Biomedical subjects
Publications and source records attributed to J A Grossman.
We report a 2-year-old girl with carpal tunnel syndrome due to a large intraneural perineurioma that required resection and nerve reconstruction.
Early surgical repair is indicated for selected infants who sustain birth trauma to the brachial plexus. In children with global or total paralysis, surgery should be performed by 3 to 4 months of age to maximize ultimate extremity function. Although the timing of surgery for children with Erb's palsy remains controversial, in properly selected cases, nerve reconstruction leads to an improvement in shoulder function and overall limb function.
Many children who sustain birth injuries to the brachial plexus suffer significant functional limitations due to various sequelae affecting the shoulder and elbow or forearm. The maintenance of full passive mobility during the period of neurological recovery is essential for normal joint development. Early surgical correction of shoulder contractures and subluxations reduces permanent deformity. Reconstruction of forearm rotation contractures significantly improves the appearance and use of the extremity for many basic activities. Each child must be carefully evaluated, therapy maximized, and the surgical approach individualized to obtain the best result.
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Seven children were operated on for pronation contractures of the forearm due to obstetric brachial plexus injuries. All underwent extensive preoperative evaluations to determine the extent of injury, secondary deformities, and capacity to perform a few basic tasks. Sequential video studies were used to document these findings. Operative procedures performed included various combinations of tendon/muscle lengthenings and/or transfers. Postoperative evaluations focused on function rather than gains in active range of motion and the patient/parental assessment of the benefit of the procedure by response to a questionnaire. All patients were followed for a minimum of I year following surgery. The average gain in active supination was 45 degrees. Each patient showed significant functional gains with a high degree of satisfaction.
This study was designed as a pilot investigation of the effect of pulsed electromagnetic fields (PEMF) stimulation on early flexor tendon healing in a chicken model using a similar stimulus to that used clinically. The PEMF used caused a decrease in tensile strength and an increase in peritendinous adhesions.
OBJECTIVE: To compare, from a managed care perspective, the 3-year costs of 3 first-line monotherapy strategies in type 2 diabetes patients: glipizide gastrointestinal therapeutic system (GITS), metformin, and acarbose. STUDY DESIGN: A Markov model, with a Monte Carlo simulation, was developed to compare the costs to achieve full glycemic control (hemoglobin A1c of < or = 7%) with each first-line strategy. PATIENTS AND METHODS: The patient population for the model was assumed to be all newly diagnosed type 2 diabetes patients eligible for monotherapy with an oral agent. Each monotherapy could be succeeded by add-on treatments. The model included the costs of routine medical care and supplies, medication, adverse events, and treatment failures. RESULTS: Using a Monte Carlo simulation, the mean 3-year cumulative costs per patient were $4971, $5273, and $5311 for glipizide GITS, metformin, and acarbose first-line strategies, respectively. The main cost drivers were drug prices. Mean 3-year cost savings for first-line glipizide GITS were $301 over metformin and $340 over acarbose. Between 83% and 85% of all simulations showed cost savings with glipizide GITS compared with the other agents. CONCLUSIONS: The model suggests first-line monotherapy with glipizide GITS should result in desirable short-term economic benefits for managed care. Because the model incorporates recommended glycemic goals and performed well in sensitivity analyses, it should be applicable to a variety of clinical practices and useful for economic assessments of new therapies. Results of this model should be verified prospectively in typical care settings.
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Six patients sustained extensive hand and upper limb trauma, including median nerve and/or thenar muscle loss. Initial treatment consisted of various median nerve and/or soft tissue reconstructions. Because of extensive palmar scarring and lack of useful opposition (Kapandji stage 3), a 2-stage opposition transfer was performed. In stage 1, a silicone rod was placed along the path of the intended tendon transfer. In stage 2, the rod was removed and the donor tendon was passed through the pseudosheath to the point of insertion at the thumb. All patients were monitored for a minimum of 1 year and all achieved significant functional improvement, documented by Kapandji stage 6 opposition in 1 patient and by at least stage 7 or 8 opposition in the other 5 patients.
We studied the anatomy and pathology of the dorsal cutaneous branch of the ulnar nerve by dissecting 10 fresh cadaver upper limbs and reviewing 6 cases of injury or entrapment of the dorsal cutaneous branch of the ulnar nerve. In all of the cadavers and in our series of cases, several anatomical features were apparent: 1) the dorsal cutaneous branch of the ulnar nerve arises from the main ulnar nerve an average of 5.5 centimeters proximal to the head of the ulna; 2) the dorsal cutaneous branch of the ulnar nerve reaches the dorsum of the hand after coursing volar to the ulnar head; 3) there was no communication between the dorsal cutaneous branch of the ulnar nerve and the superficial sensory branch of the radial nerve; and 4) no volar branches were noted. Based on our experience, disorders of this nerve are more prevalent than previously reported. This clarification of the anatomy will help prevent unnecessary injury during surgery and will be valuable in the diagnosis of disorders of the dorsal cutaneous branch of the ulnar nerve.
PURPOSE: To survey the prevalence and severity of premenstrual symptoms and compare premenstrual symptom clusters of younger (13-15-year-old) and older (16-18-year-old) adolescents, based on both chronological and gynecological age. METHODS: Physical, emotional, and behavioral premenstrual symptoms were assessed by self-report using the Premenstrual Assessment Form (PAF), in a sample of 75 adolescents. Analyses were performed to determine differences in premenstrual symptom clusters in younger and older adolescents. RESULTS: The participants had a mean age of 14.8; 96% identified themselves as Caucasian, 3% as African-American, and 1% as Asian. All participants reported at least one premenstrual symptom of minimal severity. Many reported symptoms that they considered moderate (88%), severe (73%), or extreme (56%). The symptoms most commonly reported were food cravings, breast swelling, abdominal discomfort, mood swings, stressed feeling, and dissatisfaction with appearance. Other symptoms, such as missing time at school, becoming violent with people or things, and "thinking of what it would be like to do something to self" (such as crash the car), wishing to go to sleep and not wake up, or having thoughts of death or suicide, were less frequently reported. The younger teens (13-15 years old) had significantly less intense symptoms than the older teens (16-18 years old). CONCLUSIONS: Premenstrual symptoms reported as being moderate or greater in severity were found to be quite prevalent (88%) in this sample of adolescents. Specifically those adolescents at 41 months postmenarche or greater reported specifically more intense premenstrual symptoms. In addition, a subset of adolescents expressed that they experienced aberrant behavior and passive suicidal ideations as premenstrual symptoms.
Two patients with severely deforming giant neurofibromatosis of the chest wall secondary to von Recklinghausen's disease are presented. Pain, respiratory compromise, recurrent ulcerations, cosmetic considerations, and the malignant potential of these lesions indicated wide excision and reconstruction. It is impossible to completely eradicate all neurofibromas, which may affect virtually every nerve within the chest wall including the mediastinum. However, excision of the primary mass may reduce the possibility of malignant degeneration into neurofibrosarcoma or malignant schwannoma. This type of major, full-thickness chest wall resection is now possible using musculocutaneous flaps to achieve satisfactory closure with a single-stage procedure with minimal morbidity and a short hospital stay. At the 10-year follow-up, neither patient exhibited evidence of recurrence.
INTRODUCTION: The brachial plexus originates from C5 to T1 spinal segments. The brachial plexus includes the ventral ramus, trunks, divisions, cords and branches. DEVELOPMENT AND CONCLUSIONS: Brachial plexus injuries produce clinical syndromes. The Duchenne-Erb syndrome is the most frequent presentation of obstetric brachial plexus injury. The differential diagnosis of brachial plexus palsy include decreased arm movements due to pain, or weakness caused by a lesion of the nervous system outside in the brachial plexus, or by a lesion in the brachial plexus due to non-obstetrical causes. Management of these patients initially includes considering the possibility of clavicular and humeral fractures and posterior subluxation of the shoulder; and subsequently considering the possibilities of subscapularis muscle contraction or posterior shoulder subluxation in patients that develop internal rotation contracture of the shoulder; or flexion, pronation or supination contracture in patients with forearm deformation. Treatment consist of physical therapy, administration of botulinum toxin, electrical stimulation, neurolysis, nervatization, removal of neuromas and nerve grafting, treatment of fractures and subluxation, release of muscle contracture and tendon transplantation.
INTRODUCTION: The objectives of the neurophysiological evaluation of infants with brachial plexus palsy are to determine the time of occurrence of the lesion, to locate the lesion and to determine its course. METHODS AND CONCLUSIONS: These objectives are achieved by studying affected upper extremity muscles by needle electromiography (EMG) and affected nerves by motor and sensory conduction studies. EMG is performed in the first week of life in those patients with brachial plexus palsy of unknown etiology to determine the age of the lesion for medico-legal reasons. EMG is performed before surgery for tendon transfer in the selected muscles to assure that they are normal. EMG and motor and sensory conduction studies are performed at the age of 3 and 6 months in infants with less than 4 muscle weakness to determine candidates for surgical exploration. Motor and sensory nerve conduction studies are performed intraoperative to determine the functional status of the affected axons and the best surgical procedure (neurotization, neurolysis and/or neuroma resection and homologous nerve graft).
OBJECTIVE AND METHODS: A variety of surgical procedures exist for early repair of the nerve injury in obstetrical brachial plexus palsy, including neuroma excision and nerve grafting, neurolysis and neurotization. Secondary deformities of the shoulder, forearm, and hand can similarly be reconstructed using soft tissue and skeletal procedures. This review describes our surgical approach to maximize the ultimate functional outcome in infants and children with obstetrical brachial plexus palsy.
Twenty-two digits in seven patients with chronic digital vasospasm were surgically treated after failed medical management. All patients complained of severe ischaemic pain. Chronic digital tip ulceration was present in seven digits and dry gangrene in one. Following surgical microarteriolysis all digital ulcers healed completely. Severe digital ischaemic pain was significantly improved in all digits and completely resolved in 19 of 22 digits.
We developed a protocol to improve the final total active motion for patients with isolated unicondylar fractures of the head of the proximal phalanx. The protocol includes surgical treatment followed by hand therapy. Surgical fixation is obtained using lag screw technique. Therapy includes immediate mobilization by use of a continuous passive motion machine and controlled active motion. Specially designed splints and Coban wrap are used to control the position of the digit during the first six months following surgery. Silastic gel is used to control scarring. We treated five consecutive patients over a 4-year period using this protocol. Final total active motion of the injured digit averaged 241 degrees--approximately 90% of the normal range of 260 to 270 degrees. No patients required secondary surgery.
Arthrodesis of the interphalangeal and metacarpophalangeal joints is a technically demanding procedure with significant failure rates. A method of compression arthrodesis that was developed by one of the authors (RWB) using a compression clamp and crossed Kirschner wires is reported. This technique has been used without complication in the successful arthrodesis of 125 consecutive interphalangeal and metacarpophalangeal fusions by two of the authors (RWB and JAIG). An in vivo model of small-joint arthrodesis was then developed using the rabbit humeroulnar joint to compare this method of compression clamp arthrodesis with the tension band technique. Biomechanical testing at both 2 and 8 weeks postoperatively showed compression clamp arthrodesis to compare favorably with the tension band technique.