Biomedical subjects
Publications and source records attributed to F M Hankin.
The long-term survival of patients after surgical removal of soft tissue sarcomas is dependent on many factors. This case report shows that a postsurgical clinical "cure" may depend more on the biologic behavior of the neoplasm than on any specific operative modality.
Arthrodesis of the wrist is a well established procedure that may be performed by a variety of techniques. The position of 10 degrees to 30 degrees of extension and 0 degree to 15 degrees of ulnar deviation is the most commonly accepted position for maximum hand function. Van Gemert has written an extensive monograph reviewing the results after wrist arthrodesis. He concluded that only 42% of 66 patients reviewed met all of the following desired criteria: bony union, subjective improvement of pain, improved power of grip and pinch, no loss of function in adjacent joints, and a good ergonomic score by the system that they used. A review of our cases of wrist arthrodesis shows many of the problems noted by Clendenin and Green. Our review also indicates that patients who make occupational transitions to less hand intensive activities have a better response to the procedure.
Chronic wrist pain in the teenage patient constitutes a diagnostic challenge. Carpal instability patterns and internal joint derangements may be difficult to diagnose by physical examination and conventional plain radiographs. Dynamic radiographic studies frequently provide a better understanding of abnormal wrist mechanics. We reviewed our experience with fluoroscopy and radiocarpal arthrography in 14 teenage patients with chronic wrist pain. Videotape fluoroscopy was performed in all 14 patients. Dynamic radiocarpal arthrography was then performed in 10 patients in whom fluoroscopic findings were normal or more information was needed. These imaging methods led to a diagnosis in 64% of the patients and excluded a significant anatomic carpal abnormality in the other patients. In the teenage patient, internal derangements of the intercarpal ligaments are usually posttraumatic rather than attritional in origin. Dynamic radiographic techniques provide an accurate means for the diagnosis of these specific anatomic carpal abnormalities.
The cost effectiveness of wrist fluoroscopy and arthrography was evaluated in patients with obscure wrist pain. Dynamic fluoroscopy was performed in 91 cases and was positive in 54 (59%). Radiocarpal arthrography was performed in 60 of these cases in which further information was desired. Arthrography increased the diagnostic yield to 62 of 91 cases (68%). Diagnoses included ligament and cartilage tears, and dynamic intercarpal instability. The cost per positive examination for fluoroscopy, based on total cost for fluoroscopy in 91 patients divided by number of positive cases, is $126. The cost per positive examination by arthrography alone is $377. When arthrography is done only when fluoroscopy is equivocal or negative, the cost per positive examination (fluoroscopy plus arthrography) drops to $280. Wrist arthrography is only cost effective if done after dynamic fluoroscopy fails to answer the clinical questions. When done together in this setting, the two procedures are most cost effective than arthrography alone. Based on current costs, conservative treatment of carpal instability costs about $1,500, and surgical therapy costs about $4,000. Thus, fluoroscopy and arthrography may further reduce the cost of management of obscure wrist pain by identifying those patients who would not benefit from surgical exploration.
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Fracture of the carpal scaphoid usually results from a fall on an outstretched dorsiflexed wrist. Snuffbox tenderness is an important clue. Because the fracture line may not be visible on the initial roentgenograms, follow-up films are often required. Direct palpation of the distal pole of the scaphoid can enhance the evaluation of wrist pain.
The evaluation and treatment of injuries of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb remain controversial. In a retrospective study that was done to assess our ability to determine whether displacement of the ligament (a Stener lesion) was present, we reviewed our accumulated experience with patients who had an injury of this ligament who were treated surgically between 1972 and 1984. Since our method of evaluation changed in 1977, we compared the preoperative and operative diagnoses in the twenty patients who were treated surgically from 1972 through 1976 with those in the twenty patients who were so treated from 1977 through 1984. Considering all forty patients who were treated operatively, sixteen (40 per cent) had a typical Stener lesion, and in two others (5 per cent) the ulnar collateral ligament was rolled up on itself and lying beneath the adductor aponeurosis. From 1972 through 1976, stability was tested with the metacarpophalangeal joint in complete extension or in varying amounts of flexion. Of the twenty thumbs that were evaluated by this technique and were treated surgically, 20 per cent had a Stener lesion. From 1977 through 1984, stability was tested with the joint in full flexion because of the findings in anatomical studies that were completed in 1977; the incidence of a Stener lesion in the twenty thumbs that were treated by repair or reattachment of the ligament during this time was 70 per cent.(ABSTRACT TRUNCATED AT 250 WORDS)
Soft tissue inflammatory disorders can be treated by regional administration of corticosteroid preparations. However, the local catabolic effects of these agents can result in cutaneous atrophy and pigmentary changes. Since all injectable steroid agents may produce these adverse effects, corticosteroids must be used judiciously. The physician must be familiar with the chosen steroid and its recommended dosage.
First rib lesions can present as musculoskeletal pain involving the shoulder and arm. Chronic musculoskeletal symptoms must be pursued in an adolescent. Plain radiographs remain an integral part of the diagnostic plan. While delay in the diagnosis of a benign rib lesion may not jeopardize the outcome, brachial plexus compression can result from an enlarging mass. The outcome can be worse if the lesion is malignant.
Four cases of lipofibromatous infiltration of the median nerve with long-term follow-up (average 11 years) are reported. Progressive compromise of median nerve function has been noted. Initial treatment considerations should be directed toward biopsy and alleviation of the compression neuropathy. The role of microsurgical debulking procedures remains unclear at this time.
The efficacy of a diagnostic protocol involving videotape fluoroscopy of carpal motion and radiocarpal arthrography was evaluated in patients with wrist pain unexplained by physical examination and conventional radiographs. Videotape fluoroscopy was performed as the first study in 68 consecutive cases and was positive in 44 (66%). Radiocarpal arthrography was performed after videotape fluoroscopy in 39 of the cases (57%), including the 24 in which videotape fluoroscopy was normal and 15 others in which further information was desired in spite of positive videotape fluoroscopy. The addition of radiocarpal arthrography to videotape fluoroscopy increased the diagnostic yield to 52 (76%) of the 68 cases and excluded significant anatomic or dynamic abnormality in the others. The diagnosis was proven surgically in 25 cases. This protocol was efficacious for ligament tears of the proximal carpal row, triangular fibrocartilage tears, and proximal and midcarpal instability. Videotape fluoroscopy should be the primary method of evaluating patients with unexplained wrist pain, and arthrography should be done in those cases in which fluoroscopy is either normal or does not fully explain physical findings.
Sural nerve grafts have applicability in many facets of reconstructive surgery. A harvesting technique is described which utilizes a tendon stripper introduced through a single distal incision. This method provides adequate length of autogenous graft material without significant difficulty or morbidity.
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Extravasation of vesicant agents into the soft tissues can lead to painful and indolent ulcerations. Precautions for avoiding extravasation include the use of fresh intravenous lines. The line should be placed in the forearm whenever possible. Hand veins, joint surfaces and extremities with impaired circulation should be avoided as infusion sites. If evidence of extravasation appears, the infusion must be stopped immediately and appropriate measures initiated.
A 28-year-old hyperuricemic man injured his left long finger and presented with a possible rupture of the flexor digitorum profundus. Operative exploration revealed gouty infiltration of the flexor tendon within its fibrous synovial sheath. Urate crystal deposition in tendons is rare. Superimposed trauma was a possible predisposing factor.
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Arthrodesis of the wrist may be indicated for a variety of conditions and can be achieved by many techniques. We have had experience with radiocarpal arthrodesis by fusion of the capitate to the radius after a modified proximal row carpectomy . The common feature in our 10 patients was a flexion deformity of the wrist. In five of the patients it was the result of spastic posturing. Five of the patients had a variety of other conditions. Primary arthrodesis occurred in all patients and the cosmetic improvement was appreciated by all patients. Functional improvement seemed to be most related to the preoperative condition. The follow-up evaluation averaged 5.4 years with a range from 6 months to 11 years.
The advent of potent chemotherapeutic agents has been helpful in the medical management of a variety of malignancies. Unfortunately, the side effects and complications have been significant. Our recent experience with a patient who had the avoidable complication of extravasation with doxorubicin (Adriamycin) into the upper extremity is described. Frequently, the medical management of this problem has been observation alone followed by late surgical referral. This tissue fixation of the chemotherapeutic agent is such that it stays bound locally and causes an ever enlarging ulceration of tissue. This slough can occur not only in a circumferential fashion, but also in the superficial to deep manner, resulting in full-thickness lesions. Early surgical intervention is important to shorten the morbidity and to return the patients to their home environment.