[Injuries of the distal interphalangeal joints]. / Verletzungen der Endgelenke.

Injuries of the distal interphalangeal joints mostly involve the extensor tendon. Its superficial position on the dorsal aspect of the finger often exposes the extensor tendon to closed and open injuries. Lesions of the extensor tendons are more common than those of the flexor tendons. Furthermore, injuries of the joint often occur as fractures of the dorsal base of the distal phalanx, and, less frequently, as fractures of the head of the middle phalanx. In all cases, correct diagnosis and therapy is essential. Incorrect diagnosis and neglecting of the injury by both surgeon and patient often lead to considerable complications, e.g., delayed healing and lack of function.

Biomechanical effect of isolated capitate shortening in Kienbock's disease: an anatomical study.

Multiple operations have been proposed to slow the progression of osteonecrosis and secondary carpal damage in Kienböck's disease. To assess the biomechanical changes after capitate shorting, we inserted pressure-testing devices into the carpal and radiocarpal joints in an anatomical study. Pressure sensors were placed into eight thawed non-fixated human cadaver arms to measure the forces transmitted in physiological loading. Longitudinal 9.8 N and 19.6 N forces were applied before and after capitate shortening. After capitate shortening, significant load reduction on the lunate was evident in all specimens. An average decrease of 49% was seen under a 9.8 N load and 56% under a 19.6 N load. The load was transferred to the radial and ulnar intercarpal joints. More relief of pressure on the lunate after isolated capitate shortening is achieved with a shallow angle between the scaphoid and capitate in the posteroanterior radiograph.

[Treatment of metacarpal fractures. Recommendations of the Hand Surgery Group of the German Trauma Society]. / Behandlung von Mittelhandfrakturen. Empfehlungen der Sektion Handchirurgie der Deutschen Gesellschaft für Unfallchirurgie.

The major goal in the treatment of metacarpal fractures is to restore the normal function of the hand. Radiological criteria and the clinical extent of displacement should be individually considered when taking the decision for or against conservative treatment. Internal fixation techniques must protect soft tissue structures. Small screws and plates have proven effective for head and shaft fractures, whereas intramedullary splinting is favoured for neck fractures. In instable and displaced fractures of the base of the first metacarpal, surgery is regularly performed to restore the bony shape and articular surface. To prevent functional impairments, early mobilization is desirable both during conservative treatment and following internal fixation.

[Treatment of phalangeal fractures: recommendations of the Hand Surgery Group of the German Trauma Society]. / Behandlung von Fingerfrakturen : Empfehlungen der Sektion Handchirurgie der Deutschen Gesellschaft für Unfallchirurgie.

Phalangeal fractures of the hand are characterized by a great diversity of fracture patterns. Various concepts exist for conservative and surgical treatment. A wide range of appropriate implants are available for internal fixation. However, treatment of phalangeal fractures must respect the complex anatomy of the hand and must strive to achieve the greatest possible protection of soft tissue structures. Recovery of function is the main goal of therapy. Protection of soft tissues and especially preservation of tendon sliding have to be weighed against anatomic reduction and absolute stability. Early mobilization with a high degree of patient cooperation is desirable. Treatment of phalangeal fractures always requires consideration of both the injury pattern and the patient's needs in each individual case.

[Attempted suicide by snake bite. Case report and literature survey]. / Suizidversuch durch Schlangenbiss. Kasuistik und Literaturübersicht.

Unusual suicide attempts often remain undetected, and bizarre methods can be a clue to psychotic origin. We report a suicide attempt by proxy--the bite of a puff adder--and provide a brief literature survey about further archaic self-injurious behaviour. Due to the easy availability of venomous snakes and the close networking of suicidal patients via the Internet, an increase in similar cases can be anticipated. A failed suicide attempt should always be considered in patients surviving bizarre accidents.

[Flexor tendon injuries of the hand]. / Beugesehnenverletzung der Hand.

At last, flexor tendon injuries of the hand and digit are no longer nearly impossible to treat. Many recent studies have reported a more than 75% success with excellent results, in particular in zone 2, in some cases reaching 98% satisfactory outcomes. The challenge inherent in treating and rehabilitating the zone 2 flexor tendon injury remains, however, even for the skilled hand surgeon. We must remain diligent, obeying principles outlined earlier by the first surgeons willing to attempt these repairs, while carefully gleaning the helpful and critical recommendations of the now sophisticated researchers in the subject of flexor tendon repair and rehabilitation.

Comparing biomechanical investigations about different wiring techniques of finger joint arthrodesis.

INTRODUCTION: Multiple operative techniques are currently used for finger arthrodesis in clinical practice. The present study was designed to compare the biomechanical characteristics of typical arthrodesis techniques used in daily practice. MATERIAL AND METHODS: Osteosynthesis techniques comprising wire cerclage, thread cerclage (PDS) or intraosseous wire suture were compared in a biomechanical experiment for resistance against bending loads. The mentioned techniques were applied to artificial specimens with resected articular surfaces or by using the cup-and-cone procedure. In this process, the specimens were tested using various Kirschner-wire insertion angles as well as different arthrodesis angles (20 degrees vs 40 degrees) in a 4-point bending test with each group consisting of 6 specimens of acrylic glass. The forces prevalent in the joint space were determined by prescale pressure measurement foils. RESULTS: Wire tension banding resisted significantly higher bending moments than arthrodeses with thread tension bands (p < 0.05). All set-ups with tension banding techniques tolerated significantly higher loads than the intraosseous wire sutures without additional K-wires (p < 0.05), which showed unfavorable dislocation of contact areas resulting in instability even under relatively minor bending loads. Using the cup-and-cone technique, a geometrically larger contact area could be achieved between two unloaded fragments, but this technique showed no advantages in the opposing bending moments compared with the conventional resection method. In both techniques, a dislocation of contact surfaces towards the palmar direction could be observed with increasing bending moment. While the use of thread tension band fixation reduces the risk of plastic deformation of both osteosynthetic material and bone stock, the problem of resorption rate has to be taken into account when choosing the material for the thread. CONCLUSIONS: Considering pressure distribution and stability with and without bending loads, it is not the most rigid osteosynthesis technique which should be viewed as the ideal treatment. In contrast, it is more important to consider the various and most likely conditions to be expected in daily life after arthrodesis and therefore to chose the type of technique distributing pressure as regularly as possible.

External fixation of distal radial fractures: four compared with five pins: a randomized prospective study.

BACKGROUND: The purpose of this study of distal radial fractures was to compare the radiographic and clinical results after use of a standard four-pin external fixator with those after use of a five-pin fixator with the fifth pin stabilizing the distal radial articular fragment. METHODS: In an open prospective trial, fifty patients with an unstable distal radial fracture were randomized for treatment with closed reduction and either a standard small Association for the Study of Internal Fixation (ASIF) four-pin fixator (twenty-five patients) or a five-pin external fixator (twenty-five patients). The fixators were removed at nine weeks, and all patients were assessed radiographically and clinically at six months. RESULTS: Follow-up radiographs demonstrated significantly less loss of alignment and length with the five-pin external fixator. Pin site infections were more prevalent with the four-pin fixator. The range of motion of the wrist and forearm, the grip strength, and the Lidstrom functional ratings at six months were all significantly better after use of the five-pin fixator. CONCLUSIONS: The use of a five-pin external fixator, with the fifth pin stabilizing the distal radial articular fragment, yields better radiographic and functional results than does a four-pin fixator.

Osseous integration of bovine hydroxyapatite ceramic in metaphyseal bone defects of the distal radius.

Hydroxyapatite ceramic made of bovine spongiosa was used as structural support material in a prospective study to correct bone defects experienced after reduction in distal radius fractures. The study took place over a 3-year period (1992-1999) and comprised 14 patients. Osseous integration was analyzed via biopsies and magnetic resonance imaging. Long-term follow-up monitoring involving magnetic resonance imaging in 13 of the 14 patients showed fibrovascular growth within incorporated hydroxyapatite material. Osseous integration was demonstrated in magnetic resonance images by gadolinium uptake and by the presence of osteoid layers and endothelialized vessels. Hydroxyapatite ceramic offers a biologically acceptable alternative to autologous bone when augmenting distal radius fracture fixation.

[Use of the Herbert screw with the freehand method for osteosynthesis of acute scaphoid fracture]. / Die Anwendung der Herbert-Schraube mit der Freehand-Methode zur Osteosynthese der frischen Skaphoidfraktur.

Scaphoid fracture is, in most cases, usually still treated conservatively. The disadvantages of long-term immobilization are stiffness of the wrist joint, loss of strength and higher costs. The osteosynthesis of the scaphoid fracture with the Herbert bone screw restores the exact form and length and the normal position of the scaphoid to the other carpal bones. It prevents non-unions, arthrosis and other late complications. The Freehand method is used as a percutaneous technique without utilization of a jig. The scaphoid fracture is treated with closed reduction and osteosynthesis is performed with the Herbert bone screw. The percutaneous technique preserves the inter- and intracarpal ligaments, the vascular supply and the articular surfaces of the scaphoid. Osteosynthesis by the Freehand method is sufficiently stable to withstand early functional moves on the first postoperative day.

[Cinematography, a new diagnostic procedure in evaluation of the injured painful wrist joint]. / Die Kinematografie, ein neues Diagnoseverfahren in der Beurteilung des verletzten schmerzhaften Handgelenkes.

By the X-ray Cineradiografie we are able to examine and to judge the dynamic of the wrist bones by 50 pictures/sec. in comparison to one another and also depending on their ligaments. We did an investigation of 170 patients with painful wrist. With the method we were able to make up a clear diagnosis and to propose the therapy. I.e.: If consecutive shortening of the radius after distal radius fracture resulting ingruency of the wrist joint is relevant, or a scaphoid pseudarthrosis is fixed elastically, or a scaphoic dissociation is effective. The variations were shown in comparison to normal circumstances.

Replantation of the hallux by microsurgical techniques.

In this report three cases of successful hallux replantation are presented. The indications for this type or surgery are discussed on the basis of the functional results of these replantations. In our opinion, corrective surgery is indicated in all cases of traumatic hallux and/or multiple-toe amputations.

[Personal experiences with replantation of fingers in the zone 1 area (fingertips)]. / Eigene Erfahrungen mit Replantationen von Fingern im Bereich der Zone I (Fingerkuppen).

After an amputation of a finger in zone I (up to the root of the nail) replantation with vascular anastomoses is mostly not possible. Therefore, we started to replant such amputates as a composite graft with the same medication as in replantation surgery: 500 cc low molecular dextran for 7 days, 330 mg acetyl-salicylic acid and 75 mg dipyridamol for 14 days usually. In 12 patients we replanted 16 finger- or thumbtips with 12 survivals. We had the best results in clean cut amputations. Concerning the late results we achieved always good sensibility and no evidence of any circulatory disturbance by about 6 months. The replants were useful and not painful. Occasionally we noticed some atrophy. The nail growth was nearly normal if the nail was not destroyed or severely damaged.