[Overlooked compartment syndrome of the hand after burn injury and known polytoxicomania]. / Übersehenes Kompartmentsyndrom an der Hand nach Brandverletzung und bekannter Polytoxikomanie.

A young man suffered the fatal combination of burn injuries and acute kidney failure caused by substantial rhabdomyolysis after lying on the floor in a somnolent condition for 12 h. This symptom constellation should always make physicians aware of a potential compartment syndrome.

[Reliable Flaps for Congenitally Malformed Hands]. / Bewährte Lappen an der fehlgebildeten Kinderhand.

Congenital hand malformations are rare, but hand function and aesthetics cannot be improved by surgery in every affected child. However, whenever this is possible, it is important to create an individual surgical plan for each child. Growth has to be taken into account in the accurate planning of incisions and local flaps. Just because it is technically possible, not every flap should be used in the malformed child's hand. In the following article, we present a collection of reliable flaps in the surgery of the congenitally malformed hand.

[Technique of Suspension Surgery Using Palmaris Longus Tendon for Correction of Severe Blepharoptosis]. / Suspensionsoperation der Ptose des Oberlids durch die Sehne des M. palmaris longus an den M. frontalis.

Background In cases of blepharoptosis, the upper eyelid either cannot or can only be elevated insufficiently. The aetiology may be myogenic, aponeurotic, neurogenic, mechanical, or traumatic. The most common cause of congenital ptosis is myogenic, due to the improper development of the levator muscle. Methods Frontalis suspension operation as a technique of correction often uses silicone slings or fascia lata. On the basis of 3 cases, we present our method using palmaris longus tendon. Results In all 3 cases, intra- and postoperative courses were without adverse events and all cases are still relapse-free. Discussion Our technique using palmaris longus tendon for suspension of the frontalis muscle is a very good alternative to fascia lata or silicone slings. We achieved satisfactory results for eyelid opening and symmetry.

[Nerve injuries after elbow luxation fractures in childhood : Indication and timing for surgical revision]. / Nervenverletzungen nach Ellenbogenluxationsfraktur im Kindesalter : Indikation und Zeitpunkt zur operativen Revision.

BACKGROUND: Supracondylar humerus fractures are very common in pediatric populations. In cases of dislocated fractures, closed reduction and percutaneous K­wire fixation is recommended. Initially, 10-16 % of the patients also present lesion of the ulnar nerve as well as median nerve palsy in 6.4% and radial nerve palsy in 2.6 % of cases, respectively. METHOD: We present the case of a 10-year-old boy with a dislocation of the elbow and fracture of the medial epicondyle. After closed reduction and K­wire fixation from medial, he presents a median nerve palsy. That a lesion of the ulnar nerve is also present is only noticed 3½ years posttraumatically. A surgical decompression and neurolysis of the ulnar and median nerve is performed and the postoperative grip and key strength presented. DISCUSSION: With the help of the presented case we discuss the indication and the point of surgical revision. Clinical assessment and neurosonography are essential for an exact diagnosis.

[Congenital Fibrosarcoma of the Left Index Finger - An Unusual Case]. / Kongenitales Fibrosarkom am linken Zeigefinger - ein ungewöhnlicher Fall.

Congenital fibrosarcoma is a rare mesenchymal soft tissue tumour, which most commonly develops in the peripheral extremities during infancy. Diagnostic work-up is a challenge for clinicians and pathologists alike, because in many cases the lesion initially resembles a haemangioma on macroscopic inspection. A 4-month-old boy presented with a strongly vascularised tumour of the left index finger, which had been diagnosed as a capillary haemangioma by means of a biopsy performed in another facility. The lesion had been treated with systemic and intralesional cortisone injections. Due to ulceration and the risk of infection, the tumour mass was resected with the index finger being preserved. The histological appearance was inconclusive. PCR revealed a congenital fibrosarcoma. 2 years after surgery, the boy is free from recurrence.

Defining postoperative stability in children with radial polydactyly.

UNLABELLED: There is little fundamental data on paediatric metacarpophalangeal joint instability in radial polydactyly following surgical reconstruction. We evaluated 27 thumbs in a healthy paediatric population (Group A: eight girls and 19 boys with a mean age of 9.7 years (range 2.7-14.2)) and 12 thumbs following Wassel-IV reconstruction (Group B: eight girls and four boys with a mean age at follow-up of 10.6 years (range 2.7-13.2)). Metacarpophalangeal joint radial deviation, ulnar deviation on stress testing, interphalangeal joint and metacarpophalangeal joint alignment on posterior-anterior radiographs were measured and scored according to parameters defining joint instability. The aim of our study was to provide fundamental data on thumb metacarpophalangeal joint mobility patterns and alignment for further postoperative evaluations in children. The average ulnar deviation and radial deviation on stress testing of the healthy (Group A) metacarpophalangeal joints was 25° (10°-45°) and 30° (10°-55°), respectively. In the operated (Group B) thumbs, the ulnar deviation and radial deviation was greater at 35° (10°-55°) and 30° (10°-70°). Ulnar deviation (UD) of the proximal phalanx at the metacarpophalangeal joint on posterior-anterior radiographs was a mean of 10° (range -10°-30°) in Group B; this was significantly greater than in Group A at a mean of 5° (range -5-20°) (p = 0.029). The mean radial alignment of the interphalangeal joint (distal phalanx relative to the proximal phalanx) was significantly higher in Group B (15°) than Group A (0°) (p = 0.221). In the literature on radial polydactyly, cut off values defining metacarpophalangeal joint instability in children range from 5° to 20°. According to our results, high but physiological metacarpophalangeal joint mobility of the thumb needs to be taken into consideration when evaluating children following reconstruction. Ulnar or radial deviation greater than 30°, in combination with the lack of a definite end point on metacarpophalangeal joint stress testing, may be regarded as unstable. Based on our study on healthy paediatric and reconstructed thumbs, comparison of joint stability with the healthy contralateral hand is recommended in order to define pathological instability. LEVEL OF EVIDENCE: II.

[Incisional hernias after median laparotomy. A concept for anatomic reconstruction of the abdominal wall]. / Bauchwandhernien nach medianer Laparotomie. Ein Konzept zur "anatomisch-funktionellen" Wiederherstellung.

The abdominal wall is a complex system of fibres and has its function in stabilisation of the lower back and pressure build-up for coughing and evacuation of the bowels. In case of incicional hernias after median laparotomy, which occur in 10-20%, reconstruction is a great challange for the surgeon. As methods of repair doubling of fascias, implantation of mesh grafts and muscle transfers have been described. In the following article we present a concept for anatomic and functional restoration of the abdominal wall in a selected patient population. Besides an exact surgical technique, the patient's compliance for weight reduction, special work-out and wearing a bodice pre- and postoperatively is essential for a good result.

Supporting the collateral ligament complex in radial polydactyly type Wassel IV.

Despite anatomical metacarpophalangeal joint (MCPJ) reconstruction in radial polydactyly (RP) Wassel IV, the prevention of long-term deformity and instability is still an issue. We report on clinical results following our modified surgical procedure with additional support of the hypoplastic radial collateral ligament complex (RCLC) after musculoligamentous MCPJ reconstruction. Fourteen patients (male: 10, female: 4) with radial resection of isolated RP Wassel IV (1987-2006), average age at surgery 1.7 years (0.6-8.6) were included. Distribution to group A and B depended on the procedure for MCPJ reconstruction. In group A (N = 7), RCLC reinsertion + reinforcement using autologous tendon grafts was performed (follow-up: 4.6 years (1.4-6.9)). Group B (RCLC reinsertion without support) consisted of N = 7 patients; follow-up: 9.6 years (8.2-20.2). The healthy contralateral hand (control A/control B) served as a control. Results were evaluated using our modified Tada-score considering: range of motion (ROM), interphalangeal joint (IPJ) and MCPJ stability on stress examination, palmar abduction and grip strength. Better score results (maximum 10) were seen in A: 7.3 (6-9) compared to B: 6.6 (4-10). Subscore 'stability' A: 1.1 (0-2); B: 0.9 (0-2) and 'alignment' A: 0.86 (0-2); B: 0.57 (0-2) showed greatest influence on the score result. Ulnar angulation at MCPJ level compared to healthy thumbs (control A + B) was greater (p < 0.05), with 11.4° (10-20) in group A and 14.3° (-5 to 30) in group B compared to 0° in control A and 5.7° (0-17) in control B. MCPJ ulnar deviation in A + B: 25° (0-35) compared to healthy thumbs control A + B was higher (p < 0.05). Ulnar deviation was higher in B 45° (30-60) compared to 34° (20-50) in A. In B, instability was evident in four, in A, only in one patient. In B, one patient required two re-operations due to MCPJ instability. Equivalent results were recorded regarding pinch grip and palmar abduction. Anatomical MCPJ reconstruction in combination with autologous support of the hypoplastic RCLC to enhance long-term stability is recommended.

An isometric hand tester: quantifying motor function in the hand.

The aim of this study was to develop and assess an isometric hand tester to measure multiple strength parameters of the muscles of the hand. Nineteen men and 22 women took part in a first study and 17 men were tested in a second one. Five different tests were developed: wrist flexion, wrist extension, metacarpophalangeal joint flexion, thumb adduction and proximal and distal interphalangeal joint flexion. Reliability was tested with an intraclass correlation coefficient for single measures. When the results from men and women were analysed separately, all tests except metacarpophalangeal joint flexion and thumb adduction produced intraclass correlation coefficients greater than 0.7. Combining the genders gave intraclass correlation coefficients greater than 0.9 except for metacarpophalangeal joint flexion and thumb adduction. After adjustments, intraclass correlation coefficients for metacarpophalangeal joint flexion and thumb adduction were between 0.70 and 0.83 in the second study. The new isometric hand tests improve the measurement of intrinsic and extrinsic hand muscle strength.

[Musculosceletal reconstruction in bilateral forearm transplantation]. / Muskuloskelettale Rekonstruktion bei bilateraler Unterarmtransplantation.

BACKGROUND: Improvement of motor function of the upper extremity was investigated in a patient following bilateral forearm transplantation. PATIENTS AND METHODS: Following an electric shock injury with amputation of both forearms at the proximal level a bilateral allotransplantation was performed 2003 in a 41-year-old male patient. Missing and insufficient muscles were replaced by donor units. For use of myoprothesis in case of transplant failure remnants of BR, ECRL, ECRB and ECU remained at the recipient. 3.5 mm DCP plating was used without bone grafting to stabilize the forearm bones. PT, FCR, FDS, PL of the donor was fixed to the medial epicondyle of the humerus, ECU and EDC to the periosteum of the ulna. FCU, BR, ECRL; ECRB of the donor were sutured to the corresponding fascia of the recipient muscles. For motor function NIA; NIP and the motor branches of the median nerve for PT, FCR, FDS, PL were coapted. The ulnar nerve was coapted distally to the motor branch for the FCU. Following induction therapy today IS consist of tacrolimus (trough level 8 ng/ml), everolimus (trough level 6 ng/ml) und Prednisone (5 mg/day). RESULTS: Both grafts are vital at FU of 6 years and 1 month. During the first 3 years episodes of graft rejection, opportunistic infection and transient metabolic disorder occurred which could be treated successfully by systemic, topical agents and change of IS. Bone healing appeared normal. TRM of the upper extremity improved from 32.7% before surgery to 74.6% of normal, with gain of wrist motion/forearm rotation of 8.7% and finger motion of 33, and 2%. The moderate muscle power (M4/5) of the deep flexors, the extensors and the intrinsic muscles is considered to be due to the long distance of reinnervation, a pre-existing electric damage to the nerv and repeated rejection episodes. CONCLUSION: Range of motion of the upper extremity improved primarily by extrinsic muscle function. Muscle strength and grip are moderate. The patient described the following to be most beneficial: the better range of motion, the possibility to perform tasks without visual control, the availability of his range of motion 24 h a day and a new sense of body integrity.

The Innsbruck hand transplant program: update at 8 years after the first transplant.

We herein provide an update on two bilateral hand and one bilateral forearm transplants with emphasis on immunosuppression (IS), function, morphology, and graft vascular changes at 8 years and 2 years after bilateral hand and 5 years after bilateral forearm transplantation. Between March 2000 and May 2006, three patients underwent bilateral hand or forearm transplantation at our institution. Following induction therapy with antithymocyte globulin (ATG) (n = 2) or alemtuzumab (n = 1), tacrolimus, prednisolone +/- mycophenolate mofetil (MMF) were given for maintenance IS. Later, tacrolimus (n = 1) or MMF (n = 1) was replaced by sirolimus/everolimus for long-term IS. Clinical follow-ups with evaluation of hand function, skin biopsies, X-ray, ultrasound, angiography, computed tomography angiography, electrophysiological studies, and somatosensory evoked potentials were performed at regular intervals. Three, six, and three rejection episodes were successfully treated with bolused steroids, anti-CD25 or anti-CD52 antibodies. Subsequently, skin histology remained normal without any evidence of chronic rejection. Hand function continuously improved during the first 3 years and since then remained stable with minor improvements. Investigation of hand arteries revealed no signs of occlusion or stenosis. Motor and intrinsic hand muscle function continues to improve in all patients. Protective sensation was observed in all patients; however, discriminative sensation was only accomplished after hand but not forearm transplantation. No life-threatening adverse events occurred. Despite immunologic challenging postoperative courses, patients are now free of rejection with moderate levels of IS and good functional results. No signs indicating chronic rejection have been encountered.

[Facial venous malformation presented with an unusual course]. / Ein ungewöhnlicher Verlauf einer venösen Malformation im Gesicht.

Venous malformations are constitutionally-dependent vascular anomalies. In contrast to haemangiomas, they show no spontaneous regression. We describe here the case of a 21-year-old woman with a very severe facial disfigurement caused by a large venous malformation. After intensive consultation, advice and planning, the patient decided to undergo therapy and was admitted to hospital for treatment by an interdisciplinary team, consisting of a radiologist and a plastic surgeon. Under general anaesthesia, percutaneous sclerosis was performed twice. This enabled thrombosing and subsequent extensive resection of the monstrously large tumour. The well-planned and efficiently performed surgery helped the patient to gain a significant improvement in her quality of life.

[Radical tumour resection in the upper extremity and heterotopic replantation of the hand. Analyses of functional results in two patients]. / Radikale Tumorresektion im Ellenbogenbereich und heterotope Handreplantation. Analyse der funktionellen Ergebnisse bei zwei Patienten.

We describe here two cases treated 17 years apart from each other. The patients were young males with malignant soft tissue tumours of the forearm and elbow joint. Radical tumour resection involved removal of the elbow joint. Neither of the patients consented to upper arm amputation, but agreed to undergo heterotopic replantation of the amputated distal third of the forearm together with the hand to the stump of the upper arm. The tendons of the forearm were attached to the three muscles of the upper arm, and the distal nerves were coapted with the nerve trunks of the upper arm. However, the reconstructive procedures carried out in these two patients were anatomically different. In the first patient, for technical reasons, only the deep flexor tendons were sutured. Furthermore, development of a postoperative haematoma necessitated revision surgery with split-thickness skin graft to cover the defect of the forearm. Long-term immobilisation together with a conservative approach to mobility had resulted in less than optimal results so that it appeared meaningful to re-operate the patient even 17 years after the primary operation to help him gain improved sensibility as well as motor function. These goals were achieved to a surprising extent by scar release, Z-plasty, removal of split-thickness skin graft, neurolysis, arthrodesis of the IP joint of the thumb, and tendon transposition together with intensive early postoperative sensibility and mobility training. In the second patient, longitudinal division of the muscles of the upper arm into different compartments and interweaving of the long tendons of the forearm into these muscles as well as early intensive mobility training and reintegration of the replanted hand in the body scheme resulted in the rapid gain of extremely good functional results so that the patient is now able to employs his heterotopically replanted hand quite effectively in his activities of daily living as a farmer. We believe that the differences in the surgical techniques employed and intensive postoperative training may explain the varying functional outcomes of these two patients. What is surprising is that it was possible to achieve marked functional improvement even after an interval of 17 years.

[A "simple" method for correction of the Apert's hand]. / Eine "einfache" Methode zur Korrektur der Apert-Hand.

In view of the multiple malformations in patients with Apert syndrome, numerous operations need to be carried out on the skull, midface, jaws, hands and in some cases also feet. We describe here a simplified surgical approach to hand surgery that enables several operative steps to be performed during one session and thus reduces the total number of surgical interventions. After visualising with MSCT angiography the bone and soft-tissue malformations and blood vessels, the operation is planned carefully. Transection and removal of the bony and cartilaginous bridges between the symphalangeal fingers is followed by placement of silastic sheets between the separated fingers for a period of 2 - 3 weeks to help form well-vascularised tissue over the spongy bone, which is then covered by full-thickness skin graft to promote healing. Depending on the severity of the Apert hand, numerous surgical procedures can be performed together at one and the same session. This is a simplified method in which the thumb is also straightened either during the same intervention or at a later date. This approach is explained with the help of three of our cases.

[Refixation of the M. recti abdomini on the symphysis in traumatic pubis symphysis disruption. Reconstruction to the original anatomic situation]. / Abriss der geraden Bauchmuskeln der Symphyse nach Symphysenruptur. Möglichkeit der Wiederherstellung.

Pelvic fractures may accompany other injuries and can be life-threatening. In addition, the rectus abdominis muscles might also be torn. During fracture reduction, these muscles are fixed to their insertions. The goal should be reconstruction as close as possible to the original anatomic situation. Refixation of the vertical rectus muscles that have retreated cranially results in preventing development of lower abdominal wall hernia.A hernia in combination with a symphysis disruption has been reported very seldom in the available literature. We report here on a case of hernia that developed postoperatively after treatment of traumatic pubic symphysis rupture. Primary open reduction of the symphysis was carried out and the rectus abdominis muscles were refixed to the bones. An attempt was made to repair the incisional hernia that developed by tightening the fascia. Two and a half years after the accident, the patient developed a diastasis and an abdominal wall hernia, which were repaired by refixation of the rectus abdominis muscles to the bones with Mersilene bands. Results nine months after the reconstructive surgical intervention show a firm abdominal wall without recurrence.This case shows that even 2.5 years after an accident, the rectus abdomini muscles can be fixed with Mersilene bands to the bone and anatomic reconstruction of the abdominal wall can be carried out.

Central adaptation following heterotopic hand replantation probed by fMRI and effective connectivity analysis.

In this functional magnetic resonance imaging (fMRI) study, we examined changes--relative to healthy controls--in the cortical activation and connectivity patterns of two patients who had undergone unilateral heterotopic hand replantation. The study involved the patients and a group of control subjects performing visually paced hand movements with their left, right, or both hands. Changes of effective connectivity among a bilateral network of core motor regions comprising M1, lateral premotor cortex (PMC), and the supplementary motor area (SMA) were assessed using dynamic causal modelling. Both patients showed inhibition of ipsilateral PMC and SMA when moving the healthy hand, potentially indicating a suppression of inference with physiological motor execution by the hemisphere controlling the replanted hand. Moving the replanted hand, both patients showed increased activation of contralateral PMC, most likely reflecting the increased effort involved, and a pathological inhibition of the ipsilateral on the active contralateral M1 indicative of an unsuccessful modulation of the inhibitory M1-M1 balance. In one patient, M1 contralateral to the replanted hand experienced increased tonic (intrinsic connectivity) and phasic (replanted hand movement) facilitating input, whereas in the other, pathological suppression was present. These differences in effective connectivity correlated with decreased behavioural performance of the latter as assessed by kinematic analysis, and seemed to be related to earlier and more intense rehabilitative exercise commenced by the former. This study hence demonstrates the potential of functional neuroimaging to monitor plastic changes of cortical connectivity due to peripheral damage and recovery in individual patients, which may prove to be a valuable tool in understanding, evaluating and enhancing motor rehabilitation.

Altered systemic serologic parameters in patients with silicone mammary implants.

BACKGROUND: The most common local complication in patients with silicone mammary implants (SMIs) is excessive peri-SMI connective tissue capsule formation and its subsequent contracture. However, considerable controversy remains as to whether these implants also cause systemic side effects. The present study was undertaken to identify possible alterations of serological markers in SMI patients that may herald systemic side effects. METHODS: We investigated several systemic serological parameters in 143 individuals, 93 of whom had received SMIs and 50 were controls. The patients were grouped according to the severity of capsular contracture (Baker scores I-IV) and the duration of SMI implants (less than 1 year, between 1 and 5 years, more than 5 years). We also included control groups (female blood donors, nurses with possible professional silicone exposure). Patients with breast cancer and subsequent SMI-reconstruction were excluded from the study since they are generally considered immunocompromised. The following parameters were determined: anti-neutrophil cytoplasmatic autoantibodies (cANCA), anti-nuclear autoantibodies (ANA), anti-cardiolipin antibodies (CL-Ab), rheumatoid factor (RF), complement components (C3, C4), circulating immune complexes (CIC), procollagen III (a marker of active fibrosis), anti-polymer antibodies (APA) and soluble intercellular adhesion molecule-1 (sICAM-1). RESULTS: The following parameters were increased in the sera of SMI patients: CIC, procollagen III, APA, sICAM-1. CONCLUSIONS: We found a set of parameters in serum that correlate with fibrosis development and the duration of the implants in otherwise healthy SMI carriers. Future studies will clarify whether these serological abnormalities will be useful in predicting clinical disease, and also further assess the sensitivity and specificity of these parameters. Our present recommendation as a result of this study is that SMI patients with persistent abnormal serological parameters should be monitored closely by a clinical team that includes rheumatologists.