Intramedullary osteosynthesis after external fixation.

The authors report the results of a retrospective study conducted on 30 cases of fracture of the tibia and femur submitted to external fixation and subsequently to intramedullary osteosynthesis, treated between 1991 and 1999. Intramedullary osteosynthesis was used in 24 cases (5 in the femur and 19 in the tibia) as treatment subsequent to external fixation for nonunion or delays in consolidation. Sequential nailing was used as planned treatment in the remaining 6 cases. In 83.3% of cases the fracture was open (Gustilo Anderson type I (30%), type II (20%), type III (33.3%). The mean duration of external fixation was 13.24 weeks, and infection occurred in 4 cases (13.33%) during that time. Removal of the external fixator and intramedullary osteosynthesis were carried out during the same surgical session in 40% of the cases, while nailing was preceded by a period in plaster lasting an average of 4 weeks in the remaining 60% of cases. All of the cases achieved consolidation an average of 31 weeks after trauma, and 14.7 weeks after intramedullary synthesis. We observed the occurrence of infection in 3 cases (10%), but this did not keep consolidation from occurring.

A comparative study of the heterodigital neurovascular island flap in thumb reconstruction, with and without nerve reconnection.

41 heterodigital neurovascular island flaps were used to cover defects of the tactile pad of the thumb in 17 years. With an average follow-up of 75.5 months, 30 patients were reviewed. 17 were treated by the original Littler technique and 13 were treated with the same flap reconstruction but with division of the digital nerve innervating the flap and re-anastomosis of this nerve to the proximal nerve end of the ulnar digital nerve of the thumb. Good aesthetic and functional results were achieved in both groups. Sensory acuity did not appear to decrease with time. The nerve reconnection technique solves the "double sensibility" phenomenon (present in 41.1% of our cases treated by the original technique), but two-point discrimination is less than that achieved by the Littler technique. Most complaints were related to the donor site such as hypertrophic scarring or scar contracture and cold intolerance, but these did not cause any real functional impairment.

Dorsalis pedis flap with vascularized extensor tendons for dorsal hand reconstruction.

We describe three cases of combined loss of skin and tendons on the dorsum of the hand treated with the use of cutaneotendinous dorsalis pedis free flap. The functional and aesthetic results are excellent in the hand and aesthetically acceptable in the foot. This technique is the first choice when the treatment of these injuries requires three or four tendon grafts.

Ancient schwannoma of the motor branch of the median nerve: a clinical case.

The authors present a case of ancient schwannoma of the motor branch of the median nerve. An accurate peroperative diagnosis was not possible despite the use of MRI. Sectioning of the nerve was required as the tumor could not be enucleated.

Replantation and revascularization of large segments of the hand and forearm.

From November 1985 to July 1989, the authors performed replantation or revascularization surgery on 18 patients in whom a large segment of the upper limb between the elbow and the palm of the hand had been either completely severed (9 cases) or incompletely severed with ischemia (9 cases). The operation was successful in 16 cases, and the authors were able to clinically review 14 patients (average follow-up, 23 months). The results were analyzed using a protocol based on the following parameters: range of motion, sensation, muscle strength, cold intolerance, pain, return to work, cosmesis, and the patient's level of satisfaction. The final outcome was rated excellent in 2 cases, good in 6 cases, fair in 3 cases, and poor in 3 cases. The authors point out that recovery of sensory and motor function in replantation of large portions of the hand and forearm is often difficult. Nevertheless, the good cosmetic result, the lack of pain, and the high probability of returning to work made the patients quite satisfied with this kind of reconstructive surgery.

Operative treatment of the post-traumatic boutonnière deformity. A modification of the direct anatomical repair technique.

We report 20 cases of post-traumatic boutonnière deformity treated by a modification of the direct anatomical repair technique, particularly indicated in late cases which have complete passive motion. A swallow-tailed flap is excised from the fibrous tissue between the two ends of the central slip. The proximal one is then advanced up to the coaptation with the distal edge of the scarred capsular tissue at the insertion on the middle phalanx to which it is sutured in correct tension. Excellent results have been obtained in 72% of cases and good in 5.5%. The 16% of fair results are probably due to the fact that patients didn't use the splint post-operatively and didn't cooperative with physiotherapy.

The value of computed tomography in the diagnosis of soft-tissue swellings of the hand.

Twenty patients with palpable swellings of the hand were investigated by computed tomography. The results, when compared with the pathological findings, lead us to consider this a technique of considerable value in the assessment of this kind of disease. The importance of angiography and, occasionally of magnetic resonance imaging, are also stressed.

Evaluation of ischaemic necrosis of carpal bones by magnetic resonance imaging.

Nine patients with chronic pain in the wrist were examined by M.R.I. to evaluate its accuracy in the detection of ischaemic necrosis of carpal bones. In seven patients, M.R.I. confirmed scintigraphic and radiographic signs of ischaemic necrosis. In two patients with radionuclide accumulations, M.R.I. did not confirm the diagnosis: in one, M.R.I. was totally normal and in the other it showed signs of a healing scaphoid fracture. From this limited experience, M.R.I. seems to be a sensitive imaging modality which is more specific than scintigraphy.

Neurovascular island flap by the disconnecting-reconnecting technique.

The authors report nine cases of hetero-digital neurovascular island flaps raised by the "disconnecting-reconnecting" technique for defects of the tactile pad of the thumb. At an average follow-up of 25 months, all cases had good restoration of sensibility without any "double sensibility" phenomenon and patients regained good dexterity. No tender neuromata developed and donor site complications were not troublesome.

Simple and complex dislocations of the carpus.

The authors report 33 dislocations of the carpus; 9 simple lunate dislocations and 24 complex fracture dislocations. The number and variety of the lesions and, in particular, the variety of the types of treatment carried out allow us to draw several conclusions regarding the correct management of these rare lesions based on a long-term evaluation of the results.