Biomedical subjects
Publications and source records attributed to V E Wood.
Keloid formation on the palms of the hands and soles of the feet is rare. A keloid developed 2 months after release of simple syndactyly in a young black child. The process of keloid formation is not completely understood, and surgical correction is not effective.
Release of the sheath of the flexor tendon is the accepted solution for the problem of congenital trigger digits in children. A series of 27 patients with 37 trigger digits were observed over a period of 18 years: the average follow-up on these patients was 46.9 months. Thirty-two thumbs, three long fingers, and two ring fingers showed locking and a degree of triggering. Thirty-three digits required surgery. The surgical treatment is simple and effective. The outcome in most cases shows that this is a conservative approach.
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We present a case of a child born with metacarpal synostosis of the index, long, and ring fingers associated with a simple syndactyly of the small finger and an absent thumb. At age 7 months, a syndactyly release with skin grafting to the small finger was accomplished so that it became the new thumb. At age 4 years, one of the muscles on the radical border of the hand was transferred to the small finger to act as an opposition transfer. At follow-up, the transfer contracted well and the functional capability of the hand was improved. This operation will not often be used but should be considered for the occasional patient with congenital anomalies.
To assess the efficacy of paradoxical directives, levels of challenging behaviour during 2 weeks of paradox, reprimand and extinction were compared with baseline levels in four adults with mental handicaps attending a day centre. Paradox was the most effective procedure for reducing the frequency and severity of challenging behaviour by an average of over 70% by the end of 2 weeks and up to 90% in certain subjects; extinction was least effective. Paradox was most effective with more defiant subjects, when staff rated treatment success as low, when improvement using extinction and reprimand was poorest, and in reducing aggressive behaviour. The present authors suggest the overjustification effect offers an explanation for the effects of paradox.
The windblown hand deformity, also known as congenital ulnar drift of the fingers and congenital contractures of the digits is reported infrequently in the literature. Although the syndrome is well described, authors' use of different terms is confusing. In more than 20 years of practice, we have observed 11 patients with the windblown hand and have operated on 7 hands in 4 patients. The anomaly appears to be inherited as an autosomal dominant trait and may represent a variation of some type of arthrogryposis. Ulnar drift of the digits is often present at birth and becomes more pronounced as the child grows. The one factor common to all case reports is a flexion contracture of the metacarpophalangeal joints, with ulnar deviation of the fingers. Also, the thumb is webbed to the palm by a soft tissue bridge. Most cases of the windblown hand should be treated within the first 2 years of life. Because the windblown hand has many variations, each patient must be treated individually. We report a series on the windblown hand and propose a treatment plan for this rare anomaly.
Congenital fossae, skin pits, or dimples can form about the shoulder. Little has been written about congenital supraspinous fossae or dimples. They are thought to result from the catching of tissues between a sharp bony post and the uterine wall. The skin and structures become compressed and adherent, and when the pressure is released, the surrounding parts remain tied down, forming small pits or dimples. I report on a congenital fossa in the scapular region of an infant who cried each time the arm was abducted. This congenital fossa did communicate with and adhered to the scapula. Excision of the fossa with its surrounding scar tissue about the scapula plus gentle manipulation gave free motion to the shoulder.
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This article describes a clinical entity under the new name "super digit." The anomaly represents a conglomerate of several different malformations and syndromes. Twenty patients with 24 super digits are presented. The two main types of super digits are discussed: Type I, which has two metacarpals that support a single oversized digit; and Type II, which has a single metacarpal that supports two or more digits distally. These digits, with growth, display several complications such as enlargement, deviation, angulation, loss of motion, and undergrowth. The anomalies singly and collectively present problems that require similar surgical procedures for correction.
In summary, patients with multiple hereditary exostosis often inherit hand involvement but rarely show hand deformity. The principal area of involvement appears to be around the MCP joint but the PIP joint is the most common area of deformity. Metacarpal shortening usually does not cause functional problems and need not be treated. Angular deformity, though rare, does cause problems and needs surgical treatment. Unfortunately, there is no evidence that prevention of deformity is possible by early excision of osteochondromas. Treatment, therefore, requires both osteochondroma excision and closing-wedge corrective osteotomy.
We studied 165 cases of thoracic-outlet syndrome in 142 patients in whom resection of the first rib had been performed. In seventy-three cases (44 per cent), there was compression of a nerve distally, as shown by electromyography and conduction studies. The most common secondary compression was carpal tunnel syndrome (forty-one cases). Thirteen patients needed an operation at three sites or more. Our results show that proximal compression of a nerve lessens its ability to withstand more distal compression. Once the diagnosis of thoracic-outlet syndrome has been made, the possibility of an additional distal compression neuropathy should be investigated.
Thirteen of 100 patients treated for thoracic outlet syndrome by first-rib resection postoperatively developed an associated painful superior angle of the scapula, or snapping scapula syndrome. The scapula angle was painful in 15 scapulas and the pain persisted in these 13 patients. Resection of the superior angle of the scapula was performed on 9 patients (11 snapping scapulas) with complete relief of symptoms. We propose that snapping scapula syndrome be considered a causative factor for apparent failure of thoracic outlet surgery.
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The long-term results of soft tissue metacarpophalangeal reconstruction without articular resection were reviewed in 16 hands of 12 patients with painful ulnar deviation-subluxation deformity. No splinting was used beyond 3 weeks. Patients had either lupus or rheumatoid arthritis. The mean age at operation was 66 years, with mean disease duration of 15.9 years before operation. At follow-up (mean, 81 months), complete pain relief occurred in 88% of patients and 56 degrees and 64 degrees mean active metacarpophalangeal and proximal interphalangeal range of motion was present, respectively. Ulnar drift was corrected to 6 degrees on the average. The first semiobjective grading scale for metacarpophalangeal reconstruction was introduced. There were 82% good or excellent results.
Sixteen patients with ring avulsion injuries treated at Loma Linda University over 10 years were reviewed. According to Urbaniak's classification scheme, there were two class I, seven class II, and seven class III injuries. Follow-up functional measurements showed that the grip strength of our class II patients were, on the average, no better than that of the class III patients, even though all of class III patients had amputation revisions. Five class II patients required only venous microvascular repair. We propose to modify Urbaniak's classification to IIC to include only ring avulsion injuries with venous compromise. These patients had excellent functional results, with an average total active motion of 224 degrees.
The congenital deformities that affect the thumb are reviewed in terms of the clinical problem, the type of inheritance involved, the associated abnormalities seen with the particular deformity, and the indications for surgical treatment. The thumb is often the key to establishing the diagnosis of many rare syndromes. The congenital thumb may be classified for easy identification by pediatricians, family doctors, and hand surgeons as follows: inadequate thumb, fingerlike thumb, contracted thumb, crooked thumb, extra thumb, and unusual thumb.
Two patients with hamartomas of the median nerve and one with hamartoma of the ulnar nerve associated with macrodactyly are described. Nineteen similar cases of this association have been found in the literature. There is evidence that these two conditions are part of a localized regional growth disturbance. This type of macrodactyly should be differentiated from neurofibromatosis.
Polydactyly associated with triphalangeal thumb is not rare, as among the records of 1,269 patients with congenital deformation of the upper extremity at the University of Iowa there were 21 patients with 32 hands with such involvement. More detailed classification based on Wassel's work was made. Treatment should be early, with removal of the radial digit if equal in size, excision of all accessory parts including delta bone when present, reconstruction of joint ligaments or joint fusion and osteotomy for correction of deviations. Care should be taken to avoid leaving a narrow first web space.