[Wrist impaction syndrome after distal radial or forearm fractures treated by ulnar osteotomy. Surgical techniques and results in 26 cases]. / Syndrome d'hyperpression interne du poignet après fracture de l'extrémité distale du radius ou des os de l'avant-bras traité par ostéotomie de raccourcissement de l'ulna. Technique chirurgicale et résultats de vingt-six cas.

Twenty-six of 27 patients in whom an ulnar shortening osteotomy had been performed to treat ulnar impaction following distal radius (20 patients) or forearm (6 patients) fractures were evaluated at an average follow-up of 21 months. All but 3 patients were satisfied with the end-result and according to a modified Gartland-Werley score there were 1 excellent, 10 good, 10 fair and 5 poor results. This is distinctly inferior to other reports of mainly non-traumatic indications. Degenerative changes at the distal radioulnar joint were associated with fair and poor results and careful radiological examination of this joint is mandatory before ulnar shortening is performed in posttraumatic ulnar impaction syndrome. Bony union of the osteotomy was achieved at 12 to 16 weeks postoperatively except for 2 cases and there was no difference between transverse (13 cases) and oblique osteotomies (13 cases). We therefore prefer the technically easier transverse osteotomy and recommend the use of 3.5 dynamic compression plates for stabilisation which resulted in a low complication rate in our series and enables early active wrist mobilisation.

Ulnar shortening osteotomy in posttraumatic ulnar impaction syndrome.

Twenty-eight patients (average age 45 years) with posttraumatic ulnar impaction syndrome underwent ulnar shortening osteotomy of 3-15 mm. Contributing factors were malunited fractures of the distal radius in 20, diaphyseal fractures of the ulna and radius in 6, resection of the radial head and a traumatic tear of the triangular fibrocartilage in 1 patient each. Evaluation at an average follow-up of 20 months showed a high rate of satisfied patients (89%), but according to Chun's modification of the Gartland-Werley score there were 1 excellent (3.5%), 11 good (39.5%), 11 fair (39.5%) and 5 poor (17.5%) results. Degenerative changes of the distal radioulnar joint were associated with fair and poor results, and ulnar shortening osteotomy is only recommended in ulnocarpal impaction with an intact distal radioulnar joint. Osteotomy fixation with 3.5 mm dynamic compression plates enabled immediate postoperative mobilisation and resulted in a low complication rate. There was no advantage for the technically more demanding oblique as compared with a transverse osteotomy.

Implants of pure titanium for internal fixation of the peripheral skeleton.

In a multicentre study, a clinical evaluation of the new titanium implants of the sizes 2.7, 2.0 and 1.5 mm was done. In seven centres, 133 patients were operated on and the personal, subjective opinions of the surgeons were recorded. In the opinion of these surgeons experienced in using steel implants, the outcome of the internal fixations was the same for titanium as for steel implants. Three metal-related complications occurred in the smallest size screw type (1.5 mm), namely, one screw broke and two bent. In the cases in which the implant had been removed, good tissue contact with the implant could be seen. Only in one case was there discolouring of the soft tissue due to titanium. It is recommended that surgeons who are used to handling stainless steel screws should be aware of the slightly different behaviour of titanium screws.

[Combined dorsal injuries of the thumb. A review of treatment possibilities]. / Kombinierte dorsale Verletzungen des Daumenstrahles. Eine Ubersicht über die Behandlungsmöglichkeiten.

In complex dorsal injuries of the thumb with an intact CM-joint, the reconstruction of a stable post for grip is of greater importance than restoring mobility to the MP- or IP-joint. The basis of reconstruction is primary stable internal fixation of the fractured bones, in some cases necessitating an arthrodesis or interposition of cortico-cancellous bone grafts. Extensor tendons are repaired or reconstructed if distal joint function is to be expected. In order to prevent neuroma formation, direct nerve repair is favoured, but nerve-grafting is not recommended. In exclusively dorsal lesions, there is usually no need for vascular reconstruction. The main donor areas for coverage of dorsal skin defects by pedicled island flaps are the dorsal forearm and the dorsal aspect of the index finger. Reconstruction of a mobile CM-joint and its motors should always be attempted. A CM-joint fusion is only indicated as a salvage procedure.

[Secondary flexor tendon reconstruction]. / Sekundäre Beugesehnen-Rekonstruktion.

Secondary flexor tendon repair has lost its dominant position since Claude Verdan and other pioneers demonstrated, that primary tendon suture within the former "no man's land" is even more successful than secondary tendon grafting. Secondary reconstruction may concern delayed direct tenorrhaphy, one or two staged, short or long tendon grafts, pedicled tendon transplants, pulley reconstruction, tenodesis and tendon transfer. Secondary repair may be indicated for overlooked tendon injuries, for infected wounds, traumatic or septic tendon defects, for rheumatic ruptures and finally for failed primary repair of tenolysis. The indications and techniques of the different procedures are demonstrated and discussed.

[Traumatic chondrosis dissecans of the ulnar head (case report)]. / Traumatische Chondrosis dissecans des Ulnaköpfchens (Fallbericht)]

A thirty-five-year old woman suffered from a sprain of her wrist joint. Painful blocking and snapping during supination appeared. No pathology was seen in the X-rays and the arthrogram. At surgery the expected dislocation of the extensor carpi ulnaris tendon was not discovered but rather a handle-like dissection of the cartilage of the ulnar head was squeezed into the inferior radioulnar joint by supination. The patient recovered soon after resection of the dissected cartilage. In retrospect the injury could have been diagnosed by arthrography of the inferior radioulnar joint.

[Unusual course of malignant synovioma of the flexor tendon sheath of the hand]. / Ungewöhnlicher Verlauf bei malignem Synovialom der Beugesehnenscheiden der Hand.

The authors report a synovial sarcoma of the hand with an unusual case history and a favorable outcome after two years. A forty-four-year old woman suffering from uncharacteristic pain in the right hand with slightly abnormal EMG-findings for the median nerve was treated by operative release of the carpal tunnel. No unusual findings were discovered intraoperatively. The patient continued suffering from disabling pain for another year so that a second operation was performed by another surgeon. He discovered a tumor behind the median nerve which could not be removed radically because of profuse bleeding. In spite of diagnosing a sarcoma, the patient refused further surgery, however combined radio- and chemotherapy was administered for one year. The tumor was reduced in size but did not disappear. Following open biopsy and proved presence of sarcoma, the remaining tumor was removed by amputating the ulnar part of the hand. Two years following this last operation, the patient is free of local symptoms and there is no evidence of metastases.

[Unusual healing of tendon sheath tuberculosis by intercurrent streptococcal phlegmon]. / Ungewöhnliche Heilung einer Sehnenscheidentuberkulose durch interkurrente Streptokokken-Phlegmone.

Tuberculosis of the flexor tendon sheaths in western industrial countries is rare. The author presents a case with an exceptional course and an unexpected outcome. A sixty-five year old woman suffered from tuberculosis of the flexor tendon sheath of her little finger. Appropriate tuberculostatic treatment was impossible due to damage of liver cells by chronic hepatitis. An open wound with positive cultures of mycobacterium tuberculosis persisted over eight months despite local and systemic treatment. It was only after an incidental streptococcal infection of the wound--resembling an erysipelas--that the tuberculous germs disappeared. The result was rapid healing with return of limited but useful function of the hand.

[Functional treatment of palmar edge fractures of the middle phalanx and palmar capsule ruptures of the interphalangeal joint]. / Funktionelle Behandlung palmarer Kantenfrakturen der Mittelphalanx und palmarer Kapselrupturen des Fingermittelgelenkes.

Rupture of the palmar plate of the PIP joint is frequently followed by flexion contracture. The results of operative or immobilizing treatment are disappointing and therefore 46 patients have been treated by a Capener splint. 35 of these joints could be reviewed for the functional result. Only in five cases was extension reduced by five to ten degrees, the remaining being normal in this respect. By contrast flexion was limited in 27 patients, in 19 of them by between five to ten degrees, in the remaining eight by not more than 35 degrees.

[What is the value of stable osteosynthesis of the distal radius?]. / Was leistet die stabile Osteosynthese am distalen Radius?

127 or 4% of the fractures of the distal radius seen in our department between 1968 and 1979 have been treated by internal fixation. 85 of these wrists could be reviewed after an average of 4.8 years. 70% of the fractures were multifragmentary and 87% involved the joint surface. In this difficult group correct length of the radius was restored in two thirds, and physiological angles of the joint in one third of the cases. In spite of frequent limitation of motion of the wrist joint, 80% of the patients were satisfied with the result. Careful selection of cases for internal fixation is necessary. It is indicated mainly in the Smith type fractures but may be replaced by percutaneous K-wire pinning, the external fixator or a delayed osteotomy.