Faculty Bibliography

There are large differences between nations in the diagnosis and management of children with marked impulsiveness and inattention. The differences extend to the names and definitions of disorder and the extent to which medication should be used. This paper uses data from a large randomized clinical trial of pharmacological and psychosocial treatments, conducted in North America, to clarify its implications for other parts of the world. A diagnostic algorithm was applied to 579 children, diagnosed with ADHD-Combined Type in the MTA trial, to generate the ICD-10 diagnosis of 'hyperkinetic disorder' (HD); only a quarter met these more stringent criteria. HD was a moderator of treatment response. The superiority of medication to behavioral treatment was greater for children with HD. Children with ADHD but not HD also showed some improvement with medication. The results provide evidence for the validity of HD as a subgroup of those presenting ADHD; and suggest that treatment with stimulants is a high priority in children with HD. Results also suggest that some children with other forms of ADHD will respond better to medication than to psychosocial intervention, and therefore that European guidelines should extend their indications.

PURPOSE: To compare the biomechanical properties of 4 methods of fixation of tendon grafts to bone as used for ligament reconstructions. METHODS: Thirty-two metacarpals were harvested from fresh-frozen cadavers and stripped of soft tissue. Flexor tendons were harvested from the same cadavers and cut into 2-mm-wide strips. Each tendon was fixed to a metacarpal head at the site of origin of a collateral ligament. Four different methods of fixation were tested. In group 1 the tendon was fixed to the bone with a 4.0-mm Arthrex bio-tenodesis interference screw (Arthrex, Inc., Naples, FL). In group 2 the tendon was passed through a bone tunnel and fixed with a 3.2-mm mini-Acutrak screw (Acumed, LLC, Hillsboro, OR) that was inserted in interference mode. In group 3 the tendon was passed through a bone tunnel and fixed with sutures tied over a polyethylene button. In group 4 the tendon was fixed with a mini-Mitek bone suture anchor (Mitek Worldwide, Norwood, MA). All specimens were clamped into a linear loading machine and loaded until failure. Statistical analysis was performed by 1-way analysis of variance testing. RESULTS: The differences in maximal tensile strength and stiffness were statistically significant when comparing any 2 groups. The Arthrex biotenodesis interference screw was the strongest and stiffest fixation method, followed by the Acutrak screw inserted in interference mode. Next was the suture tied over a button method. The mini-Mitek bone suture anchor was the weakest. CONCLUSIONS: Interference screw fixation of tendons to bone has statistically significant higher pullout strength and stiffness than 2 other commonly used fixation methods. The use of interference screws for fixation of tendon grafts to bone for hand ligament reconstructions is a promising new surgical technique

PURPOSE: The purpose of this study was to review our experience with a benign surface bone lesion referred to as bizarre parosteal osteochondromatous proliferation (BPOP) or Nora's lesion, named for the pathologist who described it in 1983. The lesion may be confused with a variety of tumors, particularly solitary osteochondromas, which are rare. METHODS: The files in the Department of Pathology at the Hospital for Joint Diseases were reviewed over a 21-year period for all surface bone lesions involving the tubular bones in the hand. There were a total of 10 cases of BPOP compared with only a single case of an osteochondroma. RESULTS: Radiographs generally showed a well-marginated uniformly dense mass arising from the surface of the affected bone without any disruption in its bony architecture. Surgical excision is the definitive treatment and included the fibrous pseudocapsule over the lesion, any periosteal tissue beneath the lesion, and any area of the cortex of the host bone that appeared abnormal. Although in the medical literature the recurrence rate for BPOP is high, we had only one recurrence in our series. CONCLUSIONS: BPOP is a benign surface bone lesion that may be confused with benign and malignant tumors. Although there is a cleavage plane between the lesion and host bone, we recommend excising the pseudocapsule over the lesion, any periosteal tissue beneath the lesion, and decorticating any abnormal-appearing areas in the underlying host bone. This may explain the low recurrence rate in our series

A structured meta-analysis of the available literature was performed to evaluate the outcome of the treatment of displaced intra-articular fractures of the distal radius. A comprehensive search of Medline using the key words 'radius' and 'fracture' revealed over 4,000 articles. After limiting the search to clinical trials in English and excluding pediatric and geriatric age groups as well as biomechanical and animal studies, 615 abstracts were identified in the period from 1976 to May 1998. Thirty-one articles met the inclusion and exclusion criteria. These included two prospective randomized comparative trials, two non-randomized comparative trials, one half prospective case series and half historical control, and 27 papers on case series. Four papers dealt with external fixation versus closed reduction and cast treatment and one paper looked at open reduction internal fixation with or without additional external fixation. There was insufficient data to perform a scientific meta-analysis because of the poor quality of the studies and lack of a uniform method of outcome assessment. However, the data from the comparative trials showed that external fixation was favored over closed reduction and casting. Additionally, comparing the results of the case series showed that external fixation was superior to internal fixation

A broad spectrum of tumorlike lesions and neoplasms can occur in the hand and wrist, although with somewhat less frequency than in other parts of the body. A thorough understanding of the differential diagnosis of these lesions and a comprehensive strategy for evaluation are central for effective care. Plain radiographs are diagnostic for most bony lesions, whereas magnetic resonance imaging may be necessary to help differentiate a benign soft-tissue lesion from the rare malignant neoplasm. In spite of the complex anatomy, adherence to proper oncologic principles most often will lead to a satisfactory outcome

Ulnar nerve-innervated intrinsic muscle weakness, in the absence of sensory complaints or deficits, usually is the result of compression at the ulnar nerve in zone II of Guyon's canal. In rare instances the problem is not caused by a compressive neuropathy but by a demyelinating focal motor neuropathy. Demyelinating neuropathies have been well documented in the neurologic literature but they have received little attention in the hand surgery literature. We report on one such case and the importance of differentiating the 2 neuropathies. Although surgery often is necessary for a compressive neuropathy it is contraindicated for a demyelinating neuropathy

Tear of the dorsal capsule of a finger metacarpophalangeal joint is an uncommon injury that should be differentiated from an injury to the sagittal fibers of the extensor hood. While the latter injury can often be treated nonoperatively, a dorsal capsular injury usually requires surgery, particularly in athletes who are disabled by the injury

The anatomical configuration of the carpal tunnel is that of an inelastic channel. Consequently, any increase in its volume or alteration in shape will usually result in a significant increase in interstitial pressure. At a pressure threshold of 20 mm Hg to 30 mm Hg, epineurial blood flow is compromised. When that pressure is sustained, the symptoms and physical findings associated with CTS appear. Typically, patients present with intermittent pain and paresthesias in all or part of the median nerve distribution of their hand(s). As weeks and months pass, symptoms progressively increase in frequency and severity. Eventually, thenar muscle weakness develops that initially manifests itself as 'fatigue,' or 'tiredness.' The progressive increase in symptoms and physical findings, usually accompanied by a progressive deterioration in electrodiagnostic studies, facilitates the classification of the condition into early, intermediate, and advanced stages. The increase in interstitial pressure in the carpal tunnel is in the vast majority of cases idiopathic (spontaneous). It can also be caused by a myriad of other conditions that can be classified into three other categories: intrinsic factors that increase the volume of the tunnel (outside and inside the nerve), extrinsic factors that alter the contour of the tunnel, and repetitive/overuse conditions. In addition, there is another category of neuropathic factors that affect the nerve without increasing interstitial pressure. In rare situations CTS can present as an acute problem. Far less common than the chronic form of the condition, it can follow acute wrist trauma, rheumatologic disorders, hemorrhagic problems, vascular disorders affecting a patent median artery, and high pressure injection injuries. Prompt recognition is important, followed in most cases by urgent surgical decompression of the median nerve

Three cases of rupture of a flexor tendon graft many years after surgery are presented. Two cases occurred 12 years after reconstruction and the third case occurred 21 years after reconstruction. Each rupture was intratendinous, just proximal to the flexor tendon sheath in 2 cases and at the proximal edge of the transverse carpal ligament in the third case. Active digital flexion was restored by transfer of the flexor digitorum superficialis from an adjacent finger to the distal tendon stump or by direct end-to-end repair of the rupture site reinforced with an onlay autogenous patch graft. Patients undergoing tendon grafting should be alerted to the possibility of rupture, even many years later