The Role of Dynamic Ultrasound in the Immediate Conservative Treatment of Volar Plate Injuries of the PIP Joint: A Series of 78 Patients.

INTRODUCTION: The management of volar plate avulsion fractures in the context of a stable joint and a bony fragment of less than 30% has traditionally been conservative. This study was performed to assess volar plate healing with high-resolution ultrasound in order to provide early full mobilization. MATERIAL AND METHODS: Between January 2012 and December 2013, 78 patients with volar plate injuries of the proximal interphalangeal (PIP) joints (42 distortions and 36 dislocations) were treated conservatively in our department for volar plate avulsion fracture associated with stable joint and bony fragment inferior to 30% of the intra-articular surface assessed both by radiography and ultrasound. Conservative treatment included extension stop splinting for the first 2 weeks and Coban bandage until 6 weeks postinjury. However, it may be possible to modify the duration of extension stop splinting based on clinical and ultrasound findings (with no additional X-ray) performed every 2 weeks for the first 3 months and then at 4 months postinjury. Only patients with residual contracture at the 4-month assessment had prolonged follow-up in order to ensure adequate dynamic splint therapy. RESULTS: The amount of soft tissue oedema and the mobility of the volar plate were factors used to determine return to full mobilization. Mean extension-stop-splint wear was 16 ± 2 days. During the first 2 follow-up assessments, 4 patients were excluded from the study because of the instability of the PIP joint. One patient required refixation of a large fragment of 30%, 2 patients required superficial flexor tendon (FDS) tenodesis of the unstable volar plate in hyperextension and 1 other patient required arthrodesis of the PIP joint. In 51 patients, the postoperative follow-up was free of complications at 4 months. In 18 patients, flexion contracture of 20° (range 11°-40°) and oedema during follow-up required dynamic extension splints for 3 to 5 months. After this time, 5 patients had a residual contracture of 10° to 15°. CONCLUSION: Avulsion fractures of the volar plate at the PIP joint are common. In general, they have a good outcome using the conservative treatment with extension block splints. Flexion contracture is a common complication and may be reduced by immediate splints in full extension at night and Coban bandage during the day. High-resolution sonography is a convenient tool to evaluate palmar plate stability, to assess reduction of oedema, and thus to guide safe return to full range of movement.

INTRODUCTION: La prise en charge des avulsions de la plaque palmaire lorsque l'articulation est stable et que le fragment osseux est inférieur à 30 % est habituellement conservative. Cette étude visait à évaluer la cicatrisation de la plaque palmaire à l'aide de l'échographie à haute resolution afin de favoriser un retour rapide à une mobilisation complète. MATÉRIEL ET MÉTHODES: Entre janvier 2012 et décembre 2013, 78 patients ayant des lésions de la plaque palmaire des articulations interphalangiennes proximales (IPP) (42 distorsions, 36 dislocations) associées à une articulation stable et à un fragment osseux inferieur à 30 % de la surface articulaire à la radiographie ont été traité de manière conservative et suivi par échographie. Le traitement incluait une attelle extension-stop pendant les deux premières semaines, puis un bandage CobanMD pendant les quatre semaines suivantes. Il était cependant possible d'adapter la durée du port de l'attelle en fonction des données cliniques et de l'échographie (sans radiographie) réalisée toutes les 2 semaines jusqu'à 3 mois, puis le quatrième mois suivant la lésion. Seuls les patients présentant une contracture résiduelle au bout de quatre mois étaient soumis à un suivi prolongé incluant une attelle dynamique. RÉSULTATS: L'ampleur de l'œdème des tissus mous et la mobilité de la plaque palmaire faisaient partie des facteurs utilisés pour déterminer le retour à une mobilisation complète. Le port moyen de l'attelle extension-stop était de 16±2 jours. Lors des deux premières évaluations de suivi, quatre patients furent exclus de l'étude en raison de l'instabilité de l'articulation IPP : Pour un patient, un fragment de 30% a nécessité une refixation, pour deux patients, une ténodèse du tendon fléchisseur superficiel (TFS) a permis de stabiliser l'articulation instable en hyperextension et pour le dernier patient, une arthrodèse de l'IPP fut réalisée. Chez 51 patients, la guérison était complète après 4 mois. Chez 18 patients, une contracture résiduelle de 20° de flexion (11° à 40°) a exigé le port d'une attelle dynamique d'extension pendant une durée complémentaire de 3 à 5 mois. Après cette periode, cinq patients présentaient une contracture residuelle de 10° à 15°. CONCLUSION: Les avulsions de la plaque palmaire de l'articulation IPP sont des lésions courantes. Habituellement, un traitement conservateur à l'aide d'une attelle extension-stop permet leur guérison rapide. L'echographie à haute résolution quantifie la réduction de l'œdème et la guérision de la plaque palmaire, et par là permet de limiter le port de cette attelle extension-stop. La contracture résiduelle en flexion est une complication courante qui peut être traitée par attelle dynamique.

The impact of anxiety and depressive symptoms on chronic pain in conservatively and operatively treated hand surgery patients.

The aim of this prospective study was to examine to what extent anxiety and depressive symptoms predict the level of pain at 4-month follow-up in hand surgery patients. A total of 132 consecutive patients (mean age: 51.5±17.1 years, 51.9% female) of a tertiary center for hand surgery participated in this study. The patients underwent conservative or operative treatment, depending on the nature of their hand problem. The initial pain assessment included psychometric testing with the hospital anxiety and depression scale. Ninety-nine patients underwent operative treatment and 33 patients were conservatively treated. At 4-month follow-up, the amount of pain was measured with a visual analog scale (0-10). After controlling for age, sex, and pre-surgical pain intensity, depressive symptoms were a significant predictor for increased pain levels at follow-up in conservatively treated patients. In operatively treated patients, anxiety symptoms showed a trend for being a predictor of pain level at follow-up. The findings support the assumption that psychological factors may have an impact on pain outcome in patients presenting to hand surgery clinics.

Correlation Between Sonographic and In Vivo Measurement of A1 Pulleys in Trigger Fingers.

The thickness of 210 A1 pulleys of 21 male and female healthy volunteers in two different age groups (20-35 y and 50-70 y) were measured by ultrasound. In a second group, the thickness of 15 diseased A1 pulleys and 15 A1 pulleys of the corresponding other hand of 10 patients with the clinical diagnosis of trigger finger were measured by ultrasound. During open trigger finger release, a strip of A1 pulley was excised and immediately measured using an electronic caliper. The average pulley thickness of healthy volunteers was 0.43-0.47 mm, compared to 0.77-0.79 mm in patients with trigger finger. Based on the receiver operating characteristic (ROC) curve, a diagnostic cut-off value of the pulley thickness at 0.62 mm was defined in order to differ a trigger finger from a healthy finger (sensitivity and specificity of 85%). The correlation between sonographic and effective intra-operative measurements of pulley thickness was linear and very strong (Pearson coefficient 0.86-0.90). In order to distinguish between healthy and diseased A1 pulleys, 0.62 mm is a simple value to use, which can be applied regardless of age, sex, body mass index (BMI) and height in adults.

A comparison of complications in 400 patients after native nail versus silicone nail splints for fingernail splinting after injuries.

BACKGROUND: The fingertip is the most commonly injured part of the hand and is an important aesthetic part of the hand. METHODS: In this retrospective study we analyzed data from 700 patients operated on between 1997 and 2008 for complications after nail splinting with native nail or silicone nail. Inclusion criteria were patients living in Bern/Berner Land, complete documentation, same surgical team, standard antibiotics, acute trauma, no nail bed transplantation, and no systemic diseases. Groups were analyzed for differences in age, gender, cause and extension of trauma, bony injury and extent, infection, infectious agent, and nail deformities. Statistical analysis was done using the χ (2) test, Fisher's exact test, and Pearson correlation coefficients. RESULTS: A total of 401 patients, with a median age of 39.5 years, were included. There were more men with injured nails. Two hundred forty native nails and 161 silicone splints were used. There were 344 compression injuries, 44 amputations, and 13 avulsion injuries. Forty-three patients had an infection, with gram-positive bacteria (Staphylococcus aureus) causing most infections. A total of 157 nail dystrophies were observed, split nails most often. The native nail splint group showed significantly (p < 0.015) fewer nail deformities than the silicone nail splint group; otherwise, there were no statistical differences. However, there were twice as many infections in the silicone nail group. CONCLUSION: It seems to be advantageous to use the native nail for splinting after trauma, when possible. In case of a destroyed and unusable nail plate, a nail substitute has to be used.

Treatment of open hand injuries: does timing of surgery matter? A single-centre prospective analysis.

The 6-hour paradigm for surgical treatment of open injuries should be re-evaluated in the era of systematic use of antiseptic solutions and systemic antibiotics. The current study investigates prospectively the impact of timing of surgery on the outcome of open hand injuries. The prospective evaluation included adult patients presenting with open hand injuries between 1 September 2009 and 30 June 2010 to the emergency department of the University Hospital of Berne, Switzerland. Multiple trauma, bilateral hand injuries, bite injuries, and infections were excluded. All patients underwent a standardised treatment protocol with antiseptic solution, sterile dressing, antibiotic prophylaxis, and surgical treatment upon admission. Demographic data, injury details, and delay from trauma to therapy were recorded. Microbiology was gained at surgery. Outcome measurements included infections, complications, pain, and function (clinically, DASH, Mayo score). From 116 patients (mean age 43 years) six patients suffered an infection (5.2%). The observed infections were statistically not associated with delay to surgery, treatment protocol, or to injury complexity. Neither complications, pain, nor functional outcome were statistically associated with delay to surgery, wound disinfection, or administration of antibiotics. In conclusion, early or late timing of surgical treatment of open hand injuries did not show any impact on outcome (infections, complications, pain, function) in this prospective single-centre patient evaluation.

Macroreplantations of the upper extremity: a series of 11 patients.

INTRODUCTION: Micro- or macroreplantation is classified depending on the level of amputation, distal or proximal to the wrist. This study was performed to review our experience in macroreplantation of the upper extremity with special attention to technical considerations and outcomes. MATERIALS AND METHODS: Between January 1990 and December 2010, 11 patients with a complete amputation of the upper extremity proximal to the wrist were referred for replantations to our department. The patients, one woman and ten men, had a mean age of 43.4 ± 18.2 years (range 19-76 years). There were two elbow, two proximal forearm, four mid-forearm, and three distal forearm amputations. The mechanism of injury was crush in four, crush-avulsion in five and guillotine amputation in two patients. The Chen classification was used to assess the postoperative outcomes. The mean follow-up after macroreplantation was 7.5 ± 6.3 years (range 2-21 years). RESULTS: All but one were successfully replanted and regained limb function: Chen I in four cases (36 %), Chen II in three cases (27 %), Chen III in two cases (18 %), and Chen IV in one patient (9 %). We discuss the steps of the macroreplantation technique, the need to minimize ischemic time and the risk of ischemia reperfusion injuries. CONCLUSION: Thanks to improvements in technique, the indications for limb preservation after amputation can be expanded. However, because of their rarity, replantations should be performed at specialist replantation centers. LEVEL OF EVIDENCE: Level IV.

Assessment of endothelium and inflammatory response at the onset of reperfusion injury in hand surgery.

BACKGROUND: Activation of the endothelium, complement activation and generation of cytokines are known events during ischemia-reperfusion (I/R) that mediate tissue injury. Our aim was to elucidate their respective participation at the onset of the reperfusion phase. Tourniquet application in hand surgery causes short-term ischemia, followed by reperfusion and was therefore used as the model in this study. METHODS: Ten patients were included in the study after obtaining informed consent. A tourniquet was placed on the upper arm and inflated to 250 mmHg for 116 ± 16 min, during which the surgery was performed. Venous blood and tissue samples from the surgical area were taken at baseline as well as 0, 2, and 10 min after reperfusion and analyzed for the following parameters: Endothelial integrity and/or activation were analyzed by measuring heparan sulfate and syndecan-1 in serum, and vWF, heparan sulfate proteoglycan as well as CD31on tissue. Complement activation was determined by C3a and C4d levels in plasma, levels of C1-inhibitor in serum, and IgG, IgM, C3b/c, and C4b/c deposition on tissue. Cytokines and growth factors IL-5, IL-6, IL-7, IL-8, IL-10, IL-17, G-CSF, GM-CSF, MCP-1, TNFα, VEGF, and PDGF bb were measured in the serum. Finally, CK-MM levels were determined in plasma as a measure for muscle necrosis. RESULTS: Markers for endothelial activation and/or integrity as well as complement activation showed no significant changes until 10 min reperfusion. Among the measured cytokines, IL-6, IL-7, IL-17, TNFα, GM-CSF, VEGF, and PDGF bb were significantly increased at 10 min reperfusion with respect to baseline. CK-MM showed a rise from baseline at the onset of reperfusion (p < 0.001) and dropped again at 2 min (p < 0.01) reperfusion, suggesting ischemic muscle damage. CONCLUSIONS: In this clinical model of I/R injury no damage to the endothelium, antibody deposition or complement activation were observed during early reperfusion. However, an increase of pro-inflammatory cytokines and growth factors was shown, suggesting a contribution of these molecules in the early stages of I/R injury.

Early versus delayed surgical treatment in open hand injuries: a paradigm revisited.

BACKGROUND: To date it remains unclear if a delayed surgical treatment of open hand injuries after more than 6 h may be detrimental to outcome. Previous investigations by McLain et al. (J Hand Surg Am 16:108-112, 1980 9), Nylen and Carlsson (Scand J Plast Reconstr Surg 14:185-189, 1991 10) could not find statistical proof of correlation between infection rate and delayed surgical treatment after open hand injuries up to 18 h. The current study was designed to investigate the outcome of early versus delayed surgical treatment after open hand injury. PATIENTS AND METHODS: A retrospective data analysis of all patients sustaining an open hand injury between January 1 and December 31 2006 was performed. Patients with incomplete data records were excluded. Patients were stratified according to time delay of surgical treatment and injury complexity. Complications, revision rate, and functional outcome were also investigated. RESULTS: Between January 1 and December 31 2006 a total of 458 patients with open hand injuries were treated at the University Hospital of Berne, Switzerland. The records were retrospectively analyzed and a subgroup of 100 patients were randomly determined for standardized follow-up evaluation. There were no significant differences regarding infection, complication, and revision rate between early (<6 h) and delayed (6-24 h) surgical treatment of open hand injuries. Independently from the time point of surgical treatment, patients with complex injuries and longer operative times had an increased infection rate (p = 0.05) and revision rate (p = 0.003). CONCLUSIONS: Delayed surgical treatment (6-24 h) of open hand injuries did not increase infection or revision rates in open non-devascularizing hand injuries.