Hand and forearm injuries from penetrating projectiles.

Compared with other surgical literature published after the Vietnam and Persian Gulf wars, hand surgery literature has been relatively void of information regarding projectile injury. Wound ballistics research of the past 10 years has shown that objective evaluation of tissue disruption is the only valid guide to treatment. The hand's anatomy requires hand surgeons to be more careful in tissue excision. Hand surgeons, therefore, do not have the luxury of "cutting till it bleeds." The purpose of this article is to support the methods that hand surgeons have traditionally used and to caution the inexperienced surgeon who may be inclined to excise uninjured tissue.

Compression plate arthrodesis of the elbow.

We reviewed 15 patients with an arthrodesis of the elbow using an AO compression-plate technique, after an average follow-up of 24 months. The most common indication was an open, infected high-energy injury with associated bone loss. Arthrodesis was successful in all but one patient in whom severe deep infection necessitated amputation. Eight patients were treated with the metal partly exposed in an infected wound. After removal of the metal, all wounds healed secondarily and none had clinical or radiographic signs of sepsis at latest review. Compression-plate arthrodesis of the elbow is a generally applicable method that can be used even in cases of severe bone loss. There appears to be greater certainty of union than with other techniques, and no increased risk of subsequent fracture.

Long-term histologic results of vein grafting with the telescoping anastomotic technique.

We studied the long-term histologic results of a new method for autogenous vein grafting to examine whether stenosis at the anastomosis is maintained over time. Nineteen rat inferior epigastric veins were grafted into the femoral artery using a telescoping sleeve technique at both the proximal and the distal anastomoses. Specimens were studied macroscopically and histologically three months later. Stenosis at the anastomosis was located near the tip of the inserted vessel. The smallest inner diameters of the proximal and distal anastomoses were about 80% of the corresponding femoral artery diameter; no statistically significant difference was found between the two anastomoses. The grafts had a thickened wall due to intimal hypertrophy and fibrosis of the media. The inner diameter of the graft was, however, about twice that of the femoral artery, and these graft changes did not create any apparent constriction within the graft.

New method for autogenous vein grafting with the telescoping anastomotic technique.

An experimental study was performed to examine whether a microsurgical telescoping anastomotic technique could be applied twice in one vessel, for use in autogenous vein grafting. The rat inferior epigastric vein was grafted into a defect created in the femoral artery. The original telescoping method of Lauritzen was used, with two additional suture placements, to allow anastomosis at both proximal and distal sites. By placing the four sutures symmetrically and carefully timing the removal of the proximal and distal clamps, we achieved a patency rate of 77.3%. This is a new method for autogenous vein grafting that may serve as a prototype for an easier and possibly faster vein grafting technique. Our results appear to indicate that complete coaptation of the severed vessel ends is not necessarily required for patency in microvascular repair.

AIDS in the hand patient: the team approach.

Hand surgeons and therapists were faced with a new clinical entity in the 1980s with the emergence of hand and upper extremity infections in patients with AIDS and HIV disease. This entity has become a worldwide epidemic of vast proportions and has proven to be one of the major health concerns of the 1990s. It seems likely that treatment of patients with this devastating disease for hand infections or more routine upper extremity problems will become routine in the future. The reality of surgical treatment and hands-on rehabilitative therapy for patients with a life-threatening infectious disease has been a concern voiced publicly by very few health care professionals, yet discussed quietly among colleagues quite frequently. Our aim must be to provide the highest quality of health care to this group of hand patients, just as we do for all other patients, while at the same time providing the safest possible environment for all members of the health care team. It appears that there is a higher incidence of HIV infection among hand patients than is noted in the general public; therefore, the hand surgeon and medical team should pay particular attention to the rapidly advancing front of new information available regarding care for this challenging group of patients. Hand surgeons and therapists are entering the 1990s armed with a wealth of new and valuable information about HIV disease that has been produced by intensive basic science research and clinical observations accumulated over the last 10 years. The fears generated by the initial misinformation and lack of information concerning modes of transmission of HIV have generally been supplanted by a more rational approach to patient care, fostered by the more accurate scientific information currently becoming available. Unfortunately, the rational approach to the HIV-related political and socioeconomic issues has not yet overtaken the discrimination and stereotyping of the populace stricken with HIV disease. It remains the responsibility of the medical community to continue research efforts aimed at delineating the clinical deficiencies manifested by these patients and determining their effects on treatment regimens for both the unique and commonplace medical and orthopedic problems noted in this patient population.

Deep space infections.

Joint sepsis and osteomyelitis have potentially devastating consequences in the hand. Local tissue and systemic immune system compromise increase vulnerability. Early and accurate diagnosis with specific organisms(s) retrieval is emphasized. Treatment includes drainage, debridement, appropriate antibiotics, and reconstruction when necessary.

Single-vessel forearm arterial repairs. Patency rates using nuclear angiography.

Nuclear angiograms were used to determine early and delayed patency rates following primary microvascular repair of 12 radial and 24 ulnar arteries in 36 patients. All patients had nuclear angiograms within 1 week after repair, demonstrating an early patency rate of 86.1%. Nineteen patients had additional nuclear angiograms at various intervals from 30 days to 2 years, showing a delayed patency rate of 68.4% at an average of 5.4 months follow up. Survival analysis showed that patency fell steadily during the first 90 days postoperatively, after which no further arterial occlusions occurred. Patency rates were not significantly affected by age or sex of the patient, level of forearm injury, total tourniquet time, treatment delay, or the diameter of nylon suture used for arterial repair. At follow up, there were statistically insignificant trends for higher patency rates in patients with partial vessel lacerations and in nonsmokers.

The fascial radial flap.

Six patients with full-thickness skin loss complicating traumatic problems of the hand each had a retrograde forearm fascia flap transfer. Fascial pedicle flaps were used, because more conventional means of coverage had failed or were deemed inappropriate. Four patients had an uncomplicated one-stage flap transfer. Two patients had postoperative hematoma, but no further procedures were required. One patient had superficial necrosis of more than one fourth of the flap. Hematoma and necrosis were considered to be a result of a reversed flow occurring in the radial artery and its vena comitant and to the increased vascular pressure of the flap. This technique provides soft tissue reconstruction of the hand in one stage, with the advantage of early rehabilitation.

A study of the dynamic anatomy of extensor tendons and implications for treatment.

This study correlates the excursion of the extrinsic finger extensors in zones V, VI, and VII and the extensor pollicis longus tendon in zones T IV and T V ("T" is used to designate thumb zones) with joint motion. Excursion was estimated by review of the literature, biomechanic calculations, and intraoperative observations. A simple equation determines extrinsic extensor tendon excursion in zone V, VI, and VII. This equation is substantiated by Brand's work on radians and by intraoperative studies. Guidelines are suggested for controlled motion for extrinsic finger extensors and the extensor pollicis longus tendon on the basis of our 6 years experience of treating extensor tendon injury with early passive motion.

Arthrodesis of the salvage elbow.

An elbow arthrodesis was performed as a salvage procedure in seven patients with an open elbow arthrosis resulting from open trauma and the multiple surgeries that had followed. Patients had undergone an average of four previous elbow operations since their initial injury. Patients had pain, limited motion and instability that seriously compromised ipsilateral upper extremity function. Hardware was placed posteriorly in five patients, and in two patients with predominantly posterior pathology and infection, it was placed anteriorly. All but one case was fused at 90 degrees of elbow flexion. Wounds were all left open and spontaneously healed by secondary intention. Six patients were available for an average follow up of 4 years. Time to fusion ranged from 4 to 9 months (mean 6 months). Patients were graded in terms of relief of symptoms, clinical fusion, radiographic fusion, return to employment, wound healing, shoulder and hand function, and forearm rotation. Three patients had an excellent result, two good, and in one, the result was fair. In our view, the surgical procedure of choice for a salvage elbow is an elbow arthrodesis.

Comminuted intraarticular fractures of the distal humeral condyles. Surgical vs. nonsurgical treatment.

Forty-two comminuted intraarticular fractures of the humeral condyles treated between 1975 and 1981 were analyzed in order to compare the results of operative versus nonoperative management. Twenty-nine patients were treated by open reduction and internal fixation; the remainder were treated by nonoperative techniques. Functional results were evaluated by the method of Bickel and Perry. Of the patients treated by open reduction and internal fixation, 76% had an excellent or good result. Of the nonsurgically-treated patients, only eight percent had a satisfactory result. Anatomic restoration by open reduction and rigid internal fixation in conjunction with early motion was associated with satisfactory results. The preferred surgical exposure was a posterior "U" incision with extraarticular olecranon osteotomy. This provided good visualization and facilitated anatomic restoration in these complex fractures.

Fingertip injuries.

Open fingertip injuries may be treated effectively by primary wound care followed by secondary intention wound healing. More sophisticated techniques of wound closure have only limited applicability and are associated with a significantly increased risk of failure.

Ring avulsion injuries, care of amputated parts, replants, and revascularization.

Microsurgery has improved our ability to deal with severe injuries to the upper extremity. Good medical management and judgment plus a sense of realism communicated from physician to patient is as important as the surgical technique.

A functional treatment method for interphalangeal pyogenic arthritis.

A treatment plan for pyogenic arthritis has been devised in which the accessory collateral ligaments are resected through radial and ulnar midaxial incisions. The surgical wound is debrided and copiously irrigated with an antibiotic solution, and intravenous antibiotics are instituted before operation and continued after operation. Physical therapy is begun within 24 hours of surgery and includes active range of motion (ROM) of all joints, dynamic splinting, and hand therapy to ensure both full flexion and extension. Forty patients were treated with this method within a 6-year period. Of five interphalangeal (IP) joints of the thumb, four regained 0 degree to 60 degrees full ROM and one gained 15 degrees to 65 degrees limited ROM. Of the two distal IP joints, one regained full ROM and the other became fused. Among the 33 proximal IP joints, 13 regained full ROM of 110 degrees and 13 regained limited ROM. Good functional results were obtained with this treatment plan in lieu of amputation, which previously was the most likely treatment.

Closed treatment of fractures of the hand.

Closed treatment of hand fractures avoids the stiffness associated with internal fixation. Early motion within the framework described allows the soft tissues to participate in achieving stability of the fracture and seems to speed union.