[Trapeziometacarpal denervation. Description of surgical technique and preliminary results from a prospective series of 14 cases]

INTRODUCTION

The main goal of first carpometacarpal arthritis surgical treatment is to relieve pain. The main disadvantages of the usual techniques (trapeziectomy, implant arthroplasty) are loss of strength or presence of a prosthetic device. It is difficult to propose such extensive surgery at an early stage of the disease. Selective denervation of the first carpometacarpal joint seems to be an interesting choice. We propose a new technique of denervation based on our previous anatomical investigations.

TECHNIQUE

Two incisions are needed to cut all the articular branches derive from the superficial branch of the radial nerve, the palmar cutaneous branch of the median nerve, the thenar branch of the median nerve and the lateral ante brachial cutaneous nerve.

MATERIAL

Fourteen patients were prospectively included in our study with a mean follow-up of 5 months.

RESULTS

Pain relief was very satisfying in 12 cases (mean decrease 84%). An increase in grip and key pinch strength was noted. Complications were uncommon, excepted temporary paresthésia in the radial nerve area.

DISCUSSION

This technique seems to be promising and a good indication for patients with no disabling deformity, but only long-term results will confirm the place of denervation in the treatment of first carpometacarpal arthritis.

Stiff and strong compressive properties are associated with brittle post-yield behavior in equine compact bone material

Our hypothesis was that post-yield mechanical behavior of compact bone material in compression, defined as the stress, strain, or energy absorbed between 0.2% strain-offset and the point of maximum stress, is correlated with material density, modulus, strength, histomorphometric evidence of remodeling, and post-failure gross specimen morphology. Post-yield behavior of compact bone material from the third metacarpal bone of 10 horses, ages 5 months to 20 years, was investigated using single-load compression-to-failure. The post-yield stress, strain, and absorbed energy were compared with the compressive elastic modulus, yield stress, ash density. post-failure macroscopic appearance of the specimen, and histologic evidence of remodeling. High values of elastic modulus, yield stress, and ash density were associated with low values of post-yield mechanical properties (stress, strain, and absorbed energy). Macroscopic post-failure morphology was associated with post-yield mechanical behavior, in that specimens displaying fractures were associated with lower post-yield mechanical properties, and that those without evidence of frank fracture were associated with higher post-yield mechanical properties. Microscopic evidence of remodeling activity was associated with high post-yield mechanical properties, but not with gross post-failure morphology. There was an abrupt change from relatively high values to extremely low values of post-yield mechanical properties at intermediate levels of ash density. This feature may serve as a functional tipper limit to the maximization of bone material stiffness and strength.

Ulnopalmar dislocation of the fifth carpometacarpal joint. A rare injury

Volar dislocation of the carpometacarpal joint of the little finger is an uncommon injury. It is subdivided in ulnopalmar and radiopalmar dislocations. The injury can easily be missed on standard x-rays. Closed reduction and K-wire fixation has commonly been used in the treatment, although closed reduction and casting has been reported. Only 10 cases of an ulnopalmar dislocation were published previously. We report a case of a simultaneous dislocation of the 4th metacarpophalangeal joint and an ulnopalmar dislocation of the 5th carpometacarpal joint. The combination of these injuries has not been reported yet. We review the available literature and discuss the methods of treatment.

[Aneurysmal bone cyst of the fourth metacarpal bone--a case report]

Aneurysmal bone cysts of the hand skeleton are rare (only 3 to 4 % of all ABC; Tillmann and v. Torklus 1966 ) and require a differentiated treatment. In the presented case, the fourth metacarpal bone of the right hand was affected (Enneking stage 3). On account of its rapid growth, radical excision was performed and the resected metacarpal bone was replaced by a bicortical iliac crest graft. The bone graft healed in without complications, the functional result is satisfactory. On twelve-month follow-up there were no signs of relapse.

[Injuries of the first web. Surgical indications]

Treatment of the first web injuries are based on the concept of one stage repair of the complex injuries of the hand with early motion. Radical debridement is specially important in case of muscular attrition. Fasciotomie of the first web is systematic in case of crush injuries for avoiding compartimental syndrome. For prevention of first web retraction, one or two Kirchner wires are placed in emergency between first and second metacarpal, and later a spilt in maximal anti-position of the first ray. In case of communited fractures, skeletal stabilisation use inlay internal devices, such the blocked intramedullary nail. First web reconstruction must take into consideration the cutaneous functionnal units of the hand, described by Michon. Thin and split-thickness grafts are rarely used for covering skin defects of the first web space, because their ability of retraction. Exposition of bone or tendons leads to the realisation of a flap. Soft tissue coverage must be achieved in emergency or after a second look within the first 48 hours. The kite flap is the most useful local flap for the first web space. The interosseous flap is the best choice among the regional pedicled flap. The use of the Chinese flap must be very careful, because the possibility of contusion of the radial pedicle in these types of injuries. It is only in case of contra-indication of the interosseous flap that free flaps can be realised, as the lateral arm flap or the parascapular flap. The groin flap keeps few indications for aesthetic reasons, or when regional flaps and microsurgery are contra-indicated.

[Juvenile aponeurotic fibroma. A case report with a review of the literature]

Juvenile aponeurotic fibroma is a rare benign tumour which occurs mainly in young patients under 20 years of age and especially during childhood. Clinical presentation is a unique, hard and painless tumour of the palm or sole. The treatment commonly accepted for this locally recurrent tumour is complete excision with function preservation. In this paper, we report on a case of juvenile aponeurotic fibroma of the thenar area with a thickening of the first metacarpal bone shaft. Bone involvement in juvenile aponeurotic fibroma is a very rare condition. We only found one report of a comparable case in literature.

Chondromyxoid fibroma of the metacarpal

This report describes a chondromyxoid fibroma which developed in the distal part of the second metacarpal of a 12-year-old girl. The tumor is rare, perhaps the rarest of all bone tumors, and the occurrence in a metacarpal of a young female is extraordinarily uncommon.

Metastasis of an adenocarcinoma of the stomach to the 4th metacarpal bone

Metastatic tumours of the hand are uncommon. The majority of these tumours affect the phalanges and the primary tumours are usually bronchogenic in origin, with breast and kidney tumours next in frequency. Metastatic gastrointestinal to the hand is rare and usually from the colon. We report a case of poorly differentiated adenocarcinoma of the stomach antrum presenting with a metastatic lesion to the right 4th metacarpal bone. A review of the literature is included.

Hypertrophic pulmonary osteoarthropathy without clubbing of the digits

Hypertrophic osteoarthropathy (HOA) typically occurs concurrently with clubbing of the digits, with isolated HOA being reported only rarely. We report two patients with intra-thoracic malignancy in whom HOA, demonstrated on bone scintigraphy, developed in the absence of clubbing. We also report the novel observation of involvement of the metatarsal and metacarpal bones by HOA.

Intraosseous ganglion in the first metacarpal bone

Intraosseous ganglia occur most frequently in the long bones of the lower limbs, particularly in the medial malleolus of the tibia. They usually appear as radiographically well circumscribed juxta-articular cystic lesions, containing myxoid fibrous tissue histologically. Intraosseous ganglia in the hand are very rare. Most reported cases have involved the carpal bones, in particular the lunate and scaphoid. To our knowledge, the present case is the third report of an intraosseous ganglion appearing in the first metacarpal bone; it arose in a patient who had been on dialysis for 25 years, mimicking amyloidosis of bone.

Osteopenia and reduced serum alkaline phosphatase activity in grazing lambs naturally infected with gastrointestinal nematodes

The effect of gastrointestinal nematode infections on bone development was investigated in growing sheep on pasture. Forty-five weaned lambs from six groups in a two-factorial design incorporating stocking rate (SR; low, medium and high) and presence or absence of infection on pasture were sampled in the late grazing season. Worm counts were performed at slaughter, and the left metacarpal bones were excised for bone assessment. Faecal egg counts and worm burdens, primarily of Ostertagia circumcincta and Trichostrongylus vitrinus, were considerably higher in the high SR infected group ("I-High") than in comparable animals at low or medium SRs, whereas uninfected groups showed negligible egg excretion. Clinical biochemistry revealed significantly reduced serum concentrations of albumin, calcium and alkaline phosphatase in infected lambs. Nematode infections were associated with significant reductions in bone mineral density (30% at high SR), measured by dual energy X-ray absorptiometry, and in bone size (9%). Histomorphometry indicated thinning of the trabecular structure and reduced bone formation in the infected groups, particularly the I-High group. Bone mineral density, bone tissue volume and structural changes were strongly associated with log-transformed worm counts. The study showed that lambs suffering from moderate to heavy degrees of naturally acquired gastrointestinal nematode infection developed marked osteopenia after weaning, i.eduring the later part of the grazing season.

[Ulnar nerve compression and pseudoarthrosis of the medial metacarpal bases]

A case of compression of the deep branch of the ulnar nerve associated with pseudarthrosis of the base of the fifth metacarpal and the upper shaft of the fourth metacarpal is reported. The delayed procedure consisted in volar decompression of the ulnar nerve by dividing the pisi-hamate ligament and plating and grafting of both fractures. The patient achieved marked improvement four weeks post-operatively and had complete functional recovery at follow-up of 16 years after injury without narrowing of the hamato-metacarpal joint despite synostosis of the bases of the medial metacarpals.

Chondrosarcoma of thumb metacarpal--a case report with literature review

Function preserving management of a dominant thumb metacarpal chondrosarcoma is reported, with a literature review for this uncommon neoplasm. Wide local excision of the metacarpal followed by temporary silicone block interposition and definitive iliac crest bone grafting was performed. A persistent wound defect was managed by a radial artery forearm flap. The functional result was acceptable. In the literature, there were seven cases of thumb metacarpal chondrosarcoma reported; two were treated by ray amputation, and the other five were treated by excision of the metacarpal. Three of those five had bone graft and the other two had simple resection. Of these seven cases, three had local recurrence and one a distant metastasis.

Childhood periosteal chondroma

We report here three fully documented cases of periosteal chondroma diagnosed and treated in our hospital. There have been few references since Lichtenstein first described this condition as a separate tumour, and none of them concerned children under 10 years old. deSantos accurately describes the radiological features of the tumour. All of our patients were under 10 years old at the moment of the appearance of the lesion, which was always detected in the long bones of the upper limbs. The study included a previous histological examination in two cases and a follow-up in all of them. From this study we learned that invasive diagnosis procedures are unnecessary as we could follow the behaviour and evolution of this cartilaginous benign tumour for a long period of time.

Dieterich's disease: avascular necrosis of the metacarpal head: a case report

The authors report a case of non-traumatic avascular necrosis of the third metacarpal head. This very rare condition is known as Dieterich's disease and has been associated with trauma, systemic lupus erythematosus and steroid use.

Asymmetric densitometric and mechanical adaptation of the left fifth metacarpal bone in racing greyhounds

The densitometric and mechanical structural properties of the left and right fifth metacarpal bones of 10 racing greyhounds with a fracture of the central tarsal bone and 10 without a fracture were investigated by dual energy x-ray absorptiometry and a servo-hydraulic materials testing machine. In all the greyhounds the bone mineral density of the left fifth metacarpal bone was significantly greater than that of the right (P<0.001), but there was no significant difference between the degree of asymmetry in bone mineral density in the two groups. The ultimate torque and energy-to-failure of the left fifth metacarpal bone of the greyhounds with a fracture of the right central tarsal bone were significantly higher than in the right fifth metacarpal bone and higher than in both the left and right fifth metacarpal bones of the greyhounds with no fracture (P<0.05). The ultimate torque and energy-to-failure were significantly related to bone mineral density (P<0.005), and 22 per cent of the variation in these structural properties could be explained by variations in bone mineral density. Fifth metacarpal remodelling in response to asymmetric cyclic loading is bone-specific, and structural properties are enhanced in the left fifth metacarpal of greyhounds with a fracture of the right central tarsal bone.

Syndrome of gingival hypertrophy, hirsutism, mental retardation and brachymetacarpia in two sisters: specific entity or variant of a described condition?

Two sisters born to consanguineous Lebanese parents had mental retardation and epilepsy, brachymetacarpalia, hirsutism, bulbous soft nose, thick floppy ears with abnormal configuration and gingival hypertrophy. One girl presented additionally with tetralogy of Fallot and the other with congenital hypothyroidism and bilateral ureteral stenosis. These manifestations resemble the syndrome of hypertrichosis-gingival fibromatosis-mental retardation and seizures of Anavi et al. [1989: Dev Med Child Neurol 31:538-542] but our two girls additionally have brachymetacarpia. The inheritance seems to be autosomal recessive. These two sisters may represent a hitherto undescribed syndrome. We discuss the findings in our patients in relation to the literature.

Solitary skeletal hemangioma of the extremities

OBJECTIVE

To report the clinicopathologic features of solitary skeletal hemangioma of the extremities and to review previous cases in the English language medical literature.

PATIENTS

In addition to five of our own cases, 34 literature cases with substantial and 75 with partial clinicopathologic information were found.

RESULTS

Our patients, three men and two women, ranged in age from 37 to 83 years (mean 65.6 years). The lesion was an incidental radiologic finding in two patients, while three were symptomatic. In no case was a correct preoperative radiologic diagnosis made, a malignant process being considered as a possibility in all. The hemangiomas were medullary; two involved a metacarpal, two the fibula, and one the humerus. In contrast, previously reported patients were younger (mean age 32 years), predominantly female (60%), and symptomatic in over 90% of cases. The lesion is rare in those younger than age 10 years or older than age 60 years. As in our patients, the long bones are most frequently involved (75%), with the diaphysis or metadiaphysis, as in four of our patients, the most common locations. Although 20% of cases occur in the hands or feet, metacarpal involvement is rare. Medullary origin, as in all of our cases, is most frequent, but 45% of cases are either periosteal (33%) or intracortical (12%). In the literature, cavernous hemangioma is the most frequent type. Three of our hemangiomas were cavernous, one capillary, and one venous, the latter being rarely reported in extremity bones.

CONCLUSIONS

Due to the diversity of radiologic patterns produced by skeletal hemangioma, a correct preoperative diagnosis is rarely made. Almost all patients do well, even those with less than complete removal of the lesion; local recurrence is rare. All of our patients were well following either therapeutic or simple diagnostic procedures. Due to the destructive nature of some biopsy procedures, the histologic diagnosis of hemangioma may at times also be problematic.

Giant cell tumor of the bones of the hand and foot

BACKGROUND

Giant cell tumor of the small bones of the hand and foot is suspected of having some peculiar features compared with giant cell tumor in other sites. Moreover, it could share some features with other giant cell rich lesions involving the hand and foot, and this may affect the differential diagnosis. The aim of this study was to analyze the features of lesions such as these in the files of the Rizzoli Orthopedic Institute.

METHODS

The incidence of giant cell tumors of the bones of the hand and foot seen at the Rizzoli Orthopedic Institute over 50 years (1947-1997) was taken into consideration. There were 8 lesions of the hand and 21 of the foot. Clinical information and follow-up of the patients were studied and updated. Radiographs were studied and radiographic features analyzed. Histopathologic material was thoroughly reviewed and histologic features analyzed.

RESULTS

Although the location of tumor was helpful information, radiographic features were not specific. Giant cell tumors of the small bones of the hand and foot showed a predominance in females, younger patients and more aggressive behavior than giant cell tumors of large bones. The authors did not observe multicentricity or pulmonary metastases.

CONCLUSIONS

Because the radiographic features of giant cell tumor of the hand and foot overlap those of other giant cell rich lesions in these locations, histologic diagnosis is mandatory, although it may be difficult and require the establishment of diagnostic criteria for giant cell tumor. As this tumor tends to be more aggressive than other giant cell rich lesions, treatments of choice are aggressive curettage or resection.

Giant cell tumor of the fourth metacarpal bone

Giant cell tumor is among the rare tumors of the bone. We present a case of metacarpal giant cell tumor with radiographic, computed tomographic (CT) and histologic findings, as well as grey scale and Doppler sonographic features. We also present the "doughnut"-shaped appearance on scintigraphy of the lesion, which has not been shown on a metacarpal giant cell tumor.

Intraosseous schwannoma of the metacarpal

Intraosseous schwannoma (neurilemmoma) is an extremely rare, benign neoplasm, constituting less than 0.2% of primary bone tumors. It infrequently involves the bones of the hand. We present a case of intraosseous neurilemmoma of the metacarpal.

Treatment of a traumatic osteochondral defect in the thumb carpometacarpal joint with a periosteal autograft

We report a case in which an autogenous periosteal autograft was used to resurface a large osteochondral defect in the thumb carpometacarpal joint of a young woman. Good results were found at 4-year follow-up examination.