Elective free vascularized double transfer of toe joint from second toe to proximal interphalangeal joint of index finger: a case report

Alternatives to the treatment of major injuries to the proximal interphalangeal (PIP) joint include fusion, implant arthroplasty, perichondrial grafting, single autogenous free vascularized transfer, and double autogenous free vascularized transfer. A patient presented a gunshot wound to the index finger with loss of skin and extensor tendon and PIP joint disruption. The finger was reconstructed with a composite free flap of skin and extensor tendon and PIP and distal interphalangeal joints of the second toe. A follow-up of 10 months is presented, which demonstrates PIP joint motion and finger function.     

Primary microsurgical repair of ring avulsion amputation injuries

Patients with ring avulsion injuries of the fourth and fifth digits often demand attempts at reconstruction rather than completion of the amputation. In the past, this has led to reconstruction involving a staged series of operations with results that were often less than desirable. Seven patients with ring avulsion amputation injuries that were reconstructed by use of microsurgical reanastomoses are reported. All were classified as either Carroll type IV or Urbaniak type III. Six patients (85%) had a successful replantation leading to a useful finger. The operating time averaged 5.5 hours. On average, 1.9 arteries (range 1 to 2) and 3.3 veins (range 2 to 5) were repaired for each digit. Average hospital stay was 6.7 days (range 4 to 15). Average range of motion was 0(2)/84(2) for metacarpophalangeal joint and 15(2)/90(2) for proximal interphalangeal joint (PIP) with distal interphalangeal joint ankylosis at between 0(2) and 15(2) of flexion. Sensibility was protective in all cases and good in three. If the PIP joint was damaged, completion of amputation was the treatment of choice. If the amputation is distal to the PIP with a functional superficialis tendon, primary microsurgical repair is the treatment of choice in complex ring avulsion injuries.     

True aneurysm of digital artery

A case of a true aneurysm of the ulnar digital artery of the long finger following trauma is presented. Treatment by ligation and excision resulted in relief of symptoms. To our knowledge, a case of true aneurysm of a digital artery has not been previously reported.     

Primary flexor tendon repair followed by immediate controlled mobilization.

A study was made of the results of immediate repair and controlled mobilization in 156 severed flexor tendons in 68 patients occuring over an 18-month period. Eight patients with 16 tendon injuries could not be followed. Results were obtained from examinations done 6 weeks to 18 months (mean, 5.3 months) after repair. Thirty-one of the 60 patients were less than 20 years old, and 44 of the 60 were less than 30 years old. Seventy-nine (56%) of the injuries occurred in the area known as "no man's land"; 28 patients with repair of tendons in this area were rated by our standards as "excellent" or "good"--75% of patients as compared to 84.4% for the results of repair in other areas. In one fourth of the cases of severance of both tendons, because of local conditions in the wound, the superficialis was excised, but in all others it was repaired.     

Digital venous anatomy

The veins of the digits and their valves were studied in nine cadaveric hands by sequential angiography, microdissection, routine histology, cross-sectional microradiography, and corrosion casting. The findings revealed a pattern of dorsal venous arches situated over each digit. Connections between those arches were at the level of the metacarpal heads, the point at which most of the palmar venous blood joins the dorsal system by intercapitular veins. A system of valves, which were arranged so as to direct flow from distal to proximal, from palmar to dorsal, and from radial to ulnar in the hand, was present in all veins as far distal as the pulp.     

Reconstruction of pulleys employing extensor retinaculum.

In ten cases, including five rod placements, four tenolyses, and one immediate tendon graft, 15 pulleys have been reconstructed using a strip of extensor retinaculum 6 to 8 cm long and 8 mm in width. Placed around the phalanx, overlapped, and sutured, the 15 mm segment formely over the fourth dorsal compartment has been positioned over the flexor tendod. The reconstruction has been shown to be stronger than the 10 figure-of-eight No. 4-0 sutures employed to perform it and capable of withstanding immediate active motion. No impairment, functional or cosmetic, of the extensor apparatus has been observed.     

Fasciectomy and Dupuytren's disease: a comparison between the open-palm technique and wound closure

An analysis of 153 patients treated surgically for Dupuytren's disease is presented. One hundred fifteen patients were treated with the closed-palm technique, while 38 patients were treated with the open-palm technique. The groups were comparable in terms of preoperative metacarpophalangeal and proximal interphalangeal joint involvement, as well as the total number of rays involved. The patients were analyzed in terms of average pre- and post-operative total active motion (TAM) in the digital joints. The patients in the closed-palm group had a 10% improvement in TAM surgery, while those in the open-palm group had a 17% improvement (p less than 0.05). The complication rate in the closed-palm group was 19% and in the open-palm group, 8%. There were no hematomas in the open-palm group and no infections in either group. In a later follow-up of 103 patients who could be contacted, 33 of the 78 closed-palm group showed residual contracture (42%), while five of the 25 open-palm group were similarly affected (20%).     

Localized constrictive radial neuropathy in the absence of extrinsic compression: three cases

Three patients, one with bilateral disease, experienced spontaneous onset of radial nerve dysfunction. Each demonstrated significant motor paralysis and had surgical exploration 3 weeks to 3 months after symptoms were first noted. All three patients showed well-localized hourglass constrictions of the radial nerve that could not be attributed to extrinsic compression. Each subsequently required tendon transfers for a persistent radial nerve palsy. Each showed electrical evidence of late recovery, although this was incomplete in two out of three.     

Chronic exertional compartment syndrome of the forearm: a case report

A 40-year-old man sustained a circumferential crush injury to his right forearm. Four months after injury, he experienced the onset of numbness and tingling in the distribution of the median nerve after exercise. Elevated compartment pressures of the palmar forearm and slowing of median nerve conduction after exercise suggested chronic exertional compartment syndrome. A flexor fasciotomy led to complete relief of symptoms, which allowed the patient unrestricted activity.