Scapholunate stabilization with dynamic extensor carpi radialis longus tendon transfer.

Dynamic extensor carpi radialis longus tendon transfer to the distal pole of the scaphoid acts synchronously and synergistically with wrist motion to restore the slider crank mechanism of the scaphoid after scapholunate interosseous ligament (SLIL) injury. The procedure is designed to simulate a hypothetical dorsal radioscaphoid ligament that more closely approximates the normal viscoelastic forces acting on the scaphoid throughout all phases of wrist motion than does the static checkrein effect and motion limitations of capsulodesis or tenodesis. Extensor carpi radialis longus transfer may be independently sufficient to support normal or near-normal scapholunate and midcarpal kinematics and prevent further injury propagation in patients with partial SLIL tears and dynamic scapholunate instability. Extensor carpi radialis longus transfer alone may improve carpal congruity in patients with static scapholunate instability, but SLIL and dorsal lunate ligament repair or reconstruction is essential for favorable durable outcomes. Extensor carpi radialis longus transfer offers a simple and reasonable alternative to capsulodesis or tenodesis to support these ligament repairs or reconstructions, does not require intercarpal fixation, and allows rehabilitation to proceed expeditiously at approximately 1 month after surgery.

Traumatic below-elbow amputations.

Prehension, intelligence, and erect posture distinguish humans from lower animals. Hands are instrumental for our survival and welfare. We use our hands when we work, recreate, and communicate. A handshake, a touch, a sign, or signal has significant social and communicative meanings. Hands play a major role in defining the skill level of our activities and our level of social expression and integration. Indeed, refined psychomotor precision of hand function may distinguish some individuals among us, gifting society with its more skilled craftsmen, surgeons, artisans, musicians, athletes, and the like in a highly digital world. For others, their hands are critical in providing and caring for their families. Injury severity scores may identify the majority of patients that require amputation; however, injury severity scoring system predictions in individual patients may be problematic and should be used with caution. Amputees require comprehensive multidisciplinary treatment and compassion so that they can successfully overcome their losses. Ultimately, the patients must change, adjust, and adapt to successfully reintegrate themselves into their families, peer groups, job settings, and society as a whole. Early amputation may decrease the incidence and severity of phantom pain compared to amputation after the failure of reconstruction. Early prosthetic fitting, training, and physical rehabilitation; early psychological and sociological support; and early return to work facilitate successful functional recovery. Psychological recovery may be a more arduous and extended process than physical recovery. We must teach our amputees from the outset to use their losses as an incentive for success, assist them to regain their quality of life, and encourage them to act as role models for and to educate others.

Malunions of the finger metacarpals and phalanges.

Many malunions of the finger metacarpals are mild and do not require or justify operative intervention. Early recreation of the fracture or osteotomy is more likely to be rewarded with favorable results than late operation. Rotational malunions of the metacarpals or proximal phalanges may be treated by transverse extra-articular transverse or step-cut osteotomies at or proximal to the malunion site. Rotational malunions of the proximal phalanges as great as 200 in the index, middle, and ring fingers and 300 in the small finger may be managed by transverse extra-articular osteotomy at the adjoining metacarpal base. Angular and combined angular and rotational deformities of the metacarpal can be corrected by closing wedge osteotomy at the malunion site, with adjustment for malrotation when necessary. Angular and combined angular and rotational deformities of the proximal phalanx may be corrected by dorsal opening or lateral opening or closing wedge osteotomy, with derotation when needed. Articular malunions may be treated by osteotomy at the fracture site, a sliding osteotomy of the fracture and its proximal supporting cortex, or extra-articular osteotomy. Each approach for articular malunions has its potential risks and benefits. The true risks of articular malunion correction may not be fully known, because of the small number of cases in each presented series and the short follow-ups. Finger motion may be improved by correction of deformity alone, and may be further enhanced by tenolysis of adjacent adhesions. Capsulolysis may be helpful in instances of adjacent joint contracture. Despite improvement of finger motion in a majority of cases, some degree of remaining stiffness is common. Stiffness is almost always a residual of the original injury rather than a complication of corrective surgery, and serves to reinforce the fact that primary fracture reduction, stabilization, and rehabilitation are usually the best deterrents to malunion and consequent impairment. Much of the best available information has been gained from retrospective cohort or case study reports that may have inherent flaws in study design that limit their statistical validity and ability to detect trends. Flaws may include heterogeneity; investigator enthusiasm; and a lack of enrollment, prospective controlled randomization, blinding, confidence interval determinations, and follow-up. The statistical ability to determine trends in past reports may be compromised. Past reports provide important information and advances, but should be interpreted with some discretion. The pen may be mightier than the scalpel. In spite of encouraging reported results, phalangeal and articular osteotomies, in particular, remain daunting procedures for most hand surgeons. Prospective, controlled randomized studies maybe difficult to achieve in the clinical setting because of the time that would be necessary to secure adequate enrollments for statistical validity andthe occurrence of "dropouts" before completion of adequate follow-up. Meta-analysis is difficult because of variations in discriminators for patient selection and clinical outcomes. Although multicenter studies have their own inherent flaws, they may represent the best future option to add a higher level of study design and validity as compared with past studies. The incorporation of subjective patient outcome instruments into future studies might also provide valuable information. Investigators should review previous reports with a goal of improving study designs and scientific methodology, confirming or contradicting past results, or adding new information.

Collateral ligament injuries of the metacarpophalangeal joints of the fingers.

Although complete collateral ligament tear and instability involving the metacarpophalangeal joints of the fingers, especially those on the radial aspect of the index finger, are rare, they may be underdiagnosed, underestimated, and potentially disabling. Awareness and suspicion of the injury, coupled with careful physical and imaging examinations, confirm the diagnosis and its extent. Early operative repair results in favorable outcomes in most cases. Chronic instability may lead to pain, weakness, and arthritis. Late ligament repair or reconstruction is typically slightly less reliable than acute repair, yet often improves outcomes. Arthritic joints may require reconstruction.

Palmar radiocarpal dislocation resulting in ulnar radiocarpal translocation and multidirectional instability.

Posttraumatic ulnar radiocarpal translation is a rare, often subtle, highly unstable, and potentially devastating manifestation of severe "proximal radiocarpal ligamentous instability. Radiocarpal dislocation should alert the treating physician to the risks of the spectrum of radiocarpal instabilities. Radiocarpal instability may initially be masked or unappreciated owing to presentation without radiocarpal dislocation, local pain and swelling, initially normal standard wrist radiographs, lack of recognition, or delay in the appearance of a static lesion. The specificity, sequence, and extent of extrinsic radiocarpal and ulnocarpal ligament traumatic disruptions are not fully understood, vary with injury severity, and may differ in instances of dorsal as opposed to palmar subluxation or dislocation. Multidirectional (global) wrist instability typically accompanies this ulnar radiocarpal instability in its most severe form and consequences may be dire. The carpus may be difficult to reduce or maintain owing to marked instability, compressive forces across the wrist, and soft tissue or bony fragment interposition. Additional local distal radioulnar joint or intercarpal injuries may further confound stability and require their own specific and simultaneous treatment. Radiocarpal reduction and repair of the radioscaphocapitate ligament and radiolunate ligaments may be sufficient treatment for acute isolated palmar radiocarpal instability. Temporary K-wire fixation may be added as a precaution to prevent palmar carpal subluxation during the time of ligament healing. Radiocarpal reduction, palmar and dorsal soft-tissue repair, and temporary K-wire fixation comprise one method of treatment for early recognized cases of post-traumatic ligamentous ulnar radiocarpal transposition. Halikis et al have recommended radiolunate arthrodesis. Rayhack et al have suggested that limited or complete wrist arthrodesis may be indicated for patients with delayed presentation or in acute cases with extreme instability. Wrist arthrodesis is one means of management for patients with severe radiocarpal instability confounded by distal radioulnar joint or intercarpal instability, as seen in our patient. Damaged ligaments may have a poor blood supply and often may not hold sutures or heal well. Bone anchor sutures or some type of ligament augmentation may help to restore joint stability in some patients. Loss of stability may occur later owing to ligamentous laxity or inadequate soft-tissue healing. Radiolunate, radiocarpal, or complete wrist arthrodesis may be necessary to relieve pain, restore wrist alignment and stability, and reestablish extremity function for patients with chronic radiocarpal instability. Wrist symptoms, age, general health, hand dominance, and occupation may be among the factors that influence the necessity for and timing of reconstruction. Rayhack et al have also postulated that negative ulnar variance may accommodate the occurrence of ulnar radiocarpal translocation and confound repair owing to lack of buttress at the ulnocarpal joint. They further speculated that a joint leveling procedure might improve the support for ligamentous repair or reconstruction in these cases. Permanent functional impairment must be anticipated in patients with ulnar radiocarpal instability. Impairment has typically been commensurate with the extent of the initial lesion, additional confounding local lesions, and length of follow-up.

Closed reduction of hand fractures.

Stiffness is the most frequent consequence of open hand fracture treatment. Although initial injury severity and occurrence adjacent to the flexor tendon sheath are the most highly correlated determinants of hand fracture outcome, operative intervention accentuates the ultimate risk of stiffness. Closed treatment may minimize this risk. Articular fractures are at greater risk for stiffness than extra-articular fractures. Functional tolerance for small amounts of variation from perfect anatomic restoration gives us increased latitude for closed hand fracture management. Operative treatment may be justified for simple closed fractures when they are unstable, irreducible, or open, or when the surgeon believes that the risk-to-benefit ratio is favorable.

Biomechanics and biology of plate fixation of distal radius fractures.

The fracture management principles of anatomic or near anatomic reduction, fracture stabilization, minimal operative trauma, and early joint motion are paramount in man-aging unstable distal radial fractures. The operative approach and plate selection should correlate with the fracture configuration. Plates have the advantages of providing secure fixation throughout the entire healing process without protruding wires or pins and allowing early and intensive forearm, wrist, and digital exercises. Disadvantages include additional operative trauma, including fragment devascularization; some additional risk of wrist stiffness; occasional tendon rupture; and at times, the need for plate removal. New developments in plate and screw design and operative strategies, fragment specific fixation, and plate strength have improved results with plate fixation. Fixed angle blades and locking screws and pegs enhance overall plate stability, support the articular surface of the distal radius, and are effective in fractures occurring in osteopenic bone.

Midshaft clavicular fractures: the role of operative treatment.

Plate fixation remains a staple for open fractures, closed fractures requiring open management, and nonunions, especially if bone grafting is required.

High-pressure injection injuries of the hand.

While often innocuous at presentation, high-pressure injection injuries can lead to devastating consequences. Stiffness, chronic pain, infection, and even amputation can occur, with amputation rates ranging between 16% and 48%. Early surgical decompression and debridement are the cornerstones of treatment.

Fracture fixation in the mutilated hand.

Early anatomic (or near anatomic; lingers do not impinge or overlap during flexion or extension) stable fracture fixation provides the foundation for successful wound management and for the repair, reconstruction, and healing of all damaged tissues in a mutilating hand injury. It also plays an instrumental role in pain control and affords an optimal opportunity for timely and favorable rehabilitation of and recovery from mutilating injuries of the hand. Kirschner or other wiring systems or mini external fixators may be used for simple fractures, in children, when rapid fracture fixation is necessary, and for provisional fracture fixation. Mini plates should be considered for fractures with comminution or loss and in instances of multiple fractures. Fingers with segmental injury of three or more tissues should be considered for early amputation to avoid prolonged and impaired recovery of the hand. Every effort should be made to preserve the thumb and its function by repair or reconstruction.

Complete tear of the radial collateral ligament of the third metacarpophalangeal joint.

Early repair of complete collateral ligament tears restores joint alignment, stability, and full passive range of motion.

Oblique capitate fracture of the wrist.

Capitate fractures, which usually occur at the head or neck, interrupt the intraosseous circulation to the proximal fragment, creating risks of fracture nonunion and avascular necrosis. Kirschner wire and screw fixation are successful in the treatment of these rare but serious injuries.

Oblique shear fractures of the lunate.

Traumatic fractures of the lunate are rare. This article presents two patients who had displaced oblique lunate fractures and distal radius fractures. Both fractures achieved union; however, transient avascular necrosis occurred in the proximal healing of one patient.

Autogenous bone grafting for fractures of the hand.

Autogenous bone grafting of hand fractures often occurs within the milieu of a complex wound. Risks of infection and/or stiffness increase with injury severity, contamination, and the time interval between injury and successful wound closure or coverage. A clean wound is paramount for successful tissue repair, reconstruction, and closure. Skeletal restoration is an integral component of composite wound management. Fracture stabilization enhances pain control, protects soft tissue repairs and reconstruction, inhibits infection, and facilitates bone graft consolidation and functional recovery. Mini plate fixation provides the sustained stability necessary for hand fractures with bone loss to heal. Bone grafting is an essential element of skeletal restitution for defects due to comminution or actual loss. Cancellous bone grafts heal more rapidly and are more resistant to infection than cortical bone grafts and may be preferable for partial or smaller intercalary defects. Cortical or corticocancellous grafts augment stability and may be especially useful for larger segmental diaphyseal defects and articular bone loss requiring arthrodesis.

Extraarticular hand fractures in adults: a review of new developments.

UNLABELLED: This report cites new developments in the treatment of extra-articular hand fractures in adults. Recent reports confirm that small amounts of metacarpal shortening or dorsal angulation cause minimal functional impairment. Unilateral excision of the lateral band and oblique fibers of the extensor apparatus of the metacarpophalangeal joint facilitates proximal phalangeal fracture exposure and may improve functional recovery. Results using open mini screw fixation of oblique extra-articular metacarpal and phalangeal fractures may be comparable to those of percutaneous Kirschner wire fixation. Bicortical self-tapping mini screw fixation of extra-articular oblique metacarpal and phalangeal fractures simplifies screw insertion and provides stability comparable to that of fractures fixed with lag screws. Percutaneous intramedullary wire fixation may afford suitable fixation for unstable extra-articular oblique as well as transverse metacarpal fractures. Locked intramedullary nails may offer similar advantages. Unicortical screw fixation of mini plates securing transverse extra-articular metacarpal fractures affords stability comparable to that of bicortical screw fixation while creating less bone damage. The dissection required for plate fixation and the small surface area of transverse fractures delay and occasionally impair bone healing. Primary bone grafting of diaphyseal defects in clean stable wounds may shorten and simplify treatment and decrease morbidity. As little as 1.7 mm of flexor tendon excursion during the first 4 weeks after reduction or repair may substantially diminish peritendonous adhesions at the fracture site. Synchronous wrist and digital exercises may also reduce peritendonous fracture adhesions. Early motion of adjacent joints in closed simple metacarpal fractures expedites recovery of motion and strength without adversely affecting fracture alignment and leads to earlier return to work. LEVEL OF EVIDENCE: Level V (expert opinion).