LETTERS TO THE EDITOR Epidermalytic hereditary palmoplantar keratoderma To the Editor: The treatment of the benign dyskeratosis by excision and skin grafting , as suggested by Tropet et aI, in their article "Surgical Treatment of Epidermolytic Hereditary Palmoplantar Keratoderm a" (J HAND SURG 1989;14A: 143-9) presents an innovative treatment for this disabling disorder. Evidence has been accumulating however that an equally effective treatment for the benign dyskeratosis is a partial-thickness skin exci sion.l" The disease extends as noted by the authors down into the dermalepidermal junction. The deep reticular dermis and the epithelial-lined sweat glands and hair follicles are not involved by the benign dyskeratoses. A partialthickness excision allows reepithelialization from the uninvolved epithelial linings of the sweat gland and hair follicles. A test area can be tried for partial-thickness excision and if after 3 months the area remains significantly free of disease then the remainder of the area may be treated. This minimizes the problems with skin graft donor sites and healing of the skin grafts. Such work has been done for a variety of benign dyskeratoses and this partial-thickness skin excision would appear to be worth a trial prior to a full-thickness excis ion and grafting. A . Lee Dellon, MD 3901 Greenspring Aw . Baltimore. MD 21211
Reply We do not agree that partial thickness skin excision is a reliable surgical technique for the management of epidermolytic hereditary palmoplantar keratoderma (EHPPK) for the following reasons. Although dermatome shaving resulting in a partial thickness skin removal just beneath the superficial dermal vascular plexus' has been successfully employed to treat chronic recalcitrant plaque psoriasis' f or even other disorders of keratinization such as Darier's disease;' the depth of excision is definitely insufficient to remove all the potentially involved skin, sometimes as far as down to the deep fascia according to the site, as required in EI:IPPK. Indeed, as mentioned in the discussion of our paper, the genetic defect in EHPPK does lie within all epidermal cells, therefore , it also involves epidermal appendages, such as sweat glands, which extend into the dermis and subcutis and may be a source of recurrence since these cells retain the ability to dedifferentiate and tum into keratinocytes. 180
TilE JOURNAL OF llANO SURGERY
Moreover, even if partial thickn ess skin excision was a reliable technique treatment of the palm and sole , together with the thickness and hardness of hyperkeratosis in EHPPK would not be suitable for use of the dermatome. D. Blanc , MD Department of Dermatology Hiipital St. Jacques Besancon. Fran ce Y. Tropet, MD Department of Orthopedics and Plast ic Surgery Hopital Jean Minjoz Besancon. Fran ce
REFERENCES I. Dellon AL, Chretien PB, Peck GL. Successful treatment
of Darier's disease by partial thickness removal of skin. Plast Reconstr Surg 1977;59:823-30. 2. Dellon AL. Surgical follow-up: partial thickness skin excision for the dyskeratoses. Plast Reconstr Surg 1988; 81:625-30. 3. E1berg JJ, Brandrup F. Dermatome shaving of psoriasis. Br J Dermatol 1987;117:745-50. 4. Dellon AL. Long-term remission of psoriasis after dermatome shaving. Plast Reconstr Surg 1982;70:220-9.
Psoriatic arthritis and Koebner phenomenon To the Editor: I would like to report a postoperative complication in a patient with psoriatic arthritis. A 30-year-old white woman was seen with pain and functional disability as a result of advanced psoriatic arthritis of both hands. She had spontaneous fusion of all proximal interphalangeal (PIP) joints in the neutral position. The distal interphalangeal (DIP) joints had pencil-in-cup deformities caused by severe osteolysis and opera glass (main-en-lorgnette) deformity of all DIP joints. No psoriatic skin lesions were present in the upper extremities except for fine stippling of the nails. The treatment plan included DIP joint arthrodeses with bone grafts to arrest the progressive shortening and resorption, to be followed by PIP joint arthroplasties. The patient had DIP joint arthrodeses on the right side and 4 months later, she had the same operation on the left side. Two weeks after each operation an acute episode of psoriatic skin dermatitis developed in the operative forearm beneath the splint. This was shown by the formation of multiple silvery scales on red plaques 0.5 to 4.0 em in diameter located over the forearm dorsally and volarly, as well as the dorsum of the hand. None
Vol. 16A, No.1 January 1991
Letters to the editor
of these were in the area of the surgical wound. The patient was allowed to remove the splint and apply once a day Psorcon 0.05% (class I topical steroid) ointment over the cutaneous lesions . The lesions resolved 2 weeks after the initiation of local treatment. Psoriasis may develop in the site of an injury, wound, trauma, or irritation. This is known as the Koebner phenomenon. Development of psoriatic lesions beneath the splint or cast, therefore would not be unexpected. Such lesions when adjacent to a surgical wound may compromise healing andlor predispose to jnfection, Detection and early treatment prevents this phenomenon and possible subsequent postoperative wound infection.
181
With proximal forearm tourniquet placement, if the tourniquet is inflated with the arm in extension, the ulnar nerve is transfixed in this position. If the elbow is then inadvertently flexed during surgery, the nerve is unable to glide and a traction neuritis can occur. This problem can be avoided by flexing the elbow before inflation of the tourniquet, therefore transfixing the ulnar nerve in an elongated position and preventing any subsequent traction neuritis. This problem is real. We have experienced this complication early in our use of the forearm tourniquet; fortunately, it spontaneously subsided . Charles S. Lane, MD 9001 Wilshire BlI'd, Suite 200 Beverly Hills. CA 90211
Ghazi M. Ryan. MD 3433 NW 56th St suite 850 Oklahoma City, OK 73112
~~
"Nintendinitis" To the Editor: We wish to report a problem recently brought to our attention-a problem that may actually be quite widespread. An 8-yea r-old boy was evaluated because of recurrent pain in the right thumb. There was no history of obvious trauma or systemic disease . Examination was unremarkable. Further questioning revealed that the pain occurred only with repeated flexion of the thumb and started soon after the patient received a NINTENDO video game , entertainment currently de rigueur in the American home. The symptoms appear to be secondary to a flexor pollicis longus tendinitis caused by rapid and continuous manipulation of the game's control buttons. We suggest this new problem be called "NINTENDINITIS" and suspect it affects all age groups! James Casanol'Q. MD Medical College of Wisconsin Jean Casanova, OTR Hand Rehabilitation Clinic Froedtert Hospital Milwaukee. W153226
. In the past 10 years, we have used this technique on more than a thousand patients . We have not seen paralysis of the ulnar nerve as a complication of the forearm tourniquet, perhaps because all our patients with problems in the wrist or hand had operation with the arm outstretched. The elbow was seldom flexed, certainly not for any length of time . Theoretically, if the ulnar nerve can be transfixed by a forearm tourniquet, then the traditional upper arm tourniquet could do the same. You mentioned that transient paralysis of the ulner nerve had been observed in your early cases. Could this be due to other causes e.g., the pressure effect of the edge of the tourniquet. The forearm is conical in shape as compared to the cylindrical shape of the upper arm. Unless the tourniquet cuff is wellpadded with cotton, the proximal edge of the cuff, when inflated, can be qu ite constricting. Of course, I have no objection to flexing the elbow somewhat during inflation of the forearm cuff. S. P. Chow. MD Department of Orthopaedic Surgery University of Hong Kong Queen Mary Hospital Hong Kong
Modified forearm intravenous regional analgesia for hand surgery
Aeromonas hydrophilia infection complicating dig-
To the Editor: I enjoyed reading Dr. Chow's article (1 HAND SURG 1989;14A:913-14) and I believe the forearm tourniquet is a useful adjunct to regional anesthesia. However, I believe it is important to instruct our readers of some potential hazards of this technique; namely, transfixing the ulnar nerve.
To the Editor: I wish to compliment Dr. Lowen and his coauthors for their fine review of aeromonas infections in digital replantation (J HAND SURG 198914A:714-18). I am in agreement with most of their recommendations for treatment, but wish to comment on two points to which I take mild exception.
ltal replantation and revascularlzation'
Reply We do not agree that partial thickness skin excision is a reliable surgical technique for the management of epidermolytic hereditary palmoplantar keratoderma (EHPPK) for the following reasons. Although dermatome shaving resulting in a partial thickness skin removal just beneath the superficial dermal vascular plexus' has been successfully employed to treat chronic recalcitrant plaque psoriasis' f or even other disorders of keratinization such as Darier's disease;' the depth of excision is definitely insufficient to remove all the potentially involved skin, sometimes as far as down to the deep fascia according to the site, as required in EI:IPPK. Indeed, as mentioned in the discussion of our paper, the genetic defect in EHPPK does lie within all epidermal cells, therefore , it also involves epidermal appendages, such as sweat glands, which extend into the dermis and subcutis and may be a source of recurrence since these cells retain the ability to dedifferentiate and tum into keratinocytes. 180
TilE JOURNAL OF llANO SURGERY
Moreover, even if partial thickn ess skin excision was a reliable technique treatment of the palm and sole , together with the thickness and hardness of hyperkeratosis in EHPPK would not be suitable for use of the dermatome. D. Blanc , MD Department of Dermatology Hiipital St. Jacques Besancon. Fran ce Y. Tropet, MD Department of Orthopedics and Plast ic Surgery Hopital Jean Minjoz Besancon. Fran ce
REFERENCES I. Dellon AL, Chretien PB, Peck GL. Successful treatment
of Darier's disease by partial thickness removal of skin. Plast Reconstr Surg 1977;59:823-30. 2. Dellon AL. Surgical follow-up: partial thickness skin excision for the dyskeratoses. Plast Reconstr Surg 1988; 81:625-30. 3. E1berg JJ, Brandrup F. Dermatome shaving of psoriasis. Br J Dermatol 1987;117:745-50. 4. Dellon AL. Long-term remission of psoriasis after dermatome shaving. Plast Reconstr Surg 1982;70:220-9.
Psoriatic arthritis and Koebner phenomenon To the Editor: I would like to report a postoperative complication in a patient with psoriatic arthritis. A 30-year-old white woman was seen with pain and functional disability as a result of advanced psoriatic arthritis of both hands. She had spontaneous fusion of all proximal interphalangeal (PIP) joints in the neutral position. The distal interphalangeal (DIP) joints had pencil-in-cup deformities caused by severe osteolysis and opera glass (main-en-lorgnette) deformity of all DIP joints. No psoriatic skin lesions were present in the upper extremities except for fine stippling of the nails. The treatment plan included DIP joint arthrodeses with bone grafts to arrest the progressive shortening and resorption, to be followed by PIP joint arthroplasties. The patient had DIP joint arthrodeses on the right side and 4 months later, she had the same operation on the left side. Two weeks after each operation an acute episode of psoriatic skin dermatitis developed in the operative forearm beneath the splint. This was shown by the formation of multiple silvery scales on red plaques 0.5 to 4.0 em in diameter located over the forearm dorsally and volarly, as well as the dorsum of the hand. None
Vol. 16A, No.1 January 1991
Letters to the editor
of these were in the area of the surgical wound. The patient was allowed to remove the splint and apply once a day Psorcon 0.05% (class I topical steroid) ointment over the cutaneous lesions . The lesions resolved 2 weeks after the initiation of local treatment. Psoriasis may develop in the site of an injury, wound, trauma, or irritation. This is known as the Koebner phenomenon. Development of psoriatic lesions beneath the splint or cast, therefore would not be unexpected. Such lesions when adjacent to a surgical wound may compromise healing andlor predispose to jnfection, Detection and early treatment prevents this phenomenon and possible subsequent postoperative wound infection.
181
With proximal forearm tourniquet placement, if the tourniquet is inflated with the arm in extension, the ulnar nerve is transfixed in this position. If the elbow is then inadvertently flexed during surgery, the nerve is unable to glide and a traction neuritis can occur. This problem can be avoided by flexing the elbow before inflation of the tourniquet, therefore transfixing the ulnar nerve in an elongated position and preventing any subsequent traction neuritis. This problem is real. We have experienced this complication early in our use of the forearm tourniquet; fortunately, it spontaneously subsided . Charles S. Lane, MD 9001 Wilshire BlI'd, Suite 200 Beverly Hills. CA 90211
Ghazi M. Ryan. MD 3433 NW 56th St suite 850 Oklahoma City, OK 73112
~~
"Nintendinitis" To the Editor: We wish to report a problem recently brought to our attention-a problem that may actually be quite widespread. An 8-yea r-old boy was evaluated because of recurrent pain in the right thumb. There was no history of obvious trauma or systemic disease . Examination was unremarkable. Further questioning revealed that the pain occurred only with repeated flexion of the thumb and started soon after the patient received a NINTENDO video game , entertainment currently de rigueur in the American home. The symptoms appear to be secondary to a flexor pollicis longus tendinitis caused by rapid and continuous manipulation of the game's control buttons. We suggest this new problem be called "NINTENDINITIS" and suspect it affects all age groups! James Casanol'Q. MD Medical College of Wisconsin Jean Casanova, OTR Hand Rehabilitation Clinic Froedtert Hospital Milwaukee. W153226
. In the past 10 years, we have used this technique on more than a thousand patients . We have not seen paralysis of the ulnar nerve as a complication of the forearm tourniquet, perhaps because all our patients with problems in the wrist or hand had operation with the arm outstretched. The elbow was seldom flexed, certainly not for any length of time . Theoretically, if the ulnar nerve can be transfixed by a forearm tourniquet, then the traditional upper arm tourniquet could do the same. You mentioned that transient paralysis of the ulner nerve had been observed in your early cases. Could this be due to other causes e.g., the pressure effect of the edge of the tourniquet. The forearm is conical in shape as compared to the cylindrical shape of the upper arm. Unless the tourniquet cuff is wellpadded with cotton, the proximal edge of the cuff, when inflated, can be qu ite constricting. Of course, I have no objection to flexing the elbow somewhat during inflation of the forearm cuff. S. P. Chow. MD Department of Orthopaedic Surgery University of Hong Kong Queen Mary Hospital Hong Kong
Modified forearm intravenous regional analgesia for hand surgery
Aeromonas hydrophilia infection complicating dig-
To the Editor: I enjoyed reading Dr. Chow's article (1 HAND SURG 1989;14A:913-14) and I believe the forearm tourniquet is a useful adjunct to regional anesthesia. However, I believe it is important to instruct our readers of some potential hazards of this technique; namely, transfixing the ulnar nerve.
To the Editor: I wish to compliment Dr. Lowen and his coauthors for their fine review of aeromonas infections in digital replantation (J HAND SURG 198914A:714-18). I am in agreement with most of their recommendations for treatment, but wish to comment on two points to which I take mild exception.
ltal replantation and revascularlzation'
