Biomedical subjects
Publications and source records attributed to G D Lister.
The anatomy of the deep veins of the human palm was studied in a series of dissections on 12 fresh cadaver specimens after injection of a polymerizing plastic compound into the vascular tree. Using measures of function rather than position in the hand as criteria for the classification of the vessels, six venous types were identified and characterized: arborized, arches, deep axial, web space, perforating, and synovial.
The treatment of Dupuytren's contracture is still controversial. The use of subcutaneous fasciotomy is useful in the medically unstable patient in whom long-term results may be a moot point. Limited fasciectomy is preferred over radical excision as a simpler operation and because of fewer complications. Wound closure is still a major point of contention. A prospective, randomized study of open wounds versus skin grafts versus closed procedures is needed to give more information regarding the long-term results. Currently, at our institution, we perform limited fasciectomy and leave the palm open. Early and aggressive mobilization is thought to be the key to good results.
Using electromagnetic flowmetry, the circulation through free flaps was studied in an experimental animal model. It was demonstrated that the total circulation of blood through a free flap is not affected by the establishment of an arterial through-flow or end-flow model in the recipient bed.
In 1986, The American Association for Hand Surgery and the American Society for Surgery of the Hand jointly sponsored a Role Delineation Study of Hand Surgery. The purpose of this study was to define the knowledge and skills necessary for competent hand surgery practice and to determine the responsibilities and activities of hand surgeons. Eight hundred thirty-eight hand surgeons returned a self-report questionnaire. This questionnaire was designed to collect information relative to the demographic characteristics of the respondents, the importance of 38 surgical procedures, and 60 categories of knowledge related to hand surgery, and to elicit respondents opinions regarding certification in hand surgery. This study is a first attempt to define the domain of hand surgery. The data collected in this study provide the basis for designing residency fellowship and continuing education programs and may also be used to study manpower needs, regional variations in practice patterns, and to identify the educational needs of the profession of hand surgery.
The venous anatomy of the human hand has not been accurately described. Two main reasons for this deficiency in our knowledge are apparent: technical difficulties involved with dissection and imaging of the vessels, and the seemingly limitless number of topographic patterns in this field. This paper introduces firstly, a method for injection and corrosion of hand specimens, and secondly, a routine for describing the venous anatomy, primarily based on their function, and only secondarily on their position or topography.
Fresh human cadaveric hands were injected with a liquid plastic polymer and dissected under the operating microscope. On the palmar aspect of the digits, four different venous patterns could be identified, characterized by their tributaries and branching pattern, and by the presence, position and direction of valves. Arborized veins drain a limited volume of tissue by a number of very slender vessels that come together to form a common trunk. Venous arches are found both superficial and deep, palmar and lateral; they neither branch nor have valves, except at both ends. Deep axial veins accompany the digital arteries as comitant veins. They drain to both the metacarpal comitant veins and the web space veins. Superficial axial veins run principally in the subdermal layer of the finger; they drain either directly to dorsal veins or to the natatory vein on the ligament of the same name.
In a study of the venous anatomy of the palm, a high degree of consistency has been found in the organization of the superficial vessels, which lie between the palmar fascia and the dermis. Although in the superficial palm, as previously reported for the fingers, there are large individual variations in the detailed topography, the basic functional venous anatomy remains highly consistent. The present paper demonstrates the findings from dissections of 12 human cadaver hands after injection of a polymerizing plastic solution into the vascular tree. The basic types of superficial venous structures found in the superficial palm are presented, and their functional importance for the drainage of blood from the palm is discussed.
Congenital syndactyly is associated with a wide spectrum of local anomalies that strongly influence the ultimate outcome of treatment. Surgical options, indications, timing, and prognosis are all determined by the preoperative degree of deformity. The surgeon must apply knowledge of anatomic variations and adhere to fundamental principles of technique, which are reviewed in detail.
To assist in distinguishing patients with truly decreased hand grip strength from those deliberately not gripping the dynamometer at maximal capacity, a rapid exchange grip strength test was devised and tested under four conditions. Part I, 100 normal subjects undergoing static grip testing and the rapid exchange grip test. Part II, 45 patients chosen at random from physical therapy with various hand injuries tested using only the static grip test. Part III, a blind control study on 15 normal subjects instructed to fake an injury to either the right or left hand. This group was given both the static and rapid exchange grip test. Part IV, a retrospective evaluation of 45 patients seen in a private hand practice who had both the static and rapid exchange grip test. After the dynamometer had been set to the position at which the patient had previously achieved maximal grip strength, the patient was instructed to rapidly alternate hands while gripping the dynamometer. Uninjured subjects had consistently lower rapid exchange grip test scores than previous scores at the same setting (negative rapid exchange grip). Average rapid exchange grip test scores were higher than previous scores (positive rapid exchange grip) when subjects were instructed to fake an injury with one hand. We conclude that if maximal performance has not been achieved on the static test, the rapid exchange grip shows a significant increase in grip strength on the affected side. More patients claiming worker's compensation had positive rapid exchange grips and the average score was higher than that of patients not claiming worker's compensation.(ABSTRACT TRUNCATED AT 250 WORDS)
Fourteen patients with open non-salvageable intraarticular fractures of the proximal interphalangeal joint or metacarpophalangeal joint, underwent immediate silastic arthroplasty using Swanson H.P. hinged implants. The patients' ages ranged from 14 to 49 years, with an average of 29 years. Time from surgery to final examination ranged from 4 months to 6 years, with an average of 26 months. The active range of motion obtained at the metacarpophalangeal joint arthroplasties ranged from 45 to 80 degrees, with an average of 60 degrees. The active range of motion obtained at the proximal interphalangeal joint arthroplasties ranged from 0 to 70 degrees, with an average of 29 degrees. Better results were generally obtained at the metacarpophalangeal level, and in those arthroplasties performed in non-amputated digits. There were no post-operative infections and all but one joint were stable.
To permanently release severe contracture of the first web space, suitable additional skin must be provided. Local skin is often insufficient and is unable to fill the depths of the space. Pedicle flaps are bulky, require a second operation for division, and frequently demand further procedures for revision. A precisely tailored lateral arm free flap allows unparalleled correction to be achieved with one surgical intervention. The operation can be performed under regional anaesthesia with morbidity restricted to one extremity.
Grip strength was assessed in patients with chronic wrist pain and correlated with the results of subsequent bone scans and pathology. The results showed a highly significant decrease of grip strength in patients with positive bone scans or confirmed wrist pathology compared with those with negative bone scans (p less than 0.01). We conclude that the detection of weakness of grip is a simple indicator of true pathology in "obscure" wrist pain.
Eighty-seven patients participated in a prospective, double-blind, clinical study to determine the efficacy of preventive antibiotics in the management of common open traumatic hand wounds ranging in severity from single nail bed injuries with open fractures to moderately contaminated wounds involving tendon, bone, joint, and neurovascular structures. Under current medical practice, these wounds would be treated with antibiotics. Thirty-nine patients received intravenous cefamandole and oral cephalexin and 48 received intravenously and orally administered placebo. With an overall infection rate of 1.1%, there were no infections in the antibiotics group and only one (2.1%) infection in the placebo group. Aerobic cultures from 97 similar wounds were 53.6% positive predebridement and 50.5% positive postdebridement. There was no significant difference in rates of infection or imperfect wound healing between the two groups. The preventive antibiotics administered were not necessary in treating these wounds when accompanied by debridement, irrigation, and rapid primary repair in an operating room environment.
This article describes complications due to an incorrectly positioned Hamas-designed total wrist prosthesis in a 68-year-old woman with rheumatoid arthritis. At operation the median nerve was found to be directly impinged upon by the rim of the distal portion of the prosthesis. There were divisions of the superficialis tendon to all four fingers, the profundus tendon to the index finger, and partial division of the profundus to the long finger. The prosthesis was removed, and the wrist stabilized with a Steinmann pin in the radius and the second metacarpal.
Infection has not been considered in this article with each individual implant. The incidence is low indeed. In the only publication concerned primarily with the topic of infection following silicone implant surgery, Millender et al. reviewed 2105 implants of varying kinds. There were ten infections, seven of which were with Staphylococcus aureus. The onset was remarkably late--17 days after surgery on average. In seven cases the implant had to be removed and the eventual result was good, being likened to that obtained after an excisional arthroplasty. Reviewing the complications that occur with the various implants, it becomes evident that there are three primary concerns--fracture, subluxation, and synovitis. Fracture occurs primarily in the wrist and the metacarpophalangeal implants. The incidence of fracture in the wrist implant is 8.6, 9.4, and 19.8 per cent, giving an average of the means of 12.6 per cent. In the metacarpophalangeal joint, the incidence with the Swanson design is variously 1.9, 26.2 and 21 per cent, the average of the means being 16.4 per cent. The Niebauer design is reported as having a fracture rate of 29.7 and 38 per cent, for an average of the means of 33.9 per cent. The somewhat lower incidence of fracture of the wrist implant is offset by the fact that, in contrast to the situation with the smaller joint, the fracture is almost always symptomatic, requiring treatment. Largely for this reason, silicone wrist arthroplasty is limited mainly to the rheumatoid patient, being little used for post-traumatic arthritis. Subluxation of implants occurs mainly with the carpal replacements. The incidence in independent reports are 56.5 and 50 per cent, for an average of the means of 53.3 per cent with the scaphoid; 20, 20, and 50 per cent for an average of the means of 30 per cent with the lunate; and 5.3, 10, 11.2, 29, and 32 per cent for an average of the means of 17.5 per cent with the trapezium. In the case of the trapezium, excision of a portion of the trapezoid, supplemented where necessary by ligament reconstruction to support the first metacarpal, appears to give the hope of lowering the incidence of subluxation to an acceptable level. With the lunate, preservation of an anterior shell may give satisfactory results but judgment should await longer term studies of larger groups. The scaphoid implant gives most cause for concern, both because the incidence is high and because the solutions offered have either failed or are too recent to judge and perhaps too radical to accept.(ABSTRACT TRUNCATED AT 400 WORDS)
The veins of the digits and their valves were studied in nine cadaveric hands by sequential angiography, microdissection, routine histology, cross-sectional microradiography, and corrosion casting. The findings revealed a pattern of dorsal venous arches situated over each digit. Connections between those arches were at the level of the metacarpal heads, the point at which most of the palmar venous blood joins the dorsal system by intercapitular veins. A system of valves, which were arranged so as to direct flow from distal to proximal, from palmar to dorsal, and from radial to ulnar in the hand, was present in all veins as far distal as the pulp.
An anomalous muscle is uncommonly associated with ulnar nerve compression at the wrist. Anomalies of the palmaris longus, abductor digiti minimi, flexor digiti minimi, and flexor carpi ulnaris have been described. Another case is presented in which the anomalous muscle would appear to be a duplication of the palmaris brevis. This muscle has been named the "palmaris brevis profundus."
Coverage of a dorsal defect on the hand of a child with exposed extensor tendons was provided by a denervated first dorsal interosseous muscle and splitthickness skin grafting. We do not recommend routine use of the first dorsal interosseous muscle as a flap; however, its use in cases in which the muscle has been denervated would seem justified.