Multiple digit camptodactyly caused by anomalous ulnar sided flexor digitorum superficialis insertions.

We report an anomalous insertion of the flexor digitorum superficialis (FDS) tendon causing multiple digit camptodactyly. The abnormal tendon was present in the ring and middle fingers, passing from the FDS tendon (proximal to the proximal interphalangeal-PIP-joint) to the extensor expansion (distal to the PIP joint). It was present on the ulnar aspect only, with no corresponding structure on the radial side. Division of the anomalous insertion corrected the fixed flexion deformity at the PIP joint. This anomaly has not been reported in clinical or cadaveric studies and could have been overlooked if a volar approach had been used.

Non-union of fractures of the mid-shaft of the clavicle. Treatment with a modified Hagie intramedullary pin and autogenous bone-grafting.

We reviewed a series of fifty patients who had a non-union of a fracture of the clavicle. Twenty-one patients (42 per cent) who had a symptomatic non-union of the middle of the shaft of the clavicle were treated with open reduction, internal fixation with a modified Hagie intramedullary pin, and autogenous bone-grafting, and those patients form the basis for the report. The average duration of follow-up was thirty-five months (range, five months to eleven years). Healing occurred in twenty (95 per cent) of the twenty-one patients. Intramedullary fixation has several advantages compared with other treatments, such as fixation with a plate and screws. It can be performed through a cosmetically acceptable incision in the Langer line; less dissection of the soft tissues is needed; and, after healing, the pin can be removed through a small incision under local anesthesia.

Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and Republic of Ireland.

OBJECTIVES: To determine the incidence and study the causes and outcome of congenital brachial palsy (CBP). DESIGN: Active surveillance of newborn infants using the British Paediatric Surveillance Unit notification system and follow up study of outcome at 6 months of age. SETTING: The United Kingdom and Republic of Ireland. PARTICIPANTS: Newborn infants presenting with a flaccid paresis of the arm (usually one, rarely both) born between April 1998 and March 1999. MAIN OUTCOME MEASURES: Extent of the lesion at birth and degree of recovery at 6 months of age. FINDINGS: There were 323 confirmed cases giving an incidence of 0.42 per 1000 live births (1 in 2300). Significant associated risk factors in comparison with the normal population were shoulder dystocia (60% v 0.3%), high birth weight with 53% infants weighing more than the 90th centile, and assisted delivery (relative risk (RR) 3.4, 95% confidence interval (CI) 2.9 to 3.9, p = 0.0001). There was a considerably lower risk of CBP in infants delivered by caesarean section (RR 7, 95% CI 2 to 56, p = 0.002). At about 6 months of age, about half of the infants had recovered fully, but the remainder showed incomplete recovery including 2% with no recovery. The relative risk of partial or no recovery in infants with extensive lesions soon after birth compared with those with less extensive lesions was 11.28 (95% CI 2.38 to 63.66, p = 0.000005). CONCLUSIONS: The incidence of CBP in the United Kingdom and Republic of Ireland is strikingly similar to that previously reported nearly 40 years ago. Most cases are due to trauma at delivery, which is not necessarily excessive or inappropriate. Given the uncertainty about the appropriate management of these infants, serious consideration should be given to a formal clinical trial of microsurgical nerve repair.

Arthroscopic subacromial decompression for chronic impingement. Two- to five-year results.

Subacromial decompression was performed arthroscopically on 65 patients who were evaluated two to five years after the procedure. None had full thickness rotator cuff tears. Patients with partial thickness cuff tears were included in this study in order to allow comparison of arthroscopic acromioplasty with open acromioplasty for stage II impingement. On the UCLA shoulder rating scale, 89% of the cases in this study achieved a satisfactory result. These results compare favourably with those reported following open acromioplasty. The arthroscopic procedure is technically demanding. When properly performed in patients with appropriate indications, hospitalisation is brief, return to activities is rapid, there is little risk of deltoid muscle complications, and the results are lasting.

Microvascular free-tissue transfers in elderly patients: the leeds experience.

Free-tissue transfer in the elderly has received increasing attention in the literature. Existing reports are limited by small samples or inadequate definition of the term elderly. This study reviewed 5 years' experience with free-tissue transfer in a geriatric population (mean age 75 years, range 70 to 83 years). Forty-nine free flaps were performed in 42 patients between 1986 and 1991. This review focuses on the 39 flaps undertaken in 33 head and neck cancer patients, the main indication being reconstruction after tumor resection (80 percent). In the head and neck cancer group, donor sites included the radial forearm (20), rectus abdominis (6), jejunum (5), and others (8). Thirty-four flaps (87 percent) were primarily successful. Reexploration was required in 10 patients (26 percent) for compromised flaps (5) and bleeding (5). Three of the compromised flaps were salvaged, giving an overall flap success rate of 95 percent. One patient (3 percent) died within 30 days of surgery. These results compare favorably with other published series in elderly patients, as well as with larger cohorts of younger subjects. Free flaps are safe in the elderly. Chronologic age alone should not be an exclusion criterion when selecting patients for free-tissue transfer.

Early parental experiences of obstetric brachial plexus palsy.

Early parental experiences of having a child with obstetric brachial plexus palsy were examined to determine whether there were any areas of dissatisfaction and, if so, whether these resulted from their distress and a need to blame someone, or from problems in the communication of bad news. A high level of dissatisfaction was reported with similar levels of dissatisfaction found in a mildly injured group that did not require surgery, and a severely injured group that did. This suggests either that degree of dissatisfaction is not related to degree of disability, or that dissatisfaction was due to factors other than a reaction to their child having a problem. Support was found for the latter as the parents reported details of problems in communication, particularly the giving of inaccurate and misleading information.

The Hand Injury Severity Scoring System.

A descriptive severity scoring system for injuries to the hand, distal to the carpus, has been designed. Each ray of the hand is assessed separately. Each ray's score is then multiplied by a weighting factor for that ray and added to the scores of the other rays to obtain a total score for the injury. This system has been tested on a series of specimen injuries and compared with the opinion of experienced hand surgeons. A retrospective study of hand injuries has also been conducted, and the Hand Injury Severity Score (HISS) has been found to closely correlate with return to work. Four grades of increasing severity of hand injury have been described. Although this system has been designed as a research tool, it is envisaged that it would be a useful immediate measure of severity and a guide to likely outcome.

Toe to hand transfer in children. Part 1: technical aspects.

Between 1988 and 1994 40 children (age range 9 months-14 years) with either congenital (85%) or acquired hand deformities underwent reconstruction by microvascular autotransplantation of one or more toes. Fourteen underwent a single toe transfer whilst 26 had two second toes transferred to one hand. In 14 of these cases both second toes were transferred at one operation. Whether one or two toes were transferred, the children spent on average 9 days in hospital. None of the transfers failed but 75% of the children underwent staged additional surgery to improve appearance and function. Thirty-seven of the 40 children attended with their parents for follow-up examination by an independent surgeon, a physiotherapist and a clinical psychologist in order to evaluate the results and consequences of surgery. This paper presents the technical considerations for this surgery and examines the influence of the transfer on growth.

Harvest of palmaris longus tendon: technique.

We present a modification of Bunnell's technique for harvest of the palmaris longus tendon. Using a 0.5 cm distal incision and a proximal stab incision the tendon is harvested with minimal scarring and, in our experience of over 30 cases, no morbidity.

What is cold intolerance?

There are four types of symptoms on exposure to cold in the condition known as cold intolerance: pain/discomfort, stiffness, altered sensibility and colour change. They may occur in isolation or in any combination. Symptoms were present in at least 64% of 200 patients 24 months after hand injury. Pain was found to be the most troublesome symptom. Colour change in the digits was regarded by patients as the least troublesome symptom. Symptoms may begin immediately after injury, but are more likely to develop with the first onset of cold weather if there is a lag period between injury and onset. Pre-existing cold related symptoms are uniformly made worse by hand injury. A definition of the condition has been proposed and it has been suggested that this collection of symptoms be known as "Trauma Induced Cold Associated Symptoms".

Psychological aspects of toe to hand transfer in children. Comparison of views of children and their parents.

Thirty-seven children with congenital (n = 32) or post-traumatic (n = 5) hand anomalies underwent unilateral or bilateral toe transfers. All had undergone preoperative counselling. After rehabilitation and more than 1 year after surgery, the children and their parents were reviewed by a clinical psychologist to assess the psychosocial outcome of the surgery. A high level of satisfaction was reported with regard to the surgery, in terms of function, cosmesis, donor site, psychosocial wellbeing and the reactions of others. This was true regardless of the gender of the child. However, there was a tendency for the children to be more positive in their responses than their parents.

The psychological impact of microvascular free toe transfer for children and their parents.

This paper is based on a prospective study of microvascular toe transfers which examined psychosocial, functional and aesthetic outcome for children with congenital hand anomalies and their parents. 14 families were assessed both pre-operatively and 2 years post-operatively. There were five boys and nine girls. Their ages ranged from 6 months to 13 years (mean age = 5.08 years). The parents were assessed on the basis of a parental adjustment measure, a detailed semi-structured interview and a measure of anxiety and depression. The children were assessed on the basis of behaviour and social competence, social experience, self-consciousness about the hand and the perceptions of their own functional competence. Both parents and children were asked to rate their satisfaction with the hand. In addition, function and appearance was assessed using an independent professional panel. It was found that parental adjustment to the hand was an important independent variable in determining psychosocial outcome. The children of poorly-adjusted parents had more social and psychological problems prior to surgery, and showed an increase in behavioural problems after surgery. Their parents were less anxious and happier after surgery and it was of particular benefit to them. The children of well-adjusted parents had fewer pre-operative problems and showed a general slight improvement after surgery. For all the children, there was a significant improvement in both function and appearance of the hands after surgery.

An unusual variant of the levator claviculae muscle encountered in exploration of the brachial plexus.

The levator claviculae muscle is a vestigal muscle which occurs in less than 2% of humans. The embryological origin of this muscle is controversial. We report a case in which an unusual variant of this muscle was encountered during exploratory surgery following a brachial plexus injury. The anatomical findings in this case suggest that this muscle may arise from either the sternocleidomastoid or trapezius muscles or from the primordial ventrolateral musculature.

Paroxysmal finger haematomas (Achenbach's syndrome) with angiographic abnormalities.

We present two cases of women with Achenbach's syndrome (paroxysmal finger haematomas) with abnormal angiograms.

The prespinal route in contralateral C7 nerve root transfer for brachial plexus avulsion injuries.

Contralateral C7 nerve root transfer for brachial plexus injury is described, passing the nerve through a subcutaneous tunnel on the anterior surface of the neck and chest. We recommend passing the nerve graft through the retropharyngeal space. This route has the benefits of a simpler dissection, a shorter distance and protected placement of the graft. It has been used in one clinical case.

Toe to hand transfer in children. Part 2: Functional and psychological aspects.

Forty children with congenital (85%) or acquired hand disorders underwent transfer of one or two toes to one hand. The children were reviewed with their parents and assessed for functional and psychosocial performance. There was some evidence that the older the child at the time of transfer, the better the range of motion. The passive range of motion was on average 60 degrees more than the active range of motion despite subsequent procedures such as tenolysis. All transfers recovered protective sensibility and the majority recovered good levels of two point discrimination and light touch perception. Almost all transfers were naturally incorporated into the use pattern of the limb for some or most of the time. Most parents and patients reported a very positive effect of this surgery on the child's psychosocial functioning.

Developmental and behavioural outcome in obstetric brachial plexus palsy.

Forty-four children with obstetric brachial plexus palsy were assessed for both developmental attainment and behavioural problems. Analysis of the resulting data revealed developmental and behavioural problems previously not identified, particularly in those with more severe injuries. These effects were independent of the general condition of the child at birth, as indicated by their Apgar scores. Further studies are required to provide clarification of these children's difficulties, the mechanisms by which they occur and effective strategies to address them.

The role of low-profile titanium miniplates in emergency and elective hand surgery.

We report our experience of a low-profile mini-plating system in the treatment of fractures of the hand in 57 consecutive patients (five children and 52 adults). Thirteen procedures were performed electively, and 44 procedures were performed on an emergency basis. Indications for plating included fixation of metacarpal (36) and phalangeal (eight) fractures, bony fixation following rotation osteotomy (six) digital replantation (two) or free toe transfer (two). Seventeen patients had postoperative problems, including restricted range of motion (12), rotation deformity (two), significant cold intolerance (two) or fracture (two). Plate removal was required in seven patients, twice as a result of a second injury, and plate removal was unsuccessfully attempted in one other patient. Two patients required extensor tenolysis. We have found this system to be useful for bony fixation in the hand. However, as with other methods of internal fixation in the hand, there may be complications.

Free tissue transfers to the upper limb.

90 consecutive free tissue transfers to the upper limb have been performed in 75 patients (33 children and 42 adults) by one surgeon over a 3-year period. The average age for children was 5 years, and 25 years in adults. 17 transfers were performed as emergency or urgent procedures. The main indications were congenital and traumatic defects. Included in this series were 44 toe transfers, 28 lateral arm flaps and six functional muscle transfers. The overall success rate was 99%. The re-exploration rate was 5.6% with only one failure. There were no failures in children.

Iatrogenic accessory nerve injury.

Accessory nerve injury produces considerable disability. The nerve is most frequently damaged as a complication of radical neck dissection, cervical lymph node biopsy and other surgical procedures. The problem is frequently compounded by a failure to recognise the error immediately after surgery when surgical repair has the greatest chance of success. We present cases which outline the risk of accessory nerve injury, the spectrum of clinical presentations and the problems produced by a failure to recognise the deficit. Regional anatomy, consequences of nerve damage and management options are discussed. Diagnostic biopsy of neck nodes should not be undertaken as a primary investigation and, when indicated, surgery in this region should be performed by suitably trained staff under well-defined conditions. Awareness of iatrogenic injury and its consequences would avoid delays in diagnosis and treatment.