Reconstrução tardia na mão traumatizada com perda de múltiplos dedos / Late reconstruction of a traumatized hand with loss of multiple fingers

As lesões mutilantes de mão são um desafio para o cirurgião de mão e o paciente. O cirurgião deve tomar decisões desde o debridamento inicial, escolhendo quais dedos e articulações serão preservadas e uso apropriado das partes a serem retiradas. A reconstrução tardia é a segunda parte dessa difícil tarefa. Dificuldade que se atribui à particularidade de cada lesão, do grande número de possibilidades de tratamento e seus diversos níveis de complexidade que devem ser adequados à necessidade e motivação pessoal de cada paciente. Este relato de caso apresenta uma reconstrução tardia de mão com perda de indicador e dedo médio com transplante de articulação metacarpofalângica de indicador para função de interfalangeana proximal de dedo médio.

Mutilating hand injuries are a challenge to both the hand surgeon and the patient. The surgeon must make decisions ranging from the initial debridement to which fingers and joints will be preserved and the appropriate use of the parts to be removed. Late reconstruction constitutes the second part of this difficult task. The difficulty attributed to the characteristics of each lesion, the large number of treatment possibilities, and the different levels of complexity must be adapted to the personal needs and motivation of each patient. This case report describes a late hand reconstruction with index and middle finger loss, using metacarpophalangeal joint transplantation of the index finger to gain the proximal interphalangeal function of the middle finger.

Epidermólise bolhosa distrófica: aspectos dermatológicos e cirúrgicos / Dystrophic epidermolysis bullosa: dermatological and surgical aspects

A epidermólise bolhosa é uma doença hereditária que causa alterações em proteínas estruturais da pele e consequente fragilidade da epiderme. Manifesta-se por surgimento de flictenas por todo o corpo e deformidades funcionais de membros, especialmente nas mãos, sendo que as formas mais características são pseudossindactilia e contraturas. Neste trabalho, descrevemos o caso de um paciente de 12 anos com deformidades nas mãos e flictenas pelo corpo que foi submetido à cirurgia da mão para recuperação da movimentação funcional (AU)

Epidermolysis bullosa is a hereditary disease that causes changes in structural proteins of the skin and consequent fragility of the epidermis. It is manifested by the appearance of blisters all over the body and functional deformities of limbs, especially the hands, and the most characteristic forms are pseudosyndactyly and contractures. In this paper, we describe the case of a 12-year-old patient with deformities in his hands and blisters over the body who underwent hand surgery for recovery of functional movement (AU)

Arthrodesis of Distal Interphalangeal Joints in the Hand with Interosseous Wiring and Intramedullary K-wire Fixation

BACKGROUND: To evaluate the efficacy of intramedullary K-wire fixation and interosseous wiring in the arthrodesis of the distal interphalangeal (DIP) joint with description of surgical procedure. METHODS: We retrospectively analyzed 9 cases (7 women and 2 men) of DIP joint arthrodesis. The average age of patients was 44.2 years (range, 21 to 71 years) and the mean follow-up period was 19.6 months. Joint union was evaluated on the follow-up radiographs together with postoperative complications. RESULTS: All cases achieved radiologic union of the arthrodesis site. There was no surgical complication except for one case of skin irritation by the interosseous wire knot which was removed during the follow-up period. CONCLUSIONS: Intramedullary K-wire fixation and interosseous wiring could be an alternative procedure of arthrodesis in the DIP joint.

Macrodactilia na mão: relato de caso / Hand macrodactyly: a case report

Os autores descrevem a evolução de um caso de macrodactilia digital progressiva na mão ao longo de 10 anos e os programas cirúrgicos e de reabilitação utilizados. Criança do sexo feminino foi admitida no Hospital de Reabilitação aos 10 meses de idade, apresentava macrodactilia digital progressiva no II e III quirodáctilos da mão esquerda. Evoluiu com síndrome do túnel do carpo, atrofia e perda da oponência do polegar. Aos dois anos, foi submetida a amputação do III raio; aos seis anos, a encurtamento do II dedo, epifisiodese e, aos nove anos, a retinaculotomia dos flexores, amputação do II raio e restauração da oponência do polegar com a transferência do extensor próprio do índex. Foram necessários vários procedimentos e métodos de tratamento para o alívio dos sintomas de compressão do nervo mediano e resultado final funcional satisfatório. Os autores recomendam a amputação como opção cirúrgica e o tratamento precoce da síndrome do túnel do carpo.

The authors describe the progress over a ten year period of a single hand macrodactyly digital progressive case and corresponding surgical and rehabilitation procedures used. The female child was first evaluated at the hospital at the age of 10 months, with macrodactyly digital progressive at I and II fingers of the left hand. Afterwards she developed carpal tunnel syndrome, atrophy and lost of thumb opposition. The third ray was amputated at age 2. At age 6 she was realized finger shortening, physeal arrest and at age 9 a carpal tunnel release, II ray resection and proprius extensor tendon opponensplasty. Many interventions and treatment methods were required to relieve the compression symptoms of the median nerve and satisfactory final functional result. The authors recommend amputation as a surgical option and early carpal tunnel release.

Single slip sublimins transfer for the management of post-traumatic swan-neck deformity of the fingers; preliminary study of a newly proposed technique

Swan-neck deformity of the fingers is a cause of functional and cosmetic deficit for most of the patients, the main pathology lies on the PIP joint and most of the surgical treatments depends on the integrity of the soft tissues around it including sublimins tendon that plays an important role in the success of most of the surgical procedures to describe anew surgical technique for the treatment of post - traumatic swan-neck deformity in the fingers. nine patients with post-traumatic swan-neck deformity with intact [FDS] were included in this study. The operation included transferring the insertion of one slip of the sublimins to the A4 transverse pulley this allowed a more dynamic PIP and a better hand function in comparison with other known operations further studies with larger sample and longer period of follow up may give better and more accurate results about this new procedure that can be regarded as a modified Tonkin technique

Some more about unfavourable results after corrective surgery as seen in leprosy.

The paper describes unfavourable outcomes of some of the commonly performed surgical procedures in leprosy affected persons and the underlying causes. An awareness about unfavourable outcomes of surgery is helpful to the beginners because they can anticipate the problems and take appropriate measures to prevent that and failing which prepare themselves to face and sort that out. Careful pre-operative evaluation of the patient is an important first step.

Deformidad en Boutonnière de los dedos en la artritis reumatoide / Boutonnière deformities in hand fingers due to rheumatoid arthritis

La artritis reumatoide afecta las manos en un 90 por ciento y la deformidad en boutonnière tiene una frecuencia de 36 por ciento, alcanzando un 18 por ciento en deformidades no corregibles. Esta deformidad se caracteriza por extensión de la articulación metacarpofalángica, flexión de la interfalángica proximal, e hiperextensión de la articulación interfalángica distal. Se estudiaron de 1971 a 1999 en el hospital ABC, 70 pacientes con artritis reumatoide; de éstos, 26 presentaban deformidad en boutonnière que se clasificó según Nalebuff y Millender. Los pacientes con deformidad tipo I o II fueron tratados conservadoramente y el tipo III con artrodesis primaria en 24 casos y secundaria en dos, obteniéndose mejoría cosmética y estabilidad en la prensión.

Deformidad en cuello de cisne de los dedos en la artritis reumatoidea / Swan-neck deformity of the fingers in rheumatoid arthritis

La deformidad en cuello de cisne, se caracteriza por hiperextensión de la articulación interfalángica proximal y flexión de la articulación interfalángica distal. Es limitante y progresiva. De 1971 a 1999, en el hospital ABC, fueron estudiados 33 pacientes: 29 mujeres y cuatro hombres, con un total de 48 dedos con deformidad. La distribución de acuerdo a la clasificación de Nalebuff y Millender fue: cinco casos tipo I, 12 tipo II, 13 tipo III, 11 tipo IV y siete tipo V. Se practicó sinvectomía flexora y plastia palmar en la vaina sinovial en dos casos con deformidad. Cuatro dedos con deformidad tipo III fueron tratados mediante resección artrosplástica metacarpofalángica con tenotomía de intrínsecos del lado cubital sin que se lograse mejoría. Se realizaron 16 artrodesis de articulación interfalángica proximal con deformidades IV y V, en todas se consiguió mejoría de la prensión. Sólo se registró un caso de infección superficial. El médico internista o reumatólogo debe estar familiarizado con la clasificación a fin de detrminar el estadio de la deformidad, refiriendo a los pacientes en forma temprana con el cirujano de mano, para posibilitar el realizar más procedimiento sobre partes blandas. Cuando la deformidad es avanzada, la artrodesis interfalángica proximal es un procedimiento definitivo que mejora la calidad de vida del pacientes

Tratamiento del pulgar en la artritis reumatoide / Treatment of rheumatoid thumb deformities

La artritis reumatoide lesiona al pulgar en un 60 por ciento de los casos y repercute en las actividades cotidianas del paciente. Las deformidades más frecuentes son la de Boutonniere y la de cuello de cisne. Fueron estudiados 70 pacientes con artritis reumatoide en el Hospital ABC de 1971 a 1999, de los cuales 42 presentaban deformidades en el pulgar. Los casos fueron clasificados con base en lo propuesto por Nalebuff. Veintisiete pacientes recibieron tratamiento conservador, mientras que 15 fueron tratados de manera quirúrgica de acuerdo a lo indicado por Flatt, obteniéndose buenos resultados

Rectangular flaps technique for treatment of congenital hand syndactyly

A sindactilia e uma das mais frequentes deformidades congenitas da mao. Neste estudo, sao analisados 22 pacientes submetiods a correcao de sindactilias congenitas da mao, utilizando-se a tecnica dos retalhos retangulares. Resultados considerados esteticamente e funcionalmente bons foram obtidos em 77,3 por cento dos casos, e complicacoes ocorreram em 13,6 por cento. A tecnica mostrou ser de simples execucao, e com resultados favoraveis podendo ser aplicada na maioria dos casos de sindactilias da mao

Reporte de 100 casos, experiencia de tratamiento quirúrgico en el Hospital Español de México y el Hospital San Eloy: Vizcaya España / Dupuytren's diasease: report of a 100 cases: experience of surgical treatment

En el periodo de enero de 1995 a octubre de 1997, se captaron 62 pacientes que presentaban enfermedad de Dupuytren (ED), con un total de 100 casos, utilizándose la clasificación de TUBIANA, de acuerdo a la gravedad de la enfermedad, distribuyéndose 10 casos en el grado I, 38 casos en el grado II, 42 casos en el grado III y 10 casos grado IV, todos los casos sin antecedente quirúrgico, la edad de presentación osciló, entre los 55 y 65 años de edad. El antecedente más importante que se encontró fue el heredofamiliar de 1a. y 2a. generación, una vez decidido el tratamiento quirúrgico se realizaron incisiones digitopalmares con técnica de BRUNER con liberación de nódulos y estructuras involucradas; se dejó drenaje durante 48 horas en todos los pacientes y se colocó férula antibraquipalmar con retiro de puntos a los 12 días, dentro de las complicaciones encontradas fueron hematomas en 18 casos, los cuales fueron drenados con necrosis de bordes de la herida en los casos más avanzados de la enfermedad. Un caso con infección superficial el cual cedió con antibiótico y un caso en el cual se tuvo que amputar el 5º dedo a los 6 meses de postoperatorio

Joshi External Stabilising System (JESS) in proximal interphalangeal joint (PIP) contractures in leprosy.

The authors present their experience in the use of the JESS (Joshi External Stabilising System) for correction of proximal interphalangeal joint (PIP joint) contracture deformity in 68 fingers. The use of the JESS has made this surgery easier, faster in releasing contractures and it has given better correction than the methods so far used by the same authors, like capsulotomy, local flaps and free skin grafting. The procedure is simple and has no serious side effects; it can be repeated if need be. The JESS is easy to apply, economical, reliable, reusable, well accepted by the patient. Compared to the other distractors made in USA and Europe, the JESS has an added advantage in that it costs so very much less (US $5-10), that our leprosy hospitals can afford it. In our patients, we have achieved full extension in 75% and good extension in 10.3% of the cases. These figures are much better than what was possible, in the past, with local flaps and free skin grafting. With those procedures we had excellent results in only 53% of the cases and poor result in 28%.

Retalho livre lateral do braço: avaliaçäo de dez casos / Lateral arm free flap: evaluation of 10 cases

Os autores apresentam análise de dez casos de retalho livre lateral do braço, realizado em dez pacientes, no período de março de 1994 a agosto de 1996. Foram empregados no tratamento de lesöes cutâneas de membros superiores e inferiores de natureza diversa. Quanto à composiçäo dos tecidos, foram oito retalhos fasciocutâneos, um osteocutâneo e um osteocutâneo e tendinoso. Com relaçäo à viabilidade, todos os retalhos mantiveram-se viáveis, a despeito de um caso de trombose intra-operatória e um de necrose parcial de pele, resolvidos com trombectomia e enxerto de pele parcial, respectivamente. O retalho lateral do braço mostrou-se eficaz no tratamento de defeitos cutâneos isolados ou combinados, de pequenas e médias proporçoes, quando os recursos convencionais da cirurgia reparadora eram questionáveis.

A double synergistic approach to correction of the intrinsic minus hand.

In the search of a method for the correction of the intrinsic minus hand with simplified post-operative physiotherapy training, preferably dynamic methods acting in a synergistic way, two methods were identified, one correcting clawing in extension, the other correcting clawing in flexion under strain. Forty-three patients (53 hands) were operated upon using a combination of the methods. The immediate post-operative results showed that 50 of the hands had satisfactory result. Twenty patients (26 hands) were traced and reviewed after 0.5-5.5 years (average 2.75 years) and 14 of these hands showed good, 11 fair, and one poor result. All patients reported that their hand function had improved after correction. Post-operatively, the physiotherapy staff were only required to exercise active extension and flexion of the fingers. The advantages and disadvantages of the approach are discussed. The method requires an experienced surgeon but the post-operative training is simple and there is no need for re-education of transferred tendons. I have found the method useful for patients with difficulties in re-education and for patients in programmes where the physiotherapy back up is less developed.

Prevention of post-operative "sublimis minus" deformity by modified surgical procedure at the donor finger.

"Sublimis minus" deformity occurs quite often as a post-operative deformity in the donor finger after transfer of the flexor superficialis tendon e.g., for paralytic claw finger correction. Our experience with a new procedure to avoid this outcome is described here. Long term results in 35 cases are very encouraging and the new procedure promises to be useful to prevent sublimis minus deformity. It also opens out a wider range of discretion given to hand surgeons to use the sublimis tendon more freely for transfers.

Surgical correction of claw fingers in leprosy using flexor superficialis direct lasso procedure.

One tendon of Flexor digitorum superficialis split into two or four tails and each tail looped around the A1 pulley of one affected finger, was used for correcting intrinsic minus deformity of fingers in 144 patients. This operation has the advantage of retaining superficialis tendons of the other fingers for better power grip and avoiding swan-neck deformity. Satisfactory results were noticed in 81 of the 99 patients (82%) followed up. The remaining 18 patients showed a variety of problems such as swan neck/check rein deformity in the donor finger, skin contracture and recurrence of clawing.

El colgajo fasciocutáneo radial de base distal / Radial fasciocutaneous graft of distal base

La cobertura cutánea de la mano constituye un problema complejo cuando sus estructuras óseas, articulares o tendinosas están expuestas. Presentamos nuestra experiencia con 14 colgajos fasciocutáneos radiales de base distal (CFCRBD) del antebrazo en la cirugía recosntructiva de la mano de 13 pacientes portadores de exposición osteotendinosa por heridas y quemaduras, contracturas cicatriciales postquemadura y muñones de amputación con cobertura cutánea inestable. La técnica quirúrgica consiste en el levantamiento de un colgajo fasciocutáneo radial de base distal que sigue el eje, pero no incluye la arteria radial. No hubo complicaciones en 4 casos; en 5 pacientes se observó sufrimiento isquémico superficial del borde distal del colgajo que se recuperó con tratamiento conservador y en otros 5, necrosis de espesor completo que lograron cobertura empleando secundariamente segmentos proximales del colgajo. El CFCRBD constituye una alternativa aceptable en la reconstrucción de la cobertura cutánea de la mano por la sencillez de su diseño y rápida ejecución sin requerimiento de técnica microquirúrgica. Al mismo tiempo evita las molestias de la inmovilización de los colgajos pediculados en tronco o brazo contralateral y no sacrifica vasos importantes