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.     

Experimental vascularized total joint autografts--a primate study

Autogenous vascularized and nonvascularized total joint transfers were studied in the hands of Macaca fascicularis monkeys. Nine second toe proximal interphalangeal joints were transferred as a vascularized free graft to the hand, and the excised finger joints were transferred to the foot as a nonvascularized free graft. The grafts were examined clinically and histopathologically at 16 weeks to 10 months. Two of the nonvascularized free grafts were amputated because of infection and necrosis. Three had chronic infections. The four surviving nonvascularized grafts demonstrated necrosis of the hyaline cartilage and degenerative changes. Of the nine vascularized joints, one developed a wound infection that required amputation, another failed at 2 weeks because of wound dehiscence, and the remaining seven survived with preservation of the hyaline articular surfaces. The experimental technique was designed to be easily applied to clinical use. A skin island is provided as a "patency/viability monitor." The extensor mechanism is included in the graft for early function.     

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.     

Epitheloid sarcoma: a case report.

Epitheloid sarcoma of the pulp of the thumb followed repeated penetrating injuries to the digit. It was treated aggressively and successfully to date, nearly 5 years later. In some respects this case report parallels those animal experiments in which foreign body tumorigenesis has been demonstrated, and one might entertain a correlation.     

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.     

Revascularization of digits after thirty-three hours of warm ischemia time: a case report

A case of digits revascularized after 33 hours of warm ischemia time is described. Ischemic changes had occurred already with ultimate loss of the distal segments, but most of the fingers survived to provide the patient with adequate function. Although the commonly accepted limit of warm ischemia time has been reported to be within 6 to 12 hours, revascularization of digits can be attempted in selected cases even after an apparent prolonged warm ischemia time.     

A cause of painful clicking wrist: a case report

In a patient with symptomatic unilateral clicking of the wrist, a partial tear of the scapholunate ligament with subsequent scarring of the proximal third of the dorsal portion of the ligament had occurred. At operation the dorsomedial edge of the proximal pole of the scaphoid had snapped over the dorsal edge of the lunate as the palmar-flexed wrist was being returned to a neutral position. Release of the scarred portion of the scapholunate ligament was associated with widening of the scapholunate joint space to normal dimensions and cessation of the clicking phenomenon. Fourteen months after operation there was complete relief of symptoms, a full range of wrist motion and no radiographic evidence of widening of the scapholunate space, ligamentous instability, or rotatory subluxation of the scaphoid.     

Pisotriquetral arthritis: a case report.

Degenerative arthritis of the pisotriquetral joint was diagnosed by point tenderness over the pisiform and crepitus elicited by lateral movement of the pisiform on the triquetrum. It was confirmed by a roentgenogram of the wrist (lateral view in 30 degrees supination) and injection of the pisotriquetral joint with local anesthetic. Excision of the pisiform resulted in complete relief of pain.     

Chondrosarcoma of the trapezium: a case report.

Roentgenograms of a 46-year-old Caucasian man with progressive swelling and pain at the base of the thumb who had been treated for arthritis showed an enlargement of the trapezium. The entire bone and surrounding ligaments were removed and an iliac bone graft was used to fuse the trapezoid to the first metacarpal. Sections of the tumor were diagnosed as chondrosarcoma. No recurrence is apparent 3 years after excision.     

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.     

Glomus tumor of the digits.

Eight cases of glomus tumor of the digits seen during an 8-year period are reviewed. This number comprised 1.2% of all hand tumors encountered. Symptoms of cold intolerance and exquisite tenderness were common to all. The average duration of symptoms prior to diagnosis and treatment was 7 years. Five patients gave a history of either frostbite (two) or trauma (three) prior to onset of symptoms. The tumor was subungual in six of the eight patients, with a relatively even distribution among all digits. Roentgenographic changes of erosion of the distal phalanx were present in 50% of the tumors. Surgical excision was curative in all instances.