MR angiography of the carotid bifurcation: artifacts and limitations

Although conventional angiography has traditionally been the preoperative study of choice before carotid endarterectomy, alternative noninvasive methods, particularly MR angiography, are being used increasingly for evaluation of the carotid bifurcation [1, 2]. In this essay, we illustrate the limitations of and artifacts associated with two-dimensional (2D) and three-dimensional (3D) time-of-flight (TOF) MR angiography vs conventional angiography when assessing disease of the carotid bifurcation.

Distraction method for chronic dorsal fracture dislocation of the proximal interphalangeal joint

The authors used gradual ligamentous distraction for closed reduction of nine irreducible dorsal fracture dislocations of the PIP joint. The volar fragment size was equal to or less than 40% in five and more than 50% in four. The average follow up was 18 months. The sequence of treatment required distraction, translation, and joint flexion. Overdistraction by approximately 2 mm was necessary to get sufficient soft tissue lengthening. This allowed adequate joint flexion for concentric joint reduction. Distraction and simultaneous mobilization restored the final range of motion earlier than distraction and subsequent mobilization. The final range of motion of the PIP and DIP joints was from 12 degrees to 91 degrees and 0 to 45 degrees respectively.

Preoperative diagnosis of a forearm peripheral schwannoma

A 34-year-old man had a right distal forearm mass of unknown etiology for 6 years. Magnetic resonance imaging showed a tumor in continuity with the median nerve. Fine-needle biopsy revealed it to be a schwannoma. Surgical excision was performed by separating the nerve fascicles from the tumor. The patient was asymptomatic at 12-month follow-up.

Lionfish envenomation of the hand

Lionfish (Pterois volitans) envenomation of the hand causes excruciating pain and occurs in three grades: (1) erythematous reaction, (2) blister formation, and (3) dermal necrosis. The initial treatment in all cases is to soak the hand in nonscalding water (45 degrees C) until the pain subsides by denaturing the thermolabile venom proteins. The blisters should be immediately excised to prevent dermal necrosis, inasmuch as the blister fluid contains residual active venom. To prevent a hypersensitivity reaction, any further contact with the fish should be avoided.

Trigger fingers and thumb: when to splint, inject, or operate

Fifty trigger fingers were treated by splinting of the metacarpophalangeal joint at 10 to 15 degrees of flexion for an average of 6 weeks (range, 3 to 9 weeks). Another 50 trigger fingers were injected with 0.5 ml of betamethasone sodium phosphate and acetate suspension (Celestone) and 0.5 ml of lidocaine. All patients were followed up for a minimum of 1 year (range, 1 to 4 years). Treatment was successful in 33 (66%) of the splinted digits and 42 (84%) of the injected digits. Fifty percent of the 10 splinted thumbs and 70% of the 40 splinted fingers had a successful outcome. Of the 17 unsuccessfully treated digits in the splinted group, 15 were later cured with injections and 2 required surgery. All of the 7 unsuccessfully treated digits in the injected group were cured with surgery. Patients with marked triggering, symptoms of more than 6 months' duration, and multiple involved digits had a higher rate of failure in both groups. Splinting offers an alternative for patients who have a strong objection to cortisone injection.

Liquid chromatographic determination of clobetasone-17-butyrate in ointments

A liquid chromatographic (LC) method has been developed for determination of clobetasone-17-butyrate in ointment using clobetasone propionate as an internal standard. Separation was carried out on a C18 reverse-phase column using water-methanol as a mobile phase. Methylparaben and propylparaben (both sodium salt) used as preservatives did not interfere with separation. Compounds are detected photometrically at 235 nm. Mean assay results for 0.05% commercial ointments were 100.36% (n = 5). Mean recovery of clobetasone-17-butyrate added to commercial ointment was 99.89%.

Fractures of the sesamoid bones of the thumb

Sesamoid fractures of the metacarpophalangeal joint of the thumb may be classified into two types: (1) with palmar plate intact, and (2) with palmar plate ruptured. In type 1, the patient maintains a normal flexion posture of the metacarpophalangeal joint as well as the ability to flex the metacarpophalangeal joint and interphalangeal joint. In type 2, the metacarpophalangeal joint assumes a hyperextension posture and the patient is unable to flex the metacarpophalangeal joint. Three cases are described to illustrate the two types of the injury. An open fracture of a thumb sesamoid associated with laceration of the palmar plate in a child was treated by reapproximating the palmar plate and the fracture fragments with sutures. Two additional closed fractures of the thumb sesamoid were treated by splinting the metacarpophalangeal joint in comfortable flexion for 2 to 3 weeks. Normal hand function was restored in all the three patients.

Barber's interdigital pilonidal sinus of the hand: a foreign body hair granuloma

Interdigital pilonidal sinus of the hand is an occupational disease of male barbers. Customers' hairs penetrate the supple interdigital skin, cause a sinus, and later a cyst. Through the sinus, the hairs get entrapped and may occasionally be expressed. Excision of the sinus or the cyst is curative.

Painful extensor digitorum brevis manus muscle

Diagnosis was confirmed of 10 extensor digitorum brevis manus muscles in 7 patients. The muscle is located on the dorsum of the hand, just distal to the wrist. It is most prominent with the wrist flexed to 30 degrees and the fingers fully extended. We propose that pain in the extensor digitorum brevis manus muscle is due to compression of the muscle in the rigid fibro-osseous fourth dorsal compartment. Extensor retinacular release is the treatment of choice.

Enhancement of natural killer cell activity by Nocardia opaca fractions

Three molecules derived from Nocardia opaca bacteria, NDCM, NWSMP, and PG, have been shown to express immunomodulating properties. The present study was aimed at assessing the effects of these derivatives on natural killer (NK) activity. Two experimental protocols were adopted, consisting of incubating whole or Percoll fractionated NK cells in vitro with those substances, and the other in which the derivatives were administered in vivo to mice and the activity assessed later. Incubation of spleen cells in vitro with NWSMP or its precursor NDCM promoted NK activity. This effect could be observed after only 2 h of incubation and continued until day 2. Percoll fractions 1-3, which contain most of the NK activity, were enhanced to a similar extent. Band 4, which is usually devoid of such activity, remained unresponsive even after contact with the N. opaca derivatives. PG was practically ineffective upon all the subsets. The results of experiments in vivo correlated with those obtained in vitro in that NWSMP and NDCM, but not PG, promoted NK activity. Bands 1-3 were similarly enhanced, the effect was observed after short treatment times, and could be partially cancelled by the concomitant administration of anti-interferon antibodies (anti-IFN Ab). All these findings suggest that the promoting effects of N. opaca derivatives are mediated through alpha/beta IFN. In contrast to the results observed on spleen NK cells, NK cells from the peritoneum displayed susceptibility mainly to PG, and much less to NWSMP or NDCM. The administration of PG to mice in vivo had a particularly marked promoting effect upon the cytotoxic activity of peritoneal cells. One logical explanation for the difference observed between PG and NWSMP or NDCM may be related to the specific IFN inducing properties of these compounds as well as to the different responsiveness of the NK cells present in the spleen and peritoneal cavity.

Subungual keratoacanthoma in the hand

A subungual keratoacanthoma of the thumb with a 5-year follow-up is reported. Recurrence after initial curettage necessitated amputation of the terminal phalanx as definitive treatment. The 22 subungual keratoacanthomas of the hand reported in the literature are reviewed. Although conservative treatment sparing the digit in the form of excision and curettage is recommended as the initial treatment of choice, this uncommon benign, but aggressive, lesion of the nail bed may require amputation of the involved phalanx as definitive treatment.

Anomalous muscles of the first dorsal compartment of the wrist

Exertion-induced pain and swelling in the distal forearm and radial aspect of the wrist were seen in two patients. Exploration revealed an anomalous muscle belly extending into the first dorsal compartment in both cases--an anomaly that we believe has not been previously reported. Surgical release of the compartment resulted in complete relief of pain in both patients.

Patellar metastases. A case report and review of the literature

A case of metastasis to the patella from adenocarcinoma of the lung is reported. The clinical presentation was similar to septic arthritis of the knee. Histopathologic examination established the metastatic nature of the lesion; this is the first case in which a patellar lesion was the only evidence of distant metastasis. Metastatic tumors of the patella are rare. Three cases of metastasis to the patella have been described from squamous cell carcinoma of the lung in the English literature. We report the first case of patellar metastasis from adenocarcinoma of the lung.

Unfractionated spleen cells but not natural killer (NK) cells from RFM donors prevent the progression of host-versus-graft disease in murine RFM/(T6 x RFM)F1 chimeras

Host-versus-graft (HVG) syndrome is the fatal allogenic disease which develops in susceptible strains of inbred mice following their perinatal inoculation with related F1 hybrid spleen cells. Deaths are caused by pathogenic immune complexes. It is thought that the antibody components of these complexes are produced by F1 donor B cells stimulated by the allogenic HVG reaction. To complement previous work that showed that lethal disease could be prevented if the HVG response was suppressed, the present studies tested whether or not it could also be prevented by augmenting HVG reactivity with the adoptive transfer of spleen cells syngenic with the host. The data show that unfractionated RFM spleen cells given on Days 13-14 prevented lethal disease in 86% of RFM/(T6 x RFM)F1 chimeras. Successful therapy was associated with the suppression of formation of nephropathic-immune complexes, and with the rejection of F1 donor cells or their gradual replacement by host cells. RFM spleen cells enriched for NK activity by a new improved method not only failed to prevent HVG disease but appeared to exacerbate it. This was also true of spleen cells that had been activated in vitro for 3 days with IL-2, a procedure that greatly enhanced their cytolytic activity against YAC-1 targets. It is suggested that therapy with NK cells failed, even after IL-2 activation, because they had no effect on proliferating and antibody-forming F1 donor cells that had engrafted in large numbers in the lymph nodes of the RFM hosts.

Osteochondritis dissecans of the patella

We reviewed 13 cases of osteochondritis dissecans of the patella followed-up for 18 months to 19 years. Two were treated conservatively with excellent results, and 11 by operation with six excellent, four good and one fair result. There was complete radiographic healing of the defect in 10 cases and partial healing in three. The size of the osteochondritic lesion appeared to be of prognostic significance. Osteochondritis dissecans of the patella is the result of repeated minor injuries to the articular surface. Operation is indicated for persistent pain, intra-articular loose bodies and subchondral sclerosis; excision of the fragment and curettage of the crater, with or without drilling, is recommended.

Management of skeletal giant cell tumors of the phalanges of the hand

Five cases of unicentric benign giant cell tumors of the phalanges of the hand are reported. Three patients were initially treated with curettage and bone grafting; two had recurrences that necessitated ray resection as the definitive treatment, and one was free of disease at 16 years' follow-up. The two patients who were primarily treated with ray resection were free of disease at follow-up of 2 and 1 years, respectively. Enneking's surgical staging system and Lodwick's x-ray grading of bone tumors were used to evaluate management methods.

Median nerve neuralgia caused by a fibrovascular band in the distal forearm

A 67-year-old woman had experienced exquisite focal pain and tenderness for more than 1 year in the distal forearm 4.5 cm proximal to the distal wrist crease. Surgical exploration showed a venous fibrovascular band adherent to and transversing the epineurium of the median nerve precisely at the point of maximal tenderness. Resection of the fibrovascular band completely relieved the symptoms of focal pain and tenderness.

Suppression of cytolytic T-cell activity by staphylococcal enterotoxin B-induced suppressor cells: role of interleukin 2

We have previously shown that staphylococcal enterotoxin B (SEB) is a potent inducer of suppressor T cells which function to inhibit antibody production in vitro. In the present paper we extend these studies and show that the SEB-induced suppressor cells also inhibit the development of cytotoxic lymphocytes in mixed-lymphocyte reaction (MLR) cultures. Since further analysis also showed that the level of interleukin 2 (IL-2) in cultures of SEB-primed cells was significantly reduced, experiments were carried out to determine the role of IL-2 in the inhibition of cytotoxic cell activity. Attempts to neutralize the suppression by supplementing MLR cocultures with delectinated supernatants from concanavalin A (Con A)-stimulated rat splenocytes were not successful. In addition, MLR cocultures supplemented on Day 0 with 50 units of affinity-purified IL-2 were also suppressed. Further analysis showed that the IL-2 activity in the supplemented MLR cocultures containing suppressor cells were significantly reduced by Day 3. However, repeated supplementation of the MLR cocultures with exogenous IL-2 was successful in achieving (and maintaining) "normal" levels of IL-2. The cytotoxic cell activity in these MLR cocultures remained suppressed. These results suggest that the inhibition of cytotoxic cell activity by SEB-induced suppressor cells is independent of IL-2 levels in the MLR coculture.

Conservative management of chronic mallet finger

Ten cases of chronic mallet fingers that were 4 to 18 weeks old were treated conservatively by immobilization of the distal interphalangeal joint in extension for 8 continuous weeks and for 2 more weeks at night. With a stringent rating system, there were five excellent, four good, and one fair end result. Two patients had recurrence of the deformity within a week after treatment, and both fully recovered after 8 weeks of further splinting. Splinting is a predictable, safe, and simple method of treatment for chronic mallet fingers.

Clicking at the wrist due to fibroma in an anomalous lumbrical muscle: a case report and review of literature

A 33-year-old man had clicking at the wrist and symptoms that were characteristic of carpal tunnel syndrome, which were secondary to a fibroma arising from an anomalous lumbrical muscle in the carpal tunnel. Carpal tunnel release and excision of the fibroma relieved both of the conditions.

Stress fracture of the ulnar diaphysis: review of the literature and report of a case

A 22-year-old athlete developed chronic pain in the forearm aggravated by weight lifting. Physical examination revealed localized tenderness at the junction of the middle and distal third of the ulnar diaphysis. X-ray films revealed an osteolytic lesion at the same level. The patient developed an overt fracture at the same site when he failed to stop sports activities against advice. The fracture healed uneventfully with immobilization in a sleeve cast.

Functional limb salvage with multimodality treatment in epithelioid sarcoma of the hand: a report of two cases

Two cases of epithelioid sarcoma in the hand are reported. The first presented as a space-occupying lesion causing carpal tunnel syndrome, which has not been previously reported. The second case presented with a tumor in the palm that was initially misdiagnosed as a benign tumor and was treated inadequately and recurred. With treatment consisting of surgical excision, adjuvant local radiotherapy, and pulsed systemic chemotherapy combined with early detection and aggressive treatment of distant metastases, both patients have functional hands without local recurrence. They are presently free of obvious disease and remain under close observation at short follow-up of 6 and 4 years, respectively.

Conservative treatment of mallet thumb

Four cases of mallet thumb were treated conservatively by splinting the interphalangeal joint of the thumb in extension using the Stack splint. Two patients had sharply cut the extensor tendon on the dorsum of the proximal phalanx and two had avulsion of the extensor tendon from the base of the distal phalanx. Eight weeks of continuous splinting was followed by 2 weeks of night splinting. Six months of follow-up revealed excellent range of motion in all four cases.

Pseudomalignant osseous tumor of soft tissue: a case report and review of the literature

Pseudomalignant osseous tumor of soft tissues is a rare tumor of the hand. Histopathologic differentiation of this benign lesion from malignant lesions is difficult because mitotic figures are common in typical cases, but bizarre pleomorphic and hyperchromatic nuclei never occur. Wide excision is adequate in most cases, but ray resection is indicated when this benign lesion recurs after wide excision, invades the vital structures, or causes severe functional impairment. Review of the literature revealed 15 cases of this lesion in the digits of the hand, including our case. Of these 15 cases, misdiagnosis of malignancy in three cases and loss of function in an additional four cases led to ray resection.

Tenosynovial osteochondromatosis of the extensor tendon of a digit: case report and review of the literature

Extra-articular tenosynovial osteochondromatosis in the hand rarely occurs. A case of tenosynovial osteochondromatosis of the extensor tendon of the digit is reported. None of the cases reported in the literature have involved the extensor aspect of the digits. A possible explanation for the paucity of this lesion in relation to the extensor tendons of the digits is the absence of a tendon sheath on the dorsum of the digits.

Metastatic tumor of the hand from malignant cystosarcoma phylloides of the breast. A case report

In this case report, a malignant cystosarcoma phylloides of the breast metastasized to the pulp of the little finger in a 47-year-old woman. It initially masqueraded as a whitlow. The diagnosis was helped by radionuclide bone scanning, which showed multiple areas of increased focal uptake including the terminal phalanx of the fifth finger, and the diagnosis was established by a frozen section biopsy of the tumor. The patient underwent a palliative fifth ray resection. She died within six weeks of surgery from extensive pulmonary and osseous metastases. Review of literature revealed only one other case of malignant cystosarcoma phylloides of the breast that metastasized to the hand and was initially misdiagnosed as a whitlow.

Enrichment of mouse splenic natural killer cells using discontinuous polyvinylpyrrolidone silica (Percoll) gradients

A simple and rapid method is reported here for enriching murine spleen cells with natural killer (NK) function as assessed by short-term cytolysis assay of 51Cr-labelled YAC-1 lymphoma target cells. The established method used for the enrichment of NK reactive cells, including large granular lymphocytes (LGL) from human and rat peripheral blood lymphocytes, does not substantially enrich for mouse splenic NK cell activity. A reproducible procedure for enriching mouse splenic NK cells has been developed using a four- or five-step discontinuous Percoll gradient in the density range of 1.062 g/ml (top) to 1.092 g/ml (bottom) and osmolarity (310-340 mOsm/kg) nearer to that of mouse blood and tissue. A four- to 25-fold (usually about nine-fold) increase in NK cell activity, consisting of 50-100% of the recovered lytic unit activity, is found in which are the cells forming band 3, approximately 10% of the recovered cell number. This cell population with enriched NK cell activity has a characteristic density less than or equal to 1.077 g/ml, but more than 1.070 g/ml when centrifuged under appropriate conditions. Similar enrichment was obtained with a four-step gradient at an uniform osmolarity of 320 mOsm/kg throughout. Although the lymphocytes in band 3 show relatively little heterogeneity in appearance, only a minor population of the cells contain granules.

Pigmented villonodular synovitis of the wrist invading bone--report of a case

Pigmented villonodular synovitis of the wrist joint invading adjacent bones rarely occurs. A case in which synovitis invaded the carpal and metacarpal bones at the ulnar aspect of the wrist is described. The invasion of multiple bones by the tumor and its histologic hypercellularity in this case caused concern because of its aggressive behavior. However, review of the literature on pigmented villonodular synovitis arising at the wrist and invading adjacent bones and follow-up of our patient confirmed its benign character.

Ulnar nerve entrapment neuropathy in the forearm

A 74-year-old male attorney developed rapidly progressive weakness of the fourth and fifth digits of the right hand with impairment of his grip and ability to perform cursive writing. Lancinating pain occurred spontaneously and was triggered by pressure along the ulnar border of the forearm about 5 cm proximal to the wrist crease. Nerve conduction studies revealed a complete electrical block to stimulation at a point 5 cm proximal to the wrist crease when recording from the abductor digiti minimi. Distal to this point, responses of normal amplitude and latency were recorded. Surgical exploration disclosed two fibrovascular bands coursing from the ulnar artery to the distal belly of the flexor carpi ulnaris, entrapping and grooving the ulnar nerve. Release of these bands resulted in reversal of the electrical block, complete relief of pain, and a full neurologic recovery during the ensuing six months.

Subcapsular urinoma: unusual form of "page kidney" in newborn

The first case of renal hypertension resulting from a urinoma in a kidney secondary to vesicoureteral reflux from posterior urethral valves in a newborn is presented. High-pressure reflux resulted in formation of a subcapsular urinoma. Removal of the nonfunctioning "Page kidney" cured the persistent hypertension.

Karate: historical perspective and injuries sustained in national and international tournament competitions

Karate injuries sustained in three national and three international tournaments were reviewed. Two hundred and eighty-four athletes participated in 309 matches. Athletes had an average age of 25.5 years, average years of karate practice of 7.7 years, and average years of competitive experience in tournaments of 3.1 years. Athletes were mostly black belts with gradation from brown belt to fourth degree black belt. There were 82 injuries sustained by 76 athletes within 309 matches, with an incidence of one injury in every 3.7 matches or 0.3 injuries per match. There were more injuries among the lower ranked and less experienced athletes, indicating that injuries became less frequent with increased tournament experience. Punches caused more injuries than kicks. Only 16 of the 76 injured athletes were forced to discontinue competition; one athlete was admitted to the hospital for 1 week due to a cerebral concussion.

Effect of mitral valvular regurgitation on transthoracic impedance cardiogram

Mitral valvular regurgitation consistently modified the wave form of the first derivative of the transthoracic impedance cardiogram. The transthoracic impedance cardiogram was recorded in 23 control subjects (group 1), and 23 patients with isolated mitral regurgitation (group 2). Simultaneous transthoracic impedance cardiogram, electrocardiogram, and mitral valve echocardiograms in group 1 showed that the primary diastolic wave ("O") of the transthoracic impedance cardiogram occurred synchronously with the maximal opening of the mitral valve. In group 2, the primary systolic wave (dZ/dt max) was diminished, and the "O" of the transthoracic impedance cardiogram was raised. The area under the systolic wave of the transthoracic impedance cardiogram (S) and the area under the diastolic opening of the transthoracic impedance cardiogram (D) were measured and the ratio D/(D + S) calculated. This ratio, called the mitral regurgitation fraction was (0.50 +/- 0.14) in group 2 which was higher than that found in group 1 control subjects (0.11 +/- 0.08). The mitral regurgitation fraction (15 to 77%) determined by the impedance method was closely correlated with the mitral regurgitation fraction (20 to 74%) obtained during cardiac catheterisation; it also increased during isometric handgrip and decreased during amyl nitrite inhalation. In three mitral regurgitation patients the transthoracic impedance cardiogram returned to normal configuration after surgical implantation of a prosthetic mitral valve. These data suggest that the transthoracic impedance cardiogram is quantitatively altered in patients with mitral regurgitation.

The effect of acute aortic regurgitation on the transthoracic impedance cardiogram

In nine anesthetized dogs, recordings of the first derivative of the transthoracic impedance cardiogram (ICG) were made during varying grades of acute aortic regurgitation. Acute aortic regurgitation was induced using a specially designed umbrella catheter, passed retrograde across the aortic valve into the left ventricle. The RFA (representing the fraction of the aortic reverse flow to the aortic forward flow) was computed using an electromagnetic flow probe implanted around the ascending aorta. Both the peak of the scalar ICG, dz/dtmax, which occurs at peak systolic ejection, and the nadir of the scalar ICG, X, which marks the closing of the aortic valve, increased with aortic regurgitation. The planimetered areas of the ICG during systole (S), and in early-diastole (X) increased during aortic regurgitation. These areas, S and X, correlated with the electromagnetic normalized aortic stroke volume (r = 0.90) and the regurgitant volume (r = 0.78), respectively. The ICG ratio X/S was correlated directly with the electromagnetic aortic regurgitant fraction (r = 0.86). This study demonstrates that the ICG waveform is consistently modified by experimental aortic regurgitation. Furthermore, these changes can be quantitatively related to the degree of aortic regurgitation.

Effect of aortic valvular regurgitation upon the impedance cardiogram

The first derivative thoracic impedance cardiogram, phonocardiogram, and electrocardiogram were recorded in three groups of 22 subjects each. In Group 1 (control), simultaneous impedance cardiogram, phonocardiogram, and aortic valve echocardiograms showed that the X point of the impedance cardiogram occurred synchronously with the aortic second heart sound and with echocardiographic aortic valve closure. In group 2 (clinical diagnosis of aortic regurgitation) the scalar magnitude of the impedance cardiogram O wave and the ratios of the impedance cardiogram wave form X/dz/dtmax and O/dz/dtmax were different from control. In addition, the early diastolic (X) and systolic portions (S) of the impedance cardiogram wave form of group 3 patients were planimetered and expressed as the ratio X/S, called the impedance cardiographic aortic regurgitant fraction (aortic RFI). The aortic RFI was increased by handgrip, a manoeuvre which acutely increases the magnitude of aortic regurgitation. The difference between Fick cardiac output and left ventricular angiographic output was used to calculate aortic valvular regurgitant fraction, which related closely to the impedance cardiogram. These data suggest that it is useful in the noninvasive assessment of aortic regurgitation.