Reconstructive surgery of roller injuries of the hand.

Eleven patients with roller injuries to the upper extremity are described. Nine were treated initially; two were referred for treatment within 3 weeks after injury. Six patients were injured by kneading machines in bakeries, two by hot dry-cleaning mangles, two by industrial rolling machines, and one by a transmission belt which acted as a roller. The tissue damage depends on (1) the space between the rollers, (2) the speed of the rollers, (3) the hardness of the rollers, (4) the temperature of the rollers, and (5) how violently the patient attempts to withdraw the entrapped part. Lesions may be closed, consisting of a compression of the soft tissues, which may result in skin necrosis, or a tearing and separation of the skin and soft tissues away from the deep fascia (more common on the dorsal surface of the hand), or destruction of skin and deep tissue because of burns. Closed injuries usually respond to conservative care, although decompression sometimes is necessary. Experience gained from treating these 11 patients indicates that the inexperienced surgeon often tries to replace distally based flaps. Such flaps usually die and predispose to deep infection. If the condition of the wound permits, primary skin grafts should be applied; but if the bed is of poor quality, skin grafting can be delayed for several days. If it is necessary to protect exposed deep structures, they should be covered with immediate pedicle flaps. It is better to use skin from an uninjured area for a free skin graft than to use the avulsed skin as a graft. Distant flaps should be used if secondary reconstruction is anticipated. In circumferential skin loss, a combination of pedicle skin and free skin grafts is better than encircling the part with a pedicle flap. The thumb and radial fingers should be preserved, but the ulnar fingers are expendible in severe injuries. By amputating parts of fingers, reconstruction often is simplified.     

Dorsal dislocation of the fourth and fifth carpometacarpal joints and simultaneous dislocation of the metacarpophalangeal joint of the small finger: a case report

A patient with dorsal dislocation of the fourth and fifth carpometacarpal (CMC) joints and dislocation of the metacarpophalangeal (MP) joint of the small finger was managed successfully by open reduction and transarticular fixation of the CMC joint dislocation and closed reduction of the MP joint dislocation. This rare combination of injuries has not been reported previously.     

The mechanism of the intrinsic-minus finger: a biomechanical study

To demonstrate in the cadaver model that the sequence of extension of the flexed metacarpophalangeal and proximal interphalangeal joints of the intrinsic-minus finger can be explained on the basis of moment ratios about these joints, the engineering concept of free body analysis was applied. Intrinsic-minus fingers, i.e., fingers of a cadaver in which all forces exerted by the intrinsic muscles were removed, were observed to hyperextend maximally at the metacarpophalangeal joint before extension of the proximal interphalangeal joint began. Mathematical calculation of moments provides an explanation of this sequence. This study confirmed that, when an equilibrium of forces at the hyperextended metacarpophalangeal joint is reached, the proximal interphalangeal joint is incompletely extended. These forces include: (1) the proximal pull of the extensor tendon; (2) the distal loading of the extensor tendon by the flexor tendons; (3) the force preventing spanning of the laminae.     

Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer

Fourteen patients were treated by flexor digitorum superficialis transfer for irreparable flexor pollicis longus lesions. Results measured by return of interphalangeal joint motion were good in 12 patients, with one patient achieving a fair result and one failure. This is a reliable procedure in thumbs with a grade I or II (Boyes) tendon bed and should be considered as an alternative to free tendon grafting for reconstruction in patients in whom return of interphalangeal motion is desirable.     

Surgical closure of patent ductus arteriosus in the premature infant with respiratory distress

During the period from February, 1971 to February, 1973, 30 premature infants underwent surgical ligation of patent ductus arteriosus. The gestational ages ranged from 25 to 36 wk (mean 30), and the birth weights ranged from 760 to 2010 g (mean 1274). The patients were divided into two groups on the basis of the indications for assisted ventilation. Group I consisted of 21 patients with severe hyaline membrane disease who required assisted ventilation during the first 2 days of life and could not be weaned off the respirator by 10 days of age. Group II was composed of nine infants who required intermittent positive-pressure breathing after a mean age of 8 days because of repeated apneic spells secondary to uncontrollable heart failure. All infants in Group II survived the operation and left the hospital well. Fourteen of the 21 patients in Group I survived; the seven deaths were all due to underlying severe pulmonary disease (bronchopulmonary dysplasia). The value of PDA ligation in premature infants with uncontrollable heart failure is demonstrated in this study; this procedure also appears to be beneficial in neonates with severe respiratory distress syndrome.     

Bilateral partial ruptures of the flexor carpi radialis tendon secondary to trapezial arthritis

This is a report of bilateral partial ruptures of the flexor carpi radialis tendons associated with trapezial osteoarthritis. Splinting for 4 weeks was curative. One of the tendons was exposed 4 months after rupture in conjunction with carpal tunnel release and the abnormal healed tendon was revealed.     

Vascular anatomy of flexor tendons. I. Vincular system and blood supply of the profundus tendon in the digital sheath.

The detailed blood supply of the flexor tendons in the digital canal was studied in 35 fresh human hands by means of an India ink-latex vascular injection technique. The specimens were examined by first exposing the pulley system, followed by examination of the intact tendon which had been rendered transparent by immersion in a solution of tributyl and tricresyl phosphate. Five annular and three cruciform pulleys were shown. There were five types of long vincula to the profundus (VLP) and three types of long vincula to the superficialis (VLS). The vincular systems of index and little fingers were symmetrical. Occasionally, neither the VLP nor the VLS was found in either the long or the ring fingers. The vincula received blood supply from four transverse branches of the digital arteries. A volar avascular area of the profundus tendon was seen in the cleared cross-sections, and the cross-over zone of its intrinsic vessels was found to be at the midproximal phalanx.     

Fingertip reconstruction with a palmar advancement flap and free dermal graft: a report of six cases

The palmar thumb advancement flap was first described by Moberg in 1964. It was further utilized for the thumb and defined by Posner and Smith in 1971. In 1980, Macht and Watson favorably reported their technique of palmar advancement that was applicable not only for the thumb, but also for all five digits with soft tissue tip losses. A further refinement of their technique is to augment the digital tip with an autogenous dermal graft. This dermal "padding" is placed directly over the bony tuft to act as a "shock absorber," add bulk and contour to the distal tip of the finger, increase soft tissue stability, eliminate direct percussive tenderness of the bone, and decrease disability for specific occupations such as those requiring typewriting. Six cases are reported.     

Delayed flexor tendon repair in no man's land.

Thirty seven digital flexor tendon injuries in 31 patients were treated by closure of the skin and delayed repair from 24 hours to 21 days later. All skin wounds healed without serious complication, and there were no infections. On examination at a minium of 4 months after repair, 36% had total active motion (TAM) of 220 degrees, 32% from 200 degrees to 220 degrees, 6% from 180 degrees to 200 degrees and 26% with less than 180 degrees. Under proper conditions, repair of flexor tendons can be carried out with the expectation of results comparable to more complex reconstruction procedures.     

Treatment of Dupuytren's contracture by extensive fasciectomy through multiple Y-V--plasty incisions: short-term evaluation of 170 consecutive operations.

The zigzag incision with Y-V closure has unique advantages for the treatment of Dupuytren's disease. Much skin can be mobilized to the longitudinal finger axis. There is rarely a need for skin grafting in spite of full correction of the deformity. This approach, combined with properly applied tamponade bulk dressing, allows for early use of the hand with minimal morbidity.