Infections.

Seemingly minor hand infections can have devastating consequences. The occupational health professional must be capable of early recognition and prompt intervention to avoid permanent sequelae to the patient.

Replantation and revascularization of the digits in a community microsurgical practice.

One-hundred and twenty-seven digits in Verdan zones I and II, and 24 thumbs in 106 patients were reviewed from 1979 to 1995. Patients were all followed for a minimum of 5 months to assess early results and complications, and to determine if a short course (minimum 3 days) of dextran 40 anticoagulation adversely affected digit survival. The total survival rate was 88 percent. Digits with only a single artery and vein repaired had a significantly higher rate of failure (p > .05). Index and small fingers also showed a trend toward lower survival. Vein grafts were used in 22 percent of cases. No vascular problems were noted after 5 days. Variables not affecting survival were: presence of a joint fusion, type of fixation, level of injury, number of digits, mechanism of injury, and use of vein grafts. The average hospital stay for the group was 6.5 days (+/-SD 3.3). No complications were seen with dextran use. A total of 51 complications were seen overall and the non-union rate was 10 percent. Community-based replantation and revascularization can be performed with early results equivalent to prior published studies. Complications are to be expected and demand expeditious treatment. Functional recovery of severed digits remains the benchmark for success in these injuries, however, lost digits never work.

Wrist arthrodesis using a dynamic compression plate.

In order to determine the effectiveness of wrist arthrodesis using dynamic compression plating and bone grafting, we reviewed 18 consecutive procedures in 17 patients performed using a standardized technique over a 6-year period. Fourteen patients had previously undergone an average of 2.1 operations prior to arthrodesis. Mean follow-up was 48 months. All but one patient reported considerable pain relief and were satisfied with their results. Grip strength remained limited compared to the contralateral wrist. Complications were limited to one case of reflex sympathetic dystrophy and metacarpophalangeal joint contracture, and minor problems related to the bone graft donor site.

Arthroscopic repair of radial-sided triangular fibrocartilage complex tears.

Treatment of triangular fibrocartilage complex (TFCC) tears is receiving considerable attention. Repair of peripheral tears of the TFCC has been recommended to restore the important functions of stability and load-bearing. Techniques for the reattachment of the periphery of the TFCC are evolving. Previous reports have mainly dealt with ulnar-sided (Palmer Class I-B) repairs. This report describes an arthroscopic technique for repair of radial-sided (Palmer Class I-D) TFCC tears. The procedure utilizes arthroscopic visualization with direct reattachment of the radial edge of the horizontal disk of the TFCC into the sigmoid notch of the distal radius. Fixation is achieved using sutures driven through the distal radius using long straight meniscal repair needles. Early clinical results following arthroscopic reattachment of radial-sided TFCC tears using this technique have been favorable. The technique is presented as an alternative method for repair of these lesions.

Relative articular inclination of the distal radioulnar joint: a radiographic study.

To determine the congruency of the distal radioulnar joint, 100 standardized normal wrist x-ray films were made and the following measurements taken: ulnar seat inclination, sigmoid notch inclination, and ulnar variance. The inclination angles were different in all but two cases. Relative to the long axis of the ulna, the sigmoid notch inclination averaged 7.7 degrees and the ulnar seat inclination averaged 21.0 degrees. There was a moderate correlation between the two inclination angles as well as between both sigmoid and ulnar seat inclination and ulnar variance. The data show that a wide variation between the inclination of the sigmoid notch and ulnar seat exists, which may explain why symptomatic articular incongruity can occur following ulnar shortening.

Lunate morphology: can it be predicted with routine x-ray films?

To assess our ability to predict lunate morphology, x-ray films of 81 cadaver wrists were obtained. The wrists were then dissected to determine true anatomy, specifically the presence or absence of a medial lunate facet. Thirty-five wrists were found to be type 1 lunates, while 46 were type 2. Cartilage erosion at the proximal pole of the hamate was found in association with 28 of the type 2 lunates. The accuracy of determining lunate morphology ranged from 64% to 72%. Therefore, lunate morphology cannot always be reliably predicted by a standard x-ray film. Arthrosis at the lunate-hamate articulation is frequent in association with type 2 lunates.

Venomous snake bite: current concepts of treatment.

The optimal treatment of venomous snake-bites remains controversial. Because of the variables involved in treatment, an ideal, prospective clinical trial likely will never be done. The purpose of this article is to review the available treatment methods and outline the treatment methods preferred in our institution for crotalidae envenomation.

Silicone rubber distal ulnar replacement arthroplasty.

We retrospectively reviewed 42 patients who underwent resection of the distal ulna with implantation of a silicone rubber ulnar head prosthesis (45 wrists). Two prostheses were used: the original Swanson prosthesis, and a prosthesis of our own design. Follow-up X-rays showed migration or breakage of 63% of the prostheses. No statistically significant correlation existed between the quality of functional outcome and the integrity of the prostheses. There was no significant difference between pre-operative and post-operative range of motion for the entire group or between patients with broken or intact prostheses. Histological confirmation of silicone synovitis was documented in one patient who required implant removal. We suggest that destabilization and breakage of prostheses result from fatigue failure secondary to the torque generated at the distal radio-ulnar joint during repeated pronation and supination. Use of a silicone rubber ulnar head prosthesis following distal ulna resection is not recommended.