Yasushi Morisawa

A Child with Trigger Wrist Caused by Finger Flexion and Extension: A Case Report

A 9 year-old boy presented with a mass in the left wrist and motion-induced discomfort. The patient had a trigger phenomenon on the palmar side of his wrist caused by extension and flexion of the middle finger. The patient had no significant medical history. A 5-cm mass was visualized extending from the palm over the wrist. The patient did not have finger numbness, motor impairment, thenar muscle atrophy, or a Tinel-like sign of the wrist. X-ray imaging showed no abnormalities. A magnetic resonance image (MRI) showed a mass around a single flexor tendon, a lowintensity mass on T1-weighted images (Fig. 1), and a highintensity mass on T2-weighted images (Fig. 2). Accordingly, the mass was expected to be a ganglion or cyst. On sagittal images, the mass surrounded the flexor tendon. Because the symptoms did not improve, the patient underwent surgery 2 months after he noticed the mass. The mass was excised by opening the carpal tunnel. The flexor digitorum superficialis (FDS) of the middle finger adhering to the mass was enlarged (Fig. 3). Histological analysis showed cystic synovial tissue accompanied by thickened wall, papillary proliferation towards the lumen, fibrin deposition, and lymphocyte infiltration. (Fig. 4). Based on the above findings, the patient was diagnosed with a ganglion adhering to the FDS. One year after surgery, the patient had no discomfort, recurrence, or disturbance in daily living.

A Radiographic Method for Evaluation of the Index-Hypoplastic Thumb Angle

PURPOSE Thumb metacarpophalangeal joint radial instability occurs during the pinch motion in patients with hypoplastic thumb because of thumb-index web narrowing. We devised a radiographic technique to measure the thumb-index angle, applied while the patient holds a styrene foam cone, to evaluate the relationship between the thumb and the index finger. We used this technique to compare different types of thumb hypoplasia and the groups before and after surgery. METHODS Twenty patients with hypoplastic thumbs held the styrene foam cone. The average age of the patients was 6.5 years (range, 1.6 to 12.0 y). We obtained an overhead radiograph while the patient held the cone and evaluated the apparent thumb-index web angle, the thumb to index finger metacarpal angle (1-2MCA), and the first metacarpophalangeal angle (1MPA). RESULTS In the 9 unilateral cases, no significant difference was detected between the unaffected side and the affected side in terms of thumb-index web angle, but the data showed meaningful differences in terms of 1-2MCA and 1MPA. In addition, the data showed meaningful differences between the groups before surgery and 2 years after surgery in terms of 1-2MCA and 1MPA. CONCLUSIONS Measuring both 1-2MCA and 1MPA enables evaluation of the severity of the deformity, and these parameters allowed for comparative evaluation of the severity of preoperative and postoperative narrowing of thumb-index web space and the radial instability of the thumb metacarpophalangeal joint. By focusing on these characteristics, we devised a novel approach for imaging of the thumb-index web space.

A case of pseudarthrosis of the capitate.

Pseudarthrosis of the capitate bone is extremely rare. In this case, the injury and pseudarthrosis was so old, the bone with a nutrient vessel was grafted, and bone union and excellent results are obtained.

RECONSTRUCTION OF THE FIRST WEB IN CONGENITAL THUMB ANOMALIES

Reconstruction of the first web is an important technique for thumb adduction contracture accompanying congenital anomalies. Our previous cases have been reviewed here to evaluate and compare the indications, results, and problems for these two techniques. The angle formed by the first and second metacarpals (first-second metacarpal angle; 1-2 MCA) on the anterio-posterior (AP) view of the hand, with the thumb in maximum radial abduction, was measured from X-ray. There were 37 patients (43 hands: 27 males, ten females). The average age at the time of surgery was 6.6 years (range, two to 22 years). The five-flap Z-plasty was performed on 20 hands. The spinner flap was performed on 23 hands. The Spinner flap is indicated when contractures are severe or when the preoperative 1-2 MCA is <20°. The five-flap Z-plasty is indicated when contractures are mild or when the preoperative 1-2 MCA is ≥20°.

QUANTITATION OF NEUROTROPHIN mRNA IN SKELETAL MUSCLE: CHANGES DURING THE PROCESS OF PERIPHERAL NERVE REGENERATION

Peripheral nerve injury changes the kinetics of neurotrophins. The production of several neurotrophins increases at the site of injury. Although numerous reports have described changes in neurotrophins over time in areas of nerve injury, neurotrophin mRNA is present at very low levels in target tissues, making accurate quantitation difficult. We developed a reverse transcription–polymerase chain reaction/high-performance liquid chromatography (RT-PCR/HPLC) method that enables accurate quantitation of neurotrophin mRNA. We then attempted to quantitate mRNA levels for nerve growth factor (NGF) and brain-derived neurotrophic factor (BDNF) produced by skeletal muscle innervated by the sciatic nerve following transection and reattachment of the nerve in mice. In addition, wet weights of the muscle were measured and changes in weight over time were determined. The results indicated that neurotrophin production in muscle increases as a result of peripheral nerve denervation due to transection, and decreases with nerve regeneration and reinnervation resulting from reattachment.

First and Second Metacarpal Bone Fusion for First Carpometacarpal JointArthritis in Rheumatoid Arthritis: A Case Report

A case of rheumatoid thumb carpometacarpal (CMC) arthritis with advanced osteolysis is reported. Although CMC joint arthrodesis was performed, bone union was not achieved, and pain and instability persisted. Therefore, first and second metacarpal bone fusion was performed with satisfactory results. While CMC joint arthrodesis or arthroplasty is typically performed, first and second metacarpal bone fusion appears to be a useful treatment option when there is marked osteolysis.

Surgical Repair with External Fixation of Epiphyseal Fractures of the Proximal Phalanges of Three Fingers: A Case Report.

A 13-year-old girl sustained epiphyseal fractures of the proximal phalanges of the left index, middle, and ring fingers. Though manual reduction of the 3 fingers was possible, it was difficult to maintain the reduction due to severe instability of the middle and ring fingers, and closed reduction with external fixation was performed. At 4 years post-injury, the patient had no impairment of daily activities. The use of external fixation (1) causes no injury to the epiphyseal cartilage, (2) enables accurate reduction and maintenance of reduction, (3) is technically easier than pinning, (4) enables earlier range of motion (ROM) exercises of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints of the externally fixated and other fingers, and (5) allows repeated fine adjustments after reduction. External fixation is an option for the treatment of children with highly unstable epiphyseal fractures of the proximal phalanges.

QUANTIFICATION OF NEUROTROPHINS IN SKELETAL MUSCLE FOLLOWING NERVE INJURY: COMPARISON BETWEEN SPINAL CORD INJURY AND PERIPHERAL NERVE INJURY

Purpose: We investigated the kinematics of nerve growth factor (NGF)mRNA and brain-derived neurotrophic factor (BDNF)mRNA in a skeletal muscle following spinal cord and peripheral nerve injuries by utilizing the reverse-transcription polymerase chain reaction/high-performance liquid chromatography (RT-PCR/HPLC) method. Methods: We made mice models of spinal cord transection and sciatic nerve transection, plus sham and control groups. After RNA extraction from gastrocnemius muscle of mice, RT-PCR was done. We measured the levels of NGFmRNA and BDNFmRNA in a skeletal muscle following spinal cord and peripheral nerve injuries by utilizing the RT-PCR/HPLC method. All values are analyzed and graphed as means ±SED. Bonferroni test (Post-hoc test) was used when two values were compared. Differences were considered statistically significant when p < 0.05. Results: According to the wet muscle weight, at day 7, a significant difference was found between the peripheral lesion and control group, and at days 14 and 28, significant differences were found between the spinal and peripheral lesion and control group. According to the NGFmRNA, in the peripheral nerve injury group, the levels increased up to day 28 and when compared with the control group, the levels were significantly higher at days 14 and 28. According to the BDNFmRNA, levels at days 2, 7, 14, and 28 were significantly lower in the spinal cord injury group than in the control group. However, in peripheral nerve injury group, when compared with the control group, the levels significantly increased at days 7, 14, and 28. Conclusion: We clarified marked differences in chronological changes in neurotrophin kinetics in a skeletal muscle between spinal cord injury and peripheral nerve injury.

Re: a child with a congenital deformity of the distal radius that was corrected using the Ilizarov apparatus.

Dear Sir, A male infant was born prematurely with congenital radial flexion of the right wrist. There were no other deformities or evidence of bone diseases. Radiographs obtained before the age of 1 year showed that 75% of the distal radial metaphysis was in radial flexion. This deformity worsened over time. As the patient had difficulty moving the wrist in the ulnar direction to grasp things, surgical treatment was carried out at the age of 3 years. At that time, the wrist was in 301 of radial flexion. Pre-operative radiographs showed an ossification centre in the epiphysis at the distal end of the contralateral radius, but not the involved radius (Fig 1). MRI showed irregularities in the distal radial metaphysis, and the growth of the radial metaphysis was poor. These findings suggested damage to the growth plate and the epiphyseal ossification centre. Pre-operative arthrography showed a structure resembling an epiphyseal ossification centre between the carpus and the radial metaphysis, and the articular surface of the distal radius was almost horizontal. As the radial deformity was in three planes, we used an Ilizarov apparatus for correction of the deformity and bone lengthening. One week after osteotomy, bone lengthening was started. Correction was completed 7 weeks after surgery and the apparatus was removed 10 weeks after surgery. By 30 months, an 111 radial inclination, a 3mm ulnar minus variant and a 151 palmar tilt were seen. Ulnar flexion and full grip became possible, and with the improved range of motion, there was no impairment in daily activities. The deformity was thought to be the result of growth impairment of the radial and palmar sides of the distal radial metaphysis. This can be caused by childhood osteomyelitis or trauma, but there was no history of these conditions. As radiographs showed a delay in the appearance of the epiphyseal ossification centre in the distal radius and the MRI indicated that it was damaged, congenital growth impairment was suggested. These findings are very rare and were like a reversed Madelung deformation (De Smet and Fabry, 1995). When the growth plate is damaged in children, some surgical procedures can be done on the growth plate itself, such as growth plate transfer (Gilbert and Mathoulin, 2000). However, this child was very small and the epiphyseal nucleus could not be seen radiographically, so we carried out corrective osteotomy and bone lengthening at the diaphysis. The Ilizarov apparatus was used instead of a unilateral device, because the radius was short and had a three-dimensional deformity (Houshian et al., 2004). There is no general consensus on the optimal amount of deformity correction, and bone lengthening and the timing of surgery are controversial. We think that surgery is advisable in children with increasing pain, deformity or impaired daily activities regardless of age, although re-operation may be needed if there is a recurrence of deformity in the future.