ABSTRACT
OBJECTIVE: Fracture dislocations of the multiple carpometacarpal joints [CMCJ] of the fingers are uncommon injuries that can significantly compromise hand function and durability if managed sub-optimally. These injuries are at risk of being missed as they are commonly a part of major high energy trauma with associated more obvious and immediately threatening injuries getting all the attention. The clinical and radiological parameters which could help a surgeon to detect and analyse these injuries well are discussed. The management of these injuries with emphasis on the pattern of K-wire fixation is presented. METHOD: A review of multiple CMCJ dislocations at our institution found 39 hands in 38 patients (one case with bilateral injury) over a seven-year period (January 2010 to January 2017). The pattern of injury noted in these cases was assessed and categorized. Our preferred management plan for these injuries is discussed. RESULTS: The patterns of dislocations noted in a total of 39 cases were-dorsal (25), dorsal radial (6), volar (1), volar radial (5) and divergent (2). The dorsal dislocations were the commonest (25/39) and additional 6/39 were radial-dorsal, only six displaced in a volar direction. Divergent dislocation was seen in only two cases. CONCLUSION: The pattern of dislocations noted in 39 cases in our institute (Ganga Hospital- A tertiary level trauma center) is presented to provide an overview of the spectrum of the injuries which a surgeon could face. Early surgery is recommended and should be aimed to restore perfect anatomical alignment of the skeleton. Surgeon should have a low threshold for open reduction in case of gross swelling or inability to get an anatomical closed reduction. The method of K-wire fixation presented herein has resulted in good outcome in our practice; wherein we fix the dislocated CMCJ by inserting K-wires from the radial and ulnar borders of the hand and avoiding wires in the central part of the hand. This prevents extensor tendons tethering by the K-wires. The fixation achieved by multiple K-wires passed in this manner provides enough stability to allow for early active mobilisation of the fingers. The need for careful assessment to detect associated nerve injury and compartment syndrome; and post-operative strict hand elevation and prevention of stiffness of the MCP joints has been emphasized.The CMCJ dislocations have innumerable patterns possible; however, the management principles remain the same. In spite of the gross distortion of the anatomy seen in these injuries, anatomical reduction and adequate stabilization to allow early mobilization generally results in satisfactory outcomes.
ABSTRACT
Flexor tendon injuries have constituted a large portion of the literature in hand surgery over many years. Yet many controversies remain and the techniques of surgery and therapy are still evolving. The anatomical and finer technical considerations involved in treating these injuries have been put forth and discussed in detail including the rehabilitation following the flexor tendon repair. The authors consider, recognition and mastery of these facts form the foundation for a successful flexor tendon repair. The trend is now towards multiple strand core sutures followed by early active mobilization. However, the rehabilitation process appears to be one of the major determinant of the success following a flexor tendon repair. Early mobilization is essential for all the flexor tendon repairs as it is proved to improve the quality of the repaired tendon. The art of achieving the harmony between a stronger repair and unhindered gliding of the repair site through the narrow flexor tendon sheath simultaneously can be mastered with practice added to the knowledge of the basic principles.
ABSTRACT
BACKGROUND: Non-union humeral shaft fractures are seen frequently in clinical practice at about 2-10% in conservative management and 30% in surgically operated patients. Osteosynthesis using dynamic compression plate (DCP), intramedullary nailing, locking compression plate (LCP), Ilizarov technique along with bone grafting have been reported previously. In cases of prior failed plate-screw osteosynthesis the resultant osteopenia, cortical defect, bone loss, scalloping around screws and metallosis, make the management of non-union more complicated. Fibular graft as an intramedullary strut is useful in these conditions by increasing screw purchase, union and mechanical stability. This study is a retrospective and prospective follow up of revision plating along with autologous non-vascularised intramedullary fibular strut graft (ANVFG) for humeral non-unions following failed plate osteosynthesis. MATERIALS AND METHODS: Seventy eight cases of nonunion humeral shaft fractures were managed in our institute between 2008 and 2015. Of these, 57 cases were failed plate osteosynthesis, in which 15 cases were infected and 42 cases were noninfected. Out of the 78 cases, bone grafting was done in 55 cases. Fibular strut graft was used in 22 patients, of which 4 cases were of primary nonunion with osteoporotic bone. Applying the exclusion criteria of infection and inclusion criteria of failed plate osteosynthesis managed with revision plating using either LCP or DCP and ANVFG, 17 cases were studied. The mean age of the patients was 40.11 yrs (range: 26-57 yrs). The mean duration of non-union was 4.43 yrs (range: 0.5-14 yrs). The mean follow-up period was 33.41 months (range: 12-94 months). The average length of fibula was 10.7 cm (range: 6-15 cm). Main outcome measurements included bony union by radiographic assessment and pre- and postoperative functional evaluation using the DASH (Disabilities of the Arm, Shoulder and Hand) score. Results: Sixteen out of 17 fractures united following revision plating and fibular strut grafting. Average time taken for union was 3.5 months (range: 3-5 months). Complications included one each of implant failure with bending, transient radial nerve palsy and transient ulnar nerve palsy. No case had infection, graft site morbidity or peroneal nerve palsy. Functional assessment by DASH score improved from 59.14 (range: 43.6-73.21) preoperatively to 23.39 (range: 8.03-34.2) postoperatively (p = 0.0003). Conclusion: The results of our study indicate that revision plating along with ANVFG is a reliable option in humeral diaphyseal non-unions with failed plate-screw osteosynthesis providing adequate screw purchase, mechanical stability and high chances of union with good functional outcome.
