The management of clenched fist 'fight bite' injuries of the hand.

We present a prospective study outlining the management of clenched fist 'fight bite' injuries. Over a 4-year period all patients with such injuries had surgical exploration with further débridements as necessary. For metacarpophalangeal joint injuries, a midline tendon-splitting approach was used. For proximal interphalangeal joint injuries, an approach was made between the lateral band and central slip of the extensor mechanism. A total of 147 patients with 159 joint injuries were treated, with 130 metacarpophalangeal joint and 29 proximal interphalangeal joint injuries. The joint was penetrated in 96% of joints overall. The number of débridements ranged from two to eight. Twenty patients defaulted within 1 week of surgery and were not included in the analysis of the results. All patients with metacarpophalangeal joint injury had satisfactory or good outcomes. A total of 42% of patients with proximal interphalangeal joint injuries had poor results, four requiring amputation and one a fusion. The tendon-splitting approach to the metacarpophalangeal joint allows excellent access and avoids damage to the sagittal bands and consequent instability of the extensor mechanism.

Condylar fractures of the proximal and middle phalanges.

We describe the treatment of 74 patients with phalangeal condylar fractures. Twelve patients presenting with undisplaced fractures were initially treated nonoperatively; of these, five displaced, requiring fixation. The remaining seven patients, all children, united uneventfully. Sixty-two patients presenting with displaced fractures were treated with internal fixation using a single lag screw through a lateral approach. The patients were treated semi-electively on a day surgery unit. Twenty-seven patients with unicondylar fractures, all operated on within 2 weeks of injury, regained full range of movement. Thirty-eight patients had loss of extension (range 10-35°) with fixed flexion contractures at the proximal interphalangeal and thumb interphalangeal joints and extensor lag at the distal interphalangeal joints (overall mean extension loss 10°). Although fixation was technically easier during the first week, a delay of 2 weeks before fixation made little difference to the outcome. In our experience, fractures can be taken down and fixed internally even 8 weeks after injury. If nonoperative treatment is initially embarked upon, close monitoring is required with weekly radiographs up to 3 weeks, as these fractures will frequently displace.

Cleland's ligaments and Dupuytren's disease.

The aim of this study was to investigate whether Cleland's ligaments are affected by Dupuytren's disease and assess their contribution to the flexion contracture of the proximal interphalangeal (PIP) joint. Twenty patients with Dupuytren's disease undergoing fasciectomy for a PIP joint contracture > 40° (mean 61°, range 45°-100°) were included. After excision of all other identifiable digital disease, Cleland's ligaments were assessed. If they appeared to be macroscopically affected by Dupuytren's disease they were excised, sent for histological analysis, and any further improvement of PIP joint contracture was recorded. There were 14 males and six females with a mean age of 62 (range 40-79) years. Excision of Cleland's ligaments resulted in a mean further correction of 7° (range 0°-15°). Histological analysis indicated that Cleland's ligament was clearly involved with Dupuytren's disease in 12 patients, indicating that Cleland's ligaments can be affected by Dupuytren's disease. In the remaining specimens the histological findings were equivocal. As these structures are situated dorsal to the neurovascular bundles, a specific dissection has to be undertaken to identify them. Excision of Cleland's ligaments at digital fasciectomy further avoids leaving residual disease and may yield a worthwhile further correction of PIP joint flexion contracture.

The 'metacarpal cascade lines'; use in the diagnosis of dislocations of the carpometacarpal joints.

Dislocations of the carpometacarpal joints of the ring and little fingers are common and are frequently missed at presentation. We describe a radiographic observation which assists in the confirmation of the diagnosis.

Collateral ligament avulsion fractures from the heads of the metacarpals of the fingers.

Nineteen patients with collateral ligament avulsion fractures from the metacarpal heads of the fingers were treated during a 6 year period. Seven undisplaced fractures were initially treated conservatively. Four united with full movement. Three required internal fixation for symptomatic non-union and healed without problems. Eleven patients with displaced fractures were treated by primary internal fixation using a single lag screw through a dorsal approach. Seven of these achieved a full range of movement of the injured digit by 3 months. Four patients failed to regain full flexion of the metacarpophalangeal joint. One patient with a displaced and comminuted fracture was treated with internal fixation at 8 weeks when the fragment had consolidated. As with similar fractures from the proximal phalangeal bases, these fractures are prone to non-union when treated conservatively, even when undisplaced. If fixation becomes necessary, the delay of a trial of conservative treatment does not appear to affect the outcome. Internal fixation of displaced fractures allows gentle mobilisation and facilitates union.

Avulsion fractures from the base of the proximal phalanges of the fingers.

Thirty-three patients with avulsion fractures from the base of the proximal phalanges were treated during a 6-year period. All eight fractures treated conservatively failed to unite and subsequently required surgery. The remaining 25 patients were treated with primary internal fixation using a single lag screw through a palmar approach. Surgery gave excellent results in all cases and all patients achieved a full range of movement within 3 weeks.

Vascularized pedicle graft of the lower trunk for reconstruction of the branchial plexus.

The middle trunk of an injured brachial plexus was reconstructed using a vascularized graft of the lower trunk, which was expendable because of irreparable damage to the C8 and T1 nerve roots. The graft was transferred on a vascular pedicle of mesoneurium. Useful recovery was achieved at 3 years. This technique helps to overcome the problems of limited supply and secondary sensory deficit of grafts from peripheral nerves, but is possible only if the plexus is explored early, before mobilization and transfer of nerve trunks is precluded by scarring.

Experience of the early use of technetium 99 bone scintigraphy in wrist injury.

In a retrospective study, patients with suspected scaphoid fracture had an average of three sets of scaphoid radiographs prior to scintigraphy. Scans were performed an average of 3 months after injury and many were inconclusive because of disuse changes. A prospective analysis of early scintigraphy in 35 cases over 18 months was carried out. Scans were performed at an average of 15.5 days after injury in selected cases. Patients had an average of 1.28 sets of negative radiographs prior to scanning. There were no false negative scans and in 13 with focal uptake a wrist fracture was demonstrated. Diffuse uptake was thought to be indicative of ligamentous damage or reflex sympathetic dystrophy. Early scintigraphy was found to be a sensitive, reliable and cost-effective examination in cases of suspected significant wrist injury.

Injuries to the hand in rugby union football.

Hand injuries are a common consequence of playing rugby. A prospective study of all rugby injuries referred to a hand clinic over the course of one season was carried out. 72 patients with such injuries were seen. There were 46 fractures and 26 soft tissue injuries. A substantial number were caused deliberately by opponents. One-third of the injuries were thought to be preventable.

Phalangeal fractures resulting from finger wrestling.

Two cases of proximal phalangeal fracture following finger wrestling are described. The mechanism of the injury is discussed.

Fractures of the distal femur treated with the AO dynamic condylar screw.

We report the results of treatment with the dynamic condylar screw of 21 cases of supracondylar and intercondylar fractures of the femur in patients aged 22 to 91 years. There were two nonunions and no deaths. We found the device easy to use and the good fixation allowed early patient mobilisation.

Long-term survival of a patient with malignant lymphoma of bone.

Malignant lymphoma of bone is an uncommon tumour. A number of studies have outlined the clinicopathological findings and overall favourable prognosis in adults. We report on a woman whose tumour was originally diagnosed as a secondary carcinoma of the upper femur. Twenty-three years later following proximal femoral replacement, the original histology was reviewed using immunohistochemical techniques and revised to B-cell malignant lymphoma of bone.

Reversed dynamic slings: results of use in the treatment of post-traumatic flexion contractures of the elbow.

We report our experience with reversed dynamic slings used in the treatment of post-traumatic flexion contractures of the elbow. There were 21 patients treated for deformities ranging from 35 degrees to 70 degrees (average 55 degrees). The flexion deformity after treatment varied from 25 degrees to 45 degrees (average 34.8 degrees), giving an average increase in range of movement of 39.1 per cent.

Rare intrathoracic complications in acute pancreatitis.

Ascites and pleural effusions may complicate pancreatitis but pericarditis with pericardial effusion and tamponade is rare and necrosis of mediastinal fat has not been described before. All these complications occurred in the case reported here.

Use of an F-clamp for fracture reduction during closed intramedullary nailing of the femur.

Reduction of a femoral shaft fracture before introducing a guidewire may be difficult, and time consuming. We report the use of a clamp to facilitate reduction and reduce exposure of the operator to radiation.