A biomechanical study of plate versus intramedullary devices for midshaft clavicle fixation

Background

Our understanding of finger functionality associated with the specific muscle is mostly based on the functional anatomy, and the exact motion effect associated with an individual muscle is still unknown. The purpose of this study was to examine phalangeal joints motion of the index finger generated by each extrinsic muscle.

Methods

Ten (6 female and 4 male) fresh-frozen cadaveric hands (age 55.2 ± 5.6 years) were minimally dissected to establish baseball sutures at the musculotendinous junctions of the index finger extrinsic muscles. Each tendon was loaded to 10% of its force potential and the motion generated at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints was simultaneously recorded using a marker-based motion capture system.

Results

The flexor digitorum profundus (FDP) generated average flexion of 19.7, 41.8, and 29.4 degrees at the MCP, PIP, and DIP joints, respectively. The flexor digitorum superficialis (FDS) generated average flexion of 24.8 and 47.9 degrees at the MCP and PIP joints, respectively, and no motion at the DIP joints. The extensor digitorum communis (EDC) and extensor indicis proprius (EIP) generated average extension of 18.3, 15.2, 4.0 degrees and 15.4, 13.2, 3.7 degrees at the MCP, PIP and DIP joints, respectively. The FDP generated simultaneous motion at the PIP and DIP joints. However, the motion generated by the FDP and FDS, at the MCP joint lagged the motion generated at the PIP joint. The EDC and EIP generated simultaneous motion at the MCP and PIP joints.

Conclusion

The results of this study provide novel insights into the kinematic role of individual extrinsic muscles.     

Wiederherstellung der Daumenendgelenkbeugung durch Transposition der oberflächlichen Beugesehne des Ringfingers

Objective

Restoration of active thumb flexion at the distal joint.

Indications

Loss of active flexion of the interphalangeal (IP) joint of the thumb if there is a transection of the flexor pollicis longus (FPL) tendon at the tendon channel of the thumb or thenar and direct suture is not possible but the tendon channel is intact, as alternative procedure to a free tendon graft if the transection is proximal to the tendon channel and the muscle of the FPL is contracted/injured or the FPL tendon is unharmed but the FPL muscle is partially or complete paralyzed.

Contraindications

Insufficiency of the FPL tendon channel, impairment of the superficial or deep flexor tendon of the ring finger, limited passive motion of the proximal and distal thumb joints, acute local general infection and non-compliance or incapacity of the patient.

Surgical technique

The surgical technique depends on the necessity of transosseous refixation of the FDS IV at the base of the distal phalanx of the thumb or the possibility of woven sutures through the FPL proximal to the tendon channel. If the tendon channel is intact the distal part of the FPL tendon is shortened to 1 cm, the FDS IV tendon is cut distal to the chiasma of Camper, pulled through the carpal tunnel and moved into the channel of the FPL tendon and fixed transosseously through the base of the distal phalanx of the thumb. If the transection of the FPL tendon is located proximal to the tendon channel and muscle of the FPL is injured, FDS IV tendon will be woven using the Pulvertaft technique through the FPL tendon at the distal forearm.

Postoperative management

Postoperative 6 weeks motion of thumb flexion without resistance in relieved position of the thumb through a thermoplast splint and 6 weeks of functional use of the hand with increasing weight bearing.

Results

In this study 10 patients with FDS IV transposition to reconstruct an isolated rupture of the FPL tendon could be followed for an average of 4.1 years postoperatively. The active range of motion of the IP joint of the thumb averaged 65° (10–100°), 8/10 patients achieved an equal active and passive range of motion of the IP joint of the thumb, in 2 patients some flexion insufficiency remained, 9 patients could reach the fingertip of the small finger with the thumb and 1 patient lacked 3 mm. Contracture of the proximal thumb joint developed in two patients. After removal of the FDS IV tendon two patients developed contracture of the PIP joint of the ring finger. The grip force was reduced to 81?%, lateral grip to 83?% and pinch grip to 77?%. The DASH score averaged 18 (0–31) and 8/10 patients would choose to undergo this surgery again.     

Replantation and revascularization vs. amputation in injured digits

Background

The purpose of this study was to analyze factors associated with the decision to replant or revascularize rather than amputate an injured digit as well as factors associated with successful replantation or revascularization.

Methods

We reviewed 315 complete and subtotal amputations at or proximal to the distal interphalangeal joint in 199 adult patients treated over 10 years. Ninety-three digits were replanted (30 %), 51 were revascularized (16 %), and 171 were amputated (54 %), including 5 attempted replantations. Bivariate and multivariable analyses sought factors associated with replantation vs. amputation, revascularization vs. amputation, and success of replantation or revascularization.

Results

Factors associated with replantation rather than amputation were injury to the left hand, thumb, middle digit, and ring digit, more than one digit affected, and surgeon. Factors associated with revascularization are surgeon and shorter ischemia time. Forty-five replantations (48 %) and 41 revascularizations (80 %) were successful. Successful replantation was associated with the side of injury (left side more likely to survive), zone of injury (distal interphalangeal and interphalangeal joint more likely to survive and proximal phalanx less likely to survive), and shorter ischemia time. Success of revascularization was associated with the mechanism of injury (saw and not crush injury), multiple digits involved, and the surgeon.

Conclusions

The decision to replant, revascularize, or amputate a nonviable digit and the success of replantation and revascularization are related to both injury factors, such as mechanism of injury, affected digit, and zone of injury, and the surgeon.     

Curvatures of the DIP joints of the hand

Background

The distal interphalangeal (DIP) joints of the hand are highly susceptible to osteoarthritis and trauma. Surgical treatment options mandate accurate characterization of their osseous anatomy; however, there are few studies that describe this. We describe the curvatures of the DIP joints by measuring the bone morphology using advanced imaging and modeling methods.

Methods

The fingers of 16 right hand fresh frozen human cadavers were analyzed. Fingers showing signs of DIP joint arthritis were excluded. The fingers were scanned using microtomography (microCT). Measurements of the bony morphology were made using models created from the scans.

Results

In each finger, there is no statistically significant difference between the radii of curvature of the ulnar and radial condyles of the middle phalanx head. Conversely, the radius of curvature of the distal phalanx ulnar groove is significantly greater than that of the radial groove. The radii of curvature of the groove of the distal phalanx and the condyles of the middle phalanx displayed nonconformity with disparity increasing from the index to small fingers. Remarkably, the radius of curvature of the distal phalanx central ridge and the mean radius of the middle phalanx condyles are essentially the same.

Conclusion

The purpose of this study is to gain better insight into the DIP joints of the hand. The asymmetry between the distal phalanx grooves and the middle phalanx condyles suggests that there may be a translational component to DIP joint motion. Our understanding of morphology may lend insight into the biomechanics and disease progression within the DIP joints.     

Sekundäre Rekonstruktion des digitalen A2-Ringbands

Objective

Secondary reconstruction of A2 flexor pulley for after closed rupture.

Indications

Persisting impairment of finger function and strength after combined injury of A2 and C1 pulley. Passive free movement of all finger joints.

Contraindications

Fixed flexion contractures of interphalangeal joints after complex finger injuries. Degenerative arthrosis of interphalangeal joints.

Surgical technique

A strip of extensor retinaculum approximately 10 mm in width together with the periosteum from the second floor of the extensor tunnel was used for reconstruction of the A2 pulley. After drilling bilateral burr holes in the palmar aspect of the phalanx at the distal and proximal ends of the A2 pulley, the graft was fixed by the periosteum to the bone of the phalanx, placing the synovial layer innermost.

Postoperative management

Postoperatively, patients in both treatment groups wore a palmar splint which extended from the distal interphalangeal joint to the proximal palmar crease for 4 weeks. The metacarpophalangeal joint and the proximal interphalangeal joint were held in full extension. After removing the splint, physiotherapy was started. Full load-bearing, hard manual work and sport activities were not permitted for 3 months.

Results

Fifteen patients were treated using the extensor retinaculum for reconstruction of the A2 flexor pulley. The mean follow-up time was 48 months. The average range of motion of the PIP joint was 97?%, the average power grip strength 96?%, the finger pinch strength 100?%, and the average circumference 95?% of the uninjured contralateral side. The Buck–Gramcko score showed the following results: 10 excellent, 2 good, and 1 fair.     

A novel closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation for mallet fractures

Background

Some patients with mallet fractures who undergo extension block pinning complain of exposed wires, which delay their return to sports and causes inconvenience while performing tasks that require the use of hands during the early postoperative period. The purpose of this retrospective study was to present and evaluate a novel surgical procedure for mallet fractures.

Methods

We treated 20 patients (14 males and six females; mean age, 38.4 years; range 17–68 years) with displaced mallet fractures involving >30 % of the articular surface using the closed reduction and microscrew fixation between January 2009 and January 2012. The distal interphalangeal joint (DIP) joint was immobilized with a splint for 1–3 weeks on an individual case basis. According to Wehbe and Schneider’s classification, there were 12 type IB, six type IIB, and two type IA fractures. The mean follow-up duration was 12.6 months (range 6–31 months).

Results

Bone union was achieved in all patients within a mean period of 6.8 weeks, with no incidence of infection, skin necrosis, permanent nail deformity, or secondary osteoarthritis. Only two complications—temporary nail ridging in one patient and a dorsal bump caused by the screw in one patient—were observed. Minimum postoperative displacement was observed in one patient, for whom immobilization with a splint was continued for 4 weeks. Articular incongruity was <1.0 mm in four patients and 1.0–2.0 mm in two patients. Mean DIP joint extension loss was 6.5° and mean flexion was 67.8°. The surgical outcomes were excellent in seven patients, good in nine, and fair in four according to Crawford’s evaluation criteria.

Conclusion

Our novel surgical procedure combining closed reduction with extension block and flexion block using Kirschner wires and microscrew fixation produces good clinical results with relatively few complications.     

Reconstruction of swan neck deformities after proximal interphalangeal joint arthroplasty

Background

The authors report the use of a single slip of the flexor digitorum superficialis (FDS) as a hemitenodesis through the A2 pulley in treating swan neck deformities after previous unconstrained proximal interphalangeal joint (PIP) arthroplasty.

Methods

A retrospective chart review was undertaken to identify non-constrained PIP joint arthroplasties that underwent a subsequent soft tissue hemitenodesis for swan neck deformities. The range of motion (ROM), implant design, preoperative diagnosis, and surgical approach were collected. The Michigan Hand Outcomes Questionnaire and patient satisfaction questionnaire were collected.

Results

There were 12 patients with 14 procedures reviewed. There were seven surface replacement arthroplasties (SRA) (cobalt chrome on polyethylene) and eight pyrocarbon prostheses. The primary diagnosis for the initial joint arthroplasty was osteoarthritis (8), post-traumatic (2), and rheumatoid arthritis (5). The primary dorsal approach was a longitudinal split in eleven cases, Chamay in two, and unknown in one case. Nine of the 14 revision procedures had a concomitant dorsal approach to the joint. The average final position intraoperatively was 24.2° of flexion (range 15°–40°). Final ROM was 39° with average follow-up of 30 months. The average postoperative radiographic position was 20.3° flexion with an average of 24.8° hyperextension preoperatively. There was one failure secondary to implant loosening requiring fusion.

Discussion

For patients with a swan neck deformity after PIP arthroplasty, a FDS hemitenodesis provides a treatment option with a low revision rate, retained motion, and maintenance of the original implant with no shortening of the digit.     

Neues Knochen-Band-Knochen-Transplantat aus plantaren Platten der Fußzehen und die mögliche Anwendung in der SL-Band-Rekonstruktion

Background

Various treatment options have been proposed for reconstruction of the scapholunate ligament. However, none of these methods prevent patients with scapholunate instability from developing wrist arthritis. This study was performed to investigate a new bone-ligament-bone autograft from the plantar plate of the toes for suitable reconstruction of the scapholunate interosseus ligament. The anatomical properties and the technical feasibility were investigated.

Methods

The plantar plates of the metatarso-phalangeal joints and the proximal interphalangeal joints of the 2nd–5th toes were examined in 20 cadaver feet and measurements such as length, thickness and width were recorded.

Results

The average lengths of the plantar ligaments of the proximal interphalangeal joint were 0.63 cm (D3) and 0.62 cm (D4), respectively and were therefore found to be similar to that of the scapholunate ligament. Bone-ligament-bone autografts of the plantar plates were designed and intercalated between the scaphoid and lunate bones and, contrary to all previous methods, not simply superimposed upon them.

Conclusions

It can be concluded from the data that this new graft of the proximal interphalangeal joint of the 3rd and 4th toes can be a suitable replacement for the scapholunate ligament.     

Post-traumatic reconstruction of digital joints by costal cartilage grafting: A preliminary prospective study

In digital joint defects, reconstruction is meant to obtain a stable, mobile and pain-free finger. Six patients aged 29 years in average (15–46) and who were prospectively followed-up presented with digital joint defects that affected at least half of either the proximal interphalangeal (PIP) joint or the metacarpophalangeal (MCP) joint. These defects were treated in emergency (four cases) or scheduled for an autograft of costal cartilage harvested from the ninth rib. Four digits showed lesions of the extensor system which were repaired. One digit grafted after complete amputation was no more vascularized. All patients were reviewed and prospectively followed-up by the surgeons and were also reviewed by an independent operator 16.1 months post-surgery in average (9–25). No infection occurred. None of the grafted fingers had to undergo arthrodesis or secondary amputation. One case of type 1 complex regional pain syndrome occurred. No functional or aesthetic complaint was reported, and no complication was observed at the donor site. The mean arc of motion was 33° (20–50) for the PIP joint and 37° (30–40) for the MCP joint. Mean total active motion (TAM) was 191° (160–250°), whichever the injured finger, i.e. 79.1% compared with the contralateral finger. The Buck-Gramko score averaged 11/15 (8–15). The Strickland score (interphalangeal TAM) was 57.8%, which corresponds to a medium result. The quick DASH assessment averaged 17.42 (0–47.72). Even if arthrodesis or amputation remain the conventional option in case of joint defect, prosthesis or cartilage grafting constitute solutions that allow the preservation of a functional painless finger.     

Hemi-hamate arthroplasty for the management of chronic proximal interphalangeal joint fracture dislocations: Analysis of 21 cases in Indian population and review of the literature

BackgroundChronic fracture-dislocations involving the proximal interphalangeal (PIP) joint are challenging cases. We conducted this study to analyze the outcomes following hemi-hamate autograft reconstruction of such injuries and to compare our results with the existing literature.MethodsA retrospective analysis of 21 patients with chronic dorsal PIP fracture-dislocations that were managed with hemi-hamate autograft reconstruction was done. The average articular surface involvement was 64%. The average duration between injury and surgery was 9.4 weeks (range, 6–16). Quick DASH (Disabilities of Shoulder and Hand) scores, VAS (Visual Analog Scale) scores, range of motion of the PIP joints, DIP (distal interphalangeal) joints, and MCP (metacarpophalangeal) joints were measured during serial follow-up visits.ResultsUnion and graft incorporation was seen in all cases. The average Quick DASH score at four weeks post-surgery was 66 and it improved to eight at one year (p-value<0.05). The average VAS score at four weeks post-surgery was 7.66 and it improved to 2.09 at one year (p-value<0.05). The mean flexion of the MCP joint improved from 52.85° at the end of four weeks to 72.38° at one year (p-value<0.05). The average flexion at the PIP joint improved from 10.47° at the end of four weeks to 70.47° at one year (p-value<0.05). The average DIP flexion improved from 38.33° at the end of four weeks to 62.38° at one year (p-value<0.05). The average hand grip strength was 85% of the normal side.ConclusionHemihamate autograft reconstruction is a suitable procedure for the management of chronic PIP joint fracture-dislocations, especially in cases with extensive involvement of the articular surface.Level of evidenceIII.     

The use of arteriovenous anastomosis for venous drainage during Tamai zone I fingertip replantation

PurposeThe purpose of this study was to evaluate outcomes for patients sustaining a distal fingertip amputation who underwent replantation witharteriovenous anastomosis for venous drainage over a one year period at our institution. This technique has been utilized when insufficient veins are identified in the amputated part for standard veno-venous anastomosis.MethodsA retrospective study was performed on patients presenting from 2013 to 2014. Guillotine, crush, and avulsion/degloving injuries were included if they underwent fingertip (Tamai Zone I) replantation with arterial anastomosis for vascular inflow and arteriovenous anastomosis for venous drainage. The cases were further classified as Ishikawa subzone I and subzone II.ResultsArteriovenous anastomosis for venous drainage during replantation was used in 45 digits in 35 patients. 41 of the 45 digits underwent successful replantation using this technique (91%). The mean active ROM in the DIP joint of the fingers and in the IP joint of thumbs was 65° and 57°, respectively. Sensory evaluation demonstrated a mean of 6.9 mm s2PD in digits where the digital nerves could be repaired. 11 replanted digits without nerve repair regained some sensory recovery with a mean of 9.6 mm s2PD. 91% of patients were highly satisfied with the appearance of the replanted digits based on Tamai criteria.ConclusionsArteriovenous anastomosis for venous outflow should be considered during zone I fingertip replantation if sufficient veins are not identified in the amputated part. This technique may allow for more routine and successful distal replantation.     

Transposition der oberflächlichen Beugesehnen von Mittel- und Ringfinger zur Wiederherstellung der Daumen- und Fingerstreckung (Boyes-Transfer)

Objectives

Restoration of extension in the metacarpophalangeal joints of the fingers as well as in the interphalangeal joint of the thumb by transfer of the superficial flexor tendons of the long and ring fingers (flexor digitorum superficialis III and IV).

Indications

The indications for surgery are substantial loss and palsy of muscles innervated by the radial nerve and its roots.

Contraindications

The procedure is contraindicated by reversible radial palsy, palsy or substantial loss of flexors, limited passive mobility due to contracture, ankylosis or instability of the affected joints, instability of the wrist joint, palsy of the wrist flexors, ankylosis of the wrist joint in an unfavorable position, adhesions of flexor or extensor tendons, insufficient soft tissue coverage or soft tissue defects and passage of transposed tendons through scarred tissue.

Surgical technique

The surgical technique involves division of the superficialis tendons of the long and ring fingers proximal to Camper’s chiasm and routing of the tendons to the dorsum of the hand through separate fenestrations of the interosseus membrane. The flexor digitorum superficialis tendon III is interwoven into the tendons of the extensor pollicis longus und extensor indicis and the flexor digitorum superficialis IV is interwoven into the extensor digitorum tendons.

Postoperative management

Forearm splinting in 20° wrist extension including the metacarpophalangeal joints of the fingers in extension and the thumb in the automatic stop position for 4 weeks leaving the proximal and distal interphalangeal joints free.

Results

From March 1999 to January 2010 a Boyes’ transfer was performed in 13 patients (8 female and 5 male) and the right side was affected in 8, the left side in 5 and the dominant hand in 7 cases. The patient age at the time of surgery was an average of 47?±?17 (13–73) years. The interval between radial palsy and tendon transfer was an average of 79?±?144 (4–543) months. The final follow-up was performed at an average of 82?±?35 (32–165) months. According to the Haas scoring system finger extension was excellent in 5, good in 5, fair in 3 and unfavorable in 4 cases and thumb extension was excellent in 5, good in 3, fair in 1 and unfavorable in 5 patients. The mean disabilities of the arm, shoulder and hand (DASH) score was 36?±?24 (11–85) points. Although disability of varying degrees persisted in all patients, Boyes’ transfer is considered to be a safe procedure to restore finger and thumb extension with excellent and good functional results, a high degree of patient satisfaction and few complications.     

Behandlung von Fingerkuppendefektverletzungen mit dem Semiokklusionsverband nach Mennen und Wiese

Objective

The goal of conservative treatment of fingertip defects is to restore a stable and bulky pulp with recovery of sensitivity and a good skin quality.

Indications

Traumatic defects of the fingertip with or without involvement of the fingernail and/or exposed distal phalanx.

Contraindications

Fractures of the distal phalanx with dislocation or joint involvement, necessitating an osteosynthesis. Allergy to any component of the dressing material.

Dressing technique

Application of a semiocclusive film dressing (polyurethane, bacteria- and waterproof, water vapor permeable). If necessary, debridement of necrotic tissue can precede the first film application. Until complete epithelialization of the defect, the dressing needs to be changed not more than once a week. Thereby, the wound itself must be kept untouched.

Further management

Patients must be encouraged to move all finger joints with the applied dressing. After healing, the new skin is initially protected during heavy loading and shear stress, e.g., by a leather finger glove.

Results

Based on the method of Mennen and Wiese [3], 200 fingertip injuries (some having involvement of the fingernail or exposed distal phalanx) healed within 20–30 days. The pulp was bulky remodeled with good skin quality including the “fingerprint”, as well as nearly normal sensitivity. Using this method, Quell et al. [5] reported on 42 fingertip injuries healed within 2–6 weeks. All fingers could be used without limitation; these were free of pain, with remodeled “fingerprint” and barely visible scars, regular perspiration and restored sensitivity (two-point discrimination 2–8 mm).     

Restoration of joint congruency and the glenoidal labrum after arthroscopic revision Bankart repair: a MRI match-paired analysis comparing primary Bankart repair and the uninjured labrum

Purpose

The restoration of joint congruency and labrum slope and height after arthroscopic revision Bankart repair (RB) compared to the primary arthroscopic Bankart repair (PB) remain unclear.

Methods

Twenty-three consecutive patients after RB with minor glenoid deficits were matched to 23 patients after PB and retrospectively followed by a score system and native 1.5 T magnetic resonance imaging (MRI) assessment. Bankart repair surgeries were performed using double-loaded knotless suture anchors. The glenoidal (GAA) and labral articulation arc (LAA), labrum slope, height index and morphology were assessed separately for the anterior and inferior glenoid and compared to 23 healthy volunteers [radiologic control group (RC)].

Results

Arthroscopic revision Bankart repair showed 28.0 months post-operative equivalent anterior labral congruency (LAA, 9.3°/PB 9.9°/RC 10.1°) and inferior (LAA 9.9°/PB 9.6°/RC 10.5°). The anterior GAA remain decreased (54.6°/PB 55.7°/RC 58.0°) with an original inferior GAA (85.1°/PB 83.2°/RC 83.8°). The RB labrum was slightly decreased anteriorly (slope 22.9°/PB 23.9°/RC 24.6°; height index 2.4/PB 3.0/RC 3.2). The inferior portion had an equivalent labrum slope (23.8°/PB 24.7°/RC 25.1°), but a decreased height index (2.1/PB 2.2/RC 2.3). Morphologic labrum analysis revealed significant changes between all three groups. The clinical outcome after revision surgery was good-to-excellent, but inferior to the primary stabilization and without influence of joint congruency and labrum morphology to the clinical outcome.

Conclusion

A properly applied arthroscopic revision of a Bankart repair generates sufficient restoration of the anteroinferior labral joint congruency and good clinical results.

Study design

Case series.

Level of evidence

3.     

Die Littler-Tenodese zur Behandlung der rheumatischen Schwanenhalsdeformit?t

Objective

Correction of swan neck deformity at the PIP and DIP joint by reconstruction of the oblique retinacular ligament through palmar transposition of one distally pedicled lateral band (oblique retinacular ligament reconstruction (ORL)?=?Littler?II).

Indications

Rheumatoid swan neck deformity Nalebuff stages?I?CIII (dynamic, partially contracted, contracted). The swan neck deformity should be of articular origin.

Contraindications

Advanced radiologic changes of the PIP joint (Larsen?3?C4) [12]. Extrinsic and intrinsic causes of swan neck deformity. Flexor tendon synovitis.

Surgical technique

Dorsal approach to the PIP joint. One lateral band is sectioned proximally at the level of the musculotendinous junction. It is then isolated from the extensor apparatus and left pedicled distal at the insertion. The isolated lateral band is then passed underneath the Cleland ligament from distal to proximal and is sutured to the distal edge of the A2?pulley. The correct tension of the tenodesis achieves flexion at the PIP joint and extension at the DIP joint. In contracted and partially contracted joints, the PIP joint is temporarily transfixed. Depending on the clinical findings, a synovectomy or dorsal arthrolysis of the PIP joint must be performed.

Postoperative management

Immediate postoperative mobilization of the PIP joint for flexion. A figure-of-eight finger splint has to be worn for 12?weeks. The splint must allow full PIP flexion and limit extension over 20?C30° of flexion. In case of temporary transfixation of the PIP joint, wire removal after 4?C6?weeks and start of mobilization. Passive extension over 20?C30° of flexion only after 12?weeks.

Results

From 2004?C2007, 30?PIP joints in 20?rheumatoid patients were treated for swan neck deformity. In all cases, the original method as described by Littler was used. A change of the procedure due to insufficiency of the Cleland ligament or the A2?pulley was not necessary in any of the cases. After a mean of 22?months, 26?PIP joints in 17?patients could be followed up. In 12?PIP joints, the deformity was partially contracted, in two joints contracted. In 10?joints, a dorsal arthrolysis had to be performed, while a lengthening of the medial band was performed in 1?patient. The swan neck deformity could be compensated in all cases. Preoperative hyperextension of a mean 21° could be reduced to a mean 24° of flexion postoperatively. The ROM did not change much but was shifted from the extension sector to the flexion sector of the PIP joint. In no case were complications or recurrence of the deformity noted. Pain could be reduced in all patients except one. The radiologic joint situation was Larsen stage 2.2 preoperatively and 2.3 postoperatively.     

Predictive value of metacarpophalangeal stabilization tests for simulated ulnar nerve lesion measured by a sensor glove

Study Design

A within-subject research design was used in this study. The difference of the range of motion (ROM) with and without ulnar nerve block was analyzed.

Die Behandlung bakterieller Infektionen an den Interphalangealgelenken der Hand

Objective

Radical debridement of joint infection, prevention of further infection-related tissue destruction.

Indications

Septic arthritis of interphalangeal joints in the thumb and fingers.

Contraindications

Extensive soft tissue defects. Severe impairment of blood circulation, finger gangrene. Noncompliance for immobilization or for treatment with external fixator.

Surgical technique

Arthrotomy and irrigation with isotonic solution. Radical tissue debridement. Joint preservation possible only in the absence of infection-related macroscopic cartilage damage. Otherwise, resection of the articular surfaces and secondary arthrodesis. Insertion of antibiotic-coated devices. Temporary immobilization with external fixator.

Postoperative management

Inpatient postoperative treatment with 5-day intravenous administration of a second-generation cephalosporine (e.g., Cefuroxim?) followed by 7?C10?days oral application. Adaptation of antibiotics according to antibiogram results. In joint-preserving procedures, radiographs and fixator removal after 4?weeks, active joint mobilization. If joint surfaces were resected, removal of fixator after 6?weeks; arthrodesis under 3-day intravenous broad-band antibiotic prophylaxis. Splint immobilization until consolidation (6?C8?weeks).

Results

In 10 of 40?patients, the infected joint could be preserved. All infections healed. After an average duration of therapy of 6 (3?C11)?weeks, 4?individuals were free of complaints, and 6?patients had minor symptoms. Overall range of motion in the affected finger was reduced by 25?C50° in 5?patients. All patients could return to work after 6.6 (4?C11)?weeks. A total of 30?patients were treated with joint resection and external fixator. After 5.6 (4?C8)?weeks, arthrodesis was performed, leading to consolidation in 29?patients. One patient underwent amputation after 4?months due to delayed gangrene. Treatment duration was 15.7 (7?C25)?weeks. Eight patients reported no complaints, 14 suffered mild symptoms, 5 had moderate, and 3 had severe symptoms in daily life. In 15?cases, range of motion was diminished by 10?C80° in the remaining joints of the affected finger. Patients could return to work after 16.2 (6?C28)?weeks.     

Treatment of comminuted intra-articular proximal interphalangeal joint fracture using static external fixation with or without supplementary Kirschner wires

Background

The proximal interphalangeal joint plays a crucial role in the function of the hand. It has been referred to as the anatomical and functional locus of finger function. Its injuries can cause significant loss of hand function and consequent disability. In this study, the functional and radiological results of the management of this fracture using a static external fixator with or without supplementary k wire fixation will be evaluated Patients and methods: From June 2010 to July 2012, there were 19 patients whom suffered from closed comminuted intra-articular proximal interphalangeal fracture injuries. The age of the patients at the time of injury ranged from 20 to 35 years, with a mean of 27 years. All the included patients had closed fractures with displaced articular cartilage surfaces and were treated using a static external fixator with or without supplementary k wire fixation.

Results

The mean follow up period was 18 months with a range from 12 to 24 months. The duration of bone healing till solid union ranged from 4 to 7 weeks, with a mean of 5 weeks. The mean ROM for the PIP at the follow- up evaluation was from 14.5° (range 5° to 25°) to 89.7° of flexion (range 80° to 95°). The mean visual analog pain scale averaged 1.95?±?0.7. The mean TAM score for all treated fingers was 86.6?±?5 (range 80–95). At final evaluation, no instability of the PIP was noted and all the cases showed satisfactory clinical and functional results of the affected finger.

Conclusions

Based on the clinical and radiological outcomes of this study at the final follow-up examination, it was found that the use of the static external fixator in the treatment of comminuted intra-articular proximal interphalangeal fracture is an adequate technique.     

Arthrodese der Mittel- und Endgelenke der Kleinzehen

Objective

Elimination of the fixed lesser toe deformity by arthrodesis of the proximal or distal interphalangeal joints (PIP and DIP, respectively).

Indications

Painful fixed deformity. PIP joint: fixed hammer toe or clawtoe. DIP joint: fixed mallet toe. Relative indication: flexible hammer toe, clawtoe or mallet toe.

Contraindications

General operative contraindications. Relative contraindications also include severe deformities affecting the metatarsophalangeal (MTP) joint, for which the arthrodesis should combine an operative procedure of the MTP joint.

Surgical techniques

PIP arthrodesis: Dorsal incision centered over the PIP joint, exposure of the PIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles, resection of the head of the proximal phalanx and the articular surface of the middle phalanx. The arthrodesis should be stabilised in mild plantar flexion. The tip of the toe should have contact with the surface when the push up test is done. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed. DIP arthrodesis: dorsal incision centered over the DIP joint, exposure of the DIP joint by transsecting the extensor tendon and joint capsule, release of the collateral ligaments, while carefully protecting the neurovascular bundles. Resection of the head of the middle phalanx and the articular surface of the distal phalanx. The arthrodesis should be stabilised in straight position. The arthrodesis technique depends on the implant used. The extensor tendon is sutured and the wound is closed.

Postoperative management

Postoperative full weight bearing for 3–6 weeks, depending on the arthrodesis technique used.

Results

Stabilisation of the toe with adequate alignment is achieved by arthrodesis of the affected joint. In general, digital fusion of the fixed lesser toe pathology shows a high subjective satisfaction rate among the patients, although the rate of pseudarthrosis in attempted PIP or DIP arthrodesis is quite high. Major reasons for postoperative dissatisfaction were swelling, wound necrosis, pin infection, floating toe, shortening and angulation of the toe.