Combined injuries--soft tissue management.

The combination of severe bone and soft tissue injuries challenges all hand surgeons. Immediate restoration of all damaged structures is the goal whenever possible, integrating soft tissue techniques with principles of internal fixation. Debridement must be radical and resulting defects in bone, vessel, nerve, tendon and skin must be reconstituted with the combination of free and vascularized grafts. Rigid internal fixation is mandatory to allow functional restoration of the hand to begin with a stable platform against which motor tendon units and gliding structures to move. The timing of subsequent reconstruction is based on the prerequisites of adequate vascularity and soft tissue coverage. Understanding the reconstructive ladder and the nuances of techniques regarding skin grafting, local and distant flaps and microsurgical reconstruction is necessary to complete reconstruction in a timely and appropriate fashion. Various soft tissue techniques are described; from simple skin grafting to the use of toe to hand transfers. The decision to amputate versus reconstruct is also important, particularly in today's cost conscious health care environment. Finally, a well thought out and directed rehabilitation program will allow patients to ultimately return to functional status after mutilating injuries of the hand. This article provides a comprehensive review of the combined injury.

Preoperative factors and outcome after lunate decompression for Kienböck's disease.

Preoperative factors and outcome were studied after lunate decompression for Kienböck's disease. Twenty-three patients treated with radial shortening or scaphoid-trapezium-trapezoid fusion were evaluated. The mean follow-up was 59 months. Neither good nor excellent outcomes were found with either lunate-preserving procedure when the preoperative radioscaphoid angle was greater than 60 degrees. Outcomes in the radial shortening osteotomy group were superior to those in the group treated with scaphoid-trapezium-trapezoid fusion. Lunate collapse was not prevented by either treatment method. Lunate index, carpal height, and staging did not correlate with outcome. Measurement of radioscaphoid angle provides predictive information regarding the outcome of stage III (Decoulx/Lichtman) Kienböck's disease treated with radial shortening or scaphoid-trapezium-trapezoid fusion.

Granular cell tumor of the palmar cutaneous branch of the median nerve.

Granular cell tumor rarely occurs in the hand. A patient with this tumor involving the palmar cutaneous branch of the median nerve, and twelve-month follow-up is discussed. This lesion, similar to neurofibromas, can infiltrate peripheral nerves and cannot be dissected from them. The lesion is probably of Schwann cell origin.

The intercalated tendon graft for treatment of extensor pollicis longus tendon rupture.

Twenty-one patients with ruptures of the extensor pollicis longus tendon were treated with a subcutaneously placed free tendon graft. The repair was performed a mean of 6 weeks after rupture, range from 1 to 21 weeks. Data was collected on 19 of these patients, with a mean follow-up of 30 months, range from 6 to 124 months. Near uniform satisfaction was reported. The mean loss of interphalangeal joint extension and flexion and combined metacarpophalangeal-interphalangeal joint motion was 6 degrees, 3 degrees, and 10 degrees, respectively. The mean loss of pinch strength was 7%. All patients were able to elevate their thumbs to the level of the palm. This is a simple, reliable, and effective procedure that avoids the use of an adjacent motor-tendon unit. Muscle contracture appears reversible and this procedure may be used successfully even when treatment has been delayed.

Congenital hemifacial hyperplasia: an embryologic hypothesis and case report.

Congenital hyperplasia is a developmental disorder characterized by marked unilateral asymmetry. The structural disproportions from one side to the other far exceed variations commonly seen in the normal population. Classically, as first described in 1836, the overgrowth of tissue is restricted to one-half of the body, including the extremities. In other cases the hyperplastic enlargement involves segmental areas of the body, such as the hemifacial skeleton and an extremity. A case report is presented, and the clinical characteristics of 192 cases of congenital hyperplasia in the literature are briefly reviewed. Use of the word hyperplasia to describe the condition (rather than hypertrophy) is encouraged. The authors propose a new embryologic hypothesis: asymmetrical development of the neural fold and hyperplasia of the neural crest cells are said to form the basis for the disorder. The rewards, risks, and limitations of reconstructive surgery over a 10-year period are discussed.