The anterior cubital approach for displaced pediatric supracondylar humeral fractures.

The authors report a technique of the anterior cubital approach that is an exposure for displaced pediatric supracondylar fractures. Reduction is very safe and easy with this approach. Anatomical structures that hinder reduction such as the brachialis muscle or joint capsule and neurovascular tissues can be identified easily. This technique has not been a popular form of treatment in many countries, particularly in the United States.

[External rotation osteotomy of the humerus for the treatment of shoulder problems secondary to obstetric brachial plexus palsy]. / Dogumsal brakial pleksus felcine bagli omuz sorunlarinin humerus dis rotasyon osteotomisiyle tedavisi.

OBJECTIVES: We evaluated the results of external rotation osteotomy of the humerus for the treatment of shoulder problems secondary to obstetric brachial plexus palsy. METHODS: Forty children (24 boys, 16 girls; mean age 7.5 years; range 23 months to 14.8 years) underwent external rotation osteotomy of the humerus. Involvement was at the C5-6 roots in 11 patients, C5-6-7 roots in 19 patients, and at all the roots in 10 patients. Twenty-six patients had humeral head deformity and eight patients had posterior subluxation. The shoulder was ankylosed in one patient. Zancolli and Putti signs were positive in six and eight patients, respectively. The mean active shoulder abduction was 80 degrees (range 0 to 170 degrees ) and the mean internal rotation contracture was 27 degrees (range 10 degrees to 50 degrees ). Fourteen patients, all of whom were beyond five years of age, had an abduction contracture. Preoperative and postoperative functional evaluations were made with the use of the Mallet scale. Preoperatively, 35 shoulders had a score of II, five had a score of III. Osteotomies were performed in the proximal humerus in patients older than five years and in the mid-humerus in those without a contracture or younger than five years. RESULTS: The mean postoperative shoulder abduction was 95.7 degrees (range 30 degrees to 170 degrees ). Internal rotation contractures improved in all the patients. Abduction contractures did not resolve in two patients in whom a mid-humeral osteotomy was performed. Postoperative Mallet scores ranged from II to V in five, six, 15, and 14 shoulders, respectively. Rotation provided by the osteotomy was lost in one patient because of a humerus fracture that occurred in a traffic accident. Passive total shoulder rotation remained unchanged following surgery. Patients having better preoperative range of motion and who were at younger ages benefited the most from surgical treatment. CONCLUSION: External rotation osteotomy of the humerus must be performed at early ages before the shoulder gets stiffer.

Open reduction of displaced pediatric supracondylar humeral fractures through the anterior cubital approach.

The authors performed a retrospective review of the anterior cubital approach, an alternative exposure for displaced pediatric supracondylar fractures. Anatomic structures that hinder reduction, such as the brachialis muscle or joint capsule, and neurovascular tissues can be identified easily with this approach. Sixty-one children with displaced supracondylar humeral fractures were treated surgically with Kirschner wires using the anterior cubital approach between January 1996 and August 2002. The cohort comprised 35 boys and 26 girls with a mean age of 8.7 years (range 3-13 years). Mean follow-up was 3.5 years (range 1-6 years). Preoperatively 13 children (21.3%) had a neurovascular insufficiency that required an exploration during the operation. All patients were reduced completely with full anatomic position. On follow-up, no patient had any scar formation or deformity or experienced any restricted motion. The authors conclude that the anterior cubital approach is very effective and is an option for the treatment of pediatric supracondylar humerus fractures without serious complications.

Surgical treatment of macrodactyly in older children and adults.

PURPOSE: To introduce a surgical technique for the treatment of macrodactyly in older children and adults, to represent the degree of correction obtained by the procedure, and to give the functional results. METHODS: Two thumbs and 5 fingers of 5 patients aged 12 to 32 years (mean, 17.5 years) with macrodactyly had surgery. The amount of tissue sufficient to reconstruct a normal-sized digit was left attached with the neurovascular bundle on the concave side of the macrodactylic digit and complete excision of whatever remained was performed. This requires usually arthrodesis of the distal interphalangeal joint with bone shortening. The large skin fold created during bone shortening and remaining angulations at the proximal phalanx were corrected during a second procedure. The patients were evaluated for 3 to 9 years (mean, 5.4 years) after the surgery. The length and circumferences of the involved digits and their opposites were measured before surgery and during the last follow-up examination to calculate the differences between the involved and the healthy digits, which were documented. The degree of reduction was quantified and noted. Two-point discrimination tests and active range of motion of the joints were recorded as well. RESULTS: For the thumbs an average 37% of circumference and 15% of length were reduced and for the fingers an average 44% of circumference and 35% of length were reduced. Ranges of motion of the joints of the involved digits were the same or nearly the same as before surgery in all of the cases. Two-point discriminations at the pulp of the involved digits were found to be the same as presurgical values in all digits. CONCLUSIONS: The technique is precise and simplifies the planning of the surgery. Although the macrodactylic digits with angulation deformities required a subsequent surgery for corrections patients with marked macrodactyly of the digit without a very wide proximal phalanx and metacarpal gained most from this technique.

The Brooks and Graner procedure for treatment of chronic tendinous mallet finger deformity.

Most of the mallet finger deformity results from tendinous origin. Many surgical techniques defined for chronic mallet deformity are aggressive, which often result in disappointment. The Brooks and Graner procedure is a developed surgical technique and useful procedure for chronic mallet finger deformity with tendinous origin. The method is simple and very effective for treatment of chronic mallet deformity.

Posterior interosseous artery flap in traumatic hand injuries.

INTRODUCTION: Nineteen cases of posterior interosseous artery (PIOA) flap were reviewed. The patients' mean age was 24 (range 14-53) years. MATERIALS AND METHODS: Nine patients were operated on as emergencies, and 10 patients were treated electively. Mean time of delay after trauma was 7.8 h (range 2-20 h) in emergency cases. Nine of them were non-replantable amputations. Skin defects were between 1.9 x 2.4 cm and 5.0 x 12.0 cm. Mean hospitalization time was 2.2 (range 1-5) days. RESULTS: Mean flap sensation was evaluated as 2.83-6.65 with the Semmes-Weinstein evaluation scale (only 2 patients scored less than 3.61). Five patients presented with discoloration and coolness. Average subjective evaluation was 8.2/10. Mean web opening after first web reconstruction was 40 degrees. One posterior interosseous neuropraxia ( recovered in 4 months), one distal flap necrosis, and one flap lost (due to infection) occurred as early complications. Mean follow-up was 12.8 months (range 15 days to 30 months). CONCLUSIONS: PIOA flap applications have reduced the need for lateral arm and radial forearm flaps and also shortened hospitalization time in clinical practice.

Foucher's first dorsal metacarpal artery flap for thumb reconstruction: evaluation of 21 cases.

BACKGROUND: Coverage of part of a soft tissue defect in the thumb, without bone shortening and without long-lasting immobilization in an inappropriate position leading to stiffness, is difficult to achieve OBJECTIVES: To report our experience using Foucher's modification of the first dorsal metacarpal artery flap for thumb reconstruction in 21 cases. METHODS: Foucher's flap is based on the neurovascular structures of the first dorsal metacarpal artery flap and radial nerve-sensitive branches on the dorsum of the second metacarpal and proximal phalanx. The cause of injury was work-related in all 21 cases. The patients mean age was 37 (range 17-68 years), and mean follow-up was 19 months (range 12-31). Emergency surgery was performed in 13 patients with a time delay after injury of 4-12 hours. The minimum defect was 12 x 18 mm and the maximum 20 x 40 mm. Pedicular length was 55-95 mm. A skin bridge was left intact in 16 cases. In two cases of early postoperative venous congestion and flap loss, a cross-finger flap was performed as a salvage procedure. RESULTS: Subjective satisfaction score was 8.37/10 (range 4-10); cold intolerance was experienced in 60% and dysesthesia in 33%. All except one patient are able to use their thumb in daily activity. Loss of mobility in the proximal interphalangeal joint of the index finger was less than 20 degrees. Semmes-Weinstein sensitivity evaluation score was 3.61-4.31 on the flap and 0-6.65 on the donor site. Two-point discrimination was 10.8 mm (range 8-20). Grip strength was reduced by 15% compared to the unaffected hand (hand dominance was not taken into consideration). Rehabilitation was not consistent as almost all the patients were living in another location. CONCLUSIONS: First DMCA pedicle flap is a successful thumb reconstruction method, especially in patients not disturbed by its cosmetic appearance.