SPin微型螺钉治疗手指关节内骨折

目的 探讨应用Spin螺钉治疗手指关节内骨折的方法及其临床疗效.方法 2004年10月至2007年10月,应用Spin螺钉治疗手指关节内骨折22例,男15例,女7例;年龄18～65岁,平均31岁.涉及掌指关节内骨折9例,近侧指间关节内骨折11例,远侧指间关节内骨折2例.开放性骨折9例,闭合性骨折13例.开放性损伤中合并肌腱损伤7例,1例合并拇指末节离断.采用1枚Spin螺钉内固定14例,采用2枚Spin螺钉内固定5例,采用1枚Spin螺钉并克氏针内固定3例.术后2周开始进行早期功能锻炼.结果 术后伤口均一期愈合,经6～12个月(平均8个月)的随访,无伤口感染及骨髓炎发生.所有病例骨折均愈合,临床愈合时间为3～6周,骨性愈合时间为7～12周,内固定拆除时间为8～26周,无创伤性关节炎发生.手指关节活动度按TAM法进行评价,优15例、良5例、中1例、差1例,优良率90.9%.其中掌指关节内骨折9例.8例活动度0°～90°,1例活动度O°～75°;近侧指间关节内骨折11例,8例活动度0°～11°.,2例活动度O°～90°,1例活动度0°～50°;远侧指间关节内骨折2例,活动度0°～50°.结论 对于手指关节内骨折,行切开复位,Spin螺钉内固定,具有固定可靠、复位满意等优点,是一种有效的手术方法.选择合适的适应证,熟练的手术技巧及早期功能锻炼可以获得满意的疗效.     

Volar plate arthroplasty of the distal interphalangeal joint

Ten patients with chronic dorsal fracture subluxation of the distal interphalangeal joint were managed over 5 years with volar plate advancement arthroplasty. The mean time from injury to definitive surgical treatment was 8 weeks (range, 2 weeks to 4 months). All injuries were characterized by volar comminution and impaction of the distal phalanx, with associated dorsal subluxation. Surgical treatment included volar plate advancement arthroplasty and K-wire fixation of the reduced joint for 4 weeks. All patients were evaluated at an average postoperative duration of 25 months (range, 10-60 months). The average arc of motion of the distal interphalangeal joint of the 4 fingers (6) was 42 degrees and of the interphalangeal joint of the thumb (4) was 51 degrees. All patients had a residual flexion contracture averaging 12 degrees (range, 6 degrees to 25 degrees ). Volar plate advancement arthroplasty is an effective treatment for chronic distal interphalangeal joint dorsal fracture subluxation.     

Extension splinting of palmar plate avulsion injuries of the proximal interphalangeal joint

Hyperextension injuries of the proximal interphalangeal joint have traditionally been immobilized in flexion. This may lead to a proximal interphalangeal flexion contracture of the joint. In an effort to prevent flexion contracture and to simultaneously avoid hyperextension laxity, we have immobilized these injuries in zero degrees of extension for 7 to 10 days. Immobilization is followed by buddy taping and active range of motion until 3 weeks after injury. Protective buddy taping is used until the 6-week point. We report our results using this treatment for only palmar plate avulsion fractures. We did not include proximal interphalangeal joint injuries associated with dorsal dislocation or major collateral ligament injury. Twenty-two of 45 patients were available for follow-up evaluation. Length of follow-up averaged 30 months (range, 6 to 36 months). A high percentage of patients had good or excellent results. In no patient did hyperextension laxity develop and in only one was there a flexion contracture. On the basis of these results, we recommend this treatment protocol for hyperextension injuries of the palmar plate of the proximal interphalangeal joint associated with small avulsion fractures.     

末节断指再植的功能评价

目的报道末节断指再植的远期功能效果.方法对38例42指末节断指再植成功者进行了平均2年3个月(10个月～4年6个月)的随访.结果拇指指间关节与手指远侧指间关节的平均主动活动度分别为49°和52°,两点辨别觉平均7.2mm.根据Tamai标准评价功能结果,42指中优25指,良17指.结论应强调精确吻合指神经的必要性,仅吻合一根指神经或不吻合指神经者感觉恢复较差;对累及关节的离断以关节融合为佳;再植后的萎缩为充盈不良或失用所致.     

The Two-Stage Free Flexor Tendon Grafting of the Hand

Objective Reconstruction of prehension after remote flexor tendon injury or flexor tendon destruction after disease or infection. Indications Absence of passive motion of proximal and distal interphalangeal joints. Uncooperative patient. Children under 5 years of age. Acute local or serious systemic infection. Injury of both digital nerves; circulatory disturbances. Surgical Technique Stage 1: plexus block. Tourniquet. Bruner skin incision. Exploration of tendon and tendon sheaths while preserving or reconstructing pulleys. Revision of scar. Insertion of a silicone spacer. Plaster cast for 2 weeks. Passive mobilization of fingers during 8 weeks. Stage 2: at the earliest 10 weeks after insertion of spacer when the passive range of motion is complete. Z-incisions over distal interphalangeal joint and palm, removal of spacer and insertion of palmaris longus tendon, suture at the proximal end and anchorage to the base of the distal phalanx. Results Using the score of Buck-Gramcko et al., we found 56.2% excellent and good results in 311 patients who underwent either a two-staged tendon grafting (n = 210) or a two-staged pedicled tendon grafting (n = 101). Follow-up after an average of 43 months (8-111 months) after the second stage. Due to complications, revision surgery became necessary in 19 patients (23 fingers = 13.8%): four ruptures of the tendon graft, three dehiscences of tendon suture, four avulsions of spacer, two perforations of spacer, four adhesions, two pulley insufficiences, two scar contractures, and two painful neuromas.     

有无骨片的工型锤状指手术后疗效的比较分析

目的 探讨有骨片和无骨片的Ⅰ型锤状指手术疗效的差异.方法 2005年至2010年,收治46例Ⅰ型锤状指患者,其中A组22例,为伸肌腱止点处有撕脱骨折,术中采用克氏针固定远指间关节和撕脱骨片;B组24例,为单纯伸肌腱止点处断裂,不伴撕脱骨折,术中采用克氏针固定远指间关节,根据肌腱断裂情况选择缝合方法.两组均在术后5～7周拔除克氏针.结果 术后两组随访时间为5～38个月,平均16个月.依据Patel标准评价结果:A组优7例,良5例,中3例,差7例;B组优7例,良3例,中10例,差4例.A组中功能评分为差的比例占31.8％,多于B组差的比例16.7％,但B组中功能仅恢复到中的患者占41.7％.两组优良率的差异无统计学意义(P＞0.05).结论 有远节指骨基底部撕脱骨片的锤状指功能差的患者是无撕脱骨片患者的近2倍,无骨片的锤状指功能为中的比例较大(41.7％),但两组疗效基本相同.     

Conservative treatment of mallet thumb

Four cases of mallet thumb were treated conservatively by splinting the interphalangeal joint of the thumb in extension using the Stack splint. Two patients had sharply cut the extensor tendon on the dorsum of the proximal phalanx and two had avulsion of the extensor tendon from the base of the distal phalanx. Eight weeks of continuous splinting was followed by 2 weeks of night splinting. Six months of follow-up revealed excellent range of motion in all four cases.     

Conservative management of chronic mallet finger

Ten cases of chronic mallet fingers that were 4 to 18 weeks old were treated conservatively by immobilization of the distal interphalangeal joint in extension for 8 continuous weeks and for 2 more weeks at night. With a stringent rating system, there were five excellent, four good, and one fair end result. Two patients had recurrence of the deformity within a week after treatment, and both fully recovered after 8 weeks of further splinting. Splinting is a predictable, safe, and simple method of treatment for chronic mallet fingers.     

骨软骨移植治疗儿童远侧指间关节陈旧性骨折脱位

目的探讨儿童远侧指间关节陈旧性骨折脱位的治疗方法及疗效观察。方法采用游离骨软骨移植术治疗小儿伴有骨软骨缺损的远侧指间关节陈旧性骨折脱位9例9指。结果全部患者均获18个月～13年7个月的随访，优2例，良4例，可3例。结论骨软骨移植术既能有效的矫正畸形，又可保留一定的关节活动度，不失为一种较好的治疗方法。     

掌长肌腱腱片移植治疗陈旧性锤状指畸形

目的 探讨掌长肌腱腱片移植治疗陈旧性锤状指畸形的疗效.方法 对28例陈旧性锤状指畸形的患者,采用克氏针固定远指间关节、掌长肌腱腱片移植加强修复伸肌止点的手术方法.术后6周拔出克氏针,随访时按照Patel评价体系评定.结果 术后25例获得随访,3例失访,随访时间为3～15个月,平均10个月.优9例,良13例,可2例,差1例;优良率为88%.结论 采用掌长肌腱腱片移植加强修复指伸肌腱断端,可明显纠正畸形,并获得良好的关节活动度,是治疗陈旧性锤状指畸形较有效的方法.     

掌长肌腱腱片移植治疗陈旧性锤状指畸形

目的 探讨掌长肌腱腱片移植治疗陈旧性锤状指畸形的疗效.方法 对28例陈旧性锤状指畸形的患者,采用克氏针固定远指间关节、掌长肌腱腱片移植加强修复伸肌止点的手术方法.术后6周拔出克氏针,随访时按照Patel评价体系评定.结果 术后25例获得随访,3例失访,随访时间为3～15个月,平均10个月.优9例,良13例,可2例,差1例;优良率为88%.结论 采用掌长肌腱腱片移植加强修复指伸肌腱断端,可明显纠正畸形,并获得良好的关节活动度,是治疗陈旧性锤状指畸形较有效的方法.     

Flexor digitorum profundus tendon excursions during controlled motion after flexor tendon repair in zone II: a prospective clinical study.

Intratendinous metal markers were used to study flexor digitorum profundus tendon excursions during early controlled motion with dynamic flexion traction and to evaluate their significance for results after flexor tendon repair in zone II. The mean excursion was 1 mm along the middle phalanx and 5.6 mm along the proximal phalanx. This corresponded to a mean excursion per 10 degrees of controlled distal and proximal interphalangeal joint motion of 0.3 and 1.2 mm, respectively. Compared to active motion, controlled motion of the distal interphalangeal joint mobilized the tendon with an efficiency of 36% and controlled motion of the proximal interphalangeal joint mobilized the tendon with an efficiency of 90%. Controlled-motion excursions induced by the distal interphalangeal joint along the middle phalanx had little influence on subsequent active range of motion in the distal interphalangeal joint, whereas excursions along the proximal phalanx (for which the proximal interphalangeal joint was largely responsible) did have a significant influence on subsequent total active interphalangeal range of motion.     

Silicone interpositional arthroplasty of the distal interphalangeal joint

Twenty-three female patients had silicone interpositional arthroplasty of the distal interphalangeal joint in 38 digits. The operative indications were pain and deformity of the distal interphalangeal joint. The underlying diagnosis was osteoarthritis in all but one patient who had rheumatoid arthritis. The average age at the time of operation was 58.3 years. The implants have been in place for a mean period of 72.2 months (range, 12.6 to 123.1 months). At follow-up, extension lag averaged 12.7 degrees and the range of motion of the distal interphalangeal joint had a mean value of 33.2 degrees. Compared with arthrodesis, silicone interpositional arthroplasty offers the advantage of retained motion while preserving stability.     

Management of a metacarpophalangeal joint fracture using a dynamic traction splint and early motion.

Dynamic traction and early motion have been used by hand therapists to treat proximal interphalangeal joint fractures with good results. However, metacarpophalangeal joint fractures have been neglected, perhaps because of their relative infrequency. The purpose of this case study is to report the authors' experience using dynamic traction in conjunction with early motion to treat a construction worker who fell from scaffolding and sustained a complex fracture of the left smallfinger proximal phalanx with involvement of the metacarpophalangeal joint. Range of motion of the patient's left small finger at discharge from therapy, approximately 22 weeks postoperatively, was as follows: metacarpophalangeal joint, hyperextension/65 (85 degrees passive flexion); proximal interphalangeal joint, 20/80 (5/90 passively); and distal interphalangeal joint, 0/50 (65 degrees passive flexion). The patient made a successful return to full-time construction work. The results of this case appear to support consideration of the use of dynamic traction and early motion for management of selected metacarpophalangeal joint fractures.     

Zone I flexor profundus tendon repair in children 5-10 years of age using 3 "figure of eight" sutures followed by immediate active mobilization

A review of the English medical literature over the last 20 years reporting on flexor profundus lacerations revealed only 55 reported cases of zone I flexor profundus lacerations in children. The standard repair technique in young children (5-10 years of age) has been either tendon reinsertion into bone (usually Bunnell technique) for distal zone I injuries or a 2-strand repair (usually modified Kessler technique) for proximal zone I injuries. We report on 22 children (5-10 years of age) with zone I flexor profundus tendon lacerations (10 children had distal zone I injury and 12 had proximal zone I injury) repaired with a 6-strand technique (3 separate "figure of 8" sutures) followed by early postoperative active mobilization. There were no ruptures. Using the Strickland and Glogovac criteria (on the basis of the net active motion of both the interphalangeal joints), all children qualified for an excellent outcome. However, using Moremen and Elliot criteria (on the basis of the net active motion of the distal interphalangeal joint only), 11 children had an excellent outcome, 3 had a good outcome, and 8 had a fair outcome. Our results were compared with previously reported series. It was concluded that the 6-strand figure of 8 suture technique may be used in pediatric zone I injuries and it is strong enough to allow safe early postoperative active mobilization in the 5- to 10-year age group children.     

Treatment of mallet fractures using compression fixation pins.

Fifteen patients who underwent percutaneous fixation of mallet fractures of the distal phalanx using compression fixation pins were assessed. Anatomical reduction was achieved in all patients. There were no nonunions. The mean active range of motion of the distal interphalangeal joint was 1 degrees of hyperextension to 69 degrees of flexion. The fixation was stable enough to allow early active motion exercise of the distal interphalangeal joint. This technique results in a good range of motion in a shorter period of time than other treatments.     

Distal interphalangeal joint arthrodesis: treatment with Herbert screw

From 1996 to 2000, 20 patients with a mean age of 53 underwent 20 arthrodeses with Herbert screws. There were 16 (80%) distal interphalangeal joint (DIP) and 4 (20%) thumb interphalangeal (IP) joint arthrodeses. Average follow-up was 25 months (range, 6-39 months). The diagnoses included rheumatoid arthritis in 10 patients, degenerative arthritis in 4, and post-traumatic arthritis in 6. Arthrodesis relieved pain and restored stability in all patients. Solid osseous union occurred in 19 patients (95%). The average interval to fusion was 8 weeks for DIP and 12 weeks for IP joint arthrodesis. Solid osseous union occurred in 19 patients (95%). The average interval to fusion was 8 weeks for distal interphalangeal joint arthrodesis and 12 weeks for interphalangeal joint of the thumb. There were three complications: one delayed union, one nonunion because of a short screw, and one dorsal skin necrosis with amputation. It was shown that distal interphalangeal joint arthrodesis with a Herbert screw is a technique with several advantages: good clinical results, high rates of fusion, early mobilization, and the screw does not need to be removed after the fusion heals. Potential complications may be avoided by using the Herbert mini-screw.     

Distal interphalangeal joint flexible implant arthroplasty

Twenty-one osteoarthritic distal interphalangeal joints in 13 patients were treated by flexible implant arthroplasty. Follow-up to 5 years showed results that were good to excellent, with only one complication, and a high degree of patient satisfaction. The procedure should be considered a good alternative to the more traditional distal interphalangeal joint arthrodesis.     

Functional assessment of ray transfer for central digital loss

Nineteen patients who had ray transposition for central digital loss were evaluated retrospectively with regard to postoperative function and appearance. Pinch and grip recoveries were better in patients with small-to-ring finger transfers than in those with index-to-long finger transfers. Total average pinch recovery measured 83.3% of the nonoperated side. Total grip recovery was 80.2% of the nonoperated side. Average ranges of motion for all transferred digits were 77.6 degrees (metacarpophalangeal joint), 87.6 degrees (proximal interphalangeal joint), and 80.8 degrees (distal interphalangeal joint). Overall results judged by a five-component assessment scale were excellent.     

Gedeckte Reposition und Stiftfixation des palmaren Verrenkungsbruchs des Fingerendglieds modifiziert nach Ishiguro

OBJECTIVE: Reconstruction of the anatomic configuration of the articular surface and restoration of complete movement of the finger joint. INDICATIONS: Fracture of the distal interphalangeal (DIP) joint involving > or = 30% of the articular surface. Luxation or subluxation of the distal phalanx. Fracture-dislocation > or = 2 mm. CONTRAINDICATIONS: Old fractures. Closed reduction impossible. SURGICAL TECHNIQUE: Closed reduction and pin fixation modified from Ishiguro technique without penetrating the fracture fragment. POSTOPERATIVE MANAGEMENT: Cast fixation for 4 weeks with the finger in functional position or with the proximal interphalangeal joint flexed to relax the pulley. After 4 weeks, removal of the cast and the pin and start of active motion exercises. RESULTS: Twelve patients with fracture-dislocation of the DIP joint involving more than one third of the articular surface were treated with the modified extension block technique according to Ishiguro. Time from injury to surgery was 5 days (range, 0-8 days). At a mean follow-up of 15 months (range, 9-31 months), pain on the visual analog scale (VAS, 0 = no pain, 10 = maximum pain), the active range of motion, and criteria according to Warren et al. were evaluated. Eleven patients were pain-free and one patient suffered from mild pain during strenuous work. The mean active range of motion was from -3 degrees extension (range, 0-10 degrees ) and flexion to 79 degrees (range, 45-100 degrees ). The results according to Warren et al. were very good in ten and good in two cases.