Biomedical subjects
Publications and source records attributed to R E Carroll.
Among the fibrous tumors of childhood, the juvenile aponeurotic fibroma is rare. After removal, there is a high rate of recurrence in the younger age group. If the recurrence is not aggressive and does not interfere with function, a prolonged observation may be permitted. Otherwise, a more radical extirpation may be needed.
Arthrodesis of the carpometacarpal joint of the thumb is useful in reconstruction of hand deficiencies and in eliminating pain at this site. The author has speculated that fusion of the carpometacarpal joint might lead to pantrapezial arthritis in later years. No patients with painful arthritis received this operation if they were beyond 50 years of age. Sixty-seven patients were followed for three to 25 years after surgery and none have yet developed painful pantrapezial arthritis. Many are still at an age when arthritis is not a problem. A colleague contributed a case of a 60-year-old patient who received a carpometacarpal arthrodesis and who later developed painful arthritis of the adjacent joints. This case demonstrates the need for restraint in using this procedure for the alleviation of arthritis pain in patients over 50 years of age.
Attention has been increasingly directed toward the correction of anomalies of the fingers, hands, and forearm that appear at the time of birth and early development. There are so many variations that it would be difficult to list each separately. However, during the last 50 years, a pattern of general principles and procedures has evolved that is directed to all problems in surgery of the hand. These give a broader application for steps needed for infants with just one problem solution. Now much more can be done. Instruction must be given to the family and child with a congenital anomaly that it is the basic growth pattern of the limb that is altered. This must be watched over a period of time to help modify changes that develop. Much has been done to improve the condition that comes with birth. No doubt, with time, we may have some insight into the factors that cause these changes.
A time course study was conducted on nucleologenesis after release from a mitotic block in the presence and absence of actinomycin D to determine the composition and fate of prenucleolar bodies (PNBs). Prenucleolar bodies, whether naturally occurring or induced by actinomycin D treatment, stain with silver and contain phosphoproteins B23 and C23, two of the major proteins of the interphase nucleolus as determined by double label immunofluorescence with specific antibodies. The nucleolus is formed by fusion of PNBs, which subsequently "reorganize" and form internal fibrillar and peripheral granular regions. Actinomycin D prevents fusion of PNBs, which are then randomly dispersed throughout the nucleus but they still contain proteins B23 and C23. These results demonstrate that the nucleolus is formed by fusion of prenucleolar structures whose biochemical composition resembles the mature nucleolus, since PNBs contain at least two of the major nucleolar proteins.
In this series of 1,000 cases of carpal tunnel syndrome (888 patients) there is a statistically significant incidence of bilaterality in patients with cervical arthritis. There is also a statistically significant increase in the incidence of diabetes mellitus over the general population. These findings lend further support to Upton's Double Crush hypothesis. Further, the double crush syndrome predisposes to bilateral carpal tunnel syndrome and may be an important prognostic factor. It may also be an explanation for some of the failures following carpal tunnel surgery and lead surgeons to look for other associated systemic diseases or mechanical blocks, when attempting to alleviate recalcitrant symptoms.
Sixty-seven painful pisotriquetral joints were treated by excision of the pisiform over a 30-year period. Forty-two patients had a previous history of trauma. Ulnar neuropathy was noted in 22 patients, particularly in those with associated wrist-hand fractures and subluxations or dislocations of the pisiform. The abductor and flexor digiti minimi and the palmar carpal ligament with their common fibrous origin were the most common compressing structures on the ulnar nerve. Chondromalacia was found in 29 and osteoarthritis in 20 pisotriquetral joints. Excision of the pisiform provided complete relief of localized hypothenar pain in 65 wrists with no loss of wrist motion or strength. Neurolysis produced full sensory recovery in all 22 patients and full motor recovery in five of six. No late problems associated with the flexor carpi ulnaris tendon were found after excision of the pisiform.
The elusive diagnosis of thoracic outlet syndrome and its controversial relationship with carpal tunnel syndrome is examined by a retrospective study of 1000 cases of carpal tunnel syndrome and 63 cases of thoracic outlet syndrome. Thoracic outlet syndrome is rare and difficult to accurately diagnose. The signs and symptoms of thoracic outlet syndrome lack specificity. The ancillary tests used to evaluate patients with expected thoracic outlet compression also add little objectivity to the diagnostic process. Carpal tunnel syndrome is still as inaccurately diagnosed as thoracic outlet syndrome. Carpal tunnel syndrome can easily be confused with thoracic outlet syndrome when it presents with shoulder pain. The spontaneous occurrence of these two syndromes in a single patient is extremely rare. The relationship of carpal tunnel and thoracic syndromes does not represent an example of the double crush syndrome. In this study, the incidence of combined carpal tunnel and thoracic outlet syndromes approached zero. Surgical treatment of the carpal tunnel syndrome alleviated pain from the upper extremity in the majority of patients.
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In four patients, two with brachial plexus palsy and two with arthrogryposis, the entire pectoralis major muscle was transplanted to act as an elbow flexor, rotating it on its neurovascular pedicles and attaching the tendon to the acromion and the muscle origin to the tuberosity of the radius. Excellent motion and power was restored in three patients. One procedure failed due to fibrofatty degeneration of the transplanted muscle.
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Twenty-three patients with ulnar ray deficiency were studied and the deformities described by combining Kummel's and Swanson's classifications. An individualized, functionally oriented management program is recommended with early resection of the fibrocartilaginous remnant to prevent shortening, radial bowing, and possible malrotation. Rotational deformity can be corrected by wedge osteotomy, rotation osteotomy, or proximal radial ulnar synostosis. Improved motion at the elbow can be obtained by release of contractures or resection of the radial head. Wrist deformity may require resection of the ulnar remnant and a wedge osteotomy of the radius.
Twenty-seven cases of squamous cell carcinoma of the nail bed seen by the author have been reviewed. Sixteen were thought to be primary tumors and eleven to be secondary to chronic exposure to radiation. All had been present for a long time prior to definitive treatment. The tumor was of low grade malignancy with a tendency to invade the distal phalanx. No metastases have been found. Treatment was amputation of the distal phalanx and involved tissues.
Whether there is such a condition as congenital bipartite scaphoid has long been debated. Five cases that fulfill the established criteria are presented, supplemented by a review of roentgenograms of 17,439 hands in which no case of bipartite scaphoid was detected. Serial sections of 196 fetal hands also failed to reveal any evidence of bipartite development of the scaphoid. We concluded that bipartite scaphoid is of traumatic origin and should be treated accordingly.
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