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PubMed1989

Primary repair of extensor tendons with assisted post-operative mobilisation. A series of 48 cases.

Forty-eight patients with lesions of the extensor apparatus of the hand were treated by primary repair with assisted post operative mobilisation by means of a dynamic extension, low profile splint. They were divided into three groups: 25 simple wounds of the extensor tendons of the fingers; 14 simple wounds of the extensor tendon of the thumb; 9 complex lesions. The mobility of the tendinous suture and the callus displacement were monitored by means of metallic markers implanted at operation. Functional electromyographic study during physiotherapy permitted refinement of the technique of reeducation by a limitation of the range of flexion of the proximal interphalangeal articulations. The results are divided into 4 categories: excellent 33 (60%), good 9 (16.4%), average 4 (7.3%), bad 9 (16.4%). No complications (infection, loosening of suture, reflex sympathetic dystrophy) were detected in this short preliminary series. The proposed technique produced improvement of only minor significance in comparison with traditional methods, when applied to uncomplicated wounds. Significantly improved results were obtained in the group of patients with complex lesions.

Adult↗
PubMed1996

[Kapandji enlargement plasty of A1 pulley. Results in 15 primary trigger fingers with a 5 year (2-8 years) follow-up].

We retrospectively studied 15 enlargement plasties of the A1 pulley performed in a university orthopaedic department for trigger finger. The study objectives where: 1)to evaluate whether closure of the enlarged A1 pulley led to recurrent trigger finger; 2) to determine whether the complexity of the procedure was responsible for complications. Fifteen trigger fingers operated by enlargement of the A1 pulley according to Kapandji, instead of opening of the A1 pulley, were reviewed after 5 years of follow-up (2-8 years) by an observer who did not participate in surgery. These 15 fingers (6 thumbs, 7 ringer finger, 1 long finger and 1 index finger) were operated in 14 patients (11 females, 3 males) with a mean age of 55 years at surgery. All trigger fingers were primary (no patients had pathological conditions predisposing to trigger finger). After surgery, all symptoms resolved. No recurrence was observed during the follow-up period. No loss of range of motion or loss of sensation were observed. Reflex sympathetic dystrophy was observed in one case after surgery and resolved before the sixth postoperative month. The authors recommend this procedure, which doesn not lead to recurrence despite closure of the enlarged A1 pulley. Technically more demanding than simple A1 pulley opening, this procedure was safely performed in our department despite participation of junior surgeons.

Adult↗
PubMed1999

Complications and outcome in open carpal tunnel release. A 6-year follow-up in 92 patients.

In this retrospective study, 92 patients (83% attendance rate) were examined 6 years after open carpal tunnel release. A questionnaire was answered by the patient and a physical examination was made by an independent observer. Five complications were found, of which 4 were early postoperative problems and one was a major complication with long-term disability. In one third of the patients numerous complaints were noted even after six years. Recurrences were found in 9 cases. No lacerations of nerves, tendons or vessels were seen and no patient developed reflex sympathetic dystrophy. The overall subjective outcome showed that 91% of the patients were free of symptoms or improved. The grip strength at follow-up was reduced, if the symptoms had been present for more than 12 months, as compared to less than 12 months, (p = 0.009) and when associated, unspecific brachialgia had been present (p = 0.02). No differences were found in conjunction with the operating surgeon being either an orthopaedic resident or a specialist in hand surgery. In conclusion, open carpal tunnel release had a subjectively favourable outcome, but due to complications and postoperative complaints, further investigations into alternative techniques seem necessary.

Adult↗
PubMed1997

Postoperative pain after total knee arthroplasty.

Pain, an uncommon complication following a total knee arthroplasty, has been associated with infections, loosening, reflex sympathetic dystrophy, and occasionally litigation. Radiographic abnormalities such as the anatomic alignment, size of the prosthesis, and tilt of the prosthesis after surgery have been implicated as other sources of pain. It is shown that there is no correlation between the above abnormalities and pain.

Humans↗
PubMed1997

Neuropathic pain in cancer patients: mechanisms, syndromes, and clinical controversies.

The identification of a neuropathic pain syndrome in a cancer patient requires a focused clinical evaluation based on knowledge of common neuropathic pain syndromes. If a tumor is directly involved in the etiology of the pain, oncologic treatment is an initial consideration and may include surgery, radiation, or chemotherapy. There is no single accepted algorithm for the analgesic treatment of neuropathic pain and a systematic approach utilizing therapeutic trials of specific agents at gradually increasing doses is warranted. A trial of opioids, perhaps in combination with an NSAID, is warranted. If the pain is relatively unresponsive to an opioid, a trial with an adjuvant analgesic is reasonable. For example, a tricyclic antidepressant might be selected early for patients with continuous dysesthesia, and early treatment with an anticonvulsant might be used if the pain is predominantly lancinating or paroxysmal. Other adjuvant analgesics can be selected if there is insufficient response to these agents. A trial of sympathetic blockade, pharmacologic, anesthetic or surgical, should be considered in patients with evidence of causalgia or reflex sympathetic dystrophy. Physiatric modalities such as massage, heat, or cold; counterstimulation or transcutaneous electrical nerve stimulation (TENS), and orthopedic interventions, such as braces and splints may be useful. Epidural injections or neurostimulation of the spinal cord or brain can be considered in selected cases where appropriate expertise is available. Treatment of neuropathic pain remains a challenge for both clinicians and patients. The complexity of syndromes and underlying etiologic mechanisms warrants further clinical trials to determine the best treatment modalities for individual pain syndromes.

Diagnosis, Differential↗
PubMedDate not supplied

Medical and pharmacologic management of upper extremity neuropathic pain syndromes.

Written from a neurologic and therapeutically conservative perspective, this review advocates fundamentally medical and pharmacologic management of upper extremity neuropathic pain syndromes, including chronic regional pain syndromes, formerly classified reflex sympathetic dystrophy (RSD) and causalgia. Mandatory steps include, first, a prompt serious attempt to localize the nerve lesion whenever possible using complete, sophisticated neurologic examinations, then thoughtfully selected conventional neurophysiologic and radiologic tests. Strongly discouraged are promiscuous use of "RSD" to describe all neuropathic pains, and diagnostic reliance upon thermography and uncontrolled sympathetic blocks. Conservative multidisciplinary diagnostic and treatment teams should often possess a nucleus of neurologist and hand therapist, plus additional consultants including psychiatric. Every physician and therapist managing neuropathic pain must consider psychologic and wellness issues within their responsibilities. Prompt referral to an experienced surgeon is crucial for decompression or repair of relevant, significant, objectively proven (ideally neurophysiologically) nerve and root lesions. Ambiguous professional colloquialisms, "central pain" and "central sensitization," unfortunately provide value-laden pretexts for premature invasive treatments, and animate the truly dreadful concept "central RSD". Various classes of conventional oral non-narcotic adjuvant analgesics are reviewed, and the inevitability of their empiric, non-formulaic administration. No patient-specific, rationally-identifiable molecular receptor/switch can be deduced clinically or tripped mechanistically to terminate chronic pain. Two promising new non-narcotic centrally-active medications, gabapentin and tramadol, are highlighted as harbingers of future progress. The neglected subtle art of prescription writing is stressed, particularly for medication-sensitive patients. Medical cost containment should promote critical, long overdue outcomes studies comparing conservative and invasive pain treatments.

Analgesics↗
PubMedDate not supplied

Severe heterotopic ossification after arthroscopic acromioplasty: a case report.

Heterotopic ossification is a well-recognized complication of spinal cord injury, closed head injury, total hip arthroplasty, burns, and other trauma and has been observed in various tissues such as muscles, tendons, ligaments, and menisci. Complications of arthroscopic acromioplasty are relatively uncommon and include hematoma, traction neuropathy, infection, acromial fracture, reflex sympathetic dystrophy, and instrument breakage. However, little has been reported on heterotopic ossification of the shoulder, particularly after arthroscopic surgery. Recurrent rotator cuff impingement symptoms caused by small amounts of heterotopic ossification after arthroscopic acromioplasty have been described. We report a case of severe heterotopic ossification about the shoulder after arthroscopic acromioplasty.

Acromion↗
PubMed1996

Erythromelalgia--a case study.

Erythromelalgia is a rare syndrome characterized by pain, redness, and heat involving the lower and, less frequently, the upper extremities. Symptoms occur with local or environmental stimulation and may be mild for years or become disablingly severe. A finding of relief with ice-water immersion helps distinguish erythromelalgia from disorders such as causalgia and reflex sympathetic dystrophy. Erythromelalgia may be classified in three ways: (1) early-onset, (2) adult-onset aspirin-sensitive, and (3) adult-onset non-aspirin-sensitive. Treatment options, which include medication, sympathetic blocks, and surgery, are determined by classification.

Aged↗
PubMed2002

Determining foot and ankle impairments by the AMA fifth edition guides.

The fifth edition of the Guides has been criticized for its failure to provide a comprehensive, valid, reliable, unbiased, and evidenced-based system for rating impairments and the way in which workers' compensation systems use the ratings, resulting in inappropriate compensation [8]. The lower extremity chapter utilizes numerous functional and anatomic methods of assessment, as well as diagnosis-based estimates. Though this process of using multiple approaches to measure impairment increases the chances that an underlying physical impairment may be detected, it is time-consuming and may increase rating variability [9]. McCarthy et al studied the correlation between measures of impairment for patients with fractures of the lower extremity. They found that the anatomic approach of evaluation was better correlated than functional and diagnostic methods with measures of task performance based on direct observations as well as the patient's own assessment of activity limitation and disability. Also, muscle strength assessment as described in the Guides was a more sensitive measure of impairment than range of motion [9]. The most elusive part of the foot and ankle evaluation is the inability to capture the added impairment burden caused by pain. The assessment of pain is the most problematic part of any evaluation. Pain is considered and incorporated into the impairment ratings found in the foot and ankle section, as well as the other individual chapters. Chronic pain is often not adequately accounted for, however, and the examiner must evaluate permanent impairment from chronic pain separately. The examiner has the ability to increase the percentage of organ system impairment from 1% to 3% if there is pain-related impairment that increases the burden of illness slightly. If there is significant pain-related impairment, a formal pain assessment is performed. Chapter 18 provides guidance in making these determinations. Impairments for Complex Regional Pain syndrome (CRPS), type 1 (reflex sympathetic dystrophy), and CRPS, type 2 (causalgia) should incorporate the use of a formal pain assessment in addition to the standard methods of assessment. The formal pain evaluation relies mostly on self-reports from the individual and is most heavily weighted for ADL deficits. The physician must make assessments of the individual's pain behavior and credibility for this evaluation. The formal pain assessment classifies the pain-related impairment into categories of mild, moderate, moderately severe, or severe and determines whether this impairment is ratable or not. These categories do not have impairment percentages associated with them. The individual's symptoms or presentation should match known conditions or syndromes in order to be ratable. If not ratable, the examiner should report that the individual has apparent impairment that is not ratable on the basis of current medical knowledge. In the end, pain evaluations are used administratively and, depending on the situation, may be given equal weight with the standard evaluation or may be totally disregarded.

American Medical Association↗
PubMed2003

Interobserver reliability of diagnosis in patients with complex regional pain syndrome.

Complex regional pain syndrome type I (CRPS-I), formerly reflex sympathetic dystrophy (RSD), is a chronic pain syndrome of unknown aetiology. Its diagnosis is a clinical one, for which several criteria systems have been defined. Despite their widespread use, the reliability of these criteria has never been studied. In this interobserver study 25 chronic CRPS patients were interviewed and examined by six physicians. Through structured questionnaires signs, symptoms, and diagnosis were recorded, after which observer agreement for these was calculated with kappa statistics. Physicians' agreement in assessment of signs and symptoms in CRPS patients varied greatly. More importantly, final diagnosis of CRPS showed poor observer agreement (kappa: 0.20). The kappa values were higher, had physicians applied IASP criteria, but still insufficient. The application of Bruehl's criteria results in a fair kappa of 0.38, but then frequency of CRPS diagnosis in our study population decreased from 73% to 43% in comparison with physicians' own diagnosis. We conclude that, using current criteria systems, the diagnosis of CRPS is not reliable.

Adult↗
PubMedDate not supplied

Lateral cervical epidural catheter placement for continuous unilateral upper extremity analgesia and sympathetic block.

BACKGROUND AND OBJECTIVES: The use of the laterally directed cervical epidural catheter for the treatment of acute and chronic pain has not been previously described. We have used this technique in a series of 30 patients to produce unilateral upper extremity analgesia and sympathetic block. We present a case report of a patient treated with this technique and a description of the technique and results from the series. METHODS: We placed an epidural catheter at the C6-7 vertebral interspace and directed the needle bevel and catheter to the affected side in a woman with a history of complex regional pain syndrome of the right upper extremity. RESULTS: We were able to show a unilateral block with this technique by anatomic parameters (unilateral contrast dye spread), physiologic parameters (unilateral Horner's syndrome), and symptomatic parameters (unilateral, subjective neural block). Although 1 patient treated with this technique had bilateral effects, no patient has had a predominant block on the contralateral side and there have been no complications. CONCLUSIONS: This case report shows results typical of this series of 30 patients. In this series, the laterally directed cervical epidural catheter was an effective technique to produce continuous unilateral analgesia and sympathetic block. Key Words: Analgesia (epidural), Autonomic nerve block, Reflex sympathetic dystrophy, Postoperative pain.

Anesthesia, Epidural↗
PubMed2000

[Surgical treatment of carpometacarpal joint osteoarthritis of the thumb by trapeziectomy-interposition-ligamentoplasty].

INTRODUCTION: Osteoarthritis of the carpometacarpal joint of the thumb is a common pathology. Several surgical methods exist, including trapeziectomy, arthrodesis, cemented or cementless prosthesis. Therefore, one must question the legitimacy of non prosthetic surgery. The authors have tried to answer this question. METHOD: Surgery consisted in trapeziectomy and ligament reconstruction with tendon interposition arthroplasty (LRTI). Authors reviewed 47 cases with five years follow-up. Patients were evaluated using a functional score, including pain, professional and domestic activities, and leisure involving the hand. Objective data were also assessed: thumb opposition, radiographic scaphometacarpal mobility, key and tip pinch, grasp strength. RESULTS: Functional results ranged from good to excellent in 42 cases. Opposition was satisfactory in 46 cases. Scapho-metacarpal range of motion was 16 degrees. Pinch strength was 4.2 kg and grasp strength was 23 kg. There were no complications. Loss of pinch strength was 1 to 2 kg as compared to our reference group. Such a loss does not impair patients' daily life. Age and operated side do not influence results. Scores do not decrease with time. Radiographic staging seems to be linked with scoring. Reducing the trapezial space does not influence results. We had none of the complications described in other techniques: synovitis, ossifications, loosening and reflex sympathetic dystrophy. DISCUSSION: This study, as well as literature, confirms that trapeziectomy and ligament reconstruction with tendon interposition arthroplasty gives satisfactory functional results which are stable with time and without complication. For all these reasons, the authors prefer this technique in degenerative osteoarthritis.

Activities of Daily Living↗
PubMed2001

Right and left traumatic fractures of a bilateral spontaneous fusion of the elbow. A case report.

Report of an exceptional case of spontaneous ankylosis of both elbows, without any family history, trauma, infection or rheumatological disease. An incomplete form of a congenital known syndrome or a thermal reflex sympathetic dystrophy were the most plausible etiologies. The traumatic fractures of both radio-ulnohumeral synostoses have been treated conservatively, within a five years interval period. The arthrodesis of both elbows at 35 and 80 degree of flexion did not impinge on the life autonomy and the work ability of the patient.

Accidental Falls↗
PubMed2003

[Anchovy dacron arthroplasty in the treatment of basal osteoarthritis of the thumb: long term results].

INTRODUCTION: Fifteen patients were treated for arthritis of the base of the thumb by trapieziumectomy and anchovy interposition using Dacron[symbol: see text]. The results are described. METHODS: The 15 patients were between 42- and 68-years-old at the time of operation. The mean postoperative follow-up was 3 years. Pain, pinch strength, opposition, opening of the first web space and height of the space formerly occupied by the trapezium were clinically and radiologically evaluated. RESULTS: Pain had completely disappeared in more than 80% of the patients. The mean post-surgical opposition was 8.9/10 (Kapandji score). The pinch strength and first web-space opening were improved, whereas the height of the trapezium site was always reduced by 25%. The only complication was one case of reflex sympathetic dystrophy: no case of foreign body reaction was reported. Eleven of the 15 patients were satisfied with the operation, and noted better thumb function in everyday life. DISCUSSION: The treatment of arthritis of the base of the thumb by means of trapieziumectomy and anchovy interposition is effective with respect to pain in all the studies previously published, whatever the technique used. Mobility is preserved, contrary to arthrodesis, and grip strength remains compatible with the patient's daily life. The choice of a synthetic anchovy such as Dacron[symbol: see text] allows a quicker operation and better than the ones involving sacrifice of a tendon at the wrist. Anchovy interposition remains the preferred alternative among other procedures in the treatment of basal osteoarthritis of the thumb.

Adult↗
PubMed1995

Psychogenic dystonia: a review of 18 cases.

OBJECTIVE: To review the clinical characteristics and associated features found in patients with psychogenic dystonia. METHODS: A 10 year retrospective chart review of all patients diagnosed by the author as having psychogenic dystonia. RESULTS: Eighteen patients fulfilled diagnostic criteria for "Documented" or "Clinically Established" psychogenic dystonia. Clinical characteristics of the dystonia were inconsistent or incongruous with established forms of organic dystonia. Fourteen of the 18 patients had a known precipitant. In most, the onset was abrupt and progression occurred rapidly, often to fixed dystonic postures. In contrast to idiopathic dystonia, involvement of the legs was common (12 patients), despite onset in adult life. Although cases of isolated paroxysmal dystonia were excluded in the review, 10 patients had paroxysmal worsening of dystonia or other abnormal movements. Pain was a prominent feature in 14 of 16 patients with the complaint and 1 patient with documented psychogenic dystonia also had well established reflex sympathetic dystrophy (RSD). Other psychogenic movement disorders, psychogenic neurological signs and multiple somatizations were common. Long-term follow up was available for less than one-half of the patients. Outcome varied considerably; some patients had complete resolution of symptoms (including 1 who had undergone 2 previous thalamotomies) and others remained disabled by persistent dystonia. CONCLUSIONS: Dystonia is uncommonly due to primary psychological factors. At times this is an extremely difficult diagnosis to make and even when the diagnosis is confirmed, management remains very challenging. Future studies are required in hopes of providing more efficient means of distinguishing psychogenic dystonia from other dystonic syndromes especially those which rarely follow peripheral injury or accompany RSD/causalgia syndromes.

Adolescent↗
PubMed2002

Transient bone marrow edema in renal transplantation: a distinct post-transplantation syndrome with a characteristic MRI appearance.

We describe four patients who developed severe knee pain within 3 months of renal transplantation. Plain radiographs were normal and inflammatory markers (CRP, ESR) were all within normal ranges. Magnetic resonance imaging (MRI) showed a distinctive pattern in all four cases of bone marrow signal changes, extending from the epiphyseal region into the metaphyseal region in two cases. The appearances were different from those of avascular necrosis (AVN) and reflex sympathetic dystrophy and showed no progression to develop AVN during the follow-up period of 36 months. In all cases the pain resolved over a period of 3 months without specific therapy. Follow-up MRI scans were obtained in all patients after the pain had subsided, which revealed resolution of the MRI changes. We suggest that MRI be the investigation in such patients and that bone marrow edema changes will regress without the need to withdraw cyclosporin.

Adult↗
PubMed1998

Factors associated with contractures in acute spinal cord injury.

The purpose of this study was to examine the occurrence of contractures in acute SCI and clarify possible contributing factors such as early versus late admission, level of injury, completeness of the lesion, pressure ulcers, spasticity, co-existent head injury, extremity fractures, heterotopic ossification (HO), peripheral nerve injury, and shoulder pain. The records of all patients (n = 482) admitted between 1990 and 1995 with acute SCI to a model SCI system were reviewed. Of 482 patients 44 (9%) (33 male, 11 female) developed contractures during their initial hospitalization. There were 30 tetraplegic and 14 paraplegic patients. Thirty-four patients had complete and 10 patients had incomplete lesions. The percentage of occurrence of contractures among patients admitted to the model system on the day of injury was 7.6% and among those admitted between 2 and 60 days of the injury was 15% (P = 0.05). Patients with a pressure ulcer (14.1%) were significantly more likely to have a contracture than patients without a pressure ulcer (7.1%) (P = 0.05). Contractures were also more common in patients with spasticity requiring medication; 12.7% of patients with spasticity compared to 7.8% without spasticity, had contractures (P < 0.05). Patients with a co-existent or suspected head injury (15%) were more likely to have contractures than patients without it (7.4%)(P < 0.05). Eighteen patients with a contracture had HO, extremity fracture, peripheral nerve injury or reflex sympathetic dystrophy. In conclusion, this study is one of the first to demonstrate a significant association of contractures in acute SCI with pressure ulcers and co-existent head injury and reaffirms the importance of early admission to a coordinated SCI center in the prevention of contractures.

Acute Disease↗