[Neuropathy of the median nerve caused by intraneural haematoma after carpal tunnel release in an anticoagulated patient]. / Neuropathie des Nervus medianus durch intraneurale Blutung bei einem antikoagulierten Patienten nach Karpaltunnelspaltung.

We report about the sudden onset of a median nerve neuropathy in an anticoagulated patient eight weeks after uneventful carpal tunnel release. Several differential diagnosis have to be considered: compression syndrome as well as iatrogenic damage of the median nerve due to the preliminary procedure or even concomitant disease can generate symptoms of peripheral neuropathy. We diagnosed an intraneural haematoma through surgical exploration. This rare complication of oral anticoagulation therapy occurred spontaneously and was treated successfully by interfascicular neurolysis.

[Long-term results following denervation of the wrist in patients with stages II and III SLAC-/SNAC-wrist]. / Langzeitergebnisse nach Handgelenkdenervation bei fortgeschrittenem karpalem Kollaps (SLAC-/SNAC-Wrist Stadium II und III).

INTRODUCTION: Mid-carpal arthrodesis, proximal row carpectomy and wrist arthrodesis are commonly cited in the literature as successful methods for pain reduction in patients with advanced carpal collapse (SLAC-/SNAC-wrist stages II and III). However, studies of isolated wrist denervation in patients who still possess good wrist mobility appear to be an underrepresented topic, especially in the German literature. PURPOSE: Based on follow-up results, it was possible to establish to what extent patients benefit long-term from isolated wrist denervation, whilst retaining wrist mobility. PATIENTS AND METHOD: 46 patients (6 female, 40 male) with a diagnosis of SLAC-wrist (n = 10) or SNAC-wrist (n = 36) stages II and III underwent wrist denervation of points 1 - 4, 6, 9 and 10 according to Wilhelm, between 1990 and 2001, following a positive denervation test. No previous reconstructive wrist surgery had been performed on any of the patients, whose average age at the time of denervation was 47 years. In 29 cases the dominant hand was affected, and in 22 cases the symptoms could be classified as post-traumatic. Post-operative follow-up was possible in 32 out of 46 cases (70 %), and occurred on average 6.3 years post-denervation (range 2.3 to 14 years). RESULTS: Twelve out of 32 patients (32 %) reported to be pain-free at follow-up, with a post-operative period ranging from 2.3 to 11.4 years (average 6.2 years). Six patients (18.75 %) continued to experience pain when load-bearing, which remained unchanged over a period of several years. Three patients (9 %) reported pain after stress, five patients (15.6 %) the recurrence of severe pain, which developed on average 3.8 years post-operatively. Two patients (6.25 %) experienced no analgesic benefits following wrist denervation, and four patients underwent wrist arthrodesis on average 13.5 months post-denervation, due to remaining or additional symptoms. Nineteen out of 32 patients subjectively reported a significant improvement following wrist denervation. Reassessment of range of movement post-denervation showed a reduction of 8.1 % in wrist extension/flexion, and 20 % in radio/ulna-abduction. Compared to the unaffected side, this represented an average loss of 28 % wrist extension/flexion, and 33.5 % radio/ulna-abduction. An average 51 % increase in hand strength could be shown at follow-up, leaving an average 30 % deficit compared to the unaffected hand. Evaluation of these results using the Krimmer score showed a good - very good outcome in 20 of the 32 patients (62.5 %); six patients were found to have a satisfactory outcome, and six patients a poor outcome. Subjective measures of pain (obtained using visual analogue scales) showed a reduction from 68.13 pre-operatively to 25.63 post-operatively. The DASH assessment (parts A and B) attained an average post-operative value of 17.1. CONCLUSION: Denervation of the wrist in patients with SLAC-/SNAC-wrist stages II and III can achieve a long-term elimination or reduction of pain, whilst improving hand strength, and having only a minimal impact on wrist range of movement. Wrist denervation should therefore be given preference over wrist arthrodesis, midcarpal arthrodesis or proximal row carpectomy in patients with good wrist mobility.

[Infections of flexor tendon sheath - treatment and results]. / Die Behandlung der Beugesehnenscheidenphlegmone - Behandlungsstrategie und Ergebnisse.

Infections of the flexor tendon sheath are rare. We report on 49 patients who were treated in a five-year period from 1996 to 2000. The follow-up period was 45 months on average. We used an extensive skin incision for revision and regularly placed gentamycin-PMMA-chains in the wound. All patients were treated as inpatients. We achieved good and excellent results in 85% of patients.

[Aftercare following distal forearm fractures and carpal trauma]. / Nachbehandlung nach distalen Unterarmfrakturen und Handwurzelverletzungen.

Rehabilitation following operative or conservative treatment of fractures of the distal forearm and carpal trauma takes effect through adequate immobilization and ought to be maximized by a differentiated application of every means of physiotherapy, ergotherapy, and physical medicine available. Rehabilitation of the fractured distal forearm and carpal trauma are presented based on the therapeutic guidelines as applied by the Department of Hand Surgery, Plastic and Microsurgery of the Berufsgenossenschaftliches Unfallkrankenhaus Hamburg.

[Finger reconstruction by microvascular second toe-to-finger transplantation in patients with traumatic loss of all fingers]. / Fingerrekonstruktion durch Transplantation der zweiten Zehe nach traumatischem Verlust sämtlicher Finger.

PURPOSE: To assess the utility of second toe-to-finger transplantation with neurovascular reconstruction in patients with loss of all four digits. METHOD: Analysis of 24 toe-to-finger transplantations in 18 patients regarding over-all survival, complications and secondary procedures, sensibility, function, foot symptoms, and patient satisfaction. The original metacarpophalangeal joint was preserved in 50 % of the transplantations. In six patients, a second transplantation was performed. RESULTS: A mean follow-up of 5.8 years was available in 94 % of the patients. 92 % of the transplanted toes survived, in 38 % of the cases complications occurred followed by a secondary procedure. Two-point-sensibility was present in 62 % of the transplantations, the largest range of motion of ca. 50 degrees was obtained in the metacarpophalangeal joint. An increase in the range of motion could be achieved by preservation of the original finger joint. The mean extension lag was 37 degrees independent of the preservation of the metacarpophalangeal joint. Foot symptoms were mild in four patients, in two cases severe donor-site-problems were observed. Cold intolerance was present in 47 % of the transferred toes. Overall patient satisfaction was high with 83 % of the patients confirming their decision to undergo operative treatment. CONCLUSION: Second toe-to-finger transplantation is indicated in patients with traumatic loss of all digits. By this method, a great functional gain could be achieved as well as a high level of satisfaction. The rate of complications and possible foot symptoms should be considered. The preservation of the original metacarpophalangeal joint seems to be of importance for the function of the transplanted toe.

[Comparison of functional results after reconstruction of the thumb]. / Vergleich funktioneller Ergebnisse nach Daumenrekonstruktion.

Between 1980 and 2000, 26 pollicizations of the index finger and 32 transplantations of the second toe were performed for reconstruction of the thumb after traumatic loss. Twenty-three patients with index finger pollicization and 26 patients with second toe transplantation could be reviewed after an average follow-up of 6.4 years. Vascular complications occurred in two toe transplantations and one index finger pollicization. One transplanted toe was lost after vascular complications. Mobility of the interphalangeal joints was reduced after both procedures. Pinch grip was achieved in 20 of 23 patients after pollicization and 20 of 26 patients after second toe transplantation. Sensitivity was better after pollicization. The most common complaints were cold intolerance after both procedures. Fourty of 49 patients would have the operation again, nine patients would refuse thumb reconstruction.

[Therapy of the peromelic form of symbrachydactyly by double second-toe transplantation]. / Die Behandlung der peromelen Form der Symbrachydaktylie durch zweifache freie Zehentransplantation.

From 1989 to 2001 eleven children with the peromelic type of symbrachydactyly underwent a staged double second toes transplantation for restoration of two finger rays. The second toe of the feet were transplanted first to the small finger position and in the second step to the thumb position. One failure occurred in the first toe transplantation and another developed a venous thrombosis with partial necrosis and eventually a useless ray. Eight children were reviewed retrospectively in a mean follow-up of 5.3 years. The ability to pinch was restored in four children. In all patients without complications the function of the hand improved and the sensitivity was good.

[Operative treatment of vulnerable scars and deep soft-tissue defects of the thumb with a free toe pulp neurovascular flap]. / Die Deckung ausgedehnter instabiler Narben und tiefer Haut-Weichteildefekte an der Daumenkuppe mit der Grosszehen-Pulpa-Lappenplastik1.

Because of the capability of opposition, the thumb is the most important digit of the hand. In case of deep soft-tissue defects of the pulp, it is necessary to reconstruct the palmar surface of the distal phalanx of the thumb using tissue with good sensibility. Between 1982 and 1998 at the Department of Hand Surgery, Plastic and Microsurgery of the Berufsgenossenschaftliche Unfallkrankenhaus Hamburg, we used a free toe pulp neurovascular flap for reconstruction of the pulp of the thumb in nine patients. All flaps healed without complications. Indications, operative techniques, and results of this procedure are described.

[Anatomy of the dorsal mid-hand arteries--anatomic study and review of the literature]. / Anatomie der dorsalen Mittelhandarterien--Anatomische Untersuchung und Literaturübersicht.

By dissections of 20 cold-preserved hands, we investigated the dorsal metacarpal arteries (DMA) with regard to reliability, origin and anastomoses. The first dorsal metacarpal artery showed a trifurcation with three vessels: Ramus ulnaris (A. metacarpalis dorsalis I), Ramus medialis and Ramus radialis (A. ulnodorsalis pollicis). The DMA II to IV were observed medially in their respective intermetacarpal spaces. The A. metacarpalis dorsalis V was unreliable in reaching the skin of dorsal proximal phalanges as in the DMA IV. Most reliable for reaching the skin of dorsal proximal phalanges were the radial arteries--first, second and third dorsal metacarpal arteries. The dorsal digital arteries originate close to one another at the level of the metacarpophalangeal joints. There was an increase of epifascial position, from radial to ulnar. Irregular palmar intermetacarpal anastomoses were found proximal to the ligamentum metacarpale transversum profundum but nearly consistently in the web space.

[Covering defects of the basal finger area by pedicled flaps anastomosed to the doral metacarpal arteries]. / Deckung von Defekten an den Fingergrundgliedern durch distal an den dorsalen Metakarpalarterien gestielte Lappen.

Between 1993 and 1998, 12 distally based dorsal metacarpal artery flaps were used to cover defects of the fingers and palm. All flaps were raised from the dorsum of the hand. Eleven flaps allowed direct closure of the donor site area; one case required a full-thickness skin graft. Nine flaps healed uneventfully. Distal marginal flap necrosis occurred in three cases. All of these were used to cover defects at the distal part of the middle phalanx.

Callus distraction in the hand skeleton.

From 1992 to 1996, 27 patients with traumatic amputations or malformations underwent lengthening of thumb and fingers. A total of 36 procedures were carried out. In several cases, deepening of the web space or bone transplantations proved to be necessary to improve general function or to compensate for missing bone structure. Complications included pin-track infections, necrosis of bone, non-union and scarring. Overall the results indicate that distraction of the thumb and fingers is a feasible operative technique leading to a promising improvement of function.

[Comparison of various evaluation measures for assessment of treatment success after scaphoid injuries]. / Vergleich verschiedener Bewertungsmassstäbe zur Beurteilung des Behandlungserfolges nach Kahnbeinverletzungen.

Different evaluation scores have been developed in order to assess treatment outcome of carpal injuries. The available scores are not comparable and differ in type and number of parameters. This is a retrospective study of 100 patients who presented with a fracture or a pseudarthrosis of the scaphoid from 1983 to 1997. The Cooney and the Meine scores were compared with our own score. While the Cooney score and the newly developed score show an equal distribution of results in all categories, the score of Meine led to an overall better outcome assessment. The comparative evaluation of the different scores shows that the combination of only a few well defined parameters is sufficient for assessing the treatment outcome of carpal injuries.

[Persistent scaphoid pseudarthrosis after surgical treatment: results of repeated bone transplantation]. / Persistierende Kahnbeinpseudarthrose nach operativer Behandlung: Ergebnisse der erneuten Knochenspanplastik.

From 1984 to 1993, 30 patients with persistent scaphoid non-union despite bone grafting procedures underwent additional reconstructive surgery. Twenty-five patients were followed-up between one and eleven years after revision with a mean follow-up time of 4.8 years. Fifteen patients had bone graft procedures alone, ten patients had additional internal fixation with the Herbert screw or Ender plate. At follow-up, scaphoid union was achieved in 16 patients (64%), 19 patients had arthritic changes of the radiocarpal joint. Only patients with scaphoid union showed satisfactory functional results. Five patients with failed revision surgery needed further operations for chronic wrist pain, including three wrist arthrodeses.

Intercarpal and radiocarpal resection arthroplasty and arthrodesis.

Indications for intercarpal and radiocarpal resectionarthroplasty and fusions are osteoarthritis, KIEHNBÖCK'S disease, rheumatoid arthritis and several posttraumatic disorders of the wrist joint. The resection of carpal bones leads to severe instability patterns of the wrist. In conclusion we recommend resection-arthroplasty just for treatment of the thumb carpo-metacarpal osteoarthritis. Implant resection arthroplasty of the lunate and scaphoid or total wrist implants are still causing multiple problems regarding heavy load. Therefore this implants should be confined to rheumatoid patients. Of the limited carpal arthrodeses the scaphotrapezium-trapezoid arthrodeses is the most frequent performed procedure. It can be indicated for STT-osteoarthritis, KIEHNBÖCK's disease, scapho-lunate instability and scaphoid pseudarthrosis if other surgical procedures had failed presuming there are no signs of arthrosis in the radiocarpal joint. Persisting pain especially in heavy work is quite frequent after limited arthrodesis but can be greatly releaved by simultaneous wrist denervation. In advanced cases of osteoarthritis total wrist arthrodesis is still the best choice for the patient.

[Management and after-care of extensor tendon injuries of the hand]. / Die Versorgung und Nachbehandlung von Strecksehnenverletzungen an der Hand.

The investigation and management of extensor tendons play a minor role compared to those of flexor tendons. The finger extension does not seem to be as important as the flexion. But the practical value of the hand is determined by both. Different managements are used depending on the level of extensor tendon injury. More distal located injuries require a longer restraint than those, which are located more proximal. On the one hand this depends on the blood supply of the extensor tendon, which is by far better in the lower arm and dorsal hand than peripheral. On the other hand the reason is the different amplitude of gliding of extensor tendons, which decreases from proximal to distal to lower than 1 mm. Therefore the tension on extensor tendon sutures increases from proximal to distal. The varies techniques of extensor tendon reconstruction will be described.

Ilizarov distraction-lengthening in congenital anomalies of the upper limb.

Nine patients underwent Ilizarov distraction-lengthening for congenital anomalies. All were late cases and had undergone other procedures. In five radial club hand patients with very short forearms, we achieved an average 5.8 cm increase in length with each distraction cycle. In two patients with symbrachydactyly of the cleft hand type, we achieved pinch grip between a radial and an ulnar digit by lengthening the short ray. Another case of the monodactyly type in which we tried to lengthen three transplanted proximal toe phalanges ended in failure. A soft tissue distraction was attempted in a case of camptodactyly but failed. We report the problems we encountered and suggest some solutions.

[Possibilities of preliminary treatment of infected soft tissue defects by vacuum sealing and PVA foam]. / Möglichkeiten der Vorbehandlung von infizierten Hautweichteildefekten durch Vakuumversiegelung mit PVA-Schaumstoff.

The vacuum sealing technique is a simple and cost-effective method in the treatment of traumatic and chronic soft-tissue defects. Wound cavities are filled with polyvinyl alcohol foam with embedded drainage tubes. The tubes are either drawn transcutaneously through the tissue, or placed epicutaneously, depending on the condition of the wound. The wound including the adjacent skin and the drainage tubes are covered by a transparent vapor transmitting polyurethane film. When the drainage tubes are connected with a vacuum bottle, negative pressure of 60 to 80 kPa is established. The advantages of this vacuum sealing procedure are: protection against wound contamination, complete evacuation of wound fluids independent of gravity and rapid stimulation of dense, well vascularized granulation tissue. Relief of pain and early mobilisation improve the patients comfort. Between November 1994 and July 1996, 25 patients with 28 soft tissue defects underwent this procedure. Wound closure was performed in two cases with a free flap, in five cases by a loco-regional flap, in sixteen cases with mesh-grafts, in three cases by secondary closure of the wound. Two cases were definitively treated with the vacuum sealing technique.

[Surgical treatment of scaphoid pseudarthrosis--long term outcome with the Herbert screws]. / Die operative Behandlung der Kahnbeinpseudarthrose--Langzeitergebnisse mit der Herbert-Schraube.

Between 1984 and 1993, 131 scaphoid nonunions were treated with iliac crest bone grafting and the Herbert-screw. 105 patients were followed between one and ten years with an average followup period of 4.5 years. Bony union was achieved in 93 patients with improvement of range of motion and grip strength. In 14 patients with DISI-instability, the angulation deformity was incompletely corrected with an average reduction of the scapho-lunate angle of eleven degrees. Limited athritic changes at the radial styloid were noted in 58%, intercarpal in 25% of the patients. Most frequent reasons for persistent nonunion were technical problems with the Herbert-screw.

[The supinator syndrome]. / Das Supinatorsyndrom.

BACKGROUND: The posterior interosseous nerve syndrome is a rare compression neuropathy of the upper limb, which must be differentiated from tennis elbow. The aim of our study is to show etiology, symptoms, and diagnostic methods, and to illustrate the common operative techniques. PATIENTS AND METHODS: We examined retrospectively all patients of the Department for Hand Surgery, Plastic and Microsurgery of the Berufsgenossenschaftlichen Unfallkrankenhaus Hamburg, who underwent operative treatment because of posterior interosseous nerve syndrome between 1984 and 1992. Mobility of the elbow joint, postoperative complaints and patient's satisfaction were analysed. RESULTS: 23% of patients suffered a reduction of motion of the elbow joint, 87% had less pain, and 83% were satisfied with the result of treatment. CONCLUSIONS: The value of preoperative neurophysiological examination for diagnosis of posterior interosseous nerve syndrome is not clear. Clinical examination will allow to differentiate between posterior interosseous nerve syndrome and tennis elbow. To prevent incomplete decompression of the deep radial nerve, multiple locations of compression must be considered.