Stuart H. Kuschner

Tinel's sign and Phalen's test in carpal tunnel syndrome.

Tinels sign and Phalens test are two provocative tests used in the diagnosis of carpal tunnel syndrome. A review of the literature reveals a wide range of sensitivity for these tests. Analyzing the historical data and comparing these to the Tinels sign and Phalens test results of 100 individuals without carpal tunnel syndrome (200 wrists), we conclude that the Tinels sign is not useful in the evaluation of patients with carpal tunnel syndrome, whereas Phalens test, which has a greater sensitivity and specificity, can be of use.

A biomechanical evaluation of a cannulated compressive screw for use in fractures of the scaphoid

The compressive force generated by a 3.5 mm ASIF cannulated cancellous screw with a 5 mm head was compared with that generated by a standard 3.5 mm ASIF screw (6 mm head), a 2.7 mm ASIF screw (5 mm head), and a Herbert screw. The screws were evaluated in the laboratory with the use of a custom-designed load washer (transducer) to the maximum compressive force generated by each screw until failure, either by thread stripping or by head migration into the specimen. Testing was done on paired cadaver scaphoids. To minimize the variability that occurs with human bone, and because of the cost and difficulty of obtaining human tissue specimens, a study was also done on polyurethane foam simulated bones. The 3.5 cannulated screw generated greater compressive forces than the Herbert screw but less compression than the 2.7 mm and 3.5 mm ASIF cortical screws. The 3.5 mm cannulated screw offers more rigid internal fixation for scaphoid fractures than the Herbert screw and gives the added advantage of placement over a guide wire.

Flexible implant resection arthroplasty of the proximal interphalangeal joint in patients with systemic inflammatory arthritis

Forty proximal interphalangeal joint silicone elastomer flexible implant arthroplasties in 19 patients with systemic inflammatory arthritis were reviewed. The follow-up period averaged 94 months. Before surgery, the average arc of motion was 26 degrees for the 20 digits with boutonniere deformities and 23 degrees for the 16 digits with swan-neck deformities. Eight digits had moderate (grade 2) pain, and four digits had severe (grade 3) pain. After surgery, the deformity was completely corrected in six digits. Digits with a preoperative boutonniere deformity (20 digits) achieved the same (26 degrees) arc of motion after surgery, whereas those with a preoperative swan-neck deformity (16 digits) actually lost 18 degrees. Six digits had moderate pain and one digit had severe pain at the final follow-up evaluation. Thirteen digits (7 patients) with a boutonniere deformity before surgery and a concurrent or previous silastic metacarpophalangeal arthroplasty had significantly better results than those without. Overall, there were 12 good, 18 fair, and 10 poor results. Based on this study, flexible silicone implant arthroplasty has a limited role in the treatment of proximal interphalangeal joints affected by systemic inflammatory arthritis. When performing the arthroplasty, attention should be directed first toward correction of the deformity at the metacarpophalangeal joint.

Results of dorsal wrist synovectomies in the rheumatoid hand

Seventy-eight patients with rheumatoid arthritis had 102 dorsal wrist tenosynovectomies, intraarticular synovectomies, and Darrach resection from 1962 to 1982. Follow-up after surgery averaged 11 years, with a range from 3 to 20 years. Pain was diminished in all but 17 wrists and motion decreased an average of 13 degrees. Synovitis recurred in 16 wrists and x-ray evidence of progressive intraarticular destruction was seen in 45 wrists. Revision surgery was necessary in 28 wrists.

Nodular fasciitis: A rapidly growing tumor of the hand

Nodular fasciitis is an uncommon benign neoplasm infrequently seen in the hand. There are often difficulties in diagnosis of this tumor. It is usually surgically excised while it is still small. The patient described here had a large and aggressive tumor that ruptured through the skin of the hand and extended to the periosteum of the ring metacarpal.

The thoracic outlet syndrome

The thoracic outlet syndrome is a compressive neurovascular condition of the upper extremity. The neurologic, arterial, and venous structures may be affected individually or in combination in any given patient. Multiple surgical and medical subspecialists may be involved in the care of these patients, including orthopedic, vascular, and thoracic surgeons, neurosurgeons, and neurologists. The topic is extremely controversial; some authors believe that this is a very common condition, while others question the existence of the syndrome. There is disagreement concerning the diagnosis, workup, and proper therapeutic management. The purpose of this article is to critically review and analyze the literature on this subject.

Intraosseous glomus tumor of the phalanx: A case report

The glomus tumor is a rare, benign vascular tumor. It is an innervated arteriovenous anastomosis invested by specialized perivascular muscle cells known as glomus cells.’ It was first described by Masson in 1924.* Although the tumor may occur anywhere, up to 75% are found in the hand3; the most common site is the subungual region of the finger.4 Glomus tumors arising primarily within bone are rare.’ This report describes an intraosseous lesion of the distal phalanx of the thumb. friable bloody tissue involving the entire bone. There was no penetration of the cortex and no extension of the tumor into the soft tissue, thus suggesting that the tumor originated in the bone. Microscopically, the neoplastic cells were round or slightly oval and had eosinophilic cytoplasm. Nuclei were centrally located with vesicular chromatin (Fig. 2). The neoplastic cells were immunoreactive muscle-specific actin. Muscle-specific actin is found in glomus

Sequential infection of silicone metacarpophalangeal joint arthroplasties resulting from skin breakdown

We report a case of late multiple infected metacarpophalangeal silicone implants in a patient who had had replacement arthroplasty for treatment of rheumatoid arthritis. The patient had done well for 10 years after metacarpophalangeal joint arthroplasty when an implant infection developed. Over the next 4 years the remaining three implants on her dominant extremity also became infected necessitating their removal. The origin of the infections is thought to be the result of excessive and improper usage of the hand.

CONCOMITANT INJURIES OF THE HIP JOINT AND ABDOMEN RESULTING FROM GUNSHOT WOUNDS

Septic arthritis is a devastating complication of transabdominal gunshot wounds to the hip. Five patients sustained gunshot wounds to the hip which violated the alimentary tract. Diagnosis was established with plain radiographs in three patients, arthrogram in one patient, and a gastrointestinal series in one patient. Three patients had an exploratory laparotomy with diverting colostomy followed by immediate hip arthrotomy within 24 hours and no joint infections occurred. In the other two patients, hip involvement was identified late after septic arthritis occurred. Early diagnosis, diverting colostomy, and immediate arthrotomy are recommended for gunshot wounds to the hip which involve the alimentary tract.

Extensor digitorum brevis manus An unusual cause of exercise-induced wrist pain

A 15-year-old weight lifting enthusiast presented to the hand clinic complaining of intermittent pain on the dorsum of the right hand. The patient lifted heavy weights several times a week and, over the past 6 months, he noticed a painful lump on the dorsum of the right hand following each workout. Between workouts the pain subsided gradually and the mass diminished in size but did not disappear completely. Examination revealed a soft, fusiform, nontender, freely moveable