Unstable Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint: Volar Plate Fixation with or without Bone Graft.

BACKGROUND: To evaluate the treatment of severe dorsal fracture dislocation (DFD) injuries of the proximal interphalangeal joint (PIPJ) by open reduction, bone grafting and fixation with mini-hook plates. METHODS: Fourteen patients with extensive dorsal fracture dislocation of the PIPJ were operatively treated to reconstruct the fractured middle phalanx volar lip using a fabricated hook plate in conjunction with elevation and bone grafting of depressed articular fragments where present. RESULTS: Restoration of PIPJ articular anatomy and congruence by hook plate fixation permitted full-range mobilization of the joint during fracture healing, with an average arc of motion of 81° and an average loss of extension of 12.9° at a minimum of 6 months follow up. Hook plate treatment of PIPJ fracture dislocation restores articular anatomy and joint congruence at a single sitting and permits post-operative mobilization without the need for extension block splinting. CONCLUSIONS: Our results demonstrate a good range of motion following treatment, however hardware removal and tenolysis was necessary in 36% of cases.

Parsonage-Turner Syndrome: Clinical and Epidemiological Features From a Hand Surgeon's Perspective.

BACKGROUND: Parsonage-Turner Syndrome (PTS) is a rare but serious condition characterized by spontaneous paresis of the upper extremity, typically lasting several months with variable recovery. With little literature on the behavior of PTS from a hand surgeon's perspective, accurate diagnosis and subsequent counseling of patients with PTS can be challenging. METHODS: This study is a retrospective evaluation of the clinical features of all PTS patients seen over a 9-year period. Data was collected for gender, side affected, handedness, inciting event, clinical presentation, nerve involvement, time taken for recovery, and extent of recovery. RESULTS: Thirty-eight adult cases of PTS were identified, representing an incidence of 0.34 per 1000. Fifty-five percent were female, with predomination of right handedness and dominant upper extremity involvement (60% and 58%, respectively). There was an inciting incident identified in 42% of cases, and 37% of these involved surgery. Twenty-nine percent of cases presented without experiencing typical neuropathic pain. There was a predomination of anterior interosseous nerve (AIN) or posterior interosseous nerve (PIN) involvement (42% overall). Only 44% of patients achieved a complete recovery, taking a mean duration of 10 months. CONCLUSIONS: This study highlights both the rarity and atypical spectrum of clinical presentation of PTS, especially considering the more common involvement found for AIN and PIN. This highlights the likelihood that patients presenting with PTS to a hand surgical practice may differ from those typically described in the literature. The poor rate of recovery is in line with other recent reports and contrasts with the more positive outcomes found in earlier studies.

Gamekeeper's thumb--a treatment-oriented magnetic resonance imaging classification.

PURPOSE: To investigate by magnetic resonance imaging the degree of ulnar collateral ligament (UCL) displacement in order to create a simple classification to aid in determining which UCL injuries require surgery. METHODS: We evaluated 43 cases of UCL injury with a dedicated extremity magnetic resonance imaging and measured the degree of ligament displacement. This was correlated to clinical outcome with planned surgical intervention reserved for patients with a Stener lesion. By collating results we could generate 4 types of injury based on the appearances of the UCL. RESULTS: Partial and minimally displaced UCL tears (type 1) and tears displaced less than 3 mm (type 2) typically healed by immobilization alone, whereas 90% of tears displaced more than 3 mm (type 3) failed immobilization and required surgery as did all of those with a Stener lesion (type 4). CONCLUSIONS: Our 4-stage, treatment-oriented classification of thumb UCL injury is based on the degree of UCL displacement in, with correlation with the likelihood of success with either immobilization or operative intervention. Tears of the UCL with more than 3 mm of displacement are likely to require operative repair even in the absence of a true Stener lesion.

Resurfacing glabrous skin defects in the hand: the thenar base donor site.

Defects of the glabrous skin surfaces of the palm and fingers result from numerous causes including larger fingertip injuries, unhealed burns, and after surgery for diverse pathologies. The qualities of glabrous skin are specifically tailored to the functional requirements of high-shear strength and robustness. Despite these unique properties, graft reconstruction of defects in the glabrous regions of the hand is frequently achieved with skin from nonglabrous donor sites such as the medial forearm. Nonglabrous skin has a poor color and texture match for such applications and is frequently associated with tender and unsightly donor scars. We describe our experiences of harvesting full-thickness grafts from the glabrous skin centered over the proximal flexion crease at the level of the metacarpophalangeal joint of the thumb. We have utilized this site to harvest skin grafts of up to 2 cm in width for the resurfacing of small-sized to medium-sized defects on the palmar surfaces of the hands and fingers in 28 patients under both traumatic and elective circumstances. The skin has an excellent type-match to the defect and is quick and easy to harvest due to its adjacent location to the defect. The donor scar matures quickly, and as it lies along the thumb base crease, it runs along one of the least used contact surfaces, thereby limiting the potential discomfort associated with FTSG harvest sites from other areas. Patient satisfaction with the procedure has been high, and it represents a useful alternative to traditional nonglabrous skin graft donor sites for small-sized to medium-sized defects.

Surgical correction and reconstruction of the nipple-areola complex: current review of techniques.

Nipple malformations are common congenital or acquired conditions that can have tremendous cosmetic, psychological, breast-feeding, sexual, and hygienic ramifications. Ideal reconstruction of the nipple-areola complex (NAC) requires symmetry in position, size, shape, texture, pigmentation, and permanent projection, and although many technical descriptions of NAC reconstruction exist in the medical literature, there are insufficient data presented to accurately compare outcomes. The current article comprises a thorough review of the literature, exploring the techniques described for NAC reconstruction, comparing reported outcomes and complications, and providing an evidence-based approach to NAC reconstruction. The findings of the review suggest that evidence regarding surgical correction of nipple deformity and complete NAC reconstruction is lacking, and loss of nipple projection over time is a pervasive problem common to all flap techniques. A combination of a single pedicle local flap with tattooing for complete NAC reconstruction is currently the most supported method; however, data concerning which type of reconstruction is best suited to immediate versus delayed and type of breast mound remain to be examined.