The treatment of felons and paronychias.

Infections of the distal finger have a varied presentation, course, and treatment. As in other hand infections, initial treatment should always include elevation of the extremity and the avoidance of snug clothing or constricting jewelry. Immunosuppressive states and systemic diseases such as diabetes must be considered, for they will alter the action of the causative organisms as well as the intensity of treatment that a patient will require. Appropriate, specific antibiotic treatment can be part of the initial treatment of acute felons and paronychias, but it should never replace adequate incision and drainage. Finally, "minor" finger infections are only minor when diagnosed and treated properly. If mistreated, their consequences can have long-term implications for both the individual and for society. It is important to understand the natural history, bacteriology, and anatomy of the distal finger if we are to return patients to their jobs with expedience and minimal long-term sequelae.

Percutaneous desmotomy of digits for stiffness from fixed edema.

A simple technique, not previously described, has been successful in achieving increased motion of contracted metacarpophalangeal and proximal interphalangeal joints of the hand. The procedure involves percutaneous sectioning of collateral ligaments followed by joint manipulation. Experience with 65 stiff joints treated by this minimally invasive technique followed by physical therapy revealed an average final gain of 28 degrees for metacarpophalangeal joints and 19 degrees for proximal interphalangeal joints. Mean follow-up was 13 months. This compares favorably to the more aggressive technique of open arthrolysis, thus offering a simple and effective treatment alternative.

Long-term analysis of patients having surgical treatment for carpal tunnel syndrome.

This retrospective study of 100 patients who had surgical treatment for their carpal tunnel syndrome was performed to determine what factors were associated with long-term success or failure. One hundred thirty hands were treated surgically with an average follow-up of 4 years (range, 2 to 6 years). All patients were given a course of conservative treatment that included steroid injection(s) and splinting until the patients were refractory to such therapy. Over 250 injections were given (117 wrists), with the average benefit time of 27 weeks (range 0 to 330). Most patients received two to three injections (maximum of nine). Variables associated with a failure to have long-term benefit after operation included weakness or atrophy of the abductor pollicis brevis muscle, presence of a predisposing condition, and failure to benefit from the initial steroid injection. Conversely, all 51 hands that had relief from median nerve paresthesia for more than 6 months by conservative therapy alone received long-term relief after surgery. Steroids were least effective in hands that had muscle involvement. Fifteen of the 40 hands with muscle involvement regained their muscle mass by the time of the final examination.

Pseudotendon formation after flexor tendon injury.

The biologic reconstitution of a divided flexor tendon by scar tissue forming a "pseudotendon" is described in three cases. With close inspection, one is able to differentiate a pseudotendon from a normal tendon intraoperatively by its relatively light gray color and the lack of a glistening surface. A pseudotendon lacks the tensile strength of a normal tendon and should be replaced by tendon grafting or transfer if function is to be restored.

Treatment of painful hand neuromas by their transfer into bone.

Painful neuromas in the hand are not only very disabling for the patient, but difficult to treat. We present the results of 20 painful neuromas treated by burying the neuroma in the bone. Eighteen of the 20 neuromas operated on had acceptable results, according to the criteria of Herndon et al. We present our technique and compare our results with other treatments in the literature.

Diagnosis and treatment of retained foreign bodies in the hand.

A retrospective review was conducted of 200 consecutive patients with foreign bodies in the hand seen between 1976 and 1982. Wood, glass, and metal accounted for 95 percent of the foreign bodies seen. The duration of follow-up ranged from 1 week to 3 years (average 6 weeks). Approximately 70 percent of the foreign bodies could be removed in either the office or the emergency room. The foreign bodies were removed anywhere from the day of injury to 20 years later. In 38 percent of the patients the diagnosis was missed by the initial treating physician, in many cases because a roentgenography of the injured area was not taken. Metal was visible in all of the radiographic studies obtained, glass in 96 percent, and wood in just 15 percent.

Peripartum pseudomalignant myositis ossificans of the finger.

Two cases of pseudomalignant peripartum myositis ossificans of the finger are reported. The benign diagnosis is confirmed by the histologically characteristic zone phenomenon, consisting of a transition from an inner zone of proliferating spindle cells to a middle zone of well-oriented osteoid and finally to an outer zone of mature bone. In Case No. 1, because of the question of malignancy, a ray amputation was performed. In Case No. 2, the patient was observed during the peripartum period to show diminution in the size of the tumor. The lesion was eventually treated by local excision.

"Seal finger".

Two young women developed septic arthritis in an interphalangeal joint following a seal bite. One patient was cured with tetracycline: the other required joint arthrodesis. This entity known as "seal finger" is common among sealers. Although the infection may be cured with tetracycline, in late treated or untreated cases joint destruction may occur. No causative organism has been isolated.

Common injuries of the fingernail and nail bed.

The most common injury to the dorsal distal finger is a subungual hematoma. Relief of pain is promptly achieved by draining the hematoma. If a heated paper clip is used, however, the underlying fluid may be seared and the hole plugged. Local anesthetic block followed by puncture with an 18-guage needle is advocated. When nail avulsion occurs, the free-floating proximal portion should be removed so that it will not serve as an irritant or hide any underlying pathology.

Management of the burned hand.

Current concepts in the management of acute and chronic injury to hands due to thermal burns are presented. A review of relevant functional anatomy and its alteration by the burn process is outlined. The maintenance of wrist extension, metacarpophalangeal flexion, and an open thumb web is critical in the acute phase. The physical therapist, using splints and regular exercise, is the key person in maintaining this position. The use of antibacterial agents, surgical debridement, and skin grafting is discussed. Surgical methods of reconstruction in chronic burns, the long-term role of the physical therapist, and the use of compression garments to minimize scar are stressed.

Volkmann's ischemic contracture due to soft tissue injury alone.

Fifteen upper extremities, in 14 patients in whom incipient or actual Volkmann's ischemic contracture was present, were seen in a 5 year period. Nine patients were stuporous due to drug overdose and had laid on the extremity; two had received a recent injury of main arterial trunks; two had sudden severe compression; one with chronic myelogenous leukemia had each arm involved at different times in a bizarre autoimmune response causing massive swelling. No patient had a fracture or dislocation. Pain and tenderness, loss of sensibility, resistant muscle contracture, and rock-hard muscle compartments were warning signs. Immediate fasciotomy was done. Useful function was restored when treatment was carried out in the early stages of the ischemia.

Post-traumatic trapped dislocations of the proximal interphalangeal joint.

This paper deals with the uncommon and frequently unrecognized problem of trapped dislocations of the proximal interphalangeal joint. These may be dorsal or volar. Soft tissue forming a noose, or interposed in the joint, is implicated. There is injury to one or more of the following structures: 1) extensor mechanism, 2) collateral ligament, 3) volar plate, 4) flexor tendon sheath, and 5) skin (compound dislocations). Open reduction and appropriate soft tissue repair are mandatory the essential features of diagnosis and management are discussed and four illustrative cases are presented.