John Stothard

Wrist arthroscopy: John Stanley and Phillipe Saffar. 114 pages. Over 150 illustrations including 99 in full colour. Martin Dunitz, London 1994. ISBN 1-85317-106-9. Price £45

Dear Sir, In 1991, Brunelli and Brunelli defined a new type of brachial plexus lesion to be added to the classical types, i.e., the upper, the lower and the total type. This new type was called the intermediate palsy in which the predominant lesion was the C7 root with variable involvement of the upper or lower plexus. Brunelli and Brunelli (1991) operated on several cases of intermediate obstetrical palsy and of these, 4 had avulsion of C7 with incontinuity lesions of the lower trunk. However, they did not describe the clinical picture nor the method of delivery in these cases. More recently, Zancolli and Zancolli (1993) mentioned that some of their ob’stetric palsy cases were predominantly related to C7 lesion, bult they also did not describe the clinical picture nor the method of delivery in their cases. We recently came across two papers (Jolly, 1896; Thomas, 1905) describing three cases with a similar pattern of obstetrical birth palsy in which the lesion at birth involved C7, C8 and Tl roots and on follow-up, only the muscles supplied by C8 and Tl spontaneously recovered to some extent. Thomas (1905) realized that these cases predominantly involved the C7 root and were different from the classic lower brachial palsy involving C8 and Tl only. Clinically, the affected arms were abducted, the forearms flexed, while the fingers and hands hung flaccid. No triceps reflex was obtained and no Horner’s syndrome was seen in any of the cases. All cases 613

Severe ulnar nerve entrapment at the elbow: functional outcome after minimally invasive in situ decompression

The role of in situ decompression in patients with severe ulnar nerve compression is still controversial. Thirty patients with severe ulnar nerve compression confirmed clinically and electrophysiologically underwent simple decompression. The mean age of the patients was 58 (range 26–87) years. Through incisions ≤4 cm the nerves were fully visualized and decompressed. Outcome was measured prospectively using Modified Bishop’s score (BS), grip and pinch strengths and two-point discrimination (2PD). Significant improvement in power (p = 0.01) and pinch grip (p = 0.001) was noted at 1 year. The grip strength continued to improve up to 1 year. According to the BS, 24 patients (80%) had good to excellent results at 1 year. Minimally invasive in situ decompression is technically simple, safe and gives good results in patients with severe nerve compression. The BS and 2PD were more reliable than grip strength in assessing these patients at follow-up.

Outcome of carpal tunnel release--correlation with wrist and wrist-palm anthropomorphic measurements.

Wrist and wrist–palm measurements have been associated with the diagnosis of carpal tunnel syndrome. We found no reported study about how this correlation affects the outcome after surgery. We investigated the role of the measurements in predicting outcome after open carpal tunnel release. A total of 131 patients (88 female, 43 male) responded to our postal questionnaire using the Boston Carpal Tunnel assessment (65% response rate) at a minimum of 9 months post-operatively. Symptom and functional scores showed a strong correlation. There was no statistical difference in the outcome between wrist ratio (≥0.7 vs <0.7), wrist–palm ratio (≥0.41 vs <0.41) and gender, but a better functional score was very weakly correlated with a higher wrist ratio. A very large study would be needed to show any statistical correlation between both measurement and outcome.

Selective growth disturbance of the hand following neonatal compartment syndrome: a case report

diathermy and allowed to retract into the wound. Skin was closed with 6-0 Vicryl Rapide and a light adhesive dressing was applied. The ages of 40 babies treated under local anaesthetic ranged from 3 to 18 weeks. A total of 58 accessory digits were excised. The mean duration of the procedure was 18 minutes (SD 1; range 2–20). In an audit of a group of 35 infants operated on under general anaesthesia, the ages ranged from 11 months to 2 years. The number of digits excised was 52. The mean duration of the procedure was 59 minutes (SD 6; range 10–97). The difference in duration of the procedure was statistically significant (P50.001, Student’s t-test). A telephone survey of 31 parents who were present in theatre during the operation revealed that 30 were glad the procedure had been carried out under local anaesthetic. One mother would have preferred a general anaesthetic and found the experience distressing. Two reported residual accessory skin that they felt did not warrant re-excision. Excision of minor accessory digits has been reviewed by Stewart et al. (2002) who excised ulnar duplication in infants up to 14 days old at the Aberdeen Royal Infirmary where maternity services were on the same site. They concluded that after this age babies are less passive and therefore excision under local anaesthetic is not feasible. In our practice it is inevitable that we operate on older babies, as maternity services are at other sites. We have not experienced difficulty operating on babies up to the age of 18 weeks. We have found excision of Stelling type 1 ulnar duplication up to 4 months of age under local anaesthetic to be a safe procedure associated with high satisfaction in parents.

The effectiveness of sodium tetradecyl sulfate in the treatment of wrist ganglia

BACKGROUND Ganglia are the most common benign soft tissue tumours of the hand. Although benign, a significant number of patients with wrist ganglia consult with their general practitioners, and ultimately the hand surgeon, complaining of pain. A great number of patients are concerned about the cosmetic appearance, and an equally significant number genuinely believe that the ganglion is a cancer. There are several management options resulting in varying degrees of success. These include observation only, surgical excision, aspiration only, aspiration with injection of methylprednisolone, and aspiration with injection of methylprednisolone and hyaluronidase. OBJECTIVE The main objective was to investigate the effectiveness and safety of sodium tetradecyl sulfate as a sclerosing agent after aspiration of wrist ganglia. METHODS Initial data were collected prospectively during a period of 48 months. Following this, patients were sent a postal survey at least two years after they had received treatment to access the levels of recurrence and persistent complications. RESULTS In the short term, 90% of the patients achieved complete resolution after one episode of aspiration and injection. However, there was only a 65% cure rate after two to five years. Complications were few and not significant. CONCLUSION Sodium tetradecyl sulfate is an effective sclerosing agent after aspiration of wrist ganglia with an excellent short-term efficacy and a long-term cure rate comparable to that of surgical excision.

AO manual of fracture management hand and wrist Jesse B Jupiter Thieme Verlagsgruppe, Stuttgant ISBN: 3131276118 Price: 249.95 Euros

The format of this book is strictly that of a reference manual. It does this with a series of case presentations of examples of fixation of fractures in the hand phalanges and metacarpals, the carpal scaphoid and the distal radius. There are 143 pages devoted to the hand, 46 pages to the scaphoid and 107 to the distal radius. The last 46 pages are pictures and lists of the equipment sets (but not with catalogue numbers for ordering) a glossary of terms, an index and instructions on using the enclosed DVD. The authors’ introduction states ‘‘this book is not intended to provide comprehensive coverage of these injuries nor to present alternative treatments or an extensive review of the literature’’. The introduction to the hand section states ‘‘the reader may disagree with or question the choice of treatment or even its technical application. This is expected given the variety of treatment options of hand fractures’’. These are relevant and important considerations for use of the manual. Accepting these limitations, I liked the very clear layout of this book. However, the format used, that is giving case examples with pre-operative and postoperative X-rays, diagrams of surgical exposure and technique, pictures showing movements at the end of treatment and some operative photographs, followed by a list of ‘‘expert tips’’ and common mistakes is obviously repetitive. This is definitely a ‘‘manual’’ to be consulted and not a book to be read. Having said this, there is some rather strange and unnecessary repetition, for example case 1.15 and case 1.28 are so similar that the same diagrams and largely the same text is used for both. The accompanying DVD has all the text and pictures in the book and many of the pictures can be enlarged. It also has some short videos of surgical exposures on cadavers for palmar and dorsal exposure of the wrist and dorsal exposure of the proximal phalanx and metacarpal. There are also video clips of fixation