Morton L. Kasdan

Reconstruction of the Amputated Finger Tip with a Triangular Volar Flap: A New Surgical Procedure

A triangular volar flap has been used successfully for the reconstruction of amputated finger tips. It can be applied to most finger amputations except those with extensive soft-tissue loss on the volar side of the amputated finger tip. The distally based triangular flap, carefully prepared with intact nerve and blood supply, is advanced over exposed bone and approximated to the nail matrix. The V incision is closed by converting it to a Y.

Upper extremity disorders : a literature review to determine work-relatedness

The objective of this review is to establish whether the medical literature validates a causal relationship between upper extremity disorders and work activities. Selected articles were reviewed using a Diagnostic Medical Criteria. Articles meeting this criteria were further reviewed for validity. Only 14 of 52 reviewed articles were felt to encompass medical criteria. However, these articles also contained what appear to be major validity flaws. Very little of the written material dealing with the issue of work-related upper extremity conditions incorporates what are felt to be sound medical diagnostic criteria in the definition and identification of these conditions. None of the reviewed studies have established a causal relationship between distinct medical entities and work activities. Further research using well constructed studies that incorporate reliable epidemiologic and accepted diagnostic criteria is needed. In this manner, the best of the medical and epidemiologic fields can be applied to solving these problems.

A case-control study of obesity as a risk factor for carpal tunnel syndrome in a population of 600 patients presenting for independent medical examination.

Pain, numbness, and tingling through the median nerve distribution, known as carpal tunnel syndrome (CTS), has been associated with many personal risk factors. Previous studies have implicated obesity as a risk factor for median neuropathy at the carpal tunnel. A case-control design was undertaken to explore the association between obesity and CTS. Six hundred patients presented with symptoms of upper-extremity disorders for independent medical examination related to a disability or compensation claim. The 300 patients with electrodiagnostic evidence of CTS were compared with 300 control subjects from the same initial population. All patients were categorized according to their body mass index. The analysis was stratified for the possible confounding factors of cervical spine abnormalities, Martin-Gruber interconnections, age, and sex. A statistically significant association was found between obesity and median neuropathy. The implications of such a relationship are discussed in light of the contemporary debate over the etiology of cumulative trauma disorders.

Small Blood-vessel Anastomosis for Salvage of Severely Injured Upper Extremity

1. Four cases of devascularized upper extremities are presented. In two the extremity was nearly amputated. Vein and artery reconstitution was accomplished with successful results. 2. The factors influencing thrombosis of vessels are discussed. 3. Additional experimental studies to perfect anastomosis of vessels as small as one millimeter are indicated. Techniques learned could be applied to the treatment of devascularized or amputated digits.

Postoperative results of rheumatoid arthritis patients on methotrexate at the time of reconstructive surgery of the hand.

We conducted a retrospective chart review examining the frequency of local postoperative infection and poor wound healing of 15 methotrexate-treated rheumatoid arthritis patients undergoing 155 procedures during 39 surgeries. The patients were compared to a group of rheumatoid patients not on methotrexate who underwent similar reconstructive surgery of the hand. The patients taking methotrexate were followed postoperatively for a minimum of 10 weeks, with a mean follow-up time of 1 year, 42 weeks. There were no postoperative complications that would lead to the belief that the administration of methotrexate results in poor wound healing or leaves the patient more susceptible to postoperative infection. Our findings and a review of the literature support a continuation of methotrexate therapy in rheumatoid arthritis patients scheduled for reconstructive surgery of the hand and wrist.

Carpal tunnel syndrome and vitamin B6.

We reviewed 1075 patients presenting over a 12-year period with symptoms of carpal tunnel syndrome. A total of 994 had a final diagnosis of carpal tunnel syndrome. There were 444 male and 550 female patients with a mean age of 42 years. Three-hundred and ninety-five related symptoms to their job. Surgery was performed in 27 percent of the total diagnosed cases with approximately 97 percent relief of symptoms. Satisfactory alleviation of symptoms was obtained in 14.3 percent of patients treated conservatively prior to 1980, with one or a combination of splinting anti-inflammatory agents, job or activity change, and steroid injections. In 1980, vitamin B6 (pyridoxine) was added as a method of conservative treatment. Satisfactory improvement was obtained in 68 percent of 494 patients treated with a controlled dosage (100 mg b.i.d.). While our findings were not the result of a controlled scientific study, we feel they suggest that regulated use of vitamin B6 may be helpful in treating many cases of carpal tunnel syndrome.

Expanded profile of the SHAFT syndrome.

The SHAFT syndrome is a factitious disorder in which a patient manipulates the surgeon to perform operations to fulfill his or her psychological needs. The acronym describes patients who are sad, hostile, anxious, frustrating, and tenacious. A chart review from January 1990 to June 1996 was undertaken to provide a profile to aid in the recognition and diagnosis of the SHAFT syndrome. An analysis of 28 patients revealed characteristics supporting a definitive SHAFT profile. Patients with SHAFT syndrome seek physicians to perform invasive procedures. Their typical complaint is pain, usually without objective physical findings that would support a more definitive diagnosis. Such patients tend to be women, cry with pain, describe symptoms out of proportion to objective findings, and have a history of psychiatric care.

Reconstruction of Chronically Subluxated Proximal Interphalangeal Finger Joint

1. The etiology and pathology of recurvation deformity of the proximal interphalangeal joint are discussed. 2. Four cases of recurvation deformity and a simple operative procedure to correct this deformity are presented. 3. The results obtained in these cases warrant continued use of this procedure to correct a deformity heretofore difficult to manage.

An Atypical Case of Reverse Takotsubo Cardiomyopathy During General Anesthesia in a 30-Year-Old Male With Post-Traumatic Stress Disorder

AKOTSUBO CARDIOMYOPATHY, also referred to as transient left ventricular ballooning syndrome or stressinduced cardiomyopathy, describes a rapid-onset, yet reversible systolic dysfunction that typically is triggered by an acute, stressful event. The pathophysiology is not completely understood, and similar presentations have been described as a result of the endocrine crisis of pheochromocytoma, 1 subarachnoid hemorrhage, 2 and Guillain-Barre syndrome. 3 A wide heterogeneity of presentation suggests that multiple overlapping mechanisms such as neurogenic catecholamine-induced myocardial stunning, 4 microvascular dysfunction, 5 and multivessel epicardial spasm 6,7 may play a role. Symptoms mimic an ST-segment elevation myocardial infarction. Patients present with ischemic electrocardiographic changes, reduced left ventricular ejection fraction, and a balloon-like contractility pattern that portrays a unique wall-motion abnormality that extends beyond the myocardial territory of a single coronary artery. The classic form presents as transient apical ballooning with basal hypercontractility. In more rare cases of reverse Takotsubo, the opposite is observed—transient dilatation of the basal segments of the heart with hyperkinesis of the apex. It has been estimated that 0.5% to 2% of patients with symptoms of an acute coronary syndrome may have Takotsubo cardiomyopathy. 7,8 Of these, 95% are postmenopausal women with a median age of 63 years. 4 For the first time, the authors present a case of anesthesia-induced reverse Takotsubo cardiomyopathy in a young, healthy male with a history of posttraumatic stress disorder (PTSD). In this atypical patient, anesthesia, perioperative stressors, and chronic psychologic distress may have triggered transient left ventricular ballooning.

Electrodiagnostic reports of median neuropathy at the wrist

The diagnosis of carpal tunnel syndrome (CTS) is confirmed by electrodiagnostic testing. Practice parameters for electrodiagnostic testing of CTS have been defined in a summary statement published by the American Academy of Neurology, the American Association of Electrodiagnostic Medicine, and the American Academy of Physical Medicine and Rehabilitation. All members of the Industrial Injuries and Prevention Committee of the American Society for Surgery of the Hand provided electrodiagnostic reports from their office practices indicating an electrodiagnosis of CTS or median neuropathy at the wrist. One hundred consecutive reports were analyzed to determine how often these electrodiagnostic studies adhered to the standards and guidelines of the summary statement. Variability in the thoroughness of the studies, hence in the quality of information in the reports, was noted. The clinical implications of this survey are that some patients were diagnosed and treated for CTS who did not have median neuropathy at the wrist.