John L. Bell

Injury of the Median and Ulnar Nerves: One Hundred and Fifty Cases with an Evaluation of Moberg's Ninhydrin Test

In considering the results of suture of the median and ulnar nerves, we have excluded cases in which nerve regeneration might be hindered by excessive scar, by tension at the line of suture, by long delay at carrying out operation, or by multiple operative procedures. We have attempted to correlate

Injuries to flexor tendons of the hand in children.

This presentation relates our experience with sixty children who sustained tendon injuries or combined tendon and nerve injuries of the flexor surface of the hand. Sixty-four operative procedures were performed in this series of cases. Primary repair of divided flexor structures was undertaken in five patients, and in fifty-six patients secondary reconstructive procedures were performed. The majority of the patients were less than six years of age. Operative techniques in children were the same followed for older patients. The preoperative diagnosis of tendon injuries in the child too young to cooperate was not difficult provided careful observations of the posture of the hand were interpreted properly. In the young child, nerve injuries could be suspected by the location of the surface wound. However, the absolute identity of nerve interruption had to be confirmed at the time of the operative procedure. The secondary procedures included tendon grafts within the flexor sheaths of the fingers and thumb, and repairs of multiple nerve and tendon injuries in the palm. Thirty-four children had tendon grafts inserted into the fingers. Of the latter group, 65 per cent were less than six years of age. Seven patients had tendon grafts of the thumb and fifteen had secondary repairs for injuries in the palm. Although the structures are smaller in the childs hands, the operative procedure was often less difficult than in the adult hand. In the majority of the cases, the interphalangeal joints were supple and scarring was less than in the older patients. In most of the children the long extensor tendon of a toe was used for grafting. The maintenance of postoperative immobilization of the hand challenged us frequently in the child under six years. In the child too young to cooperate, suture removal was carried out under general anaesthesia. Formal physical therapy was not prescribed for children. Follow-up examinations were continued at yearly intervals in many of the young children before the end result could be ascertained. Fifty-three children were included in the follow-up study. In children of different ages, the variance in hand size precluded the use of measurements other than degrees of active and passive motion. The influence of the preoperative condition of the hand upon the result following tendon reconstruction should be stressed. Excellent results following tendon repair in children were determined according to criteria set for older patients. However, lesser stages of functional return were assessed with more difficulty. In fifty-three patients, twenty-three excellent and eighteen good results were obtained after either primary or secondary tendon and nerve reconstruction on the flexor surface of the hand.

Treatment of acute thermal burns of the face

Abstract The objectives of the early care of burns about the face are to avoid infection and obtain healing as soon as possible. Initial treatment is facilitated by use of the exposure method. In extensive burns, shock and irritation of the respiratory tract are frequent complications which necessitate early aggressive care. Emergency tracheotomy may be necessary to relieve obstruction of the upper respiratory tract and to alleviate damage to the bronchopulmonary system. For those with extensive full-thickness burns about the face and neck, early tracheotomy is a valuable adjunct to management. Full-thickness losses in the face and neck should receive a high priority for early autogenous skin coverage. Although surgical excision is widely advocated for other areas of the body, it is not applicable for the face. However, most deep burns of this region can be prepared for split-thickness skin grafting within three weeks following injury. Failure to accomplish this objective leads to stubborn infection, increased deformity and disfigurement, and the problems faced during further reconstruction may be compounded or at times are insurmountable.

Management of acute crushing injuries of the hand and forearm over a five-year period (1948–1952)

Abstract A review of 112 patients with acute crushing injuries of the hand and forearm is reported from the period of 1948 through 1952. The causes and types of injuries are cross indexed, and the local and remote complications are presented. The surgical principles of the management of acute crushing wounds are: protection of the wound from further contamination and trauma; mechanical cleansing of the wounds; thorough removal of devitalized tissues; repair of injured deep structures, if circumstances permit; reduction of fractures and closure of the wounds. We have emphasized the importance of maintaining the injured extremity in the position of function. In 108 patients, initial coverage of the wounds was accomplished by one or a combination of methods. The keystones to primary wound healing are removal of devitalized tissues and immediate closure of the wounds.

Hand Surgery in the Medical School Curriculum

Ladies and Gentlemen. I would like to begin by expressing my gratitude to the members of this Society for the honor and privilege of serving as an officer and Councilor for ten years and as your current President. Our Society now has more than 250 members, and we need to continue our stalwart growth and expansion. No one can deny today that there is an explosive interest in surgery of the hand throughout the world. Last fall word was received of the founding of the Australian Hand Society. Today we are honored by the presence of their President, Mr. Alan H. D. Mciannet. This years Founders Lecturer is Dr. Kenya Tsuge of Japan, one of the leading hand surgeons in Asia. Mr. Graham Stack, President of the British Hand Society and an honorary member of our association, is also present today. Many other eminent hand surgeons from overseas are in the audience. To all of you, please accept our heartiest welcome to the Twenty-eighth Annual Meeting of the Amen can Society for Surgery of the Hand. In preparation for this address, many hours of thought preceded my ultimate struggle with pen and legal paper. I reflected about my interests in the field of hand surgery other than the actual practice of surgery of the hand. I did not want to reiterate what had been stated so well and now has been recorded in the literature by my predecessors in this office. During this past year my education continued as I read in more depth about the numerous problems confront ing the medical profession in the United States. I encountered a multitude of terms and abbreviations, many with which I was only vaguely familiar. Today we are expected to be conversant with such catchy titles as SESAP, SOSSUS, PSRO, HMO and innumerable other letters. The current non-technical medical literature abounds with such catch phrases as health care delivery, community medicine, peer review, continuing education, core curriculum, the fragmentation of surgery and many others. I hope that you can also take more time to become better informed about these problems. In his 1971 Presidential Address to our Society, Raymond Curtis charged that we must teach about hand surgery through every possible avenue. The response in the past two years has been a tremendous surge in postgraduate continuing education in surgery of the hand. In addition, there has been an increase in the establishment of new departments, divisions, and services of hand surgery in medical schools and hospitals. Today I would like to discuss some thoughts about instruction in hand surgery for medical students. One of our members, James Hunter of Philadelphia, has been most enthusiastic about teaching in this area, and at Jefferson Medical College has developed an official course in hand surgery, open to junior and senior students for six to twelve week blocks. He also has become involved in teaching about the hand during the first two years ofthe medical curriculum. Among young people today it is not popular to look back, but I cannot avoid recalling that prior to and during World War II, a graduate of Northwestern University Medical School was expected by his colleagues to have a special knowledge about infections and injuries of the hand. Northwesterns Allen B. Kanavel and his successors: Sumner L. Koch, Michael L. Mason and Harvey S. Allen, had established a world wide reputation because of their teachings and writings about surgical conditions involving the hand. Northwesterns students were greatly in fluenced and stimulated by those dynamic teachers in the areas of soft tissue trauma, surgical infections, thermal burns and hand injuries. During my junior year at Northwestern our entire class attended a weekly clinic conducted by Dr. Koch in one of the amphitheaters of Cook County Hospital. At each of these sessions several students were selected at random to come down and examine patients with hand prob lems of all kinds. After examining the patients the students would present the history and find ings to the rest of the class. We were expected to be able to correlate our knowledge of anatomy, physiology and pathology to the cases at hand. It was an exceedingly popular course, and al though it was held after lunch there was seldom napping or sleeping by anyone in the class.

Open crushing injuries of the hand.

A severe injury of the hand requires early skilled treatment to save tissue and restore maximal function. The foundation of the primary operative treatment is the removal of all the devitalized tissue; however, debridement must not sacrifice any living part that may be useful for repair or closure. Repair of deeper structures may have to be restricted initially. Satisfactory reduction and stabilization of fractures are primary goals. Suture of divided nerves often is helpful, but repair of flexor tendons is not indicated in crushing injuries. Primary wound closure is another aim of initial treatment.