Vol. l7A, No.6 November 1992
0.3% of gunshot patients), they are a well-recognized and well-documented phenomenon. The first case was reported in 1834. s Michelassi et al.:' reviewed cases of arterial and venous bullet emboli throughout the body; 100 of the 153 cases reported were in the arterial system. Only 30 cases of peripheral artery missle emboli were reported by Shannon et al." in a 22-year literature review. In this case the embolus lodged distal to the elbow, a unique incident and not reported in either of the two previous reviews. In this patient, the clinical diagnosis of ischemic compromise was hampered by generalized peripheral vascular spasm and acral hypoperfusion (limb-threatening ischemia) caused by persistent sepsis and intermittent shock. Resolution of shock and improved peripheral blood flow revealed a localized problem in the right hand, prompting a repeat angiogram that led to immediate operative exploration. Sudden loss of a peripheral pulse has been reported in two thirds of the patients with arterial bullet emboli."
Pellet embolus oj distal ulnar artery
Consideration of this possibility may lead to earlier diagnosis and treatment.
REFERENCES 1. Rich NM, Collins GJ Jr, Andersen CA, McDonald PT,
2.
3.
4.
5.
Kozloff L, Ricotta n. Missile emboli. J Trauma 1978; 18:236-9. Mattox KL, Beall AC Jr, Ennix CL, De Bakey ME. Intravascular migratory bullets. Am J Surg 1979;137: 192-5. Michelassi F, Pietrabissa A, Ferrari M, Mosca F, Vargish T, Moosa HH. Bullet emboli of the systemic and venous circulation. Surgery 1990; 107:239-45. Shannon JJ Jr, Vo NM, Stanton PE Jr, Dimler M. Peripheral arterial missile embolization: a case report and 22-year literature review. J Vase Surg 1987;5:773-8. Davis TD. Singular case of a foreign body found in the heart of a boy. Trans Provincial Med Surg Assoc 2:35760, 1834.
Solitary osteochondroma limiting flexion of the proximal interphalangeal joint in an infant: A case report
Tadao Kojima, MD, Hiroshi Yanagawa, MD, and Hiroshi Tomonari, MD, Tokyo, Japan
W e present a case in which a solitary osteochondroma caused restricted active and passive flexion of the proximal interphalangeal (PIP) joint of the left ring finger.
From the Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan. Received for publication Oct. 24, 1991; accepted in revised form April 6, 1992. No benefits in any form have beenreeived or will be received from a commercial party related directly or indirectly to the subject of this article. Reprintrequests: Professor Tadao Kojima, MD, The Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minnto-ku , Tokyo, 105 Japan. 3/1/38527
Case report A 7-month-old boy had normal extension of the PIP joint of his left ring finger but was able to flex the joint only 30 degrees (Fig. 1). A mass was palpable on the palmar side of the joint, and x-ray films showed an osteochondroma attached to the proximal phalanx (Fig. 2). When the patient was 9 months old, the mass was removed, and it was observed to be covered with cartilage (Fig. 3). It was sent to the pathology department, and the section showed the mass to have a cartilaginous cap with bony trabeculae, establishing the diagnosis of osteochondroma (Fig. 4). After removal of the mass, the PIP joint could be fully flexed passively, and 2 years later the patient had normal flexion (Fig. 5) with no evidence of recurrence (Fig. 6).
Discussion Shellito and Dockerty' reviewed cartilage tumors of the hand seen at the Mayo Clinic from 1908 to 1945.
THE JOURNAL OF HAND SURGERY
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Kojima et al,
Fig. 1. Preoperative photograph showing flexion disturbance of PIP joint and site of planned incision .
The Journal of HAND SURGERY
Fig. 4. Photomicrograph of tumor showing cartilaginous cap, cartilage tissue, and bone trabecula, (Magnification X 25 .)
Fig. 2. X-ray film revealing osseous protuberance at palmar side of proximal phalanx. Fig. 5. Postoperative condition at 2 years showing flexion of PIP joint of ring finger.
Fig. 3. Intraoperative photograph showing cartilaginous tumor.
Fig. 6. Postoperative x-ray film showing no evidence of tumor recurrence.
Vol. 17A, NO.6 November 1992
Solitary osteochondroma limiting flexion of PiP joint
Thirty of the 42 tumors were enchondromas, and the remaining 12 were osteocartilaginous. Also, 10 of 12 osteocartilaginous lesions were solitary, and half of the 12 lesions occurred in the phalanges. The patients' ages ranged from 10 to 25 years. Dahlin and Unni' reported that II of 640 osteochondromas occurred in the metacarpals or phalanges. Moore et al. 3 described osteocartilaginous lesions in the fingers of 10 children ranging in age from I Y2 to 16 years. Two of these had multiple hereditary exostoses, one had multiple lesions, and seven had solitary lesions. Seven lesions occurred at the distal end of the proximal phalanx. Hayashi et al. 4 reported seven cases of solitary exostoses of the finger; four were extra-articular at the distal end of the proximal phalanx, and the youngest patient was I year of age. Previous reports have indicated that solitary osteochondromas in the finger often occur at the distal end of the proximal phalanx. The osteocartilaginous lesion in the case described here was extra-articular like those reported by Hayashi et al." There have been no previous reports of osteochondromas occurring in infants under 1 year of age. Geschickter' suggested that these lesions
result from failure of the periosteum to envelope the sites of tendon and ligament insertion to bone. Moore et al. 3 proposed that these lesions are of congenital origin, unrelated to trauma. The restricted flexion of the PIP joint of the patient described here was noticed by the patient's mother when the infant was 7 months of age, which may support the hypothesis of congenital origin.
1. 2.
3.
4.
5.
REFERENCES Shellito JH, Dockerty MS. Cartilaginous tumors of the hand. Surg Gynecol Obstet 1948;86:465-72. Dahlin DC, Unni KK. Bone tumors: general aspects and data on 8542 cases. 4th ed. Springfield, Illinois: Charles C Thomas, 1986:20. Moore JR, Curtis RM, Wilgis EFS. Osteocartilaginous lesions of the digits in children: an experience with 10 cases. J HAND SURG 1983;8:309-15. Hayashi J, Ikuta Y, Murakami T, Muneshige H, Tsuge K. An experience with 16 cases of exostosis in hand. J Jpn Soc Surg Hand 1987;4:697-701. Geschickter CF. The roentgenologic diagnosis of bone tumors. Radiology 1931;16: 118-80.
The double opposing palmar flaps complex syndactyly
.
In
Double opposing flaps on the palmar surface were designed to create nail folds and to cover bony defects of the distal phalanges in the treatment of complex syndactyly. This is a two-stage procedure, and the flaps were used on 10 hands in 8 patients. There were no failures, and the results were satisfactory after a mean follow-up time of 2 1/ 2 years. The two stages were performed 2 weeks apart, and the surgery can be done as an outpatient procedure. (J HAND SURG 1992;17 A:I059-64.)
J. J. van der Biezen and J. J. A. M. Bloem, Amsterdam, The NetherLands
From the Department of Plastic, Reconstructive, and Hand Surgery, Free University Hospital, Amsterdam, The Netherlands. Received for publication June 28, Jan. 22, 1992.
1991; accepted in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: J. J. van der Biezen, Department of Plastic, Reconstructive, and Hand Surgery, Free University Hospital, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
3/1/37709
Syndactyly and polydactyly are the most frequent congenital hand anomalies. The most common presentation consists of two joined fingers but syndactyly can be part of a more complex congenital syndrome. A bony bridge between phalanges' is complex syndactyly, and there is usually one nail and nail bed (Fig. 1). The treatment aims of complex syndactyly are (1) separation without disturbing growth and function, I (2)
THE JOURNAL OF HAND SURGERY
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0.3% of gunshot patients), they are a well-recognized and well-documented phenomenon. The first case was reported in 1834. s Michelassi et al.:' reviewed cases of arterial and venous bullet emboli throughout the body; 100 of the 153 cases reported were in the arterial system. Only 30 cases of peripheral artery missle emboli were reported by Shannon et al." in a 22-year literature review. In this case the embolus lodged distal to the elbow, a unique incident and not reported in either of the two previous reviews. In this patient, the clinical diagnosis of ischemic compromise was hampered by generalized peripheral vascular spasm and acral hypoperfusion (limb-threatening ischemia) caused by persistent sepsis and intermittent shock. Resolution of shock and improved peripheral blood flow revealed a localized problem in the right hand, prompting a repeat angiogram that led to immediate operative exploration. Sudden loss of a peripheral pulse has been reported in two thirds of the patients with arterial bullet emboli."
Pellet embolus oj distal ulnar artery
Consideration of this possibility may lead to earlier diagnosis and treatment.
REFERENCES 1. Rich NM, Collins GJ Jr, Andersen CA, McDonald PT,
2.
3.
4.
5.
Kozloff L, Ricotta n. Missile emboli. J Trauma 1978; 18:236-9. Mattox KL, Beall AC Jr, Ennix CL, De Bakey ME. Intravascular migratory bullets. Am J Surg 1979;137: 192-5. Michelassi F, Pietrabissa A, Ferrari M, Mosca F, Vargish T, Moosa HH. Bullet emboli of the systemic and venous circulation. Surgery 1990; 107:239-45. Shannon JJ Jr, Vo NM, Stanton PE Jr, Dimler M. Peripheral arterial missile embolization: a case report and 22-year literature review. J Vase Surg 1987;5:773-8. Davis TD. Singular case of a foreign body found in the heart of a boy. Trans Provincial Med Surg Assoc 2:35760, 1834.
Solitary osteochondroma limiting flexion of the proximal interphalangeal joint in an infant: A case report
Tadao Kojima, MD, Hiroshi Yanagawa, MD, and Hiroshi Tomonari, MD, Tokyo, Japan
W e present a case in which a solitary osteochondroma caused restricted active and passive flexion of the proximal interphalangeal (PIP) joint of the left ring finger.
From the Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, Tokyo, Japan. Received for publication Oct. 24, 1991; accepted in revised form April 6, 1992. No benefits in any form have beenreeived or will be received from a commercial party related directly or indirectly to the subject of this article. Reprintrequests: Professor Tadao Kojima, MD, The Department of Plastic and Reconstructive Surgery, The Jikei University School of Medicine, 3-25-8 Nishishimbashi, Minnto-ku , Tokyo, 105 Japan. 3/1/38527
Case report A 7-month-old boy had normal extension of the PIP joint of his left ring finger but was able to flex the joint only 30 degrees (Fig. 1). A mass was palpable on the palmar side of the joint, and x-ray films showed an osteochondroma attached to the proximal phalanx (Fig. 2). When the patient was 9 months old, the mass was removed, and it was observed to be covered with cartilage (Fig. 3). It was sent to the pathology department, and the section showed the mass to have a cartilaginous cap with bony trabeculae, establishing the diagnosis of osteochondroma (Fig. 4). After removal of the mass, the PIP joint could be fully flexed passively, and 2 years later the patient had normal flexion (Fig. 5) with no evidence of recurrence (Fig. 6).
Discussion Shellito and Dockerty' reviewed cartilage tumors of the hand seen at the Mayo Clinic from 1908 to 1945.
THE JOURNAL OF HAND SURGERY
lOS7
1058
Kojima et al,
Fig. 1. Preoperative photograph showing flexion disturbance of PIP joint and site of planned incision .
The Journal of HAND SURGERY
Fig. 4. Photomicrograph of tumor showing cartilaginous cap, cartilage tissue, and bone trabecula, (Magnification X 25 .)
Fig. 2. X-ray film revealing osseous protuberance at palmar side of proximal phalanx. Fig. 5. Postoperative condition at 2 years showing flexion of PIP joint of ring finger.
Fig. 3. Intraoperative photograph showing cartilaginous tumor.
Fig. 6. Postoperative x-ray film showing no evidence of tumor recurrence.
Vol. 17A, NO.6 November 1992
Solitary osteochondroma limiting flexion of PiP joint
Thirty of the 42 tumors were enchondromas, and the remaining 12 were osteocartilaginous. Also, 10 of 12 osteocartilaginous lesions were solitary, and half of the 12 lesions occurred in the phalanges. The patients' ages ranged from 10 to 25 years. Dahlin and Unni' reported that II of 640 osteochondromas occurred in the metacarpals or phalanges. Moore et al. 3 described osteocartilaginous lesions in the fingers of 10 children ranging in age from I Y2 to 16 years. Two of these had multiple hereditary exostoses, one had multiple lesions, and seven had solitary lesions. Seven lesions occurred at the distal end of the proximal phalanx. Hayashi et al. 4 reported seven cases of solitary exostoses of the finger; four were extra-articular at the distal end of the proximal phalanx, and the youngest patient was I year of age. Previous reports have indicated that solitary osteochondromas in the finger often occur at the distal end of the proximal phalanx. The osteocartilaginous lesion in the case described here was extra-articular like those reported by Hayashi et al." There have been no previous reports of osteochondromas occurring in infants under 1 year of age. Geschickter' suggested that these lesions
result from failure of the periosteum to envelope the sites of tendon and ligament insertion to bone. Moore et al. 3 proposed that these lesions are of congenital origin, unrelated to trauma. The restricted flexion of the PIP joint of the patient described here was noticed by the patient's mother when the infant was 7 months of age, which may support the hypothesis of congenital origin.
1. 2.
3.
4.
5.
REFERENCES Shellito JH, Dockerty MS. Cartilaginous tumors of the hand. Surg Gynecol Obstet 1948;86:465-72. Dahlin DC, Unni KK. Bone tumors: general aspects and data on 8542 cases. 4th ed. Springfield, Illinois: Charles C Thomas, 1986:20. Moore JR, Curtis RM, Wilgis EFS. Osteocartilaginous lesions of the digits in children: an experience with 10 cases. J HAND SURG 1983;8:309-15. Hayashi J, Ikuta Y, Murakami T, Muneshige H, Tsuge K. An experience with 16 cases of exostosis in hand. J Jpn Soc Surg Hand 1987;4:697-701. Geschickter CF. The roentgenologic diagnosis of bone tumors. Radiology 1931;16: 118-80.
The double opposing palmar flaps complex syndactyly
.
In
Double opposing flaps on the palmar surface were designed to create nail folds and to cover bony defects of the distal phalanges in the treatment of complex syndactyly. This is a two-stage procedure, and the flaps were used on 10 hands in 8 patients. There were no failures, and the results were satisfactory after a mean follow-up time of 2 1/ 2 years. The two stages were performed 2 weeks apart, and the surgery can be done as an outpatient procedure. (J HAND SURG 1992;17 A:I059-64.)
J. J. van der Biezen and J. J. A. M. Bloem, Amsterdam, The NetherLands
From the Department of Plastic, Reconstructive, and Hand Surgery, Free University Hospital, Amsterdam, The Netherlands. Received for publication June 28, Jan. 22, 1992.
1991; accepted in revised form
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. Reprint requests: J. J. van der Biezen, Department of Plastic, Reconstructive, and Hand Surgery, Free University Hospital, De Boelelaan 1117, 1081 HV Amsterdam, The Netherlands.
3/1/37709
Syndactyly and polydactyly are the most frequent congenital hand anomalies. The most common presentation consists of two joined fingers but syndactyly can be part of a more complex congenital syndrome. A bony bridge between phalanges' is complex syndactyly, and there is usually one nail and nail bed (Fig. 1). The treatment aims of complex syndactyly are (1) separation without disturbing growth and function, I (2)
THE JOURNAL OF HAND SURGERY
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