was no significant difference between FDS lasso or intrinsic tenodesis procedures. The indications for intrinsic balancing during extrinsic reconstruction are developed into treatment algorithms based on the senior authors surgical experience. The authors recommended that digital intrinsic procedures be included in hand reconstruction for tetraplegic patients exhibiting intrinsic imbalance to help improve digital function and provide increased grip strength.

Two-stage reconstruction of apert acrosyndactyly

This report retrospectively reviews presenting radiographs and surgical treatment of 28 hands in 14 children with Apert acrosyndactyly with the purpose of developing a classification system to describe the decision-making process used to determine the type and staging of hand reconstruction. The average patient age at last follow-up evaluation was 7 years (range, 3-17 years). Type I deformities (7 hands) had little or no angular deformity at the metacarpophalangeal (MP) joint; two-stage reconstruction created a four-fingered hand. Type IIA deformities (11 hands) had mild MP joint angular deformity and a more proximal complex syndactyly of the middle three digits; two-stage reconstruction created a three-fingered hand with ray resection of the third digit. Type IIB deformities (7 hands) had pronation of digit 2 superimposed on the thumb and radial angulation at the MP joint of digit 2; two-stage reconstruction created a three-fingered hand with ray resection of the second digit. Type IIC deformities (3 hands) had supination of digit 4 superimposed on digit 5 with ulnar angulation at the MP joint of digits 4 and 5; two-stage reconstruction created a three-fingered hand with ray resection of the fourth digit. This report presents a classification system and four different treatment strategies based on presenting radiographs.

Extensor Retinaculum Impingement in the Athlete A New Diagnosis

Background Athletes with repetitive weightbearing hyperextension activities are predisposed to wrist pain. Purpose To describe extensor retinaculum impingement of the extensor tendons as a new diagnosis for wrist pain for the athlete performing repetitive wrist hyperextension, to present cadaveric dissections to further understand the anatomical basis for extensor retinaculum impingement, and to report treatment outcomes of extensor retinaculum impingement. Study Design Case series; Level of evidence, 4. Methods A retrospective chart review was performed for athletes treated from 1987 to 2006 for wrist pain due to extensor retinaculum impingement. Eight wrists in 7 athletes were reviewed with a mean presenting age of 19.6 years. The hallmark symptom was dorsal wrist pain, and signs were extensor tendon synovitis and tenderness at the distal border of the extensor retinaculum, provoked by wrist hyperextension. Ten cadaveric wrists were dissected and examined to evaluate anatomical factors that may contribute to extensor retinaculum impingement. Results Two athletes (2 wrists) were treated with corticosteroid injections. Five patients (6 wrists) were treated operatively, with pathologic findings of thickening of the distal border of the extensor retinaculum and concomitant extensor tendon synovial thickening or, in 1 patient, tendon rupture. Partial distal resection of the extensor retinaculum was performed to eliminate impingement. All patients had complete relief of pain and full return to sport. Conclusion Competitive sports that require repetitive wrist extension with an axial load predispose the athlete to extensor retinaculum impingement. Athletes with dorsal wrist pain and tenosynovial thickening worsened with wrist hyperextension should be considered for the diagnosis of extensor retinaculum impingement. When nonoperative management fails, surgical resection of the distal impinging border of the extensor retinaculum can eliminate pain and can still allow athletes to return to sport without diminishing the opportunity for significant athletic accomplishments.

Bilateral unicameral bone cysts in the hamate bones

This is a case report of bilateral unicameral bone cysts located in the hamate bones of a 22-year-old man. Unicameral bone cysts are rarely seen in the bones of the hand or bilaterally. In this case the diagnosis was made clinically using both radiographic and magnetic resonance imaging studies, and verified by microscopy of the biopsied specimen. Treatment consisted of curettage, autogenous bone grafting, and immobilization. To our knowledge there has not been any record in the literature of symmetrical unicameral bone cysts in the carpal bones.

Clinical manifestations of congenital insensitivity of the hand and classification of syndromes

Lesions of the upper extremity, particularly of the hand, are common in congenital insensitivity syndromes. Five cases are described with findings including fractures, infections, stiffness of fingers, self-mutilation, and traumatic amputations. The best form of treatment is preventative, since reconstructive surgery has little to offer. If conservative efforts are of no avail, amputation of the part is, unfortunately, the best way to obtain satisfactory results.