Fractures of the hand.

In managing any fractures of the hand, the basic principles of fracture management are the same whether treatment is closed or open. They are 1. Accurate reduction and stabilization of the fracture 2. Elevation and edema control 3. Mobilization of the unaffected joints 4. Early range of motion of the injured digit or digits when healing processes permit. Special situations and injuries require amendments to the basic principles. Open fractures require early and thorough wound debridement. Early fixation and serial wound debridement to assure a proper environment for bone or skin grafting are essential in caring for these severe injuries (Figs. 13-15). Numerous fixation techniques ranging from simple plaster splints, K-wires, external fixators, and small plates and screws are available for fracture care. Fractures of the hand are very common injuries that demand early recognition and treatment. The majority of fractures can be treated with closed methods. Recognition of those injuries that require operative treatment and prompt attention to detail and surgical technique will prevent many of the complications associated with these frequently encountered problems.

Severe open fractures of the lower extremity: a retrospective evaluation of the Mangled Extremity Severity Score (MESS)

Recent reports using the Mangled Extremity Severity Score (MESS) suggest that a score of > or = 7 is 100% accurate in predicting the need for amputation of severely injured lower extremities. To further evaluate the value of the MESS in predicting amputation, specifically with respect to type IIIB and type IIIC (Gustilo and Anderson) open fractures of the tibia, we retrospectively evaluated 24 patients with these injuries. A significant difference (p = 0.001) between MESS values of 13 salvaged (6.36 +/- 0.35 SEM) and 11 amputated limbs (6.36 +/- 0.54 SEM) was found. A MESS value of > or = 4 was most sensitive (100%); a MESS value of > or = 7 was most specific, and a MESS value of > or = 7 was found to have a positive predictive value of 100%. Subsequently, we addressed recent criticisms of the MESS by including nerve injury in the scoring system and by separating soft-tissue and skeletal injury components of the MESS. We modified the MESS with a score called the NISSSA and applied it retrospectively to our cases. After careful statistical comparison we found both the MESS and NISSSA to be highly accurate (p < 0.005) in predicting amputation. The NISSSA was found to be more sensitive (81.8% versus 63.6%) and more specific (92.3 versus 69.2%).

Examination and assessment of injuries and problems affecting the elbow, wrist, and hand.

In summary, injuries to the elbow, wrist, and hand are common complaints in emergency department practice. A systematic, thorough examination should be carried out meticulously on each injured patient. Routine radiographs should be taken and any additional views that are needed should be ordered. Most of the commonly missed injuries are due to an inadequate physical examination and inadequate x-ray films of the injured part.

Fractures and dislocations of the forearm.

Fractures and fracture dislocations of the forearm are common injuries that are being seen more frequently today in our active population. These injuries can occur in any sport, by direct blows to the arm or by falls on the outstretched hand. Many of these injuries are dramatic in their presentation and easily diagnosed, but only careful physical examination and radiographic evaluation avoids the pitfalls in diagnosis associated with the Monteggia's, Galeazzi's, and Essex-Lopresti's fracture dislocations. Most of these injuries require anatomic reduction to preserve the delicate interaction between radius and ulna in allowing forearm rotation. Owing to the instability of these fractures, open reduction and internal fixation is often required. Attention to detail in treatment and rehabilitation will avoid the problems of loss of motion, malunion, and nonunion associated with these injuries in the past.

Dislocation of the carpal scaphoid: an 8-year follow-up.

Isolated dislocation of the carpal scaphoid is a rare injury, with 10 cases reported in the English-language literature. We report an 8-year follow-up of a dislocated scaphoid treated with open reduction and Kirschner wire fixation. Good to excellent range of motion was the result.

Posterior interosseous nerve palsy caused by ganglions of the proximal radioulnar joint.

Three cases of ganglion cysts arising from the proximal radioulnar joint associated with a compression neuropathy of the radial or posterior interosseous nerve (PIN) are discussed. Treatment by surgical excision resulted in complete resolution of symptoms in all patients. Computed tomography scan proved to be the most useful preoperative test.