Free vascularized joint transfers in acute complex hand injuries: case reports.

The loss of function of the metacarpophalangeal joint is a significant disability. Simultaneous reconstruction of the soft tissue, extensor mechanism, joint, and flexor tendon in a complex hand injury is difficult and challenging. Free vascularized autogenous toe joint transplantation is a useful technique that provides not only joint replacement but also the soft tissue, extensor mechanism, and flexor tendon in more severe complex hand injuries. Two patients underwent immediate, free vascularized metatarsophalangeal joint transfer of the second toe to replace the long and ring finger metacarpophalangeal joint in acute complex hand injuries. The follow-up results at 16 months and 8 months postoperatively are presented.     

Zone 2 flexor tendon injuries: Venturing into the no man's land

Flexor tendon injuries are seen commonly yet the management protocols are still widely debated. The advances in suture techniques, better understanding of the tendon morphology and its biomechanics have resulted in better outcomes. There has been a trend toward the active mobilization protocols with development of multistrand core suture techniques. Zone 2 injuries remain an enigma for the hand surgeons even today but the outcome results have definitely improved. Biomolecular modulation of tendon repair and tissue engineering are now the upcoming fields for future research. This review article focuses on the current concepts in the management of flexor tendon injuries in zone 2.     

Weichteilrekonstruktionen an Hand und Fuß im Kindesalter

In the emergency department, apart from bruises and lacerations to the head the hand is one of the most injured body parts in children with 20–25%. Various injury patterns can be found ranging from trivial injuries to complex lesions requiring difficult operative procedures. There is a significant difference in the type of injury between very young and older children. The foot is much less affected by injuries (5–10%) and they are mostly trivial soft tissue lesions, such as bruises. Time-consuming soft tissue reconstructions are therefore more necessary on the hand. At this anatomic site approximately 10% are amputation injuries or tendon and nerve injuries.     

Restoration of thumb abduction damaged by electrical burn using the free dorsalis pedis flap with the extensor hallucis brevis tendon

The treatment of electrical burn injuries in the hand is difficult and challenging because the burn widely and deeply damages not only the skin and subcutaneous tissue, but also tendon, muscle, ligaments, and bone. Compound defects of the skin and abductor pollicis brevis tendon caused by an electrical injury were reconstructed using a free dorsalis pedis flap including the extensor hallucis brevis tendon. This composite flap is also applicable for reconstruction of thumb abduction, although its usefulness has been reported for reconstruction of defects of the dorsal skin of the hand including the extensor tendons.     

How to treat knee ligament injuries?

Indications for conservative treatment of knee ligament injuries can be established for all grade I or II sprains (partial tears), as well as isolated grade III sprains (complete tears) of the posterior cruciate ligament (PCL) and medial collateral ligament (MCL). These injuries should be treated with immediate mobilization. Only in isolated partial anterior cruciate ligament (ACL) tears without a positive pivot shift phenomenon is conservative treatment justified. However, many of these injuries may require operative reconstruction later. In complete ACL tears the surgical treatment consists of primary reconstruction or augmented primary repair. Today, the middle third of the patella tendon with the bone blocks is regarded as the "gold standard" for augmented repairs and late reconstructions. For the present, there is no place for synthetic prostheses in the treatment of an acute ACL rupture. Allograft replacement of the ACL must now be considered an experimental procedure. In the reconstruction of the PCL the above mentioned patella tendon graft is also preferable. Lateral collateral ligament (LCL) tears, especially if they are combined with ruptures of posterolateral ligament complex, should be repaired immediately after the injury. In these injuries late reconstructions are difficult and the results are poor. Conservative treatment of partial tears and postoperative treatment of reconstructed ligaments is twofold: on the one hand, the healing tissue should be protected and on the other hand, atrophy and wasting of uninjured tissue should be avoided. Overload and stretching of the injured ligaments should be eliminated with the aid of a suitable knee brace, but early range of motion exercises of the knee are allowed immediately.(ABSTRACT TRUNCATED AT 250 WORDS)     

Extensor tendon repair: a reconstructive technique

Extensor tendon injuries are commonly encountered and are frequently treated with less regard than flexor tendon injuries. However, several factors make them as difficult to treat and more prone to suture line rupture than their palmar counterparts. A technique is described to protect a tendon juncture on the back of the hand following tendon disruption. This allows early finger motion to prevent joint stiffness while preventing suture line disruption.     

Ligamentäre Strecksehnenausrisse am Endgelenk

Management of soft tissue ruptures of extensor tendon lesions of zone I is both difficult and controversial. Because of their superficial position already minor injury can be sufficient for laceration. Furthermore many authors are convinced of an easy way of diagnosing and repairing extensor tendon ruptures in comparison to injuries of the flexor tendons. However, this injury can cause significant hand dysfunction and has to be treated with attention in order to provide the best possible outcome for the patient. Therefore we try to evaluate the common treatment procedures and to give guidelines for management of this injury.     

The epidemiology of musculoskeletal tendinous and ligamentous injuries

This study describes the epidemiology of a range of adult musculoskeletal soft tissue injuries. Our institution is the only hospital treating adults with musculoskeletal trauma in a well-defined catchment population of about 535,000. Demographic details over 5 years were recorded prospectively. Eighteen injury types were studied including anterior cruciate ligament (ACL) rupture, acromioclavicular joint (ACJ) injury, Achilles, patellar and quadriceps tendon ruptures, hand tendon injuries and mallet finger. 2794 patients presented with ligamentous or tedinous injuries over 5 years. 74.2% of patients were male, giving an incidence of 166.6/100,000 per year for males and 52.1/100,000 per year for females. The mean age was 36.3 years: 33.1 in males, 43.6 in females. 1040 (37.2%) were knee injuries: 75.6% were male with mean age 32.9, compared with 35.3 in females. 947 cases were hand tendon injuries (33.9%): 72.1% were male, with mean age 34.5 compared with 42.0 in females. Meniscal injury of the knee was the commonest injury with an incidence of 23.8/100,000 per year. Other common injuries were hand extensor tendons (18/100,000 per year), ACJ injury (14.5/100,000 per year), Achilles tendon rupture (11.3/100,000 per year), mallet finger (9.9/100,000 per year) and ACL rupture (8.1/100,000 per year). Achilles, patellar and quadriceps tendon rupture and mallet finger were injuries of middle age; rotator cuff tears and biceps tendon rupture were commoner in the elderly but all other injuries predominated in young patients. All injuries were commoner in males. Most soft tissue injuries follow distribution curves previously described for fracture epidemiology but three new distribution curves are presented for the injuries which predominate in middle age.     

Current concepts for the use of platelet-rich plasma in the foot and ankle

Platelet-rich plasma (PRP) injections have been used and studied since the 1970s. Its use has become more popularized over the last several years in the treatment of foot and ankle injuries. Platelets are a normal product found in the clotting cascade and inflammatory process of healing. They produce granules that release growth factors that promote healing. PRP works by increasing the concentration of platelets, thereby increasing the concentration of growth factors and increasing healing potential. PRP has an advantage over many tissue engineering products in that it is autologous. It has been studied and used for the treatment of tendon injuries, chronic wounds, ligamentous injuries, cartilage injuries, muscle injuries, and bone augmentation. The results from in vitro and in vivo studies in foot and ankle injuries are promising. The applications for treatment in the foot and ankle may be broader than once thought.     

Prim?rversorgung komplizierter Beugesehnenverletzungen an der Hand

Complicated flexor tendon injuries are classified into lacerations, avulsions, ruptures, and defects. They are often a challenge for hand surgeons and frequently they present unsatisfactory functional results postoperatively. Lacerations and avulsions are usually treated by pull-out sutures and suture anchors. In ruptures, the causality should be sought. Tendon-linking, transposition and tenodesis/arthrodesis are the domain of rheumatoid arthritis. The primary transplantation of tendons is rarely indicated, ideally in non-contaminated flexor tendon defects in zones III-V with an uninjured surrounding soft tissue situation. Postoperative rehabilitation programs are very the same as in normal flexor tendon injuries.     

Tissue Engineering von Sehnen- und Ligamentgewebe Eine neue Herausforderung

Injuries to ligaments and tendons heal by formation of inferior repair tissue. This may result in severe joint dysfunction. Because of an increased occurrence of sports-related injuries, musculoskeletal disorders may become one of the major burden of health care. Tissue engineering offers the potential to improve the quality of ligament and tendon tissues during the healing process and may provide a more effective approach to the treatment of injuries to ligaments and tendons than traditional methods. Application of growth factors, gene transfer techniques, cell therapy and cell-matrix composites have shown to affect the process of ligament and tendon healing. The benefits of using mesenchymal stem cells on a three dimensional biological matrix have been shown recently. Tissue engineering will also include mechanical manipulation of tissue environments to accelerate cell differentiation and to improve matrix formation. Fibroblast-seeded polymer scaffolds could be useful in ligament and tendon replacement in which autogenous fibroblasts would be obtained through biopsy, cultured and seeded onto a scaffold.     

Complex injuries including flexor tendon disruption

The treatment of tendon injury in combined complex injuries to the hand is dictated by the presence of concomitant injuries. Early range of motion is desirable. To achieve this, fractures must be stabilized and the soft tissue envelope and vascular integrity maintained or reconstituted. In those instances in which these conditions cannot be met, the surgeon and patient should be prepared for secondary surgeries, including reconstruction or tenolysis. Although nerve integrity is not necessary for early functional success following tenorrhaphy, nerve injuries should be repaired or grafted primarily as the injury permits. In cases in which vascular compromise is encountered, the options of revascularization versus primary amputation should be discussed with the patient. With an understanding of the treatment principles, the complications associated with complex tendon injuries can be minimized. It is important to stress that optimal functional outcome is multifactorial and includes a physician-therapist team-oriented approach.     

Effect of cyclic three-dimensional strain on cell proliferation and collagen synthesis of fibroblast-seeded chitosan-hyaluronan hybrid polymer fiber

Background  

Tissue engineering techniques using biodegradable three-dimensional (3D) scaffolds with cultured cells offer more potential alternatives for the treatment of severe ligament and tendon injuries. In tissue engineering, one of the crucial roles of 3D scaffolds is to provide a temporary template with the biomechanical characteristics of the native extracellular matrix (ECM) until the regenerated tissue matures. The purpose of the present study was to assess the effect of various cyclic mechanical stresses on cell proliferation and ECM production in a 3D scaffold made from chitosan and hyaluronan for ligament and tendon tissue engineering.     

Kombinierte Beugesehnen- und Nervenverletzungen der Hand

Any restoration of hand function following tendon and nerve injury has to include the repair or replacement of the hand’s ability to perform a great many tasks. It is hard at first to appreciate fully the loss that occurs with flexor tendon injury. Also sensibility can be compromised from tendon injury without direct injury to the nerve, as object recognition in the absence of vision requires finger movement. When peripheral nerve injury is combined with flexor tendon injury, sensibility is directly impaired. There is a loss in the sense of finger or thumb position, pain temperature and touch or pressure recognition, in addition to the tendon injury. However, the outcome after operative treatment of these“minor” injuries of the hand is horrible. Therefore, we try to summarize practical consequences for the repair of combined flexor tendon and nerve injuries which will improve operative outcome. These guidelines are based on current scientific knowledge and our own experience.     

Treatment of severe four finger crush avulsion injuries

Polydigital crush avulsion injuries with complete loss of soft tissue, including nerves and vessels, where only bone and tendon structures are preserved need sophisticated treatment. Due to the complexity of the injury amputation should be avoided and the major aim is maintenance of maximum finger length by emergency soft tissue coverage, when replantation is impossible. Later reconstruction of sensation with good mechanical properties must be the ultimate aim. Two cases with a four finger crush avulsion injury are reported from the emergency situation through the subsequent secondary reconstruction to the final result. Soft tissue coverage required the full spectrum of hand surgical procedures ranging from local tissue transfer, to temporary pedicled flaps and microsurgical procedures. Possible treatment options are discussed at each step of the reconstruction. Finally, a treatment concept is presented both to ease the surgical approach for the inexperienced and to provide discussion for the experienced hand surgeon. Received: 15 December 1997 / Accepted: 22 February 1999     

Quantitative microbiology: Its application to hand injuries

Quantitative microbiologic analysis of civilian hand injuries has been accomplished in thirty-four patients. Most traumatic soft tissue injuries exhibited an insignificant level of contamination. The number of bacteria recovered from most of those wounds was comparable to that encountered in clean elective surgical hand cases. We now view most civilian hand wounds as clean wounds carrying a very low risk of infection.Our patients with traumatic hand injuries are considered candidates for immediate reconstruction, which includes vascular, bony, or neural repair as well as immediate implantation of Silastic rods in preparation for subsequent tendon grafting.     

Primäre Behandlung von offenen Strecksehnenverletzungen der Hand

OBJECTIVE: Reconstruction of extensor functions after extensor tendon injuries of the hand. INDICATIONS: Acute injuries of extensor mechanism with corresponding loss of function. CONTRAINDICATIONS: Complex injuries with loss of soft tissue. Limited possibility of extensor tendon reconstruction with combined injuries of the interphalangeal joints (in situations with irreparable joints: primary arthrodesis). SURGICAL TECHNIQUE: The treatment of extensor tendon injuries depends on the various levels of tendon laceration. Zones 1 and 2: in case of tendon disruption close to the base of the distal phalanx, refixation of tractus terminalis using a pull-out suture. In case of disruption more proximally, primary repair using mattress sutures. Temporary pinning of the distal interphalangeal joint in extension using a single transarticular Kirschner wire. Zone 3: mattress sutures of the tractus intermedius. Temporary pinning of the proximal interphalangeal joint in extension using a single transarticular Kirschner wire. Zone 4: reconstruction of the central slip and the lateral slip of extensor tendon using modified Becker sutures and mattress sutures. Temporary pinning of the proximal interphalangeal joint in extension using a single transarticular Kirschner wire. Zones 5 and 6: four-strand modified Becker sutures with additional epitendinous suture. Zones 7 and 8: core sutures using modified Kirchmayr techniques with additional epitendinous suture. POSTOPERATIVE MANAGEMENT: Zones 1-4: immobilization of the finger for 6 weeks with removal of the transarticular wire at 4 weeks. Zones 5-8: dynamic postoperative treatment in intrinsic-plus splint for 6 weeks. RESULTS: It is postulated that dynamic postoperative treatment leads to improved functional outcome after extensor tendon injuries. While for zones 1-4 no better final clinical results are observed using the dynamic postoperative protocol, early protected motion for zones 5-8 is superior to static post operative treatment.     

Therapiestandards nach Beugesehnen- und Nervenverletzungen der Hand

Background

There is little evidence for the ideal aftercare of combined nerve and flexor tendon injuries of the hand. The aim of this study was to elicit whether concomitant nerve injuries are changing the individual treatment plans after flexor tendon repair in a survey of German centres for hand surgery.

Methods

A questionnaire about aftercare of isolated and combined nerve and flexor tendon injuries of the hand was distributed to members of three German Societies of hand, trauma and plastic surgery.

Results

Isolated flexor tendon injuries in zones II to IV are treated by early mobilization in all centres, whereas isolated digital nerve repair is usually followed by immobilization (10% no immobilization, 22.5% up to 1 week, 52.5% for 2 weeks and 15% for 3 weeks). The duration of immobilization increases with lesions of the median or ulnar nerves by about 1 week. In 55% of cases concomitant nerve injury does not influence the early onset of dynamic splinting and mobilization after flexor tendon injuries.

Conclusion

There seem to be no uniform treatment guidelines for flexor tendon repair if concomitant nerve injury is present. Against the background of the current literature early controlled mobilization after tendon and nerve repair seems to be justified.     

Die Behandlung des Weichteilschadens an der Hand

A prerequisite for adequate treatment of soft tissue injuries of the hand is the analysis of depth and dimension of the defect. Treatment should be planned in advance to avoid complications like stiffness of the joints or impairment of tendon gliding. Efforts should be made to reconstruct the lost tissue with an equivalent part and all modern reconstructive treatment modalities including free flaps must be considered.     

Study of late results of flexor tendon injuries in the hand with examination of 119 patients

Summary In the care and further treatment of patients with hand injuries, a necessary requirement of the hand surgeon is that he be able to cope with the interlocking factors that are no longer influential, for example, the type and extent of the trauma or the age of the patient; the influential factors are a thought-out care plan, atraumatic action with regard to optimal restoration of the hand. This also showed a retrospective analysis of results and post-examination from flexor tendon injuries in the hand of 298 patients, who were surgically cared for from 1984 to 1994 at the surgical clinic of the University of Jena. Of the 298 patients 119 patients with 198 flexor tendon injuries (165 fingers and 33 thumbs) were followed up. For objective assessment of the treatment results, the assessment scheme Buck-Gramcko was used.