[Extensor tendon injuries at the level of the proximal interphalangeal joint]. / Strecksehnenverletzungen in Höhe des Mittelgelenks.

Closed and open injuries of the extensor mechanism at the proximal interphalangeal (PIP) joint can involve the central slip, the lateral slips or both. They are classified as zone III injuries. All open injuries on the dorsal side of the PIP joint should raise suspicion of an extensor tendon injury that is frequently overlooked. The operative strategy consists of wound revision with extensor tendon suture or refixation of the central slip. Acute closed central slip injuries are clinically diagnosed (Elson test) after ruling out bony injuries to the joint. Nondisplaced avulsions of the central slip insertion or lacerations can be treated nonoperatively by splinting. For displaced avulsions and complex injuries the treatment is surgical. In overlooked injuries a typical deformity (buttonhole/Boutonnière deformity) develops within 1-2 weeks that is characterized by an extension lag of the PIP joint and hyperextension at the distal interphalangeal joint. In early cases, when passive extension is still complete (mobile buttonhole deformity) the central slip can be immediately reconstructed. In fixed deformities complete passive extension of the PIP joint has to be restored before surgery by hand therapeutic measures or PIP joint release. Depending on the pattern of the injury and the resulting defects, a number of reconstructive techniques have been established that are summarized in this article. The functional results can be limited by tendon adhesions, imbalance within the reconstructed extensor apparatus and stiff joints that can all restrict the range of motion. Therefore, active rehabilitation protocols are mandatory for optimal results.

[Acute scaphoid fractures : Management under consideration of the new S3-level guideline]. / Die frische Skaphoidfraktur : Management unter Berücksichtigung der neuen S3-Leitlinie.

BACKGROUND: Scaphoid fractures represent the most common carpal fractures and are often problematic and frequently lead to nonunion with osteoarthritis and collapse of the wrist. The reasons for the nonunion are manifold. Therefore, the main goal of diagnosis and therapy of acute fractures is to achieve bony union and to restore the anatomic shape of the scaphoid. In the long run, only this can preserve the normal function of the wrist. METHODOLOGY: The given recommendations are based on the new S3-level guideline of the AWMF (Association of the Scientific Medical Societies). This guideline was established with involvement of all relevant medical societies based on a comprehensive and systematic review of the literature and after a process of formal consent. The focus of the guideline is recommendations regarding diagnosis and therapy of acute scaphoid fractures. MAIN STATEMENTS: After careful clinical examination consequent imaging must be performed, starting with X­rays in three standard projections. Computed tomography is indispensable for proof of a fracture and for therapy planning. The classification of Herbert and Krimmer is based on the CT under special consideration of instability and displacement of the fracture. Thus, indication for operative and non-operative treatment is mainly CT-dependent. Non-operative treatment may be indicated only for stable fractures (type A). However, operative treatment is strongly recommended for all unstable fractures (type B). For fixation, double-threaded headless screws are preferred. The operative technique depends on the fracture morphology. CONCLUSION: Diagnosis and therapy of acute scaphoid fractures are primarily aimed at the prevention of nonunion and arthritic carpal collapse with painful impairment of the wrist function. To achieve this, the S3-level guideline contains explicit recommendations.

Fracture-dislocations of the carpometacarpal joints of the ring and little finger.

We report the functional and radiographic results of 16 patients with fracture-dislocations of the ring and little finger carpometacarpal joints and 23 cases with fracture-dislocations of only the little finger carpometacarpal joint treated between 2006 and 2012. The above two cohort populations of patients were treated with either open reduction and pin fixation or closed reduction and pin fixation. These patients were followed for a mean of 13 months (range 9 to 48). The DASH scores for patients with fracture-dislocations of the ring and little finger carpometacarpal joints were 6.0 and of the little finger carpometacarpal joint 7.2. We found no functional differences in term of DASH scores after treatment between patients with fracture-dislocations of only the little finger carpometacarpal joint and both the ring and little finger carpometacarpal joints.

[Carpometacarpal fractures and fracture dislocations of rays 2-5]. / Karpometakarpale Frakturen und Luxationsverletzungen des 2. bis 5. Strahls.

BACKGROUND: Fractures and fracture dislocations of carpometacarpal joints 2-5 may be easily overlooked. This can be explained by often subtle clinical and radiographic signs. In case of clinical suspicion with apparently normal standard x-rays, a computed tomography with thin slices should be promptly performed. Therapy is predominantly operative and aims at anatomic reduction and reconstruction of joint congruity. TREATMENT: To facilitate treatment decisions, especially concerning closed or open fixation, we have defined 3 pathomorphological patterns (types I-III). Decision criteria are sagittal or coronal plane of fracture, degree of destruction of the articular surface, and radial or ulnar location of the injury. Following operative therapy, early mobilization of all finger joints should be performed.

[Injuries of the proximal interphalangeal joint]. / Verletzungen der Mittelgelenke.

BACKGROUND: Injuries of the proximal interphalangeal joint (PIP joint) are common. They are frequently underestimated by patients and initial treating physicians, leading to unfavorable outcomes. Basic treatment includes meticulous clinical and radiological diagnosis as well as anatomical and biomechanical knowledge of the PIP joint. TREATMENT: In avulsions of the collateral ligaments and the palmar plate with or without involvement of bone, nonoperative treatment is preferred. Operative stabilization is reserved for large displaced bony fragments or complex instabilities. In central slip avulsion or rupture, osseous refixation, suture, or reconstruction is common and nonoperative treatment is limited to special situations like minimally displaced avulsions. In basal fractures of the middle phalanx, elimination of joint subluxation and restoration of joint stability are priority. If the fragments are too small for fixation with standard implants, therapeutic alternatives include refixation of the palmar plate, dynamic distraction fixation, percutaneous stuffing, or replacement by a hemihamate autograft. Early motion is initiated regardless of the treatment regime. Undertreatment leads to persistent swelling, instability, and limited range of motion, which are difficult to treat. Contributing factors are unnecessary immobilization, immobilization in more than 20° flexion or transfixation by K-wires. For residual limitations, nonoperative treatment with physiotherapists and splinting is first choice. Operative treatment is reserved for persistent flexion/extension contractures persisting for more than 6 months, as well as reconstructions in boutonniere and swan neck deformity and salvage procedures for destroyed joints.

[Early corrective osteotomy after secondary displaced distal radius fractures in children]. / Frühzeitige Korrekturosteotomie bei sekundär dislozierten distalen Radiusfrakturen im Kindesalter.

Secondary fracture displacement before osseous consolidation of distal radius fractures in children occasionally leads to restricted forearm rotation. So far, there is no consistent treatment recommendation to correct this complication. We report on 5 children with an age of 8-13 years (mean age 12.3 years, 4 boys, 1 girl) with secondary displaced distal radius fractures and high functional deficits in forearm rotation (mean ROM for pro-/supination 70-0-30°) after osseous consolidation. We performed corrective osteotomies of the distal radius using a palmar approach after a mean of 38 days. Stabilisation was achieved with a fixed-angle plate system. At the final follow-up examination (mean 9 months) the forearm rotation was normal. No complications were observed. We consider corrective osteotomies of the distal radius in children with deficits of forearm rotation to be a possible strategy. Early corrective osteotomies can lead to a predictable increase of function through reestablishing normal articulation.

[Transfer of the flexor digitorum superficialis tendons of the middle and ring fingers to restore extension of fingers and thumb (Boyes' transfer)]. / Transposition der oberflächlichen Beugesehnen von Mittel- und Ringfinger zur Wiederherstellung der Daumen- und Fingerstreckung (Boyes-Transfer).

OBJECTIVES: Restoration of extension in the metacarpophalangeal joints of the fingers as well as in the interphalangeal joint of the thumb by transfer of the superficial flexor tendons of the long and ring fingers (flexor digitorum superficialis III and IV). INDICATIONS: The indications for surgery are substantial loss and palsy of muscles innervated by the radial nerve and its roots. CONTRAINDICATIONS: The procedure is contraindicated by reversible radial palsy, palsy or substantial loss of flexors, limited passive mobility due to contracture, ankylosis or instability of the affected joints, instability of the wrist joint, palsy of the wrist flexors, ankylosis of the wrist joint in an unfavorable position, adhesions of flexor or extensor tendons, insufficient soft tissue coverage or soft tissue defects and passage of transposed tendons through scarred tissue. SURGICAL TECHNIQUE: The surgical technique involves division of the superficialis tendons of the long and ring fingers proximal to Camper's chiasm and routing of the tendons to the dorsum of the hand through separate fenestrations of the interosseus membrane. The flexor digitorum superficialis tendon III is interwoven into the tendons of the extensor pollicis longus und extensor indicis and the flexor digitorum superficialis IV is interwoven into the extensor digitorum tendons. POSTOPERATIVE MANAGEMENT: Forearm splinting in 20° wrist extension including the metacarpophalangeal joints of the fingers in extension and the thumb in the automatic stop position for 4 weeks leaving the proximal and distal interphalangeal joints free. RESULTS: From March 1999 to January 2010 a Boyes' transfer was performed in 13 patients (8 female and 5 male) and the right side was affected in 8, the left side in 5 and the dominant hand in 7 cases. The patient age at the time of surgery was an average of 47 ± 17 (13-73) years. The interval between radial palsy and tendon transfer was an average of 79 ± 144 (4-543) months. The final follow-up was performed at an average of 82 ± 35 (32-165) months. According to the Haas scoring system finger extension was excellent in 5, good in 5, fair in 3 and unfavorable in 4 cases and thumb extension was excellent in 5, good in 3, fair in 1 and unfavorable in 5 patients. The mean disabilities of the arm, shoulder and hand (DASH) score was 36 ± 24 (11-85) points. Although disability of varying degrees persisted in all patients, Boyes' transfer is considered to be a safe procedure to restore finger and thumb extension with excellent and good functional results, a high degree of patient satisfaction and few complications.

[The malunited distal radius fracture - early or late correction?]. / Die fehlverheilte distale Radiusfraktur - Früh- oder Spätkorrektur?

UNLABELLED: BACKGROUND/GOAL: Despite the fact that corrective osteotomy for malunited distal radius fractures is widely accepted, the optimal timing is still a matter of controversy. The presented study compares the clinical and radiological results of early vs. late corrective osteotomy at the distal radius to evaluate the influence of timing. PATIENTS AND METHODS: We prospectively studied 34 consecutive patients with extraarticular malaligned fractures of the distal end of the radius who underwent corrective osteotomy. Early correction was performed in 14 patients (10 -women and 4 men with an average age of 48±18 years) at an average of 8±3 weeks (range, 3-13) after the injury, late correction in 20 patients (16 women and 4 men, average age of 54±19 years) at an average of 52±46 weeks (range, 24-229) -after the injury. The demographic data of the groups were statistically identical. Preoperatively and at the recent follow-up the range of motion of the wrist (ROM) and grip strength were recorded as well as pain at rest and activity (visual analogue scale), DASH score and radiological data. A conclusive evaluation was performed by the modified Mayo wrist score for the recent follow-up after 24±10 (6-44) (early correction) vs. 21±10 (8-56) (late correction) months. RESULTS: All osteotomies healed uneventfully. Early corrections required significantly less bone-grafting. The comparison of the pre- and postoperative data in the early corrrection group showed an improvement of all parameters, that was significant in four parameters. The comparison of the pre- and postoperative data in the late correction group showed an improvement of all parameters, that was significant in 5 parameters. The comparison of the postoperative data revealed nearly identical results in both groups for all parameters including the modified Mayo wrist score. CONCLUSION: The general improvement stresses the value of both, early and late reconstruction. Although no statistical difference was detectable early corrective osteotomy seems to be recommendable in early presenting patients, in order to avoid bone-grafting. In later presenting cases we recommend observation and return after 6 months in the case of persistent pain or disability. Nevertheless, the time choice of corrective osteotomy remains an individual decision in all patients.

[Giant cornu cutaneum - a grotesque manifestation of squamosus cell carcinoma in the palm]. / Cornu cutaneum giganteum - groteske Manifestation eines Plattenepithelkarzinoms in der Hohlhand.

Squamous cell carcinoma is the most common maligne primary tumour of the hand. It is almost always located on the dorsum of the hand, an occurrence in the palm is very rare. Usually these tumours are recognised early because of their clinical presentation and visible location. We report on a case in which the patient presented in our hospital only due to a massive mechanical impairment of his hand function through an oversized squamous cell carcinoma. On the basis of this case the therapeutic algorithm for large squamous cell carcinoma in the palm is illustrated and discussed.

[Complex fragmentation of the distal radial articular surface. Reconstruction with subchondral Kirschner wires and bone grafts]. / Komplexe Fragmentation der distalen Radiusgelenkfläche. Rekonstruktion durch subchondrale Kirschner-Drähte und Knochentransplantate.

BACKGROUND: Complex fragmentation of the distal radial articular surface often results in three major problems: some fragments are too small for stabilisation by standard plates or screws; in addition, substantial loss of articular surfaces and metaphyseal/subchondral bony defects frequently occur. MATERIAL AND METHODS: To solve these problems the following strategy was developed: the fixation of small articular fragments was performed by small K-wires that were placed subchondrally and countersunk in the bone. In case of lost articular surfaces a silicone foil was inserted intra-articularly to induce a cartilage-like tissue. Bony defects were replaced by iliac crest bone grafts. Additional stability was achieved by dorsal and volar plate fixation or bridge plating. RESULTS: An average of 53° of extension, 44° of flexion, 74° of pronation, and 66° of supination were achieved. The grip strength was an average of 61% of that in the contralateral limb. The average radiographic measurements were -5° of palmar inclination, 21° of ulnar inclination, and 0 mm of positive ulnar variance. A good or excellent functional result was achieved for five of seven wrists according to the rating system of Gartland and Werley. According to the modified Mayo Wrist Score four of five wrists achieved a good and one a fair result.The DASH Score averaged 19 (6-59) points. CONCLUSIONS: The applied treatment resulted in stable, mobile wrists with reasonable alignment and nearly even articular surfaces. The functional results were similar to those reported by other authors for less complex distal radius fractures. This strategy seems to be a rational approach to the reconstruction of severely comminuted intra-articular fractures of the distal radius.

[Collateral ligament injuries of the metacarpophalangeal joints]. / Kollateralbandverletzungen der Fingergrundgelenke.

Collateral ligament injuries of the metacarpal joints of the fingers are rare conditions. The injury should be diagnosed by clinical investigation and standard radiographs. Leading symptoms are local tenderness and joint instability. Instability is verified by clinical stress testing of the metacarpophalangeal joint in 90° of flexion. In Grade I injuries stability is preserved due to ligament attenuation or small partial tears. Grade II injuries show laxity with firm endpoint according to incomplete tear. In Grade III injuries instability without endpoint can be found as a result of complete tears. Radiographs may show avulsed bone fragments.In Grade I and II tears or non- displaced avulsion fragments treatment is conservative with buddy taping for 6 weeks. In case of persistent instability or grade III tears suturing or refixation of the ligament are performed. Small avulsion fragments are removed and the ligament is fixed to the bone. Greater avulsion fragments are fixed by suitable small implants. Adequate treatment will lead to reliable good results. Even in chronic tears reconstruction with local material or tendon transplants is usually successful.

[Therapy of triangular fibrocartilage complex lesions]. / Therapie von Läsionen des "triangular fibrocartilage complex".

The triangular fibrocartilage complex (TFCC) represents an important anatomical structure interposed between the ulnar carpus and the distal ulnar. Injuries and degenerative changes of the TFCC are of high clinical relevance and there are numerous treatment options available based on different concepts and which are being used to varying extents. The aim of this systematic review was to evaluate the effectiveness of different therapies for lesions of the TFCC. Studies on TFCC lesions were systematically reviewed, classified into evidence levels and selected according to predefined criteria. A total of 259 publications were identified as being potentially relevant and finally 35 studies could be included in the review. In addition, a survey was performed among German hand surgeons in order to identify commonly used procedures for TFCC lesions in Germany. The classification of Palmer is mostly used both in the literature and in Germany and therapeutic decisions are predominantly based on this classification. The systematic review revealed some common treatment strategies for traumatic and degenerative lesions. Generally, the level of evidence was poor for all identified publications. For this reason, evidence-based recommendations for the treatment of TFCC lesions could not be derived from the literature. There was broad consent between the results of the literature review and the survey.

[Closed irrigation system for pyogenic flexor tenosynovitis of the hand]. / Die Spül-Saug-Drainage zur Behandlung von Infektionen der Beugesehnenscheide an der Hand.

OBJECTIVE: Treatment of pyogenic flexor tenosynovitis within the osteofibrous channel of the thumb and finger by insertion of a closed irrigation system. INDICATIONS: Pyogenic tenosynovitis of the flexor tendons of the hand. CONTRAINDICATIONS: Necrosis of the flexor tendons or flexor tendon sheath, gangrene of the finger, extensive loss of soft tissue. SURGICAL TECHNIQUE: Insertion of a flexible irrigation catheter via a guide wire into the flexor tendon sheath and a vacuum suction drain into the finger or the palm of the hand. Extensive exploration of the flexor tendon sheath is not mandatory. POSTOPERATIVE MANAGEMENT: On days 0-3 continuous irrigation, on day 4 change of the irrigation catheter to suction, on day 5 removal of the irrigation catheter, on day 6 removal of the suction drain, on day 7 start of exercise. Irrigation volume: about 500-1500 ml/24 h isotonic solution. RESULTS: Of 35 patients treated for flexor tenosynovitis by closed irrigation, 33 were reviewed. There were 19 male patients and 14 female patients. The average age at the time of surgery was 51 (8-85) years. Hospital stay was 8.9 (3-26) days on average. At the time of follow-up, the average grip strength was 84% (23-163%) of the unaffected side. Pain at rest was 0.2 (0-4), pain during exercise 1.2 (0-8) on the analogue scale, the DASH score was 16.8 (0-58) points. According to the rating system for flexor tendon function, there were one poor, one fair, five good, and 26 excellent results.

[Intralesional sclerotherapy of venous malformations in the hand with methyl tetradecyl sulfate]. / Die intraläsionale Sklerosierung venöser Malformationen an der Hand mit Natriumtetradecylsulfat.

Congenital venous malformations (VM) at the hand are rare. VM consist of dysplastic venous vessels without progressive cellular proliferation. The therapy for VM is considerably different from that for vascular tumours (e. g., haemangiomas). Treatment options for vascular malformations are antithrombotic medication, local compression, resection of the VM, and obliteration of the lumina by percutaneous sclerosation. Here, the percutaneous sclerosation for the treatment of VM with sodium tetradecyl sulfate has been illustrated and discussed on the basis of 2 case reports.