Paul M. Weeks

A comparison of conjunctival and subciliary incisions for orbital fractures.

Abstract Although complications of conjunctival incisions have been described (Tenzel and Miller, 1971; Converseet al., 1973; Tessier, 1973; Habal and Chaset, 1974; Lynchet al., 1974), there has been no documentation of complications following subciliary incisions. This study was undertaken to compare those 2 most commonly used incisions for exposure of fractures of the infraorbital rim and the orbital floor.

The role of bone scintigraphy in diagnosing reflex sympathetic dystrophy

Three-phase bone scintigraphy is used often to diagnose reflex sympathetic dystrophy of the hand. This study presents an analysis of the literature relating three-phase bone scanning to reflex sympathetic dystrophy in the upper extremity. The data show a wide variability in scintigraphic accuracy in patients with clinically obvious reflex sympathetic dystrophy. The results of bone scintigraphy correlate best with the clinical diagnosis of reflex sympathetic dystrophy within the first 20-26 weeks of onset. Even then, the sensitivity in the most recent series approximates 50%. After 26 weeks, there is a poor correlation between three-phase bone scanning and reflex sympathetic dystrophy. Consequently, three-phase bone scintigraphy should not be used as a major criterion in diagnosing reflex sympathetic dystrophy. The diagnosis of reflex sympathetic dystrophy remains a clinical diagnosis made by an experienced hand surgeon.

The expression of transforming growth factor type beta in fetal and adult rabbit skin wounds

Transforming growth factor, subtype beta (TGF-beta) exists in several isoforms and is known to have important roles in adult wound healing by promoting collagen and extracellular matrix component deposition. It is also believed that TGF-beta influences normal developmental processes during embryo-genesis. Immunolocalization of two isoforms, TGF-beta 1 and TGF-beta 2, in healing fetal and adult rabbit skin wounds shows distinctly different forms of expression of these molecules. TGF-beta 1 and TGF-beta 2 are both expressed within the developing fetal dermis, but no differential upregulation in the area of the healing wound is noted. In contrast, the expression of TGF-beta 1 and TGF-beta 2 is increased in adult wounds by day 7 after wounding, within macrophages that are abundant by this time. High levels of TGF-beta 1 and TGF-beta 2 within adult wounds might indicate that the relative paucity and differential distribution of these factors in fetal wounds are important in the production of scar in adults and the absence of scar in the fetus. Further, these patterns of expression suggest fundamental differences between fetal and adult tissues in accomplishing wound repair.

Ulnar nerve transection as a complication of two-portal endoscopic carpal tunnel release: A case report

Endoscopic release of the transverse carpal ligament for relief of median nerve compression neuropathy has recently been promoted as superior to traditional open surgical methods. A decreased incidence of scar tenderness, postoperative hand weakness, and pillar pain and an earlier return to work have been suggested. As a consequence of the limited surgical exposure inherent to endoscopic procedures, there has been concern regarding potential risks to neurovascular structures in the hand. We report a case involving complete transection of the ulnar nerve during two-portal endoscopic carpal tunnel release requiring sural nerve grafting for reconstruction.

Management of chronic lunotriquetral ligament tears

Treatment of chronic disruptions of the lunotriquetral (LT) ligament is not well-defined. Eleven patients treated by LT fusion with use of a compression screw are reported. The injury frequently resulted from hyperextension of the wrist. Pain on the ulnar side of the wrist, limited motion, and tenderness over the LT joint exacerbated by ballottement were present. Standard radiographs were normal. Arthrography showed the ligamentous tear in all cases. After operation, immobilization was continued until fusion was apparent radiographically. Fusion was achieved in all cases between 2 and 5 months. Four patients were free of pain, four patients had pain only at the extremes of motion, and three patients had persistent pain. Mean wrist motion was as follows (preoperative/postoperative): flexion (53 degrees/45 degrees), extension (60 degrees/49 degrees), radial deviation (17 degrees/21 degrees), and ulnar deviation (25 degrees/18 degrees). Maximum grip strength as a percentage of the uninjured side was 73% preoperatively and 59% postoperatively. LT tears can exist de novo or as part of the ulnar impaction syndrome; a method for differentiation is presented.

Three-dimensional imaging of the wrist

The objective of this study was to determine the diagnostic quality of three-dimensional images of the carpal bones that could be constructed from raw data obtained from a computerized tomography scan. The quality of raw data collected was determined by collimation, slice interval, the number of projections, and x-ray tube operating specifications. The quality of two-dimensional images that were constructed from the raw data was determined by user-specified parameters including zoom or magnification factor, convolution kernels, and centering. The two-dimensional images were modified by erasure, the level of reconstruction, and animation, which permitted isolation of individual carpal bones, the construction of three-dimensional images viewing the external and internal surfaces of the bones, and the rotation of the images to provide multiple views. Representative images are presented.

Coincident rupture of the scapholunate and lunotriquetral ligaments without perilunate dislocation: Pathomechanics and management

Wrist injuries causing coincident disruptions of the scapholunate and lunotriquetral ligaments commonly result in perilunate dislocations. This article (1) describes our management of eight patients with wrist pain after coincident scapholunate and lunotriquetral ligament disruptions in the absence of perilunate dislocation; and (2) reports the results of biomechanical testing of some of the extrinsic and intrinsic wrist ligament and interprets these data to explain the injury seen clinically. The diagnosis of ligament failure was made on the basis of history, physical examination, arthrography and surgical exploration. Surgical treatment of seven patients consisted of concomitant scapho-trapezio-trapezoid fusion and lunotriquetral fusion. Three of seven patients were free of pain, two had pain only at the extremes of motion, and two required additional surgery. Biomechanical analysis of the scapholunate and lunotriquetral ligaments and two extrinsic wrist ligaments, the radiolunotriquetral and the radioscaphocapitate, confirmed the clinical suspicion that the intrinsic ligaments could be completely disrupted while the extrinsics are only partially injured. Such a scenario could account for the residual stability that prevents the development of perilunate dislocations. Coincident disruption of the scapholunate and lunotriquetral ligaments in the absence of perilunate dislocation is an unusual injury. Treatment with lunotriquetral fusion and scapho-trapezio-trapezoid fusion restored functional use in five of seven wrists while maintaining wrist motion.

Microvascular joint transplantation with epiphyseal growth

The successful free microvascular transplantation to the hand of a second metatarsal phalangeal joint with associated epiphyses is described, with follow-up data 2 1/2 years later indicating epiphyseal growth.

Clinical treatment of partial tendon lacerations without suturing and with early motion.

Partial lacerations of flexor tendons in chickens come out the strongest and glide best if they are not sutured and not immobilized. We treated 17 patients with 20 partial flexor tendon lacerations by not suturing the tendon and by early mobilization of the digit. These partial tendon lacerations varied from 25 to 95 percent of the cross-sectional area. Sixteen of obtained excellent function of the digit, and one obtained good to excellent function. This technique should be used only in cooperative patients.

The surgical management of stiff joints in the hand.

Significant and lasting improvement in stiff MP and PIP joints can be achieved by operative management. Operative intervention should be considered only after persistence of stiffness after a vigorous program of nonoperative therapy. In our series of 135 such stiff finger joints, capsulotomy increased the range of motion in MP joints by more than 30 degrees in 68 percent of the patients, more than 50 degrees in 57 percent, and more than 70 degrees in 32 percent. The increased range of motion for the PIP joints was more than 30 degrees in 63 percent of the patients, more than 50 degrees in 41 percent, and more than 70 degrees in 25 percent.Significant and lasting improvement in stiff MP and PIP joints can be achieved by operative management. Operative intervention should be considered only after persistence of stiffness after a vigorous program of nonoperative therapy. In our series of 135 such stiff finger joints, capsulotomy increased the range of motion in MP joints by more than 30 degrees in 68 percent of the patients, more than 50 degrees in 57 percent, and more than 70 degrees in 32 percent. The increased range of motion for the PIP joints was more than 30 degrees in 63 percent of the patients, more than 50 degrees in 41 percent, and more than 70 degrees in 25 percent.