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.

Transverse bayonet dislocation of the proximal interphalangeal joint

Complete dislocation of the proximal interphalangeal joint with complete rupture of both the collateral ligaments and volar plate was seen in 8 patients. We call this, "transverse bayonet dislocation of the proximal interphalangeal joint." When treated early, closed manipulation resulted in stable reduction. After a brief period of immobilization of 3 to 5 days with a dorsal aluminum splint, sustained active range of motion exercises were begun by strapping the injured finger to the adjacent finger obtaining good end results in all cases. An untreated dislocation of 5 weeks duration needed operative reduction. This was achieved with good result by release of all the retaining ligaments around the proximal interphalangeal joint including both the collateral ligaments, the volar plate, the transverse retinacular ligaments, and extensor tenolysis.

"False inhibition" of demand pacemaker due to leakage of fluid into the pacemaker lead socket

"False inhibition" of a demand pacemaker usually occurs with a microfracture of the lead system resulting in a galvanic potential at the site of the fracture or with sensing of myopotential with exercise. An increase in the slope of the leading half edge of the pulse contour is generally considered diagnostic of lead fracture. We report the case of a patient in whom "false inhibition" at rest and an increase in the slope of the leading half edge of the pulse contour were caused by leakage of fluid into the pacemaker lead socket.