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Two hundred twenty-seven successive cases of carpal tunnel syndrome confirmed by abnormal electrodiagnostic studies were reviewed. All cases underwent open carpal tunnel release by a single surgeon over a 3-year period. Thirty-two hands (14% of all cases) in 29 patients demonstrated an hourglass deformity at the time of surgery. Electrodiagnostic tests revealed no evidence of any other type of peripheral neuropathy in any patient. Postoperative electrodiagnostic studies were obtained in all cases on completion of therapy. The length of the follow-up period averaged 11 months (range, 3-35 months). The duration of preoperative symptoms ranged from 2 years to more than 10 years. Twenty-eight of the 32 hands (88%) with hourglass deformities demonstrated subjective clinical improvement or complete resolution of symptoms. Chronicity of symptoms and electrophysiologic severity did not correlate with the presence of the hourglass deformity. Presence of hourglass compression of the median nerve in carpal tunnel syndrome is therefore not a negative prognostic indicator.

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Radial artery grafts for coronary artery bypass surgery have recently gained renewed clinical interest. The procedure has been reported to be successful, with a low incidence of morbidity. Although permanent injury to the sensory nerves of the forearm has not been reported, transient or temporary dysesthesia has been known to occur. Recently, 2 patients were referred for long-standing debilitating dysesthesia in their forearms following radial artery harvesting. Electrical studies documented radial sensory nerve injury in both patients, one of whom underwent surgical treatment. Because radial artery grafting for coronary artery bypass surgery may be increasing in popularity, disability from sensory nerve injury may become more frequent. Because of the susceptibility to injury of the sensory nerves in the forearm, and because of the anatomic variations in this region, surgical personnel performing radial artery harvesting should be familiar with the pertinent anatomy so that this complication can be avoided.

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Perforations or communicating defects of the triangular fibrocartilage complex have been more commonly identified after Palmer published his classification system (J Hand Surg 1989;14A:594-606). To his variants of class 1B (traumatic) ulnar avulsion with or without distal ulnar fracture, a third category may be added: defects of the ulnar collateral ligament without any associated disruption of the triangular fibrocartilage. The ulnar collateral ligament can be defined as an ulnar capsular structure between the more discrete elements of the triangular fibrocartilage and the ulnar ligaments, with the defect or perforation being distal to the intact triangular fibrocartilage and exiting into the floor of the extensor carpi ulnaris sheath. We present 2 cases that illustrate the diagnosis, the use of both magnetic resonance imaging and arthrography to confirm the diagnosis, the associated dorsal ulnar cutaneous nerve pain distribution, and the open direct and retinacular flap repair.

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Two brief cases are presented describing burns resulting from exposure to cement and its components. Of particular interest is the etiology of such burns. Do they result from a high pH solution in contact with the skin under abrasive conditions for an undetermined period of time, or are they a consequence of possible allergic reactions to chromium or chromates? Another possible factor that has been largely unexplored is the role of the calcium ion--the other principal ionic species with which the skin is in contact. Much has been written about its role in membrane transport and other physiologic processes.

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The recognition of atypical or dysplastic nevomelanocytic nevi potentially provides clinicians with another means of identifying individuals at increased risk for cutaneous malignant melanoma. However, a great deal of controversy still surrounds these lesions, their significance, and the clinical and histologic criteria needed for their diagnosis at present. In general, dysplastic nevi tend to be asymmetrical and larger (greater than 5 mm) than ordinary acquired nevi, have a macular component, irregular and ill-defined borders, and haphazard (variegate) coloration. A clinical diagnosis of dysplastic nevi must be confirmed by histopathology, since not all clinically atypical nevi are dysplastic. While precise histopathologic criteria for dysplastic nevi are lacking, most authorities agree that an abnormal nevomelanocytic proliferative pattern as manifested by increased numbers of basilar melanocytes and/or abnormal junctional nevomelanocytic nesting in the setting of lentiginous epidermal hyperplasia, variable degrees of nevomelanocytic nuclear atypia, and a lymphocytic host response are consistent with a histologic diagnosis of dysplastic nevi. Current data for individuals with dysplastic nevi and a family history of cutaneous malignant melanoma (at least two family members with cutaneous malignant melanoma) indicate a relative risk for cutaneous malignant melanoma about 148 times that of the general population. In comparison, cutaneous malignant melanoma risk seems lower for individuals with familial dysplastic nevi (but without familial cutaneous malignant melanoma) and "sporadic" dysplastic nevi. With respect to progression to melanoma, probably the vast majority of dysplastic nevi remain stable or possibly regress. Management of individuals with histologically confirmed dysplastic nevi involves periodic skin examinations. Regional overview and life-size photography are helpful in following these patients. Patients should also be instructed in the examination of their own skin. While a definite relationship between sun exposure and dysplastic nevi remains unproved, the use of sunscreens and avoidance of unnecessary sun exposure are advised. Examination of family members for atypical melanocytic lesions is also recommended.

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Examination of a series of 16 consecutively referred women patients who have had a de Quervain's release revealed 23 associated diagnoses and 14 complications. Also, 11 consecutive women patients were referred preoperatively and, even in this small group, there were eight associated diagnoses. The complexities of de Quervain's tendinitis and the diagnosis and treatment of associated diseases and complications are described to help prevent surgical failures and prolonged disabilities in these groups of working women.

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Changes in response to heat in the dermal, subcutaneous, and muscle blood flow in the hands of 10 patients with hand infections were studied using 133Xe and recording of clearance data. A further 15 normal hands were studied in a similar manner. The application of topical heat to normal hands resulted in a decrease in the dermal blood flow (p less than 0.001), an increase in the subcutaneous blood flow (p less than 0.05), and perhaps an increase in the intramuscular flow (p less than 0.1). This suggests that surface heat promotes a shunting of the blood from the skin to deeper tissue layers. In infected hands, the blood flow was found to be significantly increased threefold in the intradermal circulation (p less than 0.01) and eightfold in the subcutaneous circulation (p less than 0.03) when compared to controls. In contrast to normal hands, in the infected hands, the blood flow decreased in all three compartments by 50 percent following application of heat. The blood flow of the normal hand in patients with infection did not respond to heat in the normal pattern. We conclude that the application of local heat to normal tissues results in shunting of blood flow from superficial tissues such as dermis to deeper ones such as subcutaneous fat and muscle. In infected tissues, the blood flow was found to be much higher than normal; however, the traditional belief in the improvement in blood flow by the application of heat was not confirmed.(ABSTRACT TRUNCATED AT 250 WORDS)

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Eleven circumscribed, full-thickness burns were treated in 9 patients with immediate excision and primary closure of the defect or by using a variety of local random cutaneous and musculocutaneous flaps. The burns were located on the face, trunk, and extremities. In 2 patients this technique was used in the management of smaller burns on one surface of the body, thus facilitating skin grafting of larger wounds on the opposite surface. The cutaneous flaps utilized included advancement flaps, V-Y flaps, Moberg flaps, and S-plasties. The timing of the excision and closure varied from 2 hours to 2 weeks following thermal injury, with no postoperative wound infections. In selected cases primary excision of deep burns and closure by use of local tissue approach ideal treatment. With certainty of the depth of destruction, this procedure should be carried out regardless of locality when technically and anatomically feasible.

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The palmar thumb advancement flap was first described by Moberg in 1964. It was further utilized for the thumb and defined by Posner and Smith in 1971. In 1980, Macht and Watson favorably reported their technique of palmar advancement that was applicable not only for the thumb, but also for all five digits with soft tissue tip losses. A further refinement of their technique is to augment the digital tip with an autogenous dermal graft. This dermal "padding" is placed directly over the bony tuft to act as a "shock absorber," add bulk and contour to the distal tip of the finger, increase soft tissue stability, eliminate direct percussive tenderness of the bone, and decrease disability for specific occupations such as those requiring typewriting. Six cases are reported.

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A case report of a young female teenager with a long history of self-destruction of her hands by chewing, scratching, and gnawing is presented. This habit was related to her successfully repaired cervical meningomyelocele in infancy. Not only did she first present with ulcerations and osteomyelitis, but also with distal autoamputation and severe iron deficiency anemia. A team approach with a pediatrician, neurologist, psychiatrist, and plastic surgeon was employed for her treatment. Behavior modification was moderately successful. Her hands and forearms were reconstructed with arthrodesis, local and distant flaps, and skin grafting without incident. She has been followed now for 4 years.

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