Fixation of Mallet Fractures Using a Modified Hook Plate Technique: A Prospective Case Series of 17 Patients / Fixação de fraturas em martelo com técnica de placa de gancho modificada: Uma série de casos prospectivos de 17 pacientes

Abstract Objective Various modalities have been suggested to manage mallet fractures; however, inappropriate treatment can lead to extension lag, a swan neck deformity, or arthritis of the distal interphalangeal joint (DIPJ). The current study aimed to evaluate the results (functional, radiological, and complications) of open reduction and internal fixation (ORIF) of mallet fractures using low-cost hook plates fabricated from low-profile titanium mini plates. Methods A prospective case series of 17 consecutive patients (average age of 32.3 years) with mallet fractures (six were Wehbe Type IB and 11 were Wehbe Type MB). Eleven (64.7%) were males. The affected hand was dominant in all patients, and the affected digit was the index in 6 (35.3%), the ring in 5 (29.4%), the small in 3 (17.65%), and the middle in 3 (17.65%) patients. The same fellowship-trained hand surgeon performed all surgeries. Results The average operative time was 37.65 minutes. After an average follow-up of 10.94 months (range 6-27), the average DIPJ motion was 50º º (range 20º-70º), the extensor lag was noted in 4 (23.5%) patients, and complications were reported in 6 (35.29%) patients. According to Crawford criteria, 6 (35.3%) patients achieved excellent results, 7 (41.2%) achieved good results, and 4 (23.5%) achieved fair results. Conclusion The modified hook plate technique for fixation of mallet fractures is a beneficiai, economical, yet demanding technique that adequately provides stable fixation to allow early DIPJ motion with acceptable functional outcomes.

Resumo Objetivo Diversas modalidades têm sido sugeridas para o tratamento de fraturas em martelo; no entanto, o tratamento inadequado pode causar retardo de extensão, deformidade em pescoço de cisne ou artrite da articulação interfalangiana distal (AIFD). Este estudo teve como objetivo avaliar os desfechos (funcionais, radiológicos e complicações) da redução aberta e fixação interna (RAFI) das fraturas em martelo com placas de gancho de baixo custo fabricadas com mini placas de titânio de baixo perfil. Métodos Série de casos prospectivos de 17 pacientes consecutivos (idade média de 32,3 anos) com fraturas em martelo (seis do tipo IB e 11 do tipo IIB de Wehbe). Onze (64,7%) pacientes eram do sexo masculino. A mão acometida era a dominante em todos os pacientes, com acometimento do dedo indicador em seis (35,3%), anelar em cinco (29,4%), mínimo em três (17,65%) e médio em três (17,65%) pacientes. O mesmo cirurgião de mão experiente realizou todas as cirurgias. Resultados O tempo operatório médio foi de 37,65 minutos. Após um acompanhamento médio de 10,94 meses (intervalo de 6 a 27), observou-se movimento médio da AIFD de 50º (intervalo de 20º a 70º), retardo de extensão em quatro (23,5%) pacientes e complicações em seis (35,29%) pacientes. De acordo com os critérios de Crawford, os desfechos foram excelentes em seis (35,3%), bons em sete (41,2%) e regulares em quatro (23,5%) pacientes. Conclusão A técnica da placa de gancho modificada para fixação de fraturas em martelo é benéfica e econômica, mas exigente; permite fixação estável e adequada para permitir a movimentação precoce da AIFD com desfechos funcionais aceitáveis.

Colgajo libre de primera arteria metatarsiana dorsal para déficit de cobertura en dígito de la mano: reporte de caso clínico / First dorsal metatarsal artery free flap for finger coverage defect: a case report

Las lesiones graves de los dedos con pérdida de sustancia y exposición de estructuras nobles constituyen un desafío para evitar la amputación. Estas situaciones han impulsado el desarrollo de un gran número de colgajos axiales, locales, con el fin de salvar el dígito. Los colgajos libres, tomados a medida, también han sido descritos para dar coberturas adecuadas y de buena calidad. Se presenta el caso de un paciente con lesión grave de dedo anular con exposición ósea y daño tendíneo, con una pérdida de cobertura de 4 4 cm. El paciente fue sometido a una reconstrucción con un colgajo libre del pie, tomando como eje vascular la primera arteria intermetatarsiana. El paciente conservó su dedo con una movilidad a expensas de la articulación interfalángica proximal (IFP), con una piel de buena calidad, pinza firme y sin dolor. La zona dadora no presentó complicaciones. En manos de un equipo entrenado, con indicación adecuada, estos colgajos logran un buen resultado estético y funcional.

Severe finger injuries with loss of substance and exposure of noble structures are a challenge to avoid amputation. These situations have prompted the development of many local axial flaps to save the digit. Customized free flaps have also been described to provide adequate and good-quality coverage. We present the case of a patient with a severe injury to the ring finger with bone exposure and tendinous damage, with a coverage defect of 4 4 cm. The patient underwent reconstruction with a free flap from the foot, taking the first intermetatarsal artery as the donor vascular axis. The patient kept his finger with mobility at the expense of the proximal interphalangeal (PIP) joint, with good-quality skin, firm clamp, and no pain. The donor area did not present complications. In the hands of a trained team, with adequate indication, these flaps achieve a good esthetic and functional result

Lesiones de punta de dedo: experiencia en el manejo en los últimos 5 años en un centro pediátrico / Fingertip injuries: experience in handling the last 5 years in a pediatric center

Las lesiones de punta de dedo son comunes en pacientes pediátricos que acuden a salas de Emergencia; son causadas por accidentes en el hogar y con aplastamiento en puerta como principal mecanismo de trauma. El tratamiento se realiza individualizado por cirujanos plásticos y cirujanos pediátricos en dependencia de la herida y el compromiso tisular. El propósito de este estudio es describir el manejo de pacientes con lesiones de punta de dedo en un centro pediátrico. Se realizó un análisis de historias clínicas en el período entre enero 2015 y diciembre 2020, se evaluaron 228 pacientes atendidos en el Hospital de Niños Dr. Roberto Gilbert Elizalde, en Guayaquil, Ecuador. Los resultados incluyen un predominio de pacientes en edad preescolar (67%), masculinos (56%) y de mano derecha (53%). Los dedos más afectados fueron el medio y anular. Los procedimientos fueron realizados por cirujanos plásticos (55%) y la técnica electiva fue bajo anestesia general. La extensión del daño involucró tejidos blandos (92%), avulsión de uña (29%) y fracturas asociadas (15%). El 3% de los pacientes presentó complicaciones que requirieron seguimiento. El tipo de reparo se seleccionó en dependencia de la extensión de la herida, se realizaron suturas simples (37%) y suturas complejas con reparo de la uña (27%). Nuestros datos son similares a los descritos en la literatura internacional, con buenos resultados a largo plazo, menor tasa de complicaciones y respuestas similares en los reparos realizados por cirujanos plásticos y cirujanos pediatras.

Fingertip injuries are common in pediatric patients who present to the emergency room. They are usually caused by accidents at home, being door-crush the main mechanism. Treatment is performed on an individual basis, by a Plastic or General Pediatric Surgeon, according to the wound findings and tissue involvement. The purpose of this study is to describe the management on a pediatric center in patients with a fingertip wound. A descriptive and retrospective analysis of medical records was carried out from January 2015 until December 2020. In this period 228 patients were seen in the Dr. Roberto Gilbert Elizalde Children´s Hospital in Guayaquil, Ecuador. A high incidence was found in the preschool age with 67% of cases. The injuries were more common in males (56 %) and more predominant on the right hand (53%). The most affected fingers were the middle and annular. Procedures were mostly performed by Pediatric Surgeons (55%) and the elective technique was under general anesthesia. Damage extension of the fingertip included soft tissues in 92% of patients, nail avulsion in 29% and associated fractures in 15%. Only 3% of patients developed complications that required follow up. The type of repair was selected according to the extension of the injury. Mostly simple sutures (37%) and complex sutures with nail repair (27%)were used.Our data is similar to the one found in international literature, with good long-term outcomes, minor complications and similar results when the repair was performed by a Plastic or Pediatric surgeon

Comparative Analysis of a Modified Secondary Healing Protocol for Fingertip Amputations and Non-microsurgical Reconstruction Techniques / Análise comparativa de um protocolo de cicatrização secundária modificado para amputações das pontas dos dedos e técnicas de reconstrução não microcirúrgicas

Abstract Objective To describe and compare the results obtained with a secondary healing protocol for fingertip amputations and their relationship to injury severity according to the Allen classification. Methods Medical records of 127 fingertip injuries were revised, and a retrospective, comparative, analytical study the amputations treated conservatively was performed. Injury characteristics, healing time, and complications were described and analyzed. Results Between April 2017 and May 2019, 127 fingertip injuries were treated conservatively. The average age of the sample was of 28.33 years. The average healing time was of 4.31 weeks. The complications during the follow-up were observed in 18.9% (n= 24) of the cases, but none require revision treatment. A statistically significant relationship between the development of complications and treatment revision according to the Allen classification was not found (p ≥ 0.05). Conclusion The proposed secondary healing protocol has shown to be safe and effective in types 1 to 3 fingertip amputations in the Allen classification, and it should be included as a therapeutic option even in injuries of greater extension than those that have traditionally been limited to.

Resumo Objetivo Descrever e comparar os resultados obtidos com um protocolo de cicatrização secundária para amputações das pontas dos dedos e sua relação com a gravidade da lesão de acordo com a classificação de Allen. Métodos Foram revisados os prontuários clínicos de 127 lesões nas pontas dos dedos, e realizou-se um estudo retrospectivo, comparativo e analítico das amputações tratadas de forma conservadora. Foram descritas e analisadas as características da lesão, o tempo de cicatrização, e as complicações. Resultados Entre abril de 2017 e maio de 2019, foram tratadas de forma conservadora 127 lesões nas pontas dos dedos. A idade média da amostra era de 28,33 anos. O tempo médio de cicatrização foi de 4,31 semanas. As complicações apresentadas durante o acompanhamento afetaram 18,9% (n = 24) dos casos, porém nenhum exigiu tratamento de revisão. Não foi encontrada relação estatisticamente significativa entre o desenvolvimento das complicações e a revisão do tratamento de acordo com a classificação de Allen (p ≥ 0,05). Conclusão O protocolo de cicatrização secundária proposto mostrou-se seguro e eficaz nas amputações das pontas dos dedos conforme os tipos de 1 a 3 da classificação de Allen, e deve ser incluída como opção terapêutica mesmo em lesões de maior extensão do que aquelas tradicionalmente limitadas.

Lesiones traumáticas en la mano por el uso de amoladora. Un problema en nuestro medio / Traumatic injuries to the hand from the use of an angle grinder. A problem in our field

Introducción: Las lesiones en las manos causadas por amoladora son comunes y generalmente ocurren en adultos jóvenes. En países en desarrollo, el ámbito doméstico y el trabajo informal son los escenarios más frecuentes. El objetivo de este estudio fue describir factores asociados a las lesiones por amoladora, y cuantificar y clasificar las heridas, según la gravedad y la región anatómica de la mano involucrada. Materiales y Métodos: Se realizó un estudio epidemiológico, retrospectivo. Entre 2016 y 2020, estudiamos a los pacientes con heridas de mano causadas por amoladora. Se analizaron el nivel educativo, la experiencia con la herramienta, el material cortado, el uso de equipo de protección personal, la edad y el sexo. Para determinar el patrón de las lesiones se realizó un análisis clínico-anatómico y radiológico detallado e individualizado. La gravedad fue evaluada con el Hand Injury Severity Score. Resultados: Se evaluó a928 pacientes (920 hombres y 8 mujeres, edad promedio 42 años). Solo el 22,4% usaba equipo de protección personal en el momento del accidente. El 84,5% (776 casos) realizaba tareas inusuales para la que esta herramienta no fue diseñada. La mano más afectada fue la izquierda (62,06%). En 784 pacientes, las heridas involucraban los dedos, el patrón de asociación predominante fue entre el 2do y 3er dedo (54,44%). Las lesiones fueron leves (24,1%), moderadas (41,3%), graves (26%) y mayores (8,6%). Conclusiones: Las lesiones por amoladora pueden resultar devastadoras. Una actualización epidemiológica reforzaría la necesidad de desarrollar métodos preventivos con el fin de disminuir su alta incidencia. Nivel de Evidencia: IV

Introduction: Hand injuries caused by angle grinders are frequent and generally take place among young adults. In developing countries, the domestic and informal work environments are the most frequent places where this could happen. The present study is aimed at describing associated factors to these types of injuries. Lesions were quantified and classified according to the sever-ity and anatomic region of the hand involved. Methods: An epidemiologic, retrospective study was performed between 2016 and 2020. The patients' level of education, previous experience using the machine, use of personal protective equipment (PPE), sex, and age were analyzed. To determine the pattern of the injuries, a clinical-anatomical and a detailed and individualized radiological analysis were performed on each patient. The severity was measured using the "Hand Injury Severity Score" (HISS). Results: 928 patients were studied (920 men, 8 women, average age of 42 years [range 18-67]). Only 22.4% were wearing PPE at the time of the accident. 776 participants were performing tasks for which the tool was not intended (84.5%). The left hand was the most af-fected (60%). In 784 patients, the injuries involved their fingers (84.48%); the predominant pattern was the index and middle finger (55%). According to the HISS, 24.1% were minor injuries, 41.3% were moderate, 26% were serious, and 8.6% were severe. Con-clusions: Injuries caused by an angle grinder can be devastating. We believe that an epidemiological update is likely to increase the need to develop preventive methods to decrease its high incidence. Level of Evidence: IV

Reconstrucción en amputaciones distales de dedos en niños con injerto compuesto y vendaje semioclusivo / Reconstruction of distal finger amputations in children with composite autograft and semi-oclusive dressing

La reconstrucción de una amputación distal de dedo en un niño es un desafío. Los procedimientos propuestos son muchos, y los resultados no han sido buenos. La reconstrucción con reposición del segmento a modo de injerto compuesto, o con técnicas microquirúrgicas, parece ofrecer la mejor de las posibilidades, pues se conservan estructuras irremplazables, como el lecho ungueal y el hiponiquio, lo que permite que los niños mantengan un pulpejo anatómico y con función normal. Presentamos una serie de tres pacientes pediátricos tratados con una nueva técnica, que combina la reposición del segmento, como un injerto compuesto, y el uso de curación semioclusiva (composite autograft and semi-oclussive dressing, CASOD, en inglés). Hemos observado buenos resultados.

The reconstruction of finger tip amputation in children is challenging. There are many procedures described to treat this injury, none of which present optimal results. Repositioning of the amputated segment as an autograft or with microsurgical techniques seems to offer the best outcome. It enables the preservation of otherwise irreplaceable structures, such as the nail bed and the hyponychium, thus enabling children to mantain an anatomically and functionally normal finger pad. We present a series of three pediatric patients treated with tha new technique, which combines composite autograft and semi-oclusive dressing (CASOD). The results observed so far have been promising.

Osteosíntesis en fracturas oblicuas o espiroideas largas de metacarpianos: comparación entre tratamiento con tornillos interfragmentarios solos y placa con tornillos / Osteosynthesis in long oblique and spiral metacarpal fractures: Comparison between interfragmentary screws and plating

Objetivos: Comparar el tratamiento de pacientes con fracturas oblicuas o espiroideas largas de metacarpianos, mediante reducción abierta y fijación interna con tornillos interfragmentarios solos o placas y tornillos. Materiales y métodos: Se realizó un estudio retrospectivo comparativo entre 2 grupos de pacientes: uno con 24 pacientes tratados con tornillos interfragmentarios solos y otro con 17 pacientes tratados mediante osteosíntesis con placas y tornillos. En ambos, se utilizó un abordaje longitudinal dorsal, y se les indicó inmovilización posoperatoria con valva de yeso y rehabilitación con el mismo equipo de terapistas ocupacionales. Tras un seguimiento mínimo de 12 meses, se evaluaron los resultados con el puntaje DASH, la movilidad activa total, la distancia pulpejo-palma y la fuerza con dinamometría comparativa. Se consideró significativo un valor p <0,05. Resultados: El tiempo promedio de seguimiento fue de 24.5 meses (rango 12-43).No se hallaron diferencias estadísticamente significativas en el puntaje DASH, la movilidad activa total, la distancia pulpejo-palma y la fuerza. El tiempo hasta el reingreso laboral fue inferior en el grupo tratado con placas y tornillos, aunque se registraron dos casos de retiro de material, sumado, en uno de ellos, a adherencia tendinosa (tenólisis). Conclusiones: El tratamiento de pacientes con fracturas oblicuas o espiroideas largas de metacarpianos, mediante tornillos interfragmentarios solos o placas y tornillos logró resultados similares, se destaca el menor tiempo hasta la reincorporación laboral y la mayor cantidad de complicaciones con placas y tornillos. Nivel de Evidencia: III

Objective: To compare open reduction and internal fixation with interfragmentary screws and with plates and screws for the treatment of long oblique or spiral metacarpal fractures. Materials and methods: A comparative retrospective study was carried out between 2 groups of patients treated surgically. In the first group, 24 patients were treated with interfragmentary screws and in the second group, 17 patients were treated with plate and screw osteosynthesis. A dorsal longitudinal approach was used. Postoperatively, immobilization was performed using a plaster splint; both groups followed rehabilitation with same occupational therapist team. After a minimum follow-up of 12 months, they were evaluated with the DASH score, total active motion (TAM), pulp-to-palm distance, and comparative contralateral dynamometry. A p value < 0.05 was considered significant. Results: The average follow-up was 24.5 months (range 12-43 months). There were no statistically significant differences in DASH, TAM, pulp-to-palm distance, and strength. The group treated with plate and screw fixation returned to work earlier, although there were two cases of implant removal, in addition to tendon adherence (tenolysis) in one of them. Conclusions: The treatment of patients with long oblique or spiral metacarpal fractures with interfragmentary screws or plates and screws showed similar outcomes; the treatment with plate and screws allowed an earlier return to work but had a greater number of complications. Level of Evidence: III

Reparación primaria de los flexores en la zona II. Actualización y técnica quirúrgica / Primary flexor tendon repair in zone II. Update and surgical technique

La reparación primaria de los tendones flexores en la zona II ha sido un desafío desde el surgimiento de la cirugía de la mano como especialidad luego de la Segunda Guerra Mundial. Desde Bunnell hasta hoy, la forma de operar y rehabilitar estos tendones ha evolucionado y cambiado considerablemente gracias a estudios anatómicos, biológicos y, sobre todo, mecánicos. Actualmente la técnica quirúrgica se basa en realizar una sutura fuerte y prolija, que no sufra fricción dentro de la vaina y que tolere la carga necesaria para la movilidad activa del dígito sin resistencia. Se han descrito múltiples configuraciones de puntos con diferentes materiales. Operando con anestesia local, la prueba de flexo-extensión activa intraoperatoria revela la resistencia del tipo de sutura elegida y ha cobrado importancia para definir el protocolo de rehabilitación. El tratamiento de los flexores en la zona II es, hasta el momento, un conjunto inseparable de técnica quirúrgica y rehabilitación asociada. La manipulación farmacológica del proceso biológico reparador es el principal campo de investigación actual

Primary flexor tendon repair in zone II has been a challenge since the emergence of hand surgery as a specialty after World War II. From Bunnell to today, the way of operating and rehabilitating these tendons has evolved and changed considerably thanks to anatomical, biological and --above all --mechanical studies. Currently, the surgical technique is based on performing a strong and neat suture, which does not suffer friction within the sheath and which tolerates the load necessary for the active motion of the finger without resistance. Multiple suture configurations with different materials have been described. Under local anesthesia, the intraoperative active flexion-extension test reveals the resistance of the type of suture chosen and has gained importance in defining the rehabilitation protocol. Treatment of flexors in zone II is, so far, an inseparable set of surgical technique and a suitable rehabilitation protocol. Biological strategies to enhance the tendon healing process are currently the main field of research

Rehabilitación de los tendones flexores en la zona II. ¿Qué aspectos debemos tener en cuenta a la hora de abordar a los pacientes? Revisión bibliográfica / Rehabilitation of flexor tendons in zone II. What aspects should we take into account when assisting these patients? Literature review

El tratamiento de los tendones flexores es un tema de interés y genera un desafío constante tanto para los cirujanos como para los rehabilitadores. Se han descrito numerosas técnicas quirúrgicas y tratamientos con la finalidad de mejorar el resultado funcional, aunque hoy en día no existe un protocolo ideal. El objetivo de este artículo es analizar la información relevante a los efectos de planificar la rehabilitación de los pacientes con lesiones de tendones flexores en la zona II. Entre otros aspectos tendremos en cuenta la solidez de la sutura, el edema, la cicatriz, el tipo de inmovilización utilizada y el deslizamiento tendinoso. Es necesario contar con un buen equipo de trabajo formado por el cirujano, el terapista de mano y el paciente a fin de planificar la rehabilitación más adecuada para cada caso. Nivel de Evidencia: V

The treatment of flexor tendons is a topic of interest and creates a constant challenge for both surgeons and rehabilitators. Numerous surgical techniques and treatments have been described in order to improve functional results, although nowadays there is no ideal protocol. The objective of this article is to analyze the relevant information in order to plan the rehabilitation of patients with flexor tendon injuries in zone II. Among other aspects, we will take into account the strenght of the suture, the edema, the scar, the type of immobilization and the tendon gliding. Good teamwork is required between the surgeon, the hand therapist, and the patient in order to plan the most appropriate rehabilitation for each case. Level of Evidence: V

In Vitro Biomechanical Study on the Figure-of-Eight and Kessler Sutures in Swine Flexor Tendons / Estudo biomecânico in vitro das suturas em oito e de Kessler de tendões flexores de porcos

Abstract Objective To evaluate the biomechanical properties of the "figure-of-eight" and Kessler suture techniques for tendons. Methods Flexor tendons of porcine fingers were divided into two groups with triple central "figure of eight" sutures (six passages) and Kessler sutures (two passages) associated with simple and continuous peripheral sutures, and submitted to continuous longitudinal mechanical tests, to obtain the mechanical properties of maximum load and energy at maximum load. Results The mean maximum load and energy at maximum load in the "figure-of-8" suture were of 63.4 N and 217.3 N.mm respectively; in the Kessler suture, the values were of 34.19 N and 100.9 N.mm respectively. The statistical analysis indicated that the "figure-of-eight" suture is mechanically superior to the Kessler technique. Conclusion Under the conditions of this experiment and in the flexor tendon of porcine fingers, the triple "figure-of-eight" suture (six passages) is more resistant than the Kessler suture (two passages). The "figure-of-eight" suture with six passages enables active movement in the immediate rehabilitation of the flexor tendon repair of the finger, with little risk of rupture or suture spacing.

Resumo Objetivo Avaliar as propriedades biomecânicas dos pontos de sutura tendinosa em "oito" e de Kessler. Métodos Tendões flexores dos dedos de membros superiores de porcos foram divididos em dois grupos com suturas triplas centrais em "oito" (seis passagens) e de Kessler (duas passagens) associadas a suturas periféricas contínuas simples, e submetidos a ensaios mecânicos longitudinais contínuos, obtendo-se as propriedades mecânicas de carga máxima e de energia na carga máxima. Resultados As médias da carga máxima e da energia na carga máxima na sutura em "8" foram de 63,4 N e 217,3 Nmm, respectivamente; na sutura de Kessler, os valores foram de 34,19 N e 100,9 Nmm, respectivamente. A análise estatística indicou que o ponto em "oito" é superior mecanicamente ao ponto de Kessler. Conclusões Nas condições deste experimento e no tendão flexor de dedo de membro superior de porcos, o triplo ponto em "oito" (seis passagens) é mais resistente do que o ponto de Kessler (duas passagens). O triplo ponto em "oito", com seis passagens, permite movimentação ativa na reabilitação imediata de reparo de tendão flexor de dedo de membro superior com pouco risco de ruptura ou espaçamento na sutura.

Colgajo dorsolateral versus colgajo en isla mediopalmar radial para el tratamiento de lesiones traumáticas distales del pulgar. Evaluación clínica / Dorsolateral flap vs. radial midpalmar island flap in the treatment of traumatic distal thumb injuries. Clinical evaluation

Objetivo: Evaluar clínicamente a pacientes con lesiones distales combinadas del pulgar tratados mediante colgajo dorsolateral o colgajo en isla mediopalmar radial. Materiales y Métodos: Se comparó retrospectivamente a 20 pacientes (14 hombres y 6 mujeres; promedio de edad 35 años) con lesiones traumáticas combinadas distales del pulgar, operados por dos cirujanos, con técnicas diferentes. Los pacientes no tenían antecedentes quirúrgicos y el seguimiento mínimo fue de 24 meses. Se evaluaron el resultado subjetivo usando el índice de satisfacción, la escala analógica visual para dolor y el puntaje QuickDASH, y el resultado objetivo mediante el test de discriminación de 2 puntos, el tiempo quirúrgico promedio y la necesidad de reeducación espacial digital. Resultados: La media desde el ingreso hasta el alta laboral fue de 7 semanas (rango 6-8). Resultados promedio posoperatorios: escala analógica visual 01/10, ambos grupos. Grupo con colgajo dorsolateral: índice de satisfacción 97%, test de discriminación de 2 puntos 4 mm, puntaje QuickDASH 2,5; tiempo quirúrgico 45 min, sin necesidad de reeducación espacial digital. Grupo con colgajo en isla mediopalmar radial: índice de satisfacción 92%, test de discriminación de 2 puntos 6 mm, puntaje QuickDASH 8, tiempo quirúrgico 60 min; 4 pacientes requirieron reeducación espacial digital. Conclusión: Los colgajos dorsolateral y en isla mediopalmar radial resultaron eficaces en el tratamiento de lesiones traumáticas distales del pulgar, aunque el colgajo dorsolateral tuvo mejores puntajes de evaluación objetiva y requirió menos tiempo quirúrgico. Nivel de Evidencia: III

Objective: To clinically evaluate patients with combined distal thumb lesions treated by a dorsolateral flap or radial midpalmar island flap. Materials and Methods: We retrospectively compared 20 patients (14 males and 6 females, averaging 35 years) with combined distal thumb traumatic lesions, who were operated on by two surgeons using different techniques. Patients had no previous surgical history and a minimum follow-up period of 24 months. Subjective outcome was evaluated by satisfaction index (SI), visual analogue scale (VAS), and QuickDASH score. Objective outcome was evaluated by two-point discrimination test (TPDT), average surgical time (ST), and need for digital spatial reeducation (DSR). Results: Time from admission to medical discharge averaged 7 weeks (range, 6-8). Average postoperative results: VAS for pain, 01/10 (both groups); IS, 97% vs. 92% (dorsolateral flap group vs. radial midpalmar island flap); TPDT, 4 mm vs. 6 mm; QuickDASH, 2.5 vs. 8; ST, 45 minutes vs. 60 minutes; need for DSR, 0 vs. 4 cases. Conclusion: Both the dorsolateral flap and the radial midpalmar island flap techniques were effective in the treatment of distal thumb traumatic lesions, although the dorsolateral flap achieved better objective evaluation scores and required less ST. Level of Evidence: III

Colocación de un tornillo transfisario medial en la cadera espástica de niños con parálisis cerebral. Eficacia y seguridad / Medial transphyseal screw placement for spastic hip treatment in children with cerebral palsy. Effectiveness and safety

Introducción: En estudios experimentales y clínicos, los resultados con el tornillo excéntrico transfisario medial para producir varo fueron alentadores. El propósito de este estudio fue determinar si colocar un tornillo en el fémur proximal es un gesto eficaz y seguro en caderas espásticas de niños con parálisis cerebral. Materiales y Métodos: Se incluyó a pacientes con parálisis cerebral infantil y caderas en riesgo. Se compararon la serie A: pacientes con liberación de partes blandas más colocación de un tornillo excéntrico transfisario medial en el fémur proximal y la serie B: pacientes solo con liberación de partes blandas. Se determinaron el test de Rang, el índice de migración de Reimer, el ángulo cervicodiafisario y las complicaciones, antes de la cirugía y después. Resultados: Se operó a 18 pacientes (36 caderas): 10 de la serie A y 8 de la serie B, con una mediana de edad de 51 meses y una mediana de seguimiento, de 3 años. Al comparar por delta de medianas todas las variables preoperatorias y posoperatorias, hubo una diferencia estadísticamente significativa solo en el delta de mediana del ángulo cervicodiafisario de las caderas izquierdas (-5 vs. 0, p 0,02). Conclusiones: La liberación de partes blandas es eficaz para prevenir la luxación de la cadera espástica. La colocación de un tornillo transfisario excéntrico en la cadera espástica no produjo cambios y no fue inocua. La hemifisiodesis medial de la cadera es una atractiva solución teórica para tratar los problemas ocasionados por el valgo excesivo, pero se requieren más estudios. Nivel de Evidencia: III

Introduction: Animal and clinical studies have shown promising results for the varus-producing placement of a medial eccentric transphyseal screw. The purpose of this study was to establish if the placement of a screw in the proximal femur is an effective and safe approach for spastic hips in children with cerebral palsy (CP). Materials and Methods: We compared two series of pediatric CP patients (Gross Motor Function Classification System [GMFCS] III, IV and V) with "hips at risk." Series A patients were treated with soft-tissue release plus a medial eccentric transphyseal screw in the proximal femur. Series B patients were only treated with soft-tissue release. Patients were evaluated pre and postoperatively to determine their Rang test score, Reimer's migration index (MI), diaphyseal cervical angle, and complications. Results: From a total of 18 patients operated, 36 hips, 55% (10) belonged to the A Series and 45% (8) to the B Series. The median age was 51 months (IQR, 41-108). The median follow-up was 3 years (IQR, 2.4-5.8). The comparative analysis of all preoperative and postoperative variables yield only one statistically significant difference: the median left hip diaphyseal cervical angle (-5 vs. 0, P 0.02). Conclusions: The release of soft tissues was effective to prevent the spastic hip dislocation. The placement of medial eccentric transphyseal screw in spastic hips produced some complications and no beneficial changes. Medial hemiphysiodesis of the hip remains nothing but an attractive theoretical solution for the treatment of problems caused by excessive valgus. However, further studies are warranted. Level of Evidence: III

Reimplante de falange distal de dedo sin anastomosis venosa con anestesia local / Distal phalanx replantation under local anesthesia and without venous anastomosis

Presentamos a un paciente que sufrió una amputación traumática de la falange distal del 5to dedo de su mano izquierda, y fue tratado mediante un reimplante sin anastomosis venosa. En el mismo acto quirúrgico, se le realizó una artrodesis definitiva con clavijas. La cirugía se efectuó con anestesia troncular del dedo, por lo cual no se requirió de un anestesista ni fue necesario un tiempo adecuado de ayuno. Debido a la localización distal de la amputación y a la ausencia de una vena dorsal viable para ser anastomosada, se optó por un drenaje venoso controlado mediante la extracción de la placa ungueal, el frotado del lecho ungueal y la colocación periódica (cada 3 h, por 7 días) de una gasa impregnada con heparina. Además, el paciente fue anticoagulado con enoxaparina 40 mg y ácido acetilsalicílico cada 24 h, por 21 días. El reimplante fue exitoso. Nivel de Evidencia: IV

We present a patient who experienced a traumatic amputation of his left fifth finger distal phalanx, and was treated using replantation without venous anastomosis. The same surgical procedure also included a final arthrodesis with Kirschner wires. Surgery was performed with digital block anesthesia, which did not require the presence of an anesthesiologist nor fasting. The distal level of the amputation and the lack of viable options for dorsal vein anastomosis motivated our decision for venous drainage controlled by nail-plate removal, nail-bed scrubbing and periodic (every 3 hours during 7 days) dressing with heparin-impregnated gauze. In addition, the patient received anticoagulant therapy with aspirin and enoxaparin 40 mg every 24 hours for 21 days. The replantation procedure was a success. Level of Evidence: IV

Interobserver Analysis of Albertoni Classification for Mallet Finger, Using Plain Radiography: Importance of the Goniometer / Análise interobservador da classificação das lesões em dedo em martelo segundo Albertoni, utilizando-se radiografias simples: Importância do uso do goniômetro

Abstract Objectives The objective of the present study is to evaluate the intraobserver and interobserver reliability of the Albertoni classification for mallet finger. Evaluation of goniometer device application is also an objective. Methods A total of 10 lateral radiographs of patients with mallet finger were selected and measured by 60 orthopedic surgeons with and without the use of goniometer. Results The intra- and interobserver reliability coefficients found were high. With the use of a goniometer, the interobserver reliability coefficient was even higher, but without statistical relevance. Conclusion The Albertoni classification showed high intraobserver and interobserver reliability in assessing mallet finger lesions, and the goniometer is dispensable for this purpose.

Resumo Objetivos Quantificar o grau de concordância intra- e interobservador da classificação Albertoni e avaliar a importância do uso do goniômetro na diferenciação do grau da lesão. Métodos Foram selecionados 10 casos de dedo em martelo, os quais foram avaliados por 60 examinadores. Resultados A concordância interobservador sem o uso do goniômetro foi elevada. Com o uso do goniômetro, obteve-se um "kappa" ainda maior, porém sem relevância estatística. Conclusão A Classificação de Albertoni possui elevada concordância intra- e interobservador, e o uso do goniômetro se mostrou dispensável para classificar.

Triple open dislocation in the index finger of the hand without a high-energy trauma / Triple luxación abierta del segundo dedo de la mano tras traumatismo de baja energía

A simultaneous double dislocation (both proximal [PIP] and distal [DIP] interphalangeal joints) of a triphalangeal finger is a rare entity. The most common hand affected is the right hand. In the case of a closed triple dislocation (metacarpophalangeal [MCP], PIP and DIP joints); there are only two cases in the literature revised. In this case, we report an open triple dislocation in the index finger of the left-hand of a 54-year-old man treated by closed reduction and 3 weeks of immobilization followed by active mobilization with satisfactory results.

La luxación simultánea de las articulaciones interfalángicas proximal (IFP) y distal (IFD) de un dedo de tres articulaciones es una rara entidad. La mano que es afectada con más frecuencia es la derecha. Con relación a una triple luxación cerrada (articulación metacarpofalángica [MCF], IFP e IFD), sólo hay descritos dos casos en la literatura revisada. En este caso, describimos una triple luxación abierta del segundo dedo de la mano en un varón de 54 años de edad tratada mediante reducción cerrada,e inmovilización durante 3 semanas seguida de movilización activa supervisada, con resultado final satisfactorio.

Preliminary study on functional and aesthetic reconstruction by using a small artery-only free medial flap of the second toe for fingertip injuries

OBJECTIVES: This study was designed to introduce the feasibility of fingertip reconstruction by using a free medial flap of the second toe without vein anastomosis. METHODS: In total, 8 patients with fingertip injuries were treated successfully with this method. Patients who underwent reconstruction from September 2016 to October 2017 in our hospital with an artery-only free medial flap transfer of the second toe for fingertip injuries were included, and patients who underwent additional procedures that may impact the postoperative results and were followed up for less than 6 months were excluded. Clinical trial registration: ChiCTR19000021883. RESULTS: According to the Allen classification, five patients had Type 3 injuries, and three patients had Type 4 injuries. One arterial nerve and one digital nerve were repaired at the same time. No additional dissection was performed in either the donor or recipient site of the dorsal or volar vein. Postoperative venous congestion was monitored based on the color, temperature and the degree of tissue oxygen saturation. The flap size ranged from 1.20*1.0 cm2 to 1.80*1.0 cm2. The reconstruction time was 71.86 (SD 14.75) minutes. The two-point discrimination and the monofilament results were satisfying; cold intolerance did not appear in five patients, and the other three patients had cold intolerance with grades of 4, 12 and 26, which were considered satisfactory. Moreover, leech therapy, continuous bleeding and needle sutures were not utilized in any cases. CONCLUSIONS: Reconstruction with a small artery-only free medial flap transfer of the second toe led to satisfactory sensory and motor function in the selected patients with fingertip injuries.

Repair of soft tissue defects of the fingers with medial plantar venous flap

SUMMARY OBJECTIVE To report the surgical procedures and efficacy of using medial plantar venous flap for the repair of soft tissue defects of the fingers. Methods From March 2010 to April 2012, medial plantar venous flaps were harvested to repair the wounds of 31 fingers in 29 cases. Among them, there were 13 middle fingers with defects at the tips in 11 cases, 7 fingers with defects in the dorsal part in 7 cases, and 11 fingers with defects in the finger pulp in 11 cases. The size of the defects ranged from 1.2cm×1.5 cm to 2.5cm × 3.5cm. Medial plantar venous flaps of 1.5cm × 2cm - 3×4 cm were harvested. Full-thickness skin grafts were adopted for the donor areas. RESULTS All 31 flaps survived, except for 1 flap with arterial crisis and 2 cases with venous crisis. These conditions were timely corrected by secondary anastomosis of artery and vein and the flaps survived. The wounds and the donor areas achieved healing by the first intention. All grafted skins survived. Postoperative follow-up was conducted for 26 fingers in 24 cases for 4-12 months, excluding 5 cases with lost follow-up. The dorsal part of the damaged fingers had normal morphology, and the skin color and texture were similar to those of the normal skin. After the repair of defects in the fingertip and pulp, fingerprints appeared, and the protective sensation was restored. CONCLUSION The soft tissue defects of the fingers can be satisfactorily repaired with medial plantar venous flap, and little damage is caused to the donor area. This method is proven effective for the repair of soft tissue defects of the fingers.

RESUMO OBJETIVO Relatar os procedimentos cirúrgicos e a eficácia do uso de retalhos plantares mediais venosos para reparo de defeitos de tecidos moles dos dedos. METODOLOGIA De março de 2010 a abril de 2012, foram colhidos retalhos plantares mediais venosos para reparar ferimentos de 31 dedos em 29 casos. Entre eles, 13 dedos médios com defeitos nas pontas em 11 casos, 7 dedos com defeitos na parte dorsal em 7 casos e 11 dedos com defeitos na polpa digital em 11 casos. O tamanho dos defeitos variava de 1,2 cm × 1,5 cm a 2,5 cm × 3,5 cm. Foram colhidos retalhos plantares mediais venosos de 1,5 cm × 2 cm a 3 cm × 4 cm. Foram adotados enxertos de pele de espessura total na área doadora. RESULTADOS Todos os 31 retalhos sobreviveram, com exceção de 1 retalho com crise arterial e 2 casos com crise venosa. Esses problemas foram corrigidos a tempo com anastomoses secundárias das artérias e veias e os retalhos sobreviveram. Os ferimentos e áreas doadoras atingiram cicatrização por primeira intenção. Todos os enxertos de pele sobreviveram. Foi realizado acompanhamento pós-operatório em de 26 dedos em 24 casos por 4 a 12 meses, sendo que dos casos tratados 5 não tiveram acompanhamento. As partes dorsais dos dedos lesionados apresentaram morfologia normal, com cor e textura da pele muito similares a da pele normal. Após o reparo dos defeitos nas pontas e polpas digitais, impressões digitais apareceram e a sensação protetora foi restaurada. CONCLUSÃO Os defeitos de tecido mole dos dedos podem ser reparados de forma satisfatória com retalhos plantares mediais venosos, com poucos danos à área doadora. Este método mostrou se eficaz para o reparo de defeitos de tecido mole dos dedos.

Colgajo de Atasoy: revisión de una técnica clásica para reconstrucción digital / Atasoy flap: review of a classical technique for digital reconstruction

Resumen Aproximadamente el 50% de las lesiones de mano atendidas en urgencias corresponden a la punta de los dedos, dentro de estas el manejo de las amputaciones requiere una cobertura adecuada, aseguramiento de la sensibilidad táctil, mantención de la longitud y provisión de un lecho de crecimiento y almohadilla para la uña y pulpejo respectivamente; así, con resultados estéticos y funcionales que permitan una incorporación laboral temprana. El presente artículo realiza la descripción de la técnica colgajo de Atasoy o de V en Y, una herramienta que logra las metas reconstructivas en amputaciones dorsales oblicuas o transversas. Lo anterior basados en la literatura, disecciones en cadáveres y casos clínicos. MÉD.UIS. 2018;31(1):57-63.

Abstract Approximately 50% of hand injuries attended in the emergency room correspond to the fingertips, among these the management of amputations requires adequate coverage, ensuring tactile sensitivity, preservation of finger length and provision of a growth bed and pad for the nail and pulp respectively; thus, with esthetic and functional results that allow an early labor incorporation. This article describes the Atasoy or V in Y flap technique, a tool that achieves the reconstructive goals in oblique or transverse dorsal amputations. The above based on the literature, corpse dissections and successful clinical cases. MÉD.UIS. 2018;31(1):57-63.

Evaluation of interobserver agreement in Albertoni's classification for mallet finger / Avaliação de concordância interobservador da classificação de Albertoni para dedo em martelo

ABSTRACT Objective: To measure the reliability of Albertoni's classification for mallet finger. Methods: Agreement study. Forty-three radiographs of patients with mallet finger were assessed by 19 responders (12 hand surgeons and seven residents). Injuries were classified by Albertoni's classification. For agreement comparison, lesions were grouped as: (A) tendon avulsion; (B) avulsion fracture; (C) fracture of the dorsal lip; and (D) physis injury-and subgroups (each group divided into two subgroups). Agreement was assessed by Fleiss's modification for kappa statistics. Results: Agreement was excellent for Group A (k = 0.95 (0.93-0.97)) and remained good when separated into A1 and A2. Group B was moderate (k = 0.42 (0.39-0.44)) and poor when separated into B1 and B2. In the Group C, agreement was good (k = 0.72 (0.70-0.74)), but when separated into C1 and C2, it became moderate. Group D was always poor (k = 0.16 (0.14-0.19)). The general agreement was moderate, with (k = 0.57 (0.56-0.58)). Conclusion: Albertoni's classification evaluated for interobserver agreement is considered a reproducible classification by the method used in the research.

RESUMO Objetivo: Avaliar a reprodutibilidade da classificação de Albertoni para dedo em martelo. Métodos: Foi feita uma avaliação por meio de questionário no qual foram avaliadas 43 radiografias em perfil da articulação interfalângica distal de dedos da mão, com lesão tipo dedo em martelo. Todas as lesões foram caracterizadas pela classificação de Albertoni, por 19 entrevistados (12 cirurgiões de mão e sete residentes). Foi então avaliada a concordância com o coeficiente Kappa generalizado, separadas por grupos - (A) avulsão tendínea; (B) fratura avulsão; (C) fratura do lábio dorsal e (D) lesão fisária - e por subgrupos (cada grupo dividido em 1 e 2). Resultados: A concordância foi excelente para o grupo A (k = 0,95 [0,93-0,97]) e manteve-se boa quando separados em A1 e A2. No grupo B, a concordância foi moderada (k = 0,42 [0,39-0,44]), e foi ruim quando separada em B1 e B2. No grupo C, a concordância foi boa (k = 0,72 [0,70-0,74]), mas quando separada em C1 e C2 se tornou moderada. No grupo D foi sempre ruim (k = 0,16 [0,14-0,19]). A concordância geral foi moderada (k = 0,57 [0,56-0,58]). Conclusão: Pela avaliação da concordância geral, a classificação de Albertoni é considerada reprodutível pelo método usado na pesquisa.