LETTERS TO THE EDITOR Split-thickness skin grafts for coverage of defects in the hand To the Editor: Supplementary to the excellent article of Robotti and Edstrom on the “Split-Thickness Plantar Skin Grafts for Coverage in the Hand and Digits” (J HAND SURG 1991;16A:143-6), it might be of interest to remark that we no longer regard the forearm a cosmetically acceptable donor site for skin grafts.’ This is not contradicted by Robotti and Edstrom, who mention the forearm as one of the traditionally used donor areas, but they indicate that the use of this sort of skin may lead to complications in the recipient site. However, since more and more patients seek our help for correction of the scars on the donor site we, unlike Zoltie,’ fully agree with the opinion that “grafts from the volar aspect of the forearm or antecubital fossa result in unjustifiable disfigurement and usually are only used for the convenience of the surgeon.“3 J.J. Hage, MD, and J.J.A.M. Bloem, MD, PhD Department of Plastic Surgery Academic Hospital Free University P.O. Box 7057 N-1007 MB Amsterdam. The Netherlands
We agree that when a donor site for a skin graft is chosen, the recipient site should not be the only consideration. The donor site itself may cause complications worse than the original problem, as in the case of the forearm, in which some very unattractive scars can be produced in a regrettably conspicuous area, after only the slightest delay in healing. Our inclusion of the forearm in the list of traditional donor sites was done only for completeness. Lee E. Edstrom. MD
Bilateral palmaris profundus causing bilateral carpal tunnel syndrome To the Editor: I read with interest the article by Doctors Floyd, et al. (J HAND SURG 1990;15A(2):364-6) regarding a case of bilateral palmaris profundus muscle. They concluded in their article that this muscle was the cause of the patients bilateral carpal tunnel syndrome. I have recently treated a patient for carpal tunnel syndrome who also had a palmaris profundus muscle. This muscle was enclosed within the investing tissue surrounding the median nerve and ran on its palmar ulnar side. The photograph shows the palmaris profundus muscle dissected free of the nerve and enclosed in a ligaloop.
REFERENCES Hage JJ, Bloem JJAM. The forearm, no longer a suitable donor area in skin defects of the hand. Ned Tijdschr Geneeskd 1991;135:174-7. Zoltie N. Forearm split-skin donor sites: are they cosmetically acceptable? Ann Plast Surg 1988;21:1 l-3. Beasley RW. Cosmetic considerations in surgery of the hand. In: Tubiana R, ed. The hand. Vol. II. Philadelphia: WB Saunders, 198596-103.
Reply We appreciate the opportunity to answer the letter from Drs. Hage and Bloem regarding our article, “SplitThickness Palmar Skin Graft for Coverage in the Hand and Digits. ” They point out that they “no longer regard the forearm as a cosmetically acceptable donor site for skin grafts,” correctly identifying the forearm as a donor site that is likely to produce complications.
THEJOURNAL OF HANDSURGERY
Fig. 1. Constriction
of nerve in midcarpal tunnel region.
Vol. 17A, No. 1
Letters to the editor
I believe that the palmaris profundus muscle is not necessarily always the cause of carpal tunnel syndrome. In this patient, the illustration shows a classic hourglass constriction of the nerve in the midcarpal tunnel region. This finding seemed to be the cause of the carpal tunnel syndrome. The associated muscle that inserted into the palmar fascia, appeared to be a mere curiosity. I would support the anatomic findings of Dr. Floyd’s article. I would, however, question the assumption that the palmaris profundus muscle is usually the cause of carpal tunnel syndrome. In my own case it was clearly not the cause of nerve compression. Ron H. Stark, MD 3070 North 51st. St., Suite 406A Milwaukee, WI 53210
Reply Thank you for forwarding Dr. Stark’s letter. I offer the following reply. While Dr. Stark is correct in questioning the assumption that the palmaris profundus was the causative factor in our patient with bilateral carpal tunnel syndrome, we would point out that the presence of an aberrant and extraneous structure coursing through the carpal canal would occupy space and doubtless contribute to a compressive median neuropathy regardless of primary etiology. It follows that its absence would allow more room for the median nerve such that the patient might not be symptomatic. Proof of its causal relationship would be difficult to ascertain unless the presence of this structure could be demonstrated preoperatively. Then perhaps it could be excised without violating the transverse carpal ligament and the patient could be followed for resolution of symptoms. If the symptoms persisted, Dr. Stark’s objection would be substantiated. Timothy Floyd, MD 2600 Preston Rd, #610 Plano, TX 75093
Technical considerations in pectoralis major transfer To the Editor: I am a few months behind on my journal reading, but I came across an error in a recent publication. In the January issue, the article entitled “Technical Considerations in Pectoralis Major Transfer for Treatment of the Paralytic Elbow,” by Matory and associates (I HAND SURG 199 1; 16A: 12-8) makes an anatomic or nomenclature mistake. Specifically, Dr. Matory lists the segmental innervation of the pectoralis major muscle as coming from the medial and the lateral pectoral nerve. This, of course, is correct. What is incorrect in the manuscript is the anatomic location described. The medial pectoral nerve originates from the medial cord of the brachial plexus, whereas the lateral pectoral nerve originates from the lateral cord. Their names describe their origin rather than their anatomic position in reference to the midline or, in this case, the sternum. Therefore, the lateral pectoral nerve enters the pectoralis major muscle at a location medial to that of the socalled medial pectoral nerve. Dr. Matory’s excellent article is affected by this nomenclature error in only a minimal degree. I hope I don’t seem to be nit-picking but I felt I should bring this matter to your attention. Congratulations and good luck in your new position as Editor. Michael S. Norris, MD, FACS 1828 El Camino Real, Suite 602 Burlingame, CA 94010
Reply Thank you for your note regarding the segmental innervation of the pectoralis major muscle. Please note that there is considerable nomenclature confusion throughout the anatomic and clinical literature. Current recommendations by clinical and pathologic anatomists are to refer to the segmental innervation by anatomic location rather than by derivation from cord components. If you have further questions, please forward. W. Earle Matory, Jr., MD Division of Plastic and Reconstructive Surgey University of Massachusetts Medical Center 55 Lake Ave. North Worcester, MA 01655