Digital artery damage associated with closed crush injuries.

This retrospective study describes closed finger crush injuries in seven patients (eight fingers) in which each finger sustained a loss of blood supply. Clinical findings included numbness, decreased two-point and sharp/dull sensation, cyanosis or pallor, and decreased capillary filling. Fractures, especially transverse fractures near the proximal interphalangeal joint or distal interphalangeal joint, were usually present and often showed longitudinal crush fracture lines. Exploration and revascularization were carried out in seven fingers, all of which survived. The only finger not explored progressed to necrosis and amputation. Crush injuries to the fingers, especially those associated with displaced fractures, should be carefully evaluated for symptoms and signs of ischaemia.

Emergency cross-arm transfer.

This report describes a case of cross-arm transfer. Satisfactory function was restored, including good protective sensation, excellent grip strength, and surprisingly good return to preoperative activities. Cross-arm transfer should be considered in situations where bilateral arm amputation is present and neither can be replanted because of tissue loss.

Clinical evaluation and temperature monitoring in predicting viability in replantations.

Experiences with temperature and clinical monitoring in a series of 111 patients with 188 revascularized digits were reviewed. Criteria for abnormal temperature monitoring were defined. Monitoring of only clinical parameters showed a sensitivity of 1.00 and specificity of .97, but this technique was time-consuming and required experienced interpretation of subtle clinical changes. Temperature monitoring gave a sensitivity of 1.00, while the specificity was only .61. Drops in temperature were frequently not associated with vascular problems. Review of digits with abnormal clinical or temperature monitoring showed five patterns of abnormality. The first three groups had either abnormal clinical or temperature monitoring, but all fingers survived without reexploration. The fourth and fifth groups showed abnormalities in both clinical and temperature monitoring; all but one finger were found to be nonviable. Combined clinical and temperature monitoring was highly effective in early prediction of vascular compromise, with a sensitivity of 1.00 and a specificity of .99. The authors recommend the use of temperature monitoring. If a temperature drop occurs, monitoring of the clinical parameters can then be done. If both temperature and clinical monitoring yield abnormal results after a specified time, intervention should be carried out.

Compression syndromes in reflex sympathetic dystrophy.

Over an 8-year period we treated 93 cases of reflex sympathetic dystrophy. The initial treatment consisted of long-acting intramuscular corticosteroids and active exercises. Twenty-two patients who did not respond significantly to this treatment had carpal tunnel syndrome. In addition, five had cubital tunnel syndrome, one had ulnar tunnel syndrome, and one had a herniated disk of the cervical spine. All nerves were decompressed with significant improvement in the patient's condition. Pain was relieved in all except three who had mild pain. Motion of the proximal interphalangeal joint improved from an average of 35 degrees before operation to 76 degrees after operation. Grip strength improved from an average of 4 pounds to 27 pounds.

Technical factors related to Herbert screw fixation.

We reviewed 24 patients treated for an acute fracture or a nonunion of the scaphoid bone using the Herbert screw. Mean follow-up in 22 patients who returned for examination was 17 months. The overall union rate was 67% for both acute fractures and nonunions. Fracture healing correlated strongly with technical factors of the procedure. The fracture failed to heal in seven of nine cases with poor scaphoid realignment, inaccurate jig placement, or improper screw length for a nonunion rate of 78%. Conversely, without these technical problems, 14 (93%) of 16 fractures achieved union. Applying Herbert's criteria, a satisfactory rating for clinical function was achieved in 59% of all patients and for patient satisfaction in 68% of all patients. Although the postoperative immobilization period was reduced using the screw, the final functional result in our nonunions was similar to that reported for the Russe bone grafting procedure. Appropriate modifications of the standard technique and recognition of equipment limitations may improve union rates.

Central slip tenotomy for chronic mallet finger deformity.

Twenty patients with chronic mallet finger deformity were treated with central slip tenotomy. Seventeen patients had normal passive motion at the distal joint preoperatively. In them the average extensor lag was 37 degrees before the operation and 9 degrees after the operation. The average recurvatum at the proximal interphalangeal (PIP) joint was 10 degrees before the operation; postoperatively the extensor lag was less than 2 degrees.

Pathologic anatomy of the forearm: intersection syndrome.

Intersection syndrome of the forearm is a common painful condition that is infrequently diagnosed. It presents with pain and swelling in the area where the muscle bellies of the abductor pollicis longus and extensor pollicis brevis cross the common wrist extensors. The etiology is not well understood, but operative treatment of 13 patients has shown that the basic pathologic abnormality is stenosing tenosynovitis of the sheath of the common radial wrist extensors.

Lunotriquetral sprains.

Injuries to the ulnar side of the carpus have not been well defined. Lunotriquetral (LT) sprains have only recently been described and are often unrecognized. They usually occur from hyperextension: and twisting of the wrist. Symptoms include pain, weakness, limitation of motion, and a "click" with lateral motions. The sprain may be associated with dorsal subluxation of the ulnar head and supination of the carpus. Physical examination discloses point tenderness, laxity, and often a snap over the LT joint. Dorsopalmar manipulation of the triquetrum on the lunate demonstrates crepitus and laxity. A radiocarpal arthrogram is helpful in confirming the diagnosis. Palmar-flexion instability patterns represent a more extensive continuation of this injury, which then may be termed an LT dissociation. Treatment with adequate immobilization for acute injuries appears to be useful if the diagnosis is established early. Chronic sprains may require stabilization of the LT joint by ligament repair, reconstruction, or LT fusion. Associated injuries, such as carpometacarpal (CMC) or hamulus fractures, have been noted. Results of treatment have varied considerably and depend in part on the severity and chronicity of the condition at the time of recognition.