Michael L. Mason

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.

Significance of the American College of Surgeons to progress of surgery in America

Abstract The progress of surgery in America and the progress of the American College of Surgeons are synonomous because the College has set itself to discover needs and to shape its activities toward meeting them. It is not a membership organization whose primary object it is to protect and to promote the interests of its members individually. The purpose is rather to provide an avenue through which the members may submerge their individual and selfish interests and unitedly focus effort on improving their service to the patient. The active interest of the organization in the education and training of the surgeon and in improvement of the environment in which he works in hospitals and in industry, is centered not upon him personally but upon enabling him to obtain better surgical results. This larger concept completely coincides with the highest motive of the individual surgeon who has dedicated himself to service. The formula that the College follows is almost always the same, whether great projects like the standardization of hospitals and the organization of cancer clinics, or lesser ones like the standardization of surgical dressings and the approval of surgical equipment, are involved. First comes recognition of the problem. Second comes survey to determine the actual conditions and the extent of the need. Third, the co-operation of other groups concerned is sought, and effort is made to avoid duplication of effort. Fourth, a permanent set-up is established, either as a function of an administrative department or of a committee or committees under administrative guidance. Fifth, a standard is formulated, the meeting of which will help to correct the fault or overcome the deficiency. Sixth, the need and the way in which it can be met are publicized. Seventh, surveys are made to determine who are meeting the standard, and the approval list is publicized as a spur to competition. Eighth, assistance is given in meeting the requirements. Ninth, constant resurveys are made to assure maintenance of the standard. Tenth, progressive interpretation of the standard is made to conform with scientific, technical and ideologic advancement. Participation in the activities is possible for an exceedingly large proportion of the fellowship at any given time. There are executive, credentials and judiciary committees in every state and province, and in ninety-one different districts there are in addition committees on applicants. On the eighty-five regional fracture committees are 1,400 men. On the Board of Governors are 150 members. More than 200 Fellows are serving on the other committees, including the Committee on the Library, the Committee on Fractures and Other Traumas, the Committee on the Hall of the Art and Science of Surgery, the Committee on Bone Sarcoma, the Committee on Medical Motion Pictures, the Joint Committee on Nursing Service with American Nurses Association, the Committee on Graduate Training, the Advisory Council for Ophthalmology, the Advisory Council for Otolaryngology, the Board of Regents, Executive Committee, Finance Committee and Advisory Council to the Board of Regents. Participation in the meetings is another activity that is well supported by the entire fellowship. The roster of names of speakers, leaders of discussions, and clinical demonstrators at the Clinical Congress and Sectional Meetings through the years constitutes a roll call of the outstanding American and many foreign surgeons, and the published papers furnish year by year records of progress in surgery in general and in special fields. Looking ahead, the College faces with the rest of the nation, as it did once before, the threat of war. With the same enthusiastic response, it is rising to the needs of the national defense program. The chairman of the Board of Regents, Dr. Abell, is chairman of the committee appointed in September, 1940, to co-operate with the national defense commission of the United States on all phases of public health. Serving with him are the three Surgeons General, all Fellows of the College. The 1940–1941 president, Dr. Graham, is chairman, and Regent Alton Ochsner of New Orleans is vice chairman of the Advisory Committee on Surgery of the National Research Council, appointed in June, 1940. This committee has several subcommittees to represent the various surgical specialties and to investigate specific problems. Most of the members of the committees are Fellows of the College, so that again the organization that represents the surgical profession in action and as a whole, is in a national emergency enabling the surgeon to present a united front. There are those now who criticize the American College of Surgeons because of its size, its inclusiveness, as once there were those who feared it would be an “oriental oligarchy,” patterned after the “aristocracy of the old world.” It is true that the College fellowship roll of nearly 13,000 makes it the largest surgical organization in the world. However, the aim has never been to create an exclusive organization for the purpose of giving distinction to the members, but to set the qualifications Just high enough so that they can be attained with reasonable effort under existing circumstances by the competent surgeons upon whom the public throughout the country must rely and for whose competency an authoritative gauge is needed as a basis for public confidence. The aim “to elevate the standards of surgery” is interpreted as an obligation to elevate the standards of the greatest possible number of surgeons. Succinctly, Donald C. Balfour, in his presidential address in 1935, stated the significance of the American College of Surgeons to progress of surgery in America: “The accomplishments of the American College of Surgeons are recorded in the status attained by American surgery today.”

Principles of management of open wounds of the hand

Abstract The principles of care of open wounds have developed from an appreciation of the factors dealing with wound healing and from a knowledge of the source of wound contaminants. The introduction of chemotherapeutic drugs and of the antibiotics have not altered the principles of wound care. These general principles of care are: (1) Immediate and continuous protection from contaminants; (2) primary surgical care at the earliest moment; (3) mechanical cleansing of the wound ; (4) surgical excision of devitalized tissue; (5) careful hemostasis; (6) anatomic restoration of the tissues; (7) closure of the wound; (8) compression dressing; (9) putting the part at rest and (10) elevation. Specific principles, in addition to the above, apply to the hand because of technical and functional considerations. These are: (1) General anesthesia for all but the simplest procedures; (2) bloodless field secured by bloodpressure apparatus; (3) save all viable skin tags; (4) save all possible finger length; (5) tendon repair only in suitable wounds; (6) nerve repair in all wounds; (7) splint the hand in position of function except following nerve and tendon repair and (8) functionally, the hand is a grasping, pinching, sensory end organ.

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.

Injuries to Flexor Tendons of the Hand in Children

Open injuries of the flexor surface of the hand often result in dlivision of nerves and tendons even though the skin wound appears minimal. In children, division of nerves and tend!ons is caused most commonly l)y broken glass or other sharp ohjects (Table I). This paper is concerned with the sum-gical management of sixty children who had ten(!on or combined tendon and nerve injuries of the flexor surface of the

Primary closure of open injuries of the hand.

Practically all open wounds of the hand may be closed by suture or skin graft at the initial operation. This insures prompt healing, minimizes contracture and permits early function. If secondary operations are required, they may be undertaken at an earlier date.