Biomedical subjects
Publications and source records attributed to F D Burke.
A rare association of anterior interosseous nerve palsy with pregnancy has been reported previously (Sood and Burke, 1997). We report further on this patient who has now experienced three separate anterior interosseous nerve palsies associated with pregnancies.
Sixteen patients with paralysis of the anterior interosseous nerve (AIN) in 19 limbs who were treated in a single unit were reviewed at a mean of 6.4 years (range 2-14 years) following onset of the paralysis. There was a high incidence of incomplete lesions (seven limbs) and of associated neurological lesions (six limbs) in the same or opposite upper extremity. Patients treated conservatively and with surgical exploration showed no difference in the time of onset of recovery, the time taken to achieve complete recovery or the extent of recovery. Those with incomplete lesions recovered well irrespective of the type of treatment. A distinct cause of compression of the AIN or visible changes in the AIN were seen in just three of the eight limbs that were explored. Surgery is indicated in complete lesions with no evidence of recovery for at least 6 months; incomplete lesions and other neurological signs are indications for conservative management in the first instance.
This randomized prospective study compared the results of trapeziectomy alone, or combined with tendon interposition or ligament reconstruction in 76 women with basal thumb osteoarthritis. At 3 month and 1 year follow-up the results of the three procedures were indistinguishable in terms of pain relief, hand function and thumb strength. In the short term at least, tendon interposition and ligament reconstruction do not improve the results of trapeziectomy.
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We report a case of melorheostosis of the hand which showed a sclerotomal pattern of involvement, with swelling and pain. Surgical debulking resulted in correction of the deformity and relief of pain.
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Equipment used in the mass vaccination of farm stock is a source of high pressure injection injury. We present four cases due to chicken vaccine, and one due to pig vaccine. Unlike injuries caused by paint or oil guns the vaccination delivers a fixed volume. Although the vaccine is in a mineral oil carrier it appears to elicit little inflammatory reaction in a small dose. The outcome is related to the volume injected. In chicken vaccine the dose is small enough to allow conservative or minimally invasive management. The large volume in pig vaccine requires treatment as for conventional high pressure injection injuries.
Upper limb surgeons have little in the way of training in the identification or management of the psychological aspects of limb injury. Surgeons in training tend to see their specialty in technical terms, only slowly appreciating that the psychological state of the patient profoundly affects outcome in many cases. The case report that follows charts the psychological progress of a patient following severe upper limb injury. Surgeons usually view rehabilitation in physical terms. This report emphasizes the psychological aspects of a major limb injury to a policeman (MP) who subsequently studied psychology at PhD level.
The findings are presented of a conference on Outcomes of Hand Surgery organized by the audit committee of British Society for Surgery of the Hand in 1993. Measures of outcome in terms of movement, power, sensibility, pain, activities of daily living, complications and patient satisfaction are considered, and an example of a patient evaluation measure given as an appendix.
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Two cases of aneurysmal bone cyst in the hand are reported. In one case the entire first metacarpal was resected and grafted using the fourth metatarsal. In the second case diaphysectomy of the middle phalanx of the index digit was performed, and the proximal phalanx of the second toe was used as graft. Satisfactory length and function were maintained, the grafts remained viable and there was no donor site morbidity. Transplant of a metatarsal or toe phalanx to the hand, as a free non-vascularized graft, is a relatively straight forward operation, requires minimal refashioning of the graft, provides articular surfaces for joint reconstruction and leaves little donor site morbidity.
12 patients with pain in the piso-triquetral region are described. 11 had radiological evidence of osteoarthritis of the piso-triquetral joint, which was confirmed in the nine cases treated by excision of the pisiform. Seven of these had complete relief of symptoms. The clinical findings are constant and relief of pain by conservative treatment is usually only temporary. Ulnar nerve symptoms were present in four patients and these were also relieved by surgery. Excision of the pisiform is a useful operation for this condition, which often remains undiagnosed due to incomplete clinical and radiological evaluation. Full return to normal function is the rule if the problem is not associated with other wrist pathology.
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To estimate the overt need for hand surgery in an average sized district general hospital and to assess the resources required to meet this need, data were collected prospectively on all new trauma and elective patients presenting from 1 June to 30 November 1989 to the Derby Hand Unit, Derbyshire Royal Infirmary, Derby. In all, 1740 new patients with hand disorders (1082 trauma and 658 elective) were seen. All were followed up for 6 months or until discharge. Based on the Derby Hand Unit practice, the overt need for hand surgery in an average sized district general hospital was estimated and the resources required to satisfy this need were defined. Such a hospital serving a population of 250,000 should expect about 23 new trauma patients and 17 new elective patients each week. To service this demand requires between three and six outpatient clinics, between three and eight inpatient beds and three operating sessions each week. The net annual cost of such a service in 1989-1990 would be 318,753 pounds.
A retrospective review of the 11 patients attending the Hand Unit at the Derbyshire Royal Infirmary over the last 5 years with high-pressure injection injuries is presented. The machines and materials that cause these injuries are outlined and the methods of treatment and rehabilitation are described in detail. The study demonstrates the morbidity of high-pressure injection injuries, particularly those inflicted by paint spray guns, and highlights a frequent delay between injury and decompression of the injured part. We wish to emphasize the importance of early diagnosis, referral, exploration and rehabilitation to ensure an optimal outcome, and to point out that failure to refer early is becoming an increasing focus of negligence claims.
Data was collected prospectively on all patients from one health district attending the Hand Unit at Derbyshire Royal Infirmary to determine the needs for hand surgery and the resources utilised to meet them. 475 patients per 100,000 population presented with hand injuries and 289 patients per 100,000 with elective hand disorders each year. For every 100,000 population, the trauma cases required 139 inpatient days and 1723 outpatient visits. Elective cases required 221 inpatient days and 1039 outpatient visits.
In an attempt to avoid the complications associated with taking autologous bone graft for use in the treatment of non-union of the scaphoid, a clinical trial of the use of totally de-proteinized heterologous bone graft has been carried out. Ten patients with established non-union of the scaphoid were treated with internal fixation and grafting using one such commercially available material, Pyrost. The clinical and radiological results in eight patients about one year later are reported. The operative use of this material proved difficult because of its poor mechanical properties and it is not recommended as a substitute for the patient's own bone.
In a prospective study, eight patients with 15 hands affected by both vibration white finger and carpal tunnel syndrome were treated by surgical decompression of the carpal tunnel. On review six months later, the symptoms of carpal tunnel syndrome were improved in all cases and the symptoms of white finger were improved in half of the cases. Nerve conduction studies and palmar skin histology are discussed.