Thomas L. Greene

Back pain and vertebral changes simulating scheuermann’s disease

Summary Nineteen adolescent patients who presented with mechanical-type back pain and vertebral changes consisting of intravertebral disc herniation, disc space narrowing, and minimal wedge deformity are described. The symptoms and signs were primarily located at the dorsolumbar junction. A specific strenuous activity or traumatic event was clearly associated with the onset of symptoms in 16 of the 19 patients. Spondylolysis or spondylolisthesis (grade I or II) at L5-S1 was also found in 32% of the patients. Most patients responded well to a program of rest, exercises, salicylates, and temporary avoidance of the particular activity involved. Some required orthoses to obtain relief. No patient had a progressive kyphotic deformity during the follow-up period. The relationship of this condition to increased stresses applied to the immature spine, particularly in a preflexed posture, is emphasized.

Evaluation of normal values for stationary and moving two-point discrimination in the hand

Stationary and moving two-point discrimination were tested in a normal population stratified by age and sex. The 467 subjects tested consisted of 202 females and 265 males whose ages ranged from 4 years to 92 years. Statistical analysis of the data revealed the following: (1) Moving two-point values were of lesser magnitude than stationary two-point values in all areas tested; (2) test values for median innervated areas were lower by both methods than values for ulnar innervated areas; (3) there was a gradual increase in the magnitude of the test values for both methods with advancing age; (4) female subjects consistently tended to discriminate at shorter distances when compared with male subjects at corresponding sites; and (5) the absolute values obtained were dependent upon the individual examiner, but the statistical significance applied to the data of all of the examiners.

Lipofibromas of the median nerve: Long-term follow-up of four cases

Four cases of lipofibromatous infiltration of the median nerve with long-term follow-up (average 11 years) are reported. Progressive compromise of median nerve function has been noted. Initial treatment considerations should be directed toward biopsy and alleviation of the compression neuropathy. The role of microsurgical debulking procedures remains unclear at this time.

Scaphoid-trapezium-trapezoid fusion in the treatment of chronic scapholunate instability

Limited intercarpal arthrodesis for chronic scapholunate instability has been the subject of several recent publications. We have followed nine patients, who had scapho-trapezio-trapezoidal (S-T-T) fusion for scapholunate instability. All nine patients were re-examined recently after an average follow-up period of 19 months (range, 12 to 25 months). Six of the nine patients believed that their symptoms were significantly improved. The postoperative range of wrist motion (ROM) was decreased in all directions of motion. The pinch strength averaged 86% on the treated side and the grip strength averaged 74% of the unoperated side. Review of follow-up x-ray films showed radiographic evidence of union in eight of nine patients. We conclude that, with careful patient selection and close attention to operative detail, S-T-T fusion can be an effective treatment for scapholunate instability. However, the results are not uniformly predictable, and neither range of motion nor strength is normal after the procedure.

The upper extremity and psychiatric illness

Thirty-three patients who had various conversion reactions manifested by signs and symptoms involving the upper extremities were seen over a 13-year period. Factitious lymphedema, factitious ulcers, clenched fists, as well as other dysfunctional postures of the hand and upper extremity, were the most frequently recognized patterns of illness. Denial of knowledge of the cause of the physical problem and a lack of insight into the illness are major parts of the disease process. Twenty-nine of the 33 patients in this study had work-related and therefore compensable injuries. The physical signs and symptoms resolved in four of the patients when compensation was withdrawn. The average follow-up in this study was 4 1/2 years. Unfortunately, the long-term follow-up of these patients revealed that this disease process was chronic and most frequently failed to resolve. Various efforts at treatment have been unsuccessful, including extensive psychotherapy. Confrontation with the patient is contraindicated.

Central carpal instability - Capitate lunate instability pattern: Diagnosis by dynamic displacement

Eleven patients have been diagnosed as having a central carpal instability that has, to our knowledge, not been previously described. The clinical symptom complex is one of pain and clicking in the region of the midcarpus and, at times, frank snapping, usually while lifting heavy objects. Tight grasping, especially in supination, tends to provoke the symptoms. In ten of the patients, the diagnosis of instability was demonstrated by a dynamic traction displacement technique with the aid of fluoroscopy, in one patient the instability pattern was recognized only at the time of surgical exploration of the carpus. One patient has undergone a surgical procedure to reinforce the dorsal ligamentous support at the capitate lunate area. The other ten patients have become asymptomatic as a result of modifying their activities. The capitate lunate instability pattern (CLIP wrist) is a definite and distinct entity, which may be diagnosed with appropriate studies.

Distal ulnar physeal injury.

We reviewed 18 patients and two traumatic amputation specimens with injuries involving the distal ulnar physis. Type 1 growth mechanism injuries were the most common fracture pattern with premature physeal closure and ulnar shortening occurring in 55% of the patients. Other consequences included radial bowing, ulnar angulation of the distal radius, and ulnar translocation of the carpus. Most of the patients, however, were asymptomatic. Initial radiographic diagnosis of this physeal injury may be difficult because of the relatively late ossification of the distal ulnar physis. Concomitant ulnar physeal injuries must be suspected in any injury to the distal radius, especially when an ulnar metaphyseal or styloid fracture is not readily evident.

Preliminary soft tissue distraction in congenital forearm deficiency

Four patients (five limbs) were treated with preliminary soft tissue distraction using an Orthofix external distractor. The patients ages ranged from 6 months to 14 years. Forearm deficiencies treated included partial absence of the radius (one patient), radial aplasia (two patients, three limbs), and partial absence of the ulna (one patient). Soft tissue distraction (mean, 55 days) was continued in radial deficiency until the hand could be passively centralized without residual radial deviation, allowing centralization to be accomplished through a single mid-dorsal incision. Mean measurement of distraction for the radial deficiencies was 1 cm. In the ulnar deficiency, soft tissue distraction was carried out until the cut radius was distal to the partially absent ulna (98 days) allowing for the creation of a one-bone forearm using the entire radius. Distraction (1 mm/day) was done by the childrens parents with no distractor removed because of patient intolerance. All radial deficiency limbs remained centralized at a mean followup period of 14 months.

Treatment of unstable metacarpal and phalangeal fractures with tension band wiring techniques.

The techniques of tension band fixation are applied in the treatment of metacarpal and phalangeal fractures. The technique uses standard, readily available materials. The variability of the fixation techniques allows for secure fixation of virtually any long bone fracture in the hand, even when other methods are not applicable. Nonunion, malunion, loss of fixation, infection, or tendon rupture have not occurred. The technique allows for early active motion and return to full activity usually within for to six weeks. Most patients achieve full painless motion in that time.

Calcifying tendinitis in the hand

Two cases of acute calcification in the hand are presented with a review of the clinical presentation, pathological findings, differential diagnosis, and treatment. The value of radiographic study is emphasized. A variety of conservative, non-operative treatments have been successfully utilized in the past and are reviewed. The importance of differentiating this infrequent problem from an acute infectious process is emphasized, inasmuch as hospitalization and surgical drainage may be indicated for an acute infection but not for cases of calcifying tendinitis.