Silicone block interposition for traumatic bone loss.

In situations where bone is lost secondary to trauma, the use of a hand-carved silicone block provides good results. When bone grafting is undertaken, a well-defined membrane will have enveloped the implant. Incising the membrane allows easy block removal, and after freshening the bone ends, a cavity awaits the bone graft. This technique offers simplicity and adequate stability for therapy, and secondary bone grafting is facilitated by the created space.

Synchronous subungual glomus tumours in adjacent digits.

In the hand, glomus tumours usually present as a single lesion comprising one or more discrete masses affecting the subungual area of one digit. We report a case in which typical glomus tumours occurred simultaneously in the subungual area of two adjacent digits.

Ulnar nerve compression in Guyon's canal caused by calcinosis in scleroderma.

Calcium deposits in Guyon's canal secondary to scleroderma caused low ulnar nerve paralysis in a 70-year-old white woman. Excision of calcium deposits resulted in rapid alleviation of pain. After nerve regeneration, the patient's clawing disappeared, and she was able to abduct and adduct all digits.

Guillain-Barré syndrome during childhood.

Guillain-Barré syndrome is an acquired disease of the peripheral nervous system. The etiology appears to be autoimmune in nature. The major clinical features are progressive weakness and loss of reflexes, with respiratory failure being a serious complication. The prognosis for Guillain-Barré syndrome in children is good with proper intensive care and early detection of the disease.

Haemangioma of the digital nerve: a case report.

An intra-neural haemangioma of the digital nerve of the left index finger is described, the first report of such a lesion in a digit. Treatment consisted of excision of the tumour and the affected portion of the nerve, followed by direct coaptation of the nerve ends.

A case of neurofibroma of the palmar cutaneous branch of the median nerve.

This case report describes a previously unreported entity, a neurofibroma of the palmar cutaneous branch of the median nerve. The lesion presented as a palmar mass with an overlying abnormality of the skin. Treatment consisted of excision of the lesion. Infiltration of the terminal branches of the nerve by the tumour prevented nerve reconstruction but provided a previously unknown diagnostic clue: fibrosis of an area of skin innervated by the involved nerve, which had the appearance of a callosity.

Transfer of the trapezius for flail shoulder after brachial plexus injury.

Shoulder arthrodesis is often used to treat flail shoulder after a brachial plexus injury, but has a high complication rate and entails loss of passive mobility. We have reviewed 27 patients with brachial plexus injury treated by transfer of the trapezius to the proximal humerus at an average time from injury of 31.3 months. Pre-operatively, all 27 shoulders were subluxated, with an average abduction of 3.5 degrees. Postoperatively, shoulder abduction averaged 45.4 degrees, and subluxation was abolished. All patients were satisfied with their improvement in function. Trapezius transfer is recommended as a simple procedure that requires only a brief period in hospital, allows early rehabilitation, and gives a satisfactory outcome, while retaining passive mobility of the shoulder.

Ring avulsion injuries: classification and prognosis.

Fifty-five cases of ring avulsion injury were reviewed to examine how extent of injury and surgical management correlated with results. After injury, three patients had adequate circulation. Of 52 patients with inadequate circulation, 8 had primary amputation; salvage was attempted in 44. Of these 44, 9 fingers were amputated secondarily, 19 were successfully revascularized, and 16 were successfully replanted. Return-to-work time averaged between 4.5 and 10.3 weeks. Cold symptoms occurred in 65% of salvaged fingers. Range of motion was usually normal at the metacarpophalangeal joint; most patients had 90 degrees or better combined arc of motion at the proximal and distal interphalangeal joints. Two-point discrimination of less than 10 mm returned in 47% of patients with injured nerves. Most patients whose fingers were successfully salvaged were glad they had had the procedure. We conclude that amputated digits are salvageable and propose a classification system that includes skeletal injury.

Delayed rupture of the extensor pollicis longus tendon after nonunion of a fracture of the dorsal radial tubercle.

Several apparently conflicting mechanisms have been proposed to explain the seemingly spontaneous delayed rupture of the extensor pollicis longus tendon (EPL). The following case, the first of its kind of which we are aware, may help to clarify the relationships between these mechanisms. Traumatic hyperextension of a patient's wrist brought the styloid process of the third metacarpal into contact with Lister's tubercle, fracturing it. Chronic chafing of the EPL on the nonunited fracture's jagged surface seemed to cause its spontaneous rupture 18 months later. The long period between accident and rupture is evidence that rupture was not caused by crush injury. Because a fracture of Lister's tubercle will not normally be visible on radiographs, after accidents in which this may have occurred or when the EPL ruptures more than 3 months after injury, we recommend that special radiographs of Lister's tubercle be taken to determine if such a fracture exists.

The lateral arm free flap in releasing severe contracture of the first web space.

To permanently release severe contracture of the first web space, suitable additional skin must be provided. Local skin is often insufficient and is unable to fill the depths of the space. Pedicle flaps are bulky, require a second operation for division, and frequently demand further procedures for revision. A precisely tailored lateral arm free flap allows unparalleled correction to be achieved with one surgical intervention. The operation can be performed under regional anaesthesia with morbidity restricted to one extremity.

Transmetacarpal amputations and replantation: the importance of the normal vascular anatomy.

Three transmetacarpal injuries are described in which the patency of one common digital vessel alone provided blood flow to all fingers. Transverse commissural vessels connect the digital vessels proximal to the proximal and distal interphalangeal joints. Retrograde flow to the adjacent common digital vessels revascularises the other digits. The volar metacarpal vessels, if not ligated, may allow continued bleeding into the palm following reattachment of a transmetacarpal amputation. These vessels may have been responsible for failure of the replantation in one case.

Perichondrial resurfacing arthroplasty in the hand.

A retrospective study of 36 perichondrial resurfacing arthroplasties, 16 metacarpophalangeal (MP) joints, and 20 proximal interphalangeal (PIP) joints with a minimum follow-up of 3 years was conducted to further define indication and contraindication of this procedure. The overall results for MP joints were 56% good, 25% fair, and 19% revision, and for PIP joints, 55% good, 15% fair, and 30% revision. All arthroplasties for healed pyarthrosis failed. Concomitant tendon repair was a cofactor in the high failure rate. Patient age had a direct influence on the outcome of the arthroplasty. In MP joint arthroplasties, 100% of patients in their 20s had good results and 75% in their 30s had good results. In PIP joint arthroplasties, 75% of patients in their teens and 66% in their 20s had good results. Good results were not recorded in MP or PIP joints for patients older than 40 years of age. Perichondrial resurfacing arthroplasty should be considered contraindicated in the treatment of arthropathies resulting from healed pyarthrosis, systemic diseases with joint involvement, concomitant tendon reconstruction, and age over 40 years. The procedure is indicated and can be utilized in the treatment of traumatic arthritis of the MP and PIP joints of the hand in young individuals.

Primary microsurgical repair of ring avulsion amputation injuries.

Patients with ring avulsion injuries of the fourth and fifth digits often demand attempts at reconstruction rather than completion of the amputation. In the past, this has led to reconstruction involving a staged series of operations with results that were often less than desirable. Seven patients with ring avulsion amputation injuries that were reconstructed by use of microsurgical reanastomoses are reported. All were classified as either Carroll type IV or Urbaniak type III. Six patients (85%) had a successful replantation leading to a useful finger. The operating time averaged 5.5 hours. On average, 1.9 arteries (range 1 to 2) and 3.3 veins (range 2 to 5) were repaired for each digit. Average hospital stay was 6.7 days (range 4 to 15). Average range of motion was 0(2)/84(2) for metacarpophalangeal joint and 15(2)/90(2) for proximal interphalangeal joint (PIP) with distal interphalangeal joint ankylosis at between 0(2) and 15(2) of flexion. Sensibility was protective in all cases and good in three. If the PIP joint was damaged, completion of amputation was the treatment of choice. If the amputation is distal to the PIP with a functional superficialis tendon, primary microsurgical repair is the treatment of choice in complex ring avulsion injuries.

Reconstruction of severe transmetacarpal mutilating hand injuries by combined second and third toe transfer.

This paper reports on nine instances of combined second and third toe-to-hand transfers in eight patients for severe transmetacarpal mutilating hand injuries. In four cases, the transfer included an innervated flap from the fibular side of the great toe to provide sensibility to a previously constructed osteoplastic thumb. Prehensile function was significantly improved by providing chuck or tripod pinch as well as improved pulp-to-pulp and lateral pinch. At a mean follow-up of 20.3 months, there was only one failure.