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PubMed1990

Fasciectomy for treatment of Dupuytren's disease and early complications.

This review of 103 cases of hands operated on for treatment of Dupuytren's disease demonstrates the significant increase of postoperative stiffness as related to recurrences and staging of the disease, but not to sex. On the contrary, the frequency of reflex sympathetic dystrophy after fasciectomy is sex related affecting females. The protective effect of guanethidine may be a valuable therapeutic adjunct for female patients. We propose that the disease be staged on the basis of anatomic findings, inasmuch as staging based on degree of contracture alone is insufficient for comparative studies.

Dupuytren Contracture↗
PubMed1993

Diagnosis of occult scaphoid fractures by intrasound vibration.

We investigated a new means of diagnosing occult scaphoid fractures. Eighty-six patients underwent vibratory testing at presentation, while the clinical examination and standard four-view x-ray examination findings were unknown to the persons who performed the vibratory testing of both the injured and uninjured wrists. Thirty-six patients had radiographically confirmed scaphoid fractures and, after their vibratory tests, were eliminated from the study. Fifty patients, 39 men and 11 women, were believed to have scaphoid fractures on the basis of history and clinical examination findings but were included in the occult scaphoid study group because standard four-view x-ray films of the wrists did not reveal a scaphoid fracture. Distinction between the fracture and no-fracture patients was made with a limited two-phase technetium bone scan and delayed x-ray examination. All patients with known scaphoid fractures (36) had positive findings on vibratory examination. Vibratory testing identified all six of the patients with occult scaphoid fractures (sensitivity 100%). Results of two examinations were false-positive, and none were false-negative (specificity 95%). One of the patients with false-positive results had a fracture of the trapezium, and the other had reflex sympathetic dystrophy. The vibratory testing of injured wrists is inexpensive, noninvasive, and easy to perform, and it involves no ionizing radiation.

Carpal Bones↗
PubMed1992

Bone death in transient regional osteoporosis.

A 48-year-old man developed transient regional osteoporosis, with hip and later knee pain. He responded well to lumbar sympathectomy. The femur and tibia adjacent to the painful knee were osteoporotic, while the medial femoral condyle showed increased uptake in a bone scan. In the femoral condyle, bone histology showed areas of dead bone undergoing osteoclastic resorption, and increased bone formation. The tibial bone was histologically normal. The partial bone death in the distal femur suggests that the disorder may be related to both avascular necrosis of bone and reflex sympathetic dystrophy.

Bone Resorption↗
PubMed2004

[Pain after anterior cruciate ligament reconstruction: detail and treatment].

OBJECTIVE: Several factors can influence the occurrence of pain after anterior cruciate ligament (ACL) ligamentoplasty, namely, factors linked to the selection of graft, the surgical technique and rehabilitation program. The aim of this research was to review the literature for different types of pain experienced after ACL reconstruction to illuminate better prevention and treatment. METHOD: We reviewed reports by searching the PUBMED* research engine using the key words pain, complication, and anterior cruciate ligament. RESULTS: We found an increasing incidence of anterior pain after use of the patellar tendon for ACL reconstruction. Some anterior pain can be mistakenly interpreted as donor site morbidity or patello-femoral problems, but it is in fact linked to graft impingement caused by bad placement of tunnels and/or proliferation of a fibrovascular nodule on the ACL graft ("cyclops syndrome"). Some posterior-external pain, sometimes associated, can occur under the same circumstances. Cartilage, ligament or meniscal lesions or saphenous nerve injuries can explain some occurrences of pain. Pain linked to loco-regional factors such as reflex sympathetic dystrophy appear to be rare with rehabilitation and surgery. CONCLUSION: The treatment of pain after ACL reconstruction lies first in the establishment of an etiologic diagnosis. Prevention, by controlling tendon-muscular and joint stress during rehabilitation, is essential and requires sound knowledge of biomechanical data.

Anterior Cruciate Ligament↗
PubMed2006

Edema of the paretic hand in elderly post-stroke nursing patients.

Post-stroke edema of the paretic hand constitutes an additional, functional, and esthetic nuisance for the patient. Although often encountered in daily practice, it is not even mentioned in the stroke chapters of the various textbooks. The phenomenon is far from being elucidated and various aspects are still obscure. In this study we tried to estimate the extent of post-stroke hand edema (PSHE) in a sample of elderly patients. The study group consisted of 188 elderly post-stroke nursing patients with hemi or only hand paresis. Seventy, age matched, non-paretic patients were examined as controls. The basis of comparison was the difference in circumference between the two arms at three sites: mid-finger, hand, and wrist as measured in the control group. Values above two standard deviations (S.D.) of the mean difference in circumference of the controls, at two or three sites, were considered as edema. Edema of the paretic hand was detected in 37% of post-stroke patients. Most (about three-quarters), could be classified as simple PSHE, while the rest may have had reflex sympathetic dystrophy (RSD).

Aged↗
PubMed2004

Endoscopic carpal tunnel release: modification of Menon's technique and data from 191 cases.

PURPOSE: Endoscopic carpal tunnel release using Menon's technique has been shown to reduce recovery time, although previous studies have shown that there is still a considerable risk of nerve complications. The purpose of this study was to evaluate data from 227 hands of 191 patients who underwent releases with Menon's technique. TYPE OF STUDY: Prospective study. METHODS: Endoscopic releases were performed as an outpatient intervention by one surgeon. Follow-up evaluations included were analysis of satisfaction, quantitative measurements of grip strength, return to work time, and complications. After the surgery on the first 50 hands in 41 consecutive cases, the technique was modified. Prospectively, changes in the technique are due to difficulties maintaining the knife within the center of the cannula's slot and a relatively high complication rate. In the modified technique, a 2.7-mm 25 degrees endoscope and a triangular diamond-tipped knife were used to allow for more room for the instruments and a more safe procedure. RESULTS: During the first month after the surgery, 91% of the patients had better subjective satisfaction scores and by 12 weeks, 81% obtained 75% to 100% or greater grip strength. Within 3 weeks, 70% of the patients had returned to work. Twelve of 50 hands operated on using the original technique had nerve disturbance diagnosed at follow-up. Three of these 12 patients developed reflex sympathetic dystrophy. One patient had partial median nerve injury that was repaired at the time of the index operation. There was no serious complication observed in 177 hands of 150 cases operated on using the modified Menon's technique, except one postoperative hypoesthesia along the long and ring fingers that improved with time. CONCLUSIONS: The procedure is suitable for outpatient surgery and the risk of inadvertent damage to the neurovascular structures can be dramatically reduced with the modifications to the technique. LEVEL OF EVIDENCE: Level IV.

Adult↗
PubMed2005

External fixation for unstable intra-articular distal radial fractures in women older than 55 years. Acceptable functional end results in the majority of the patients despite significant secondary displacement.

UNLABELLED: Unstable intra-articular distal radial fractures in women older than 55 years were treated by closed reduction and external fixation to achieve the best functional outcome. Sixteen women had radiographic and functional assessment. Despite initial good alignment secondary displacement occurred in 11 patients, probably due to the comminution of the fracture and possibly influenced by osteoporosis. Malunion of the distal radius was seen in two patients and intra-articular incongruity with an intra-articular step exceeding 1 mm was observed in two other patients. The functional outcome was excellent or good in 10 and fair in two patients. Four patients had a poor functional outcome. Two of these patients had a significant loss of reduction, one resulting in a malunion. The other two had an intra-articular incongruity of more than 1 mm. Three of the four patients with a poor functional outcome had clinical signs of reflex sympathetic dystrophy. CONCLUSION: Closed reduction and external fixation of "bad case" severely comminuted unstable distal radial fractures in the elderly may result in an acceptable functional outcome in the majority of the cases, although significant secondary displacement occurred in eleven of the sixteen patients.

Accidental Falls↗
PubMed2006

Vascularised bone grafts for the management of non-union.

Non-union of the long bones may have severe consequences, particularly when combined with other post-traumatic sequelae, such as tendon adhesions, reflex sympathetic dystrophy and infection, among others. In these cases, it is important to treat the delayed union or non-union first or at the same time with the other problems in order to achieve adequate function. Once the normal bony healing process has been slowed or stopped, it is necessary to provide both stability to the fracture site, as well as a biological stimulus for the fibrocartilagenous callus to finish the healing process. Vascularised grafts, such as the free fibula, offer not only structural support, but also promote bone healing. The later is achieved by trabecular bone formation, as well as vascular sprouting from pedicle vessels.

Bone Transplantation↗
PubMed2005

Sternal erythema: a distinctive postsurgical eruption.

BACKGROUND/OBJECTIVE: Wound complications constitute a diverse array of surgical and dermatologic entities. We sought to describe the clinical and pathologic attributes of a series of patients in whom a distinctive thoracic surgical wound eruption developed after coronary bypass grafting. METHODS: We performed a detailed chart review, including history, surgical procedure notes, and biopsy findings, obtained from 3 patients; we examined the data and reconciled them with conventional etiologies in an attempt to discern a shared diagnosis and pathogenesis. RESULTS: The patients were white men (59, 68, and 73 years of age) in whom roughly symmetrical asymptomatic erythema developed within the borders of their sternal thoracotomy wounds between 1 and 2 years after open heart surgery. The cutaneous findings consisted of macular erythema and poikiloderma that blanched with external pressure. Biopsy findings yielded epithelial atrophy with capillary telangiectases. CONCLUSION: Although cellulitis, dermal hypersensitivity to surgically implanted hardware including sternal wire, and an anatomic variant of costal fringe remain as possible diagnoses, an additional consideration includes a form of postsurgical reflex sympathetic dystrophy.

Aged↗
PubMed2006

Dorsal (AO/ASIF) pi-plate osteosynthesis in the treatment of distal intraarticular radius fractures.

The results and complications using the dorsal 2.4 mm 2.7 mm (AO/ASIF) pi-plate for the treatment of distal radius fractures were evaluated in a prospective study of 42 patients followed up clinically and radiologically and seven patients followed up with telephone call and radiological follow-up for an average time of 12.1 (range 4-32) months in a group of 50 patients with intraarticular distal radial fractures treated consecutively using this method. Twelve complications occurred in 10 patients including two extensor tendon ruptures, two transient cases of CRPS Type 1 (Reflex Sympathetic Dystrophy, Algodystrophy), two instances of screw loosening, three cases of posttraumatic carpal tunnel syndrome and three permanent sensory irritations on the dorsum of the hands. Using the AO score, there were 37 successful and 12 tolerable results, with no unsatisfactory outcomes. Using the NYOWR scale, there were 17 very good and 25 good results, with no satisfactory or poor outcomes. These results suggest that this osteosynthesis provides adequate fixation of comminuted distal intraarticular radius fractures with a reasonable incidence of complications.

Adult↗
PubMed1998

Upper extremity radionuclide bone imaging: the wrist and hand.

Bone scintigraphy of the hands and wrists represents an important adjunct imaging technique that complements plain film radiographic examination. The use of the three-phase bone scan provides clinical information not only regarding osseous uptake but the blood flow and extravascular distribution of the radiotracer as well. Scintigraphic evaluation of the hands and wrists is employed in acute and chronic conditions. In the event of an equivocal or negative plain film, the bone scan can identify occult fractures. Of particular concern is the identification of scaphoid fractures due to the higher incidence of osteonecrosis. Work related injuries represent a significant health issue. The bone scan can be a part of the algorithm for evaluating chronic pain syndromes including reflex sympathetic dystrophy. The complimentary roles of bone scanning and imaging with gallium-67 citrate or radiolabeled leukocytes has proven useful in the evaluation of acute or chronic osteomyelitis. In addition, the diphosphonates are useful in identifying solitary and multiple primary bone tumors. In the case of primary bone tumor, thallium-201 can be used to evaluate response to therapy. Although uncommon in the hand and wrist, the bone scan can identify metastatic tumors or tumor-related conditions such as hypertrophic osteoarthropathy. Finally, bone scintigraphy may be useful in identifying location and extent in a variety of conditions such as fibrous dysplasia, histiocytosis X, and Paget's disease.

Bone Diseases↗
PubMed2000

Shoulder pain as an unusual presentation of pneumonia in a stroke patient: a case report.

Etiologies of shoulder pain in the hemiplegic population, such as glenohumeral subluxation, frozen shoulder, and reflex sympathetic dystrophy (RSD), have been described extensively. We present an 89-year-old woman with right hemiparesis secondary to ischemic lacunar infarction who developed sudden onset of right shoulder pain on the fifth day of inpatient rehabilitation. The pain was severe, limiting range of motion (ROM) and participation in therapy. Extensive investigations to rule out subluxation, fracture, connective tissue disease, RSD, and pulmonary embolism were negative. Ultimately, her shoulder pain and decreased ROM completely resolved with antibiotic treatment for right lower lobe pneumonia. We conclude that her symptoms were possibly referred pain from diaphragmatic irritation transmitted via right C4 sensory axons in the phrenic nerve, which shares the same dermatome as the right acromion area. This case was an unusual presentation of pneumonia in an elderly woman with hemiplegia. We recommend that pneumonia be considered in the differential diagnoses of shoulder pain.

Aged↗
PubMed1996

Electrical stimulation of the cingulum bundle and surrounding cortical tissue reduces formalin-test pain in the rat.

Surgical lesions of the cingulum bundle in humans produce marked decreases in severe pain associated with cancer, reflex sympathetic dystrophy and other forms of chronic pain. Similarly, a temporary block of the anterior cingulum bundle in the rat by microinjection of lidocaine produces significant decreases in formalin-pain and reduces autotomy following peripheral neurectomy. The present study explored the effect of electrical stimulation of the cingulum bundle/surrounding cortical tissue (CB/CT) on tonic pain in the rat. Experiment 1 examined changes in formalin-induced pain responses following a 2.5-min period (30 s/min for 5 min) of electrical stimulation of the CB/CT 15 min prior to the formalin injection. The stimulation produced a significant reduction of first-period and second-period pain responses. Experiment 2 examined changes in formalin-induced pain responses following a 2.5-min period (30 s/min for 5 min) of electrical stimulation of the CB/CT 20 min following the formalin injection. The stimulation produced a dramatic reduction in second-period pain responses which persisted for the duration of the 35-min post-stimulation test period. The fact that either electrical stimulation or surgical section of the CB/CT produces pain relief suggests that this region serves a complex role in pain processing. Since the cingulum bundle has major connections with all other structures of the limbic system, it is possible that electrical stimulation disrupts patterned activity in the system, which is known to play an especially important role in the affective-motivational dimension of pain.

Animals↗
PubMed2003

Dorsal plating for displaced intra-articular fractures of the distal radius.

Thirty patients with a mean age of 42 years and a dorsally displaced intra-articular fracture of the distal radius were treated by dorsal plating (Forte, PI and AO T plates). Twenty-eight required autogenous iliac crest bone graft. Mobilisation was started at 1-2 weeks and patients were left free by 6-8 weeks. At a minimum of 6 months (mean 11 months) functional outcomes were excellent or good in 93% according to the Gartland and Werley score and 60% according to Green and O'Briens modified score. The mean time taken to return to work was 10 weeks. At the final follow-up, three patients had intra-articular steps, two of <1mm and one of <2mm. Four patients had five major complications. One extensor tendon rupture, one reflex sympathetic dystrophy (RSD), one significant radial shortening requiring a Darrachs' procedure, one painful and incongruent distal radio-ulna joint (DRUJ) also requiring a Darrachs' and one early subluxation of the DRUJ requiring re-operation. Eleven patients had plates removed. The indications for this was either irritation of extensor tendons, restriction of movement, as part of the treatment of one of the above complications or as part of the initial treatment protocol. In these high energy injuries in the younger age group there exists no ideal solution. Internal fixation allows more predictable restoration of anatomy and early return to function.

Adult↗
PubMed1986

Radionuclide bone scintigraphy in pediatric orthopedics.

Radionuclide bone scintigraphy is highly sensitive and specific for diagnosing the musculoskeletal disorders of childhood. Conditions such as neonatal osteomyelitis, septic arthritis, diskitis of childhood, Legg-Calvé-Perthes disease, the osteochondroses, the "toddler's fracture," sports injuries, spondylolysis, myositis ossificians, and reflex sympathetic dystrophy are readily defined. High-quality state-of-the-art scintigraphy is essential in infants and young children.

Adolescent↗
PubMed2006

[Grammont reversed prosthesis for acute complex fracture of the proximal humerus in an elderly population with 5 to 12 years follow-up].

PURPOSE OF THE STUDY: Aim of this retrospective study was to analyze outcome in 23 cases of Delta III reverse ball-and-socket total shoulder prosthesis for acute complex fractures of the proximal humerus in an elderly population with poor bone quality. In such a population, this procedure could escape the difficulties of a reliable and efficient refixation of the tubercles. MATERIAL AND METHODS: From 1993 to 2000, 23 Delta III prostheses were implanted by a single operator for acute injury: 18 three-part and four-part fractures and 5 fracture-dislocations. The study population included two men and 21 women, mean age 75 years, 10 dominant sides. Surgery was performed under general anesthesia in the semi-sitting position via the anterolateral approach without osteotomy of the acromion, with 10-20 degrees retroversion of the humeral stem (except in one shoulder) and cement fixation in two. For five shoulders, the tubercles could be re-fixed. Postoperative physiotherapy was not possible in all patients. Outcome was assessed with the Constant score and with ap and lateral Lamy radiographs. RESULTS: Seven patients died so the series included sixteen cases for analysis. Complications were: reflex sympathetic dystrophy (n=2), postoperative Acinetobacter infection (n=1) requiring revision to clean and drain allowing preservation of the prosthesis, and early postoperative anterior dislocation (n=1) (10 degrees stem anteversion) with surgical revision to re-orient the stem. At mean follow-up of 86 months, the Constant score was 60 points (contralateral shoulder 83 points). Outcome, influenced in case of re-fixation of the tubercles, was good for pain (14.1), activity (13.3), strength (16.1), anterior elevation (6.5), and abduction (6.5), but very poor for external (1.1) and internal (2.4) rotations. The radiographs showed: aseptic glenoid loosening (n=1) at 12 years with surgical revision in 2005 with Constant score at 6 months follow-up of 48 points, inferior scapular notching (n=11) according the the Nérot classification (six stage 1, four stage 2, one stage 3, at 2, 4.3 and 5 years follow-up), inferior spurs (n=9) appearing at mean 2.5 years follow-up (stable after emergence without clinical impact), proximal humeral resorption (n=4) (medially for three at mean 8 year follow-up and one laterally at 10 years), and a humeral radiolucent line (n=1) at 5 years follow-up. DISCUSSION: For acute complex fractures of the proximal humerus in elderly subjects with poor bone quality, when an efficient and reliable re-fixation of the tubercles is difficult or impossible, reverse ball-and-socket shoulder prosthesis is a possible alternative providing good functional outcome except for rotations but with the risk of inferior scapular notching. Although not problematic in the mid term, these notches may contribute to glenoid loosening with bone loss in the long-term. Nevertheless, this procedure seems to improve the status of patients with such fractures.

Aged↗
PubMed2001

Microsurgical junctional DREZ coagulation for treatment of deafferentation pain syndromes.

BACKGROUND: In the treatment of intractable deafferentation pain, different procedures in the DREZ have proved most effective. For most of the spot-like techniques special equipment is mandatory. In this study the technique and the results of junctional DREZ coagulation for treatment of different pain syndromes with the help of bipolar forceps is presented. METHODS: In 40 patients with intractable deafferentation pain syndromes a junctional DREZ coagulation lesion along the entire dorsolateral fissure of the involved spinal cord segments was made using bipolar forceps. Etiologies of the pain included avulsion of the brachial plexus (21 cases), postherpetic pain (4 cases), phantom pain (3 cases), peripheral nerve injury (3 cases), reflex sympathetic dystrophy (2 cases), spinal cord transsection (1 case), and syringomyelia (6 cases). RESULTS: Of 21 patients who underwent junctional DREZ surgery for pain because of brachial plexus avulsion 10 (47.6%) had complete, 7 (33.3%) excellent, 3 (14.3%) good, and 1 (4.7%) fair pain relief (follow-up 20 to 120 months). In the group of 19 patients (follow-up 6 to 84 months) with pain syndromes other than postavulsion pain we achieved excellent results in 10 cases (52.6%), good in 8 (42.1%) and no pain relief in 1 case (5.3%). Transient sensory neurological disturbances lasting up to 8 weeks were observed in 6 (15%) cases; permanent sensory and motor deficit in 1 (2.5%) case. CONCLUSIONS: Clinical results of junctional coagulation DREZ lesion for the treatment of deafferentation pain syndromes are promising. There is no need for special equipment for creating DREZ lesions. The lesions are precisely placed with only a bipolar electrode. Postoperative complications are rare and transient. We believe that the junctional coagulation includes the entire dorsolateral sulcus and DREZ structures important for deafferentation pain.

Adult↗
PubMed1997

Autonomic neuropathy in extra-hepatic portal vein thrombosis: evidence for impaired autonomic reflex arc.

BACKGROUND/AIMS: Autonomic dysfunction is common in cirrhosis, and may be associated with increased mortality and hyperdynamic circulatory changes. Our aim was to investigate whether autonomic disturbances occur in extrahepatic portal vein thrombosis and their correlation with hemodynamic abnormalities. PATIENTS AND METHODS: Heart rate variation in response to standing, deep breathing, and Valsalva maneuver, and blood pressure response to sustained handgrip and to standing, were studied in 16 subjects with portal vein thrombosis (10 males, 30.8+/-2.8 years: mean+/-SE), 12 with cirrhosis (7 males, 52+/-2.3 years), and 10 healthy controls (7 males, 30.8+/-3.0 years). Supine resting, and 10- and 30-min standing epinephrine and norepinephrine levels were measured and results correlated with cardiac output. RESULTS: Autonomic dysfunction occurred in 62% of portal vein thrombosis and 75% of cirrhosis subjects, but in no controls (p<0.02). Similarly, postural hypotension occurred in portal vein thrombosis (-10.25+/-0.65 mmHg, p=0.003) and cirrhosis (-7.42+/-0.82 mmHg, p=0.007) but not in controls. All groups had similar baseline epinephrine and norepinephrine concentrations. Epinephrine increased significantly in controls (45%, p<0.01 and 49%, p<0.02) after 10 of 30 min standing but not in the portal vein thrombosis or the cirrhotic group, and norepinephrine increased after 10 and 30 min standing in cirrhotics (128%, p<0.004 and 130%, p<0.008) and controls (129%, p<0.002 and 116%, p<0.004), but not portal vein thrombosis (34.5% and 39%, NS vs baseline). Portal vein thrombosis and cirrhosis groups had increased cardiac output (4441+/-509 and 3262+/-292) vs controls (1763+/-212 ml/min/m2, p<0.002), but there was no correlation with autonomic neuropathy or with catecholamine levels. CONCLUSIONS: Autonomic dysfunction and impaired catecholamine response to orthostatic stress occur commonly in portal vein thrombosis and suggest an impairment of the autonomic reflex arc, but changes do not correlate with hemodynamic abnormalities.

Adult↗