John A. I. Grossman

Ulnar Nerve Laceration as a Result of Elbow Arthroscopy

We report a case of an ulnar laceration during elbow arthroscopy in a 31-year-old man.

The Management of Pigmented Lesions of the Nail Bed

Pigmented lesions of the nail bed, especially without a history of trauma, represent a diagnostic challenge to the clinician. These lesions are often categorized as melanonychia striata (MS), which refers to any linear tan-brown-black pigmentation of the nail bed. The differential diagnosis of MS includes subungual hematomas, onchomycosis nigricans, junctional nevi, melanoma in situ (MIS), and malignant melanoma (MM). Our algorithm at the New York University (NYU) Medical Center for the treatment of pigmented lesions of the nail bed is presented. A histopathologic diagnosis with any evidence of melanocytic atypia, however subtle, requires absolute confirmation by complete excision. The absence of a clear margin or recurrence requires total nail bed excision and reconstruction using a full-thickness graft. The diagnosis of MIS is similarly treated. The surgical management of subungual MM is discussed. All cases of MM of the hand treated at NYU were reviewed. In all, 30 patients were treated from 1982 to 1995. Follow-up ranged from 6 months to 13 years. In our series, there were 8 cutaneous and 22 subungual melanomas. There was a marked delay in treatment of both groups, with subungual melanomas more often erroneously treated as other pathology prior to correct diagnosis. The 5-year survival rate was 100% for patients with cutaneous lesions, but only 80% for those with the subungual variety. There was a statistical difference in the depths of the lesions (subungual, 3.68 mm; cutaneous, 1.36 mm) with a p-value of 0.008. The role of elective lymph node dissection in the absence of clinical metastases as well as intraoperative sentinel lymphatic mapping remains controversial and is discussed.

Early operative intervention for birth injuries to the brachial plexus.

Early surgical repair is indicated for selected infants who sustain birth trauma to the brachial plexus. In children with global or total paralysis, surgery should be performed by 3 to 4 months of age to maximize ultimate extremity function. Although the timing of surgery for children with Erbs palsy remains controversial, in properly selected cases, nerve reconstruction leads to an improvement in shoulder function and overall limb function.

Botulinum toxin type A as an adjunct to the surgical treatment of the medial rotation deformity of the shoulder in birth injuries of the brachial plexus

We retrospectively reviewed 26 patients who underwent reconstruction of the shoulder for a medial rotation contracture after birth injury of the brachial plexus. Of these, 13 patients with a mean age of 5.8 years (2.8 to 12.9) received an injection of botulinum toxin type A into the pectoralis major as a surgical adjunct. They were matched with 13 patients with a mean age of 4.0 years (1.9 to 7.2) who underwent an identical operation before the introduction of botulinum toxin therapy to our unit. Pre-operatively, there was no significant difference (p = 0.093) in the modified Gilbert shoulder scores for the two groups. Post-operatively, the patients who received the botulinum toxin had significantly better Gilbert shoulder scores (p = 0.012) at a mean follow-up of three years (1.5 to 9.8). It appears that botulinum toxin type A produces benefits which are sustained beyond the period for which the toxin is recognised to be active. We suggest that by temporarily weakening some of the power of medial rotation, afferent signals to the brain are reduced and cortical recruitment for the injured nerves is improved.

Outcome following nonoperative treatment of brachial plexus birth injuries.

Ninety-one infants who sustained a brachial plexus birth injury were treated with only physical and occupational therapy. The children were evaluated at 3-month intervals and followed for a minimum of 2 years. Sixty-three children with an upper or upper-middle plexus injury recovered good to excellent shoulder and hand function. In all of these children, critical marker muscles recovered M4 by 6 months of age. Twelve infants sustained a global palsy, with critical marker muscles remaining at M0—M1 at 6 months, resulting in a useless extremity. Sixteen infants with upper and upper-middle plexus injuries failed to recover greater than M1—M2 deltoid and biceps by 6 months, resulting in a very poor final outcome. These data provide useful guidelines for selection of infants for surgical reconstruction to improve ultimate outcome. (J Child Neurol 2004; 19: 87—90).

Outcome after later combined brachial plexus and shoulder surgery after birth trauma

Of 22 infants aged between 11 and 29 months who underwent a combined reconstruction of the upper brachial plexus and shoulder for the sequelae of a birth injury, 19 were followed up for two or more years. The results were evaluated using a modified Gilbert scale. Three patients required a secondary procedure before follow-up. Three patients had a persistent minor internal rotation contracture. All improved by at least two grades on a modified Gilbert scale.

The Effect of Pulsed Electromagnetic Fields on Flexor Tendon Healing in Chickens

This study was designed as a pilot investigation of the effect of pulsed electromagnetic fields (PEMF) stimulation on early flexor tendon healing in a chicken model using a similar stimulus to that used clinically. The PEMF used caused a decrease in tensile strength and an increase in peritendinous adhesions.

Cervicothoracic Extradural Arachnoid Cyst: Possible Association With Obstetric Brachial Plexus Palsy

The association of cervicothoracic extradural arachnoid cysts and obstetric brachial plexus palsy has not previously been reported. We report two patients with this association. The first patient is a 9-month-old boy with left obstetric brachial plexus palsy that developed bilateral leg weakness at 6 months of age owing to compression of the spinal cord by a C6 to T8 left cervicothoracic extradural arachnoid cyst. The second patient is a 3-year-old girl with bilateral brachial plexus palsy and spastic paraparesis who had magnetic resonance imaging at 3 days of age that showed intraspinal cord injury and a cervicothoracic extradural arachnoid cyst compressing the spinal cord. We believe that the association of cervicothoracic epidural arachnoid cysts and obstetric brachial plexus palsy in these patients was causal and recommend that the possibility of a cervicothoracic epidural arachnoid cyst be considered in patients with brachial plexus palsy and evidence of spinal cord injury. (J Child Neurol 2002;17:770—772).

Hand function in children with an upper brachial plexus birth injury: results of the nine-hole peg test.

Aim  The aim of this study was to evaluate hand function in children with Erb upper brachial plexus palsy.

Giant neurofibromatosis of the chest wall: two patient reports.

Two patients with severely deforming giant neurofibromatosis of the chest wall secondary to von Recklinghausens disease are presented. Pain, respiratory compromise, recurrent ulcerations, cosmetic considerations, and the malignant potential of these lesions indicated wide excision and reconstruction. It is impossible to completely eradicate all neurofibromas, which may affect virtually every nerve within the chest wall including the mediastinum. However, excision of the primary mass may reduce the possibility of malignant degeneration into neurofibrosarcoma or malignant schwannoma. This type of major, full-thickness chest wall resection is now possible using musculocutaneous flaps to achieve satisfactory closure with a single-stage procedure with minimal morbidity and a short hospital stay. At the 10-year follow-up, neither patient exhibited evidence of recurrence.