Facet Inclinations and Interfacet Angle of the Distal Radius on Posteroanterior Radiographs: Clinical Associations With 3 Carpal Pathologies.

PURPOSE: The radiographic interfacet angle (IFA), scaphoid facet inclination (SFI), and lunate facet inclination (LFI) of the distal radius were measured in patients with 3 distinct wrist pathologies to determine whether there is an association between these radiographic measurements and these conditions. METHODS: Posteroanterior wrist radiographs were compiled from patients with 3 types of common wrist pathologies (scaphoid waist fracture [n = 54], scapholunate [SL] dissociation [n = 23], and dorsal ganglion [n = 51]). The patients were all Caucasians aged 20 to 45 years who met strict radiographic criteria. The IFA, SFI, and LFI values of these patients were compared with those obtained from 400 normal wrist radiographs of subjects who met the same selection criteria. RESULTS: In men with a scaphoid waist fracture, the IFA and SFI were significantly greater than in normal men, whereas the LFI was significantly lower. In the SL dissociation group, for all patients and for subgroups stratified according to sex, the IFA and SFI were significantly lower than in the normal matched groups. In the dorsal ganglion group, differences were found in the IFA and SFI for women, but not for men. CONCLUSIONS: The facet orientations of the distal radius in patients with scaphoid fracture, SL dissociation, and dorsal ganglion differed from those in the normal population. The IFA alone is most likely to be associated with all 3 pathologies. The SFI and LFI are less likely to be associated with patients with carpal pathologies. CLINICAL RELEVANCE: Patients with a greater IFA may be susceptible to scaphoid fractures when they fall on an overstretched hand. Patients with a smaller IFA may be susceptible to SL dissociation when they fall on an overstretched hand.

The clinical anatomy of crucifixion.

Crucifixion was a widely used form of execution for capital crimes in antiquity. Civilizations and empires perfected the technique, leading to centuries of discussions, controversies, and questions, many of which concerned the death of Jesus Christ. To this day, much remains to be discovered in both religious and scientific realms. However, the aim of this study is to discuss such facts as are known from the medical perspectives of clinical anatomists. Nails/spikes were driven through the hands/wrists and feet of five adult cadavers, and the cadavers were then dissected to observe the anatomical structures that had been injured or placed at risk for injury. While many historical and archeological facts remain to be discovered, we hope that this cadaveric study will enhance our modern understanding of ancient practices from a medical and anatomical perspective. Clin. Anat. 32:12-21, 2019. © 2019 Wiley Periodicals, Inc.

A Self-Inflicted Gunshot Wound With an Unusual Hand Injury.

Self-inflicted gunshot wounds are a common cause of firearm-related deaths. The appearance and location of the entry wound, other concomitant findings at autopsy, and correlation with the scene and circumstances are critical in determining the manner of death. A case of a 72-year-old man with a self-inflicted gunshot wound with an unusual injury pattern is described. There was a contact range gunshot entry in the right temple, and an exit wound was seen in the left parietal region. There was a re-entry with an associated exit wound on the left hand.

Venous super-drained posterior interosseous artery flap for dorsal hand defects.

BACKGROUND: Posterior interosseous artery flap PIAF is one of the most preferred reconstructive options for upper extremity defects. As a reverse flap, venous congestion is always a threatening factor. In this report authors aimed to present their experience with venous super-drained posterior interosseous artery flap VS-PIAF. METHODS: Between January 2013 to September 17, 2017 patients were treated with VS-PIAF. Tumor excision, trauma, traffic accident, burn contracture release, and industrial injuries were the causes of defects. Defects were located on the dorsum of the hand, first web space, ulnar and radial side of the hand, and the palm. All the defects were reconstructed with a VS-PIAF, which a distal superficial end-to-end venous anastomosis was added to overcome venous congestion problems. RESULTS: The flap sizes were between 5 × 7 cm and 8 × 12 cm. All the flaps have survived completely without any early or late complications. No venous problems were seen. The donor areas were healed uneventfully. The mean follow-up time was 15.3 months. The results of reconstructions were satisfactory, no functional restrictions was seen. CONCLUSION: The major drawback of PIAF is venous congestion problems that can be manageable with adding a distal superficial end-to-end venous anastomose. VS-PIAF is a robust, much safer and easy-to-learn reconstructive method for upper extremity defects.

[Treatment Options for Inveterate Injuries of Deep Finger Flexors - Primary Transplantation with Tendon Graft]. / Moznosti osetrení u zastaralých poranení hlubokých flexoru prstu ruky ­ primární transplantace slachovým stepem.

Injuries of the flexor finger apparatus are very common. Primarily, it is routinely treated by suture of the tendon. Isolated deep flexor injuries, when the flexion restriction only reaches the DIP joint, are sometimes overlooked by the surgeon or by the patients themselves, especially if the deep flexor is injured, after a closed rupture or cutaneous injury with a small skin wound. The patient is then sent to a department specializing in hand surgery after a few weeks. Subsequent shortening of the tendon apparatus makes flexor suture more difficult or sometimes even impossible. Many ways of suturing the tendons and subsequent treatment are described. The treatment results vary immensely. It depends on the mechanism of injury, injury zone, the suture suture technique used, time that has elapsed since primary treatment, surgeon experience and subsequent postoperative and rehabilitative care. One of them is reconstruction of the flexor apparatus by primary transplantation of an autologous tendon graft. Most commonly, the tendon graft is taken from the palmaris longusfrom the same hand. The tendon graft can subsitute the entire area of zones I and II. The tendon suture is made in the palm proximal to the A1 pulley outside the tendon sheath in the area where the muscular belly of thelumbricalis is located on the tendon of the deep flexor. The distal end is reinserted to the base of the distal phalanx. The primary use of the autologous tendon graft can be used in the reconstruction of obsolete deep-flexor injuries in Zone II, but also in primary treatments. This type of treatment has a number of advantages. Performing the reinforcement of the tendon at the base of the distal phalanxand the suture in the palm of the hand completely eliminates the complications caused by the tendon suture in zone II. There is no injury to the tendon sheath, or the need for intersection of the tendons. The transplanted tendon is smaller in diameter than the deep flexor, so it can also be used for older injuries when the tendon sheath is in partially missing. It removes painful palmar resistance by restoring the right position and a tension of tendon of lumbricalis and the tendon of the deep flexor. This type of reconstruction allows immediate active or semi-rehabilitation of the hand and fingers. Key words:tendon, injury, hand, transplantation, surgery, flexor, reconstruction, rupture, treatment.

"Defense" type wounds in suicide.

"Defense" type wounds are sustained when a victim is attempting to ward off an attacker, or a weapon. A 39-year-old woman is reported who was found deceased with incised wounds to the dorsa of both hands that resembled defense wounds. Examination of the flexor surfaces of both wrists, however, revealed horizontal incised wounds typical of self-infliction. Perfusion of the subclavian arteries produced leakage of water from peripheral veins within wounds on both hands and the right wrist. Death was due to exsanguination from incised wounds of the hands and right wrist; manner suicide. This case demonstrates the difficulties that may arise in differentiating self-inflicted from assaultive wounds. On occasion suicidal sharp force injuries may be multiple and in atypical locations. In these circumstances a high index of suspicion for homicide must be maintained.

Fireworks type, injury pattern, and permanent impairment following severe fireworks-related injuries.

BACKGROUND: There is a paucity of clinical data on severe fireworks-related injuries, and the relationship between firework types, injury patterns, and magnitude of impairment is not well understood. Our objective was to describe the relationship between fireworks type, injury patterns, and impairment. METHODS: Retrospective case series (2005-2015) of patients who sustained consumer fireworks-related injuries requiring hospital admission and/or an operation at a Level 1 Trauma/Burn Center. Fireworks types, injury patterns (body region, injury type), operation, and permanent impairment were examined. RESULTS: Data from 294 patients 1 to 61years of age (mean 24years) were examined. The majority (90%) were male. 119 (40%) patients were admitted who did not undergo surgery, 163 (55%) patients required both admission and surgery, and 12 (5%) patients underwent outpatient surgery. The greatest proportion of injuries was related to shells/mortars (39%). There were proportionally more rocket injuries in children (44%), more homemade firework injuries in teens (34%), and more shell/mortar injuries in adults (86%). Brain, face, and hand injuries were disproportionately represented in the shells/mortars group. Seventy percent of globe-injured patients experienced partial or complete permanent vision loss. Thirty-seven percent of hand-injured patients required at least one partial or whole finger/hand amputation. The greatest proportion of eye and hand injuries resulting in permanent impairment was in the shells/mortars group, followed by homemade fireworks. Two patients died. CONCLUSIONS: Severe fireworks-related injuries from homemade fireworks and shells/mortars have specific injury patterns. Shells/mortars disproportionately cause permanent impairment from eye and hand injury.

Friction Blisters on the Hands Treated Successfully Using 2-Octyl Cyanoacrylate: A Case Report.

BACKGROUND: Friction blisters on the hand are challenging to treat as conventional dressings are prone to saturation, contamination, and loosening with active hand use and other mechanical stresses. Alternative methods and materials for dressing hand blisters warrant exploration. CASE SUMMARY: A 48-year-old male surgeon presented with friction blisters over his bilateral thumbs. The patient complained of significant difficulty in keeping his dressings clean and dry, significant pain with hand hygiene, and functional limitations at work. The patient's blisters were dressed with 2-octyl cyanoacrylate (Dermabond; Ethicon US LLC, Somerville, New Jersey), applied directly onto the wound bed. The patient was able to perform his normal duties immediately, without the need for additional intervention. Six days postapplication, the Dermabond sloughed off, revealing an epithelialized surface. CONCLUSION: Dermabond is a promising agent for dressing unroofed blisters of the hand, as it provides a barrier to moisture and contamination, while allowing the wound to epithelialize, without functional cost.

Severe Hand Injuries From Fireworks: Injury Patterns, Outcomes, and Fireworks Types.

PURPOSE: The purpose of this study was to characterize injury patterns and outcomes of fireworks-related hand injuries and determine if there was an association with certain fireworks types. METHODS: A retrospective cohort study was conducted on patients treated at a trauma center between 2005 and 2015. A total of 105 patients sustaining operative hand injuries due to fireworks were identified. Medical records were reviewed to identify injury patterns, treatment outcomes, and fireworks types. RESULTS: Eighty-eight patients (84%) sustained 92 thumb and/or first web space injuries. There were 12 thumb soft tissue-only injuries (13%) and 80 thumb fractures/dislocations (87%). Of these, there were 52 thumb carpometacarpal (CMC) joint dislocations (57%) and 36 thumb fractures outside the thumb CMC joint (39%). Fifteen hands (16%) sustained both thumb CMC joint dislocations and additional thumb fractures. Twenty-three hands (25%) required thumb revision amputation. The number of surgeries for acute reconstruction ranged from 1 to 7, with 17 patients (19%) requiring 3 or more. Sixty-three hands had deep first web space injuries, and 11 (17%) required flaps acutely for first web space reconstruction. Six hands required secondary reconstruction of a first web space contracture. An external fixator was applied to 6 hands to maintain the first web space; none of these required secondary web reconstruction. Excluding isolated pin removals and dressing changes under anesthesia, 19 patients (22%) required later-stage surgeries. Shells/mortars (59%) were the most common fireworks type causing injury. CONCLUSIONS: Among operative hand injuries, fireworks most commonly fracture the thumb, destabilize the thumb CMC joint, and deeply damage the first web space. The first web space requires particular consideration because deep injury may result in adduction contracture and require secondary reconstruction if not prevented. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Indications and Predictors for Reconstructive Surgery After Hand Burns.

PURPOSE: The objective of this study was to analyze the prevalence, indications, and type of reconstructive surgery and predictors of the outcomes of reconstructive surgery after hand burns. METHODS: A retrospective cohort study was conducted that included all patients admitted with acute hand burns in the Dutch burn centers from January 1998 through December 2002. The details of reconstruction including frequency, timing, indication, and techniques were collected over a 10-year follow-up period. RESULTS: Hand burns were seen in 42% (n = 562 of 1,334) of all patients admitted with acute burns. Reconstructive surgery during the 10-year follow-up period was required in 15%. Contractures, especially of the first web space and little finger, were the most frequent indications for reconstructive surgery. Web spaces 1 to 3 and the little finger were the location most frequently operated on. The most frequently performed surgical technique was release of the contractures and the use of a random flap. Eighty percent of the reconstructive surgery patients required more than 1 reconstructive procedure, most often within 2 years of the initial injury. Secondary operations at the same location were required in 12%. In 40% of the patients, the first reconstructive surgery was performed within the first postburn year. Significant independent factors related to the need for reconstructive hand surgery were a larger area of full-thickness burns and surgical treatment of the hand during the acute phase. CONCLUSIONS: Reconstructive surgery was required in 15% of patients who sustained hand burns. The majority of the patients requiring reconstructive surgery of the hand needed 2 or more operations to correct the contractures of the hand. Contractures of the little finger and first web space were the locations most frequently operated on. Patients with more extensive burns and who required hand surgery during the acute phase were more likely to need reconstructive surgery. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Computed Tomography Angiography Allows the Classification of the First Dorsal Metatarsal Arteries.

Background Conventional angiography is an invasive technique. Submillimeter computed tomography angiography (CTA) has been shown to be an effective alternative for peripheral artery branches. This study aimed to assess the use of CTA to guide the choice and design of foot donor area for finger or thumb reconstruction. Methods This was a retrospective study of 79 patients who underwent finger or thumb reconstruction between January, 2011 and March, 2014. All these patients underwent preoperative CTA to determine the exact blood supply at the donor site. Preoperative imaging and intraoperative findings at the donor site were compared. Results Among the 79 patients (158 feet), 474 artery segments (dorsalis pedis artery [DPA], first dorsal metatarsal artery [FDMA], and toe web artery [TWA]) were evaluated using CTA. Image satisfaction rates of the vessels were 100.0 ± 0.0%, 89.2 ± 3.2%, and 60.1 ± 5.0% for DPA, FDMA, and TWA, respectively. Among the 158 feet, 90 were Gilbert type I (57.0%), 52 were Gilbert type II (32.9%), 13 were Gilbert type III (8.2%), and 3 were with poor visibility and could not be classified (1.9%). In all 79 patients, the CTA image of the FDMA was consistent with the intraoperative observations. All reconstructed fingers survived. Follow-up was available for 69 patients. After a 6- to 18-month follow-up, the reconstructed fingers and donor area recovered well, and the reconstructed fingers had strong holding power, without pain. Conclusion CTA can produce three-dimensional images for extremity arteries, allowing the preoperative assessment of blood supply and planning of donor site.

Management of a patient with small-area burns, severe sepsis and superficial vein thrombosis.

UNLABELLED: Sepsis is frequently seen in severely burned patients, however it is not common in those with small-area burns. We present a case of a 22-year-old man suffering from a hot crush injury to his left hand dorsum covering 1% of his total body surface area. The patient developed severe sepsis and superficial vein thrombosis, probably due to wound infection. Culture of the wound secretion indicated Corynebacterium striatum. Following intensive topical and systemic treatment the severe sepsis was controlled. The local wound was repaired by the abdominal skin pedicle flap which had taken well by day 27 post admission. A topical superficial vein thrombosis, unintentionally found 42 days after admission, was partially excised. This case demonstrates that when treating severe sepsis in patients with small-area burns, the timely recognition and diagnosis along with active systemic support, play a vital role in successful management. DECLARATION OF INTEREST: None of the authors have any financial interest to declare.

[Fatal electric accident due to adverse error situation]. / Tödlicher Stromunfall aufgrund ungünstiger Fehlerkonstellation.

Despite wearing high-impedance shoes, a young male died while trying to connect a garden pump (230 V). The cause of death could easily be determined on the basis of testimonies of eye-witnesses and an electric mark on the body. Histological and electron microscopic examinations showed metallisation of the electric mark (pure iron). Intensive investigative efforts were needed, however, to reproduce the current path, which resulted from three different coactive failures. The electrotechnical characteristics of the case and the resulting current path are described.

Advances in the healing of flexor tendon injuries.

The intrasynovial flexor tendons of the hand are critical for normal hand function. Injury to these tendons can result in absent finger flexion, and a subsequent loss of overall hand function. The surgical techniques used to repair these tendons have improved in the past few decades, as have the postoperative rehabilitation protocols. In spite of these advances, intrasynovial flexor tendon repairs continue to be plagued by postoperative scar formation, which limits tendon gliding and prevents a full functional recovery. This paper describes the current challenges of flexor tendon repair, and evaluates the most recent advances and strategies for achieving an excellent functional outcome.

Use of data to inform expert evaluative opinion in the comparison of hand images-the importance of scars.

Evaluation of a likelihood ratio is widely recognised as the most logical and appropriate means of assessing and expressing the weight of expert scientific evidence. This paper describes the application of such an approach to cases involving the comparison of images of hands that contain visible scars. Such evidence is frequently provided in cases of alleged child sexual abuse in which images of the perpetrator's hand are compared with images of the suspect/accused's hand. We illustrate how data provided from a database of hand images can be used to inform the probabilities that are an essential part of evaluating a likelihood ratio and, hence, how data have a bearing on the appraisal of the weight of evidence that can be attributed when scars are present within an image.

The incidence of scarring on the dorsum of the hand.

When undertaking image comparison of the hand between accused and perpetrator, it is not unusual for scars to be identified on the back of the hand. To investigate the occurrence of scarring in a discreet sample, a database of 238 individuals was examined, and the dorsum of the right and left hands was gridded for each individual. The position, size and type of scar were recorded within each grid. It was found that, in general, males exhibited a higher incidence of scarring than females. However, males were more likely to show scarring on their left hand whereas females were more likely to exhibit scarring on their right hand. Contrary to the literature, scarring was not most prevalent along the borders of the hand but occurred more frequently in association with the index and middle finger corridor regions. Surgical scars were rare as were large scars whereas linear scars smaller than 6 mm were the most frequently identified. Close to half of the sample did not exhibit scarring on one hand. The importance of understanding the pattern of scarring on the back of the hand is discussed in the light of forensic image comparison analysis.

Use of integra artificial dermis to reduce donor site morbidity after pedicle flaps in hand surgery.

PURPOSE: To assess the results obtained with Integra artificial dermis to cover donor site following the harvesting of pedicle flaps for hand reconstruction. METHODS: Between April 2010 and August 2013, 11 patients (8 men and 3 women; mean age, 37 y) were treated with Integra Dermal Regeneration Template (Integra LifeSciences, Inc., Plainsboro, NY) to cover donor defects after raising pedicle flaps for hand and finger reconstruction: radial forearm flap (4 cases), ulnar artery perforator flap (2 cases), and heterodigital island flap (5 cases). After neodermis formation the silicone layer of the artificial dermis was removed (on average after 22 days) and a split- or full-thickness epidermal autograft placed. RESULTS: No infections, hematoma, or bleeding were recorded during the entire phase in which the artificial skin was applied. Two patients experienced a partial skin graft loss. Median follow-up was 20 months, and results included an average Vancouver Scar Scale rating of 2.7 and an average DASH score of 39. There were no cases of graft adherence to the underlying tendons or muscles. CONCLUSIONS: Favorable cosmetic and functional outcomes were obtained using a dermal regeneration template for the treatment of donor site defects. Despite the drawback of an additional surgical procedure (secondary skin graft), the use of this artificial skin produced soft-tissue augmentation and graft-skin quality, reducing donor site morbidity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.