Open fractures of the hand.

Open fractures of the hand are a challenging clinical problem for the orthopedic surgeon. The fracture is often comminuted with substance loss. Additionally, the fracture site can be contaminated by foreign material. The soft tissue envelope is violated with a variable degree of tissue devitalized. The wound contamination and tissue destruction lead to a rate of infection that can be much higher than that for a closed fracture. Initially, management of a significant soft tissue injury must take precedence over definitive fracture fixation. Proper staging of debridement, wound closure, and definitive fixation is paramount in minimizing infection while obtaining fracture union.

Magnetic resonance imaging of a glomus tumor of the fingertip.

Magnetic resonance imaging has been shown to help in the diagnosis of a glomus tumor in an unusual location in a fingertip. We report a case where magnetic resonance imaging confirmed the presence of a lesion before operation.

Late flexor pollicis longus tendon rupture due to retained glass fragments.

A retained glass fragment caused a flexor pollicis longus tendon rupture 23 years after the patient's initial injury. A review of the literature shows that although previous cases of delayed damage from retained objects have been reported, this is the first report of a tendon injury that was preceded by such a long asymptomatic period. The lesion was treated with a flexor digitorum superficialis tendon transfer from the ring finger with excellent functional results.

Clinical and radiologic features of primary osteoarthritis of the hand.

An appreciation of the salient clinical and radiologic presentations of osteoarthritis, as well as associated tenosynovial problems (stenosing tenosynovitis and carpal tunnel syndrome), is necessary for effective diagnosis. The treatment of osteoarthritis is predicated upon an understanding of the anatomy and pathomechanics of the disease process. Relevant features of the anatomy of the joints of the hand have been reviewed. The correlation of pathologic abnormalities with their radiologic findings has been presented. The degenerative joint disease termed osteoarthritis affects primarily cartilagenous and osseous tissues, while synovial changes are less pronounced. The characteristics of osteoarthritis of the interphalangeal, carpometacarpal joint of the thumb, and metacarpophalangeal joints of the hand have been reviewed.

Constrained total shoulder arthroplasty. Long-term follow-up observations.

Constrained total shoulder arthroplasty is a salvage procedure for patients with disabling pain and a nonfunctioning rotator cuff mechanism. Considering the advanced pathologic process and severe symptoms of these patients, the results of pain relief are gratifying. Many of the patients have weak or absent deltoid muscles, and active overhead motion is not possible. A method of attaching the metal glenoid to the scapula has been designed to reduce the risk of loosening. However, constrained total shoulder arthroplasty does produce considerable stress on bony attachments. Careful patient selection and an excellent, carefully supervised postoperative rehabilitation program are mandatory for success. Before considering a constrained total joint arthroplasty, the surgeon should carefully assess the patient's needs and consider other less extensive shoulder reconstructions.

An overview of replantation and results of 347 replants in 245 patients.

A review of 245 patients requiring replantation surgery from 1970 to 1978 revealed a 70% survival rate for complete amputation. In this group, there were 347 replanted parts, including the lower extremity. Upper-extremity survival rates alone (greater than 90%) are higher than for lower extremity replantation. Meaningful assessment of replantation must include not only survival data but functional criteria as well. While functional data are incomplete on several early cases, our assessment criteria are reviewed. Criteria should include two-point discrimination sensibility ratings, grip strength, range of motion, absence of cold intolerance, and return to employment. Evaluation of candidates for replantation is critical, and the importance of teams with microsurgical skills working in special centers is emphasized.

Total shoulder replacement with a constrained prosthesis.

Forty-three shoulder-joint replacements were performed in forty-two patients using a constrained joint. Twelve material failures were experienced in the first series of twenty-two shoulders and only two in the second, modified series (twenty-one shoulders). Loosening of the glenoid components was not encountered, although radiolucent lines have been observed about some of the components. A basic feature of the design was to allow dislocation of the metal head from its cup when excessive motion of the components is attempted by the patient and a specific torque is exceeded. A method of insertion and design considerations allowed us to achieve strong attachment between the metal glenoid and the scapula.

Constrained total shoulder joint replacement: a critical review.

Constrained total shoulder replacement is a salvage procedure for the patient with disabling pain and a nonfunctioning rotator cuff mechanism. The results of pain relief have been gratifying. When active overhead motion is a goal of treatment a strong deltoid muscle is required. The rationale for fixing a fulcrum is to substitute for the loss of the rotator cuff mechanism that stabilizes the humeral or prosthetic head on the shallow glenoid. The best method of attachment for the glenoid component to an intact glenoid vault described herein has been found to be superior to other methods. In particular, the vault should not be mutilated. This is borne out by the clinical experience and laboratory testing that loosening or pull-out does not occur with an intact glenoid. Moreover, the attachment is stronger than the dry bone just medial to the vault where fracture always occurred through the suprascapular notch in laboratory tests. Although there may be good pain relief with this operation, active function still depends on residual deltoid muscle power wherein a poor deltoid will only allow passive motion. Moreover, the outcome of any shoulder operation still depends in large measure on the excellence of the postoperative rehabilitation program. Finally, other worthwhile shoulder operations should be given first consideration in order to serve the needs of individual patients.