The lateral digital flap for Dupuytren's fasciectomy at the proximal interphalangeal joint--a study of 84 consecutive patients.

Fasciectomy is the most common operation performed for Dupuytren's disease. However, as the joint contracture increases, issues of skin deficiency following release become significant. For severe or recurrent disease dermafasciectomy is advised, but a digital transposition flap provides a viable alternative without the need for a skin graft for less-severe disease with moderate skin deficiency. A retrospective review identified 84 patients who had undergone this operation. The flap used was proximally based on the midlateral aspect of the finger allowing direct closure of the donor site. Ninety hands with 134 digits were operated on and 83% of the patients had a full correction. About 70% remained fully corrected at 1 year. All flaps were performed for proximal interphalangeal joint involvement. The mean pre-operative contracture was 34 degrees, corrected postoperatively to 5 degrees. The recurrence rate was 9%. Two percent of the patients had local infection but no flap necrosis was seen. A lateral digital transposition flap is a very stable operation for Dupuytren's disease with moderate skin deficiency and our patients achieved favourable results when compared to other studies that used local flaps combined with skin graft.

Results of surgical treatment of Dupuytren's disease in women: a review of 109 consecutive patients.

PURPOSE: Dupuytren's disease is not as commonly reported in women as in men. Our literature search yielded only two such studies. The purpose of this study was to further examine the presentation and surgical outcome of Dupuytren's disease in women, including complications and to compare these outcomes to a similar cohort of men and to previous studies of Dupuytren's disease in women. METHODS: A retrospective case series review was undertaken, and we identified all women who were admitted for surgical correction of Dupuytren's disease since 1990. Comparison was made with men operated during the same period. Pre- and postoperative measurements for lack of extension at the metacarpophalangeal joint (MCPJ), proximal interphalangeal (PIP) joint, and distal interphalangeal (DIP) joint were made by the senior author. SPSS (Statistical Package for the Social Sciences, SPSS Inc., Chicago, Il) was used for statistical analysis. The t test was used to compare the two groups. RESULTS: One hundred nine women were identified, with 119 operated hands, out of a total of 657 patients operated. Comparisons were made with 548 men. The average age at presentation was 63 years in women, and there was no significant difference between the two groups. One hundred five of the patients had digital involvement. The little and ring fingers were involved most frequently. Thirty-four had involvement of the MCPJ. Mean preoperative contracture was 35 degrees . Mean postoperative contracture was 1 degrees . Proximal interphalangeal joint involvement was seen in 66 patients. Mean preoperative contracture was 42 degrees . Mean postoperative contracture was 7 degrees . Distal joint involvement was identified in only 4 digits. There was no statistical difference with the men as regards digital involvement and joint involvement; however, correction at the PIP joint was significantly lower. Fasciectomy was performed in 107 cases (90%), fasciectomy and local flap in 7 cases (6%), and dermafasciectomy in 5 cases (4%). The most common complication was digital nerve/artery injury (6 patients), and disease recurrence rate was 22%. These were statistically similar to the men. CONCLUSIONS: Dupuytren's disease is less prevalent in women but its symptomatic presentation is similar to that in men, with more severe involvement of the PIP joint and a similar recurrence rate. The surgical outcomes, however, were equivalent with regard to final contracture correction, recurrence, and complication rates.

Stabilization of the ulna stump after Darrach's procedure at the wrist.

We studied the outcome of patients with chronic distal radioulnar joint symptoms who were treated with excision of the distal ulna and reconstruction using the flexor carpi ulnaris tendon. Twelve patients with 14 wrists were assessed. Ten patients were posttraumatic, and two had bilateral surgery for rheumatoid arthritis. Average age was 37 years at time of operation. Follow-up averaged 20 months (9 months to 4 years). All patients except one reported improvement in pain symptoms. Grip strength of the operated hand as measured by dynamometer readings was 67% of the strength of the normal hand with five wrists achieving an excellent result in grip strength. Eleven patients reported a subjective improvement in functional activities. An improved range of motion was obtained in all patients. We discuss the importance and basis for ligamentous reconstruction following excision of the distal ulna and review the literature for other previously described procedures.

Dynamic external fixator for pilon fractures of the proximal interphalangeal joints: a simple fixator for a complex fracture.

We describe a very cheap, simple and effective dynamic external fixator for treatment of pilon fractures of the proximal interphalangeal joint. At final follow-up, nine such fractures had regained an average range of motion of 79 degrees (range, 65-90 degrees ). There was high patient satisfaction and there were no serious complications.

Low velocity gun shot wounds of the brachial plexus.

28 patients with low velocity gunshot wounds of the brachial plexus were treated at Groote Schuur Hospital from 1980 to 1991. Delayed exploration of the brachial plexus (up to 7 months after injury) was performed in nine (30%) of the patients. The other 19 patients did not have exploration of the plexus; most of these patients showed signs of recovery within 2 to 4 weeks of injury. Injury to the subclavian or axillary artery occurred in nine (30%) of the cases. The average length of follow-up of the patients was 19 months (range 2-90 months). Of the 19 patients treated non-operatively, 15 (79%) had an excellent or good result and four (21%) a fair result. The indications for surgery were the absence of improvement within 3 months of injury or persistent pain. Surgery was indicated for significant pain in five of the nine patients; postoperatively two had complete relief of pain, two improvement in the pain and one no improvement. Of the nine surgically treated patients, three (33%) had a good result, two (22%) a fair result and four (45%) a poor result. The potential for recovery was not dependent on the severity of the injury at presentation or the presence of vascular injury but on the appearance of signs of recovery within 4 weeks of injury.

Brachial plexus injury after median sternotomy.

Serious brachial plexus injury after median sternotomy is uncommon. However, affected patients experience considerable morbidity and their return to regular employment is often delayed. The pathogenesis of the injury is multifactorial. Wide sternal retraction is the major etiologic factor. Management is primarily conservative and should be guided by a team experienced in upper limb and hand surgery. Our experience at a major referral center during a 3-year period is described.

Brachial plexus lesions associated with dislocated shoulders.

We reviewed 28 patients with brachial plexus lesions caused by shoulder dislocation. Contrary to most other reports, we found that the neurological lesions involved the infraclavicular and the supraclavicular brachial plexus. With supraclavicular lesions the involvement was always of the suprascapular nerve, and this always recovered spontaneously. Isolated axillary nerve lesions had the poorest prognosis for spontaneous recovery. We explored all lesions that showed no recovery after three to five months and performed either grafting or neurolysis. We discuss the combinations of nerve lesions, their recovery, the surgical indications, and the operations. We also suggest a new classification for these injuries which is more clinically relevant than the anatomical classification of Leffert and Seddon (1965).

Obstetric traction injuries of the brachial plexus. Natural history, indications for surgical repair and results.

Of a consecutive series of 70 babies with obstetric traction injury to the brachial plexus we were able to review 40 who had had only conservative treatment. We found that if recovery in the upper roots had not started by three months of age then, at follow-up there was a significant residual functional deficit. In a further 22 babies who showed no recovery of the upper roots by three months, exploration and sural nerve grafting were performed; 20 of these children were reviewed at one year. Good recovery of the deltoid was seen in 80% and of the biceps in 55%, while 25% had good external rotation at the shoulder. We conclude that if there is disruption of the upper roots with no sign of recovery at three months, grafting of these roots provides the best chance of useful recovery.

Stab wounds involving the brachial plexus. A review of operated cases.

Of 64 patients with stab wounds involving the brachial plexus operated on by one surgeon, 18 were followed up in detail, with a view to reviewing operative techniques, results and the lessons to be learned. Primary nerve grafting produced better results than end-to-end repair, even in fresh cases. The recognition of nerve compression by a false aneurysm is important, since in these cases, vascular repair alone may not give recovery and neurolysis may be necessary. The overall results of operation were good; lesions of C5 and C6 roots recovered better than those of more distal roots.

Synovial sarcoma of the hand--a literature study.

Ninety cases of synovial sarcoma of the hand, including eight case reports have been described during the last fifty years, (1934-1984). 8.5% of all synovial sarcomata involve the hand, and affect predominantly individuals under the age of thirty. The five-year survival of these cases was 18% and the ten-year survival 9%.