Time heals all wounds - Outcomes of deep palmar wrist injuries may improve long after reinnervation.

Despite the clinical importance of deep wrist injuries (DWIs), data on the timeframe of possible improvements in hand function are scarce. We tested the hypotheses that a) the length of follow-up is positively correlated with the outcome, and b) this correlation is tempered by nerve involvement. All patients admitted to the Clinic of Plastic Surgery with an acute DWI between 2008 and 2016 were contacted for a follow-up examination including two-point discrimination, range of motion, grip, and pinch strength, as well as DASH and MMWS questionnaires and employment status. Possible confounders such as age, handedness, and intentionality of the injury (accidental or suicidal) were assessed and controlled for statistically. Fifty-three patients were reviewed (74% male and 26% female, 86% right-handed, 70% accidental injuries, mean age at injury 42.0 ± 17.1 years), an average of 4.3 ± 2.9 years after their injury. In patients with a nerve injury, length of follow-up had significant effects on two-point discrimination, grip and pinch strength, self-reported symptom severity and impairment. Contrary to conventional knowledge, the clinical outcome of DWIs may improve beyond 3 years when there is nerve involvement. This important prognostic finding has far-reaching implications for both clinicians (e.g., asked to give their medical opinion) and patients (e.g., considering re-training after a DWI).

[Combination of a universal antidote and temporary skin substitute for chemical burns: Extended case report]. / Kombination von universellem Antidot und temporärem Hautersatz bei Verätzungen: Erweiterter Fallbericht.

In this article we describe our experiences in the treatment of chemical burns with Diphoterine(®) solution and Suprathel(®) as a temporary skin substitute material, a treatment which in the past was not commonly used for this pattern of injuries. In the study period from October 2012 to December 2013 we treated five patients (four male and one female including two children and three adults) with chemical burns by decontamination with Diphoterine(®) and wound covering with Suprathel(®). The control group included five patients with similar injury patterns who were treated with Diphoterine(®) and occlusive wound dressings. No wound infections occurred in any of the five cases and no interactions were observed between Suprathel(®) and the chemical substance involved. In four cases the skin areas with IIa-IIb degree damage showed good wound healing and only slight scarring in the follow-up after 3 months and one of the five patients had to be treated surgically. Suprathel(®) can be used as a temporary skin substitute for the treatment of skin burns and is also available for the treatment of chemical burns.

Epidemiology of pneumonia in a burn care unit: the influence of inhalation trauma on pneumonia and of pneumonia on burn mortality.

The aim of this study is to determine the epidemiological characteristics of burn patients developing pneumonia, as well as the predisposing factors and the mortality of these patients. Infectious complications present serious problems in severely burned patients. Pneumonia, in particular, is a major cause of morbidity and mortality in burn patients. Patients with inhalation injuries are exposed to a greater risk due to the possible development of infectious complications in the lower respiratory tract. During their stay in our Burn Care Unit, 22.9% of our burn patients developed pneumonia and 10.9 % of these patients died. Risk factors for the development of pneumonia in burn patients were found to be inhalation trauma, high ABSI score, the Baux and modified Baux index, and high ASA score (p<0.01). Age and gender showed no significant correlation to the incidence of pneumonia. In this study we were able to determine the incidence of pneumonia in burn patients, their mortality and the strong correlation of the presence of inhalation injury with the development of pneumonia.

Le but de cette étude est de déterminer les caractéristiques épidémiologiques des patients brûlés qui développent une atteinte pulmonaire , ainsi que les facteurs prédisposants et le taux de mortalité . La pneumonie est une cause majeure de morbidité et de mortalité chez les patients gravement brûlés. Les patients atteints de lésions par inhalation sont exposés à un risque plus élevé en raison de l'évolution possible de complications infectieuses dans les voies respiratoires inférieures. Au cours de leur séjour dans notre unité de soins aux brûlures, 22,9% de nos patients brûlés ont développé la pneumonie et 10,9% de ces patients sont décédés. Les facteurs de risque pour le développement de la pneumonie chez les patients brûlés retrouvés sont le traumatisme de l'inhalation, le score élevé de ABSI, l'incice de Baux et l'indice Baux modifié, et le score ASA élevé (p <0,01). L'âge et le sexe des patients n'ont montré aucune corrélation significative à l'incidence de la pneumonie. Dans cette étude, nous avons pu déterminer l'incidence des complications pulmonaires du fait des lésions par inhalation .chez les patients brûlés, ainsi que sur le taux de mortalité.

Management of difficult intra-articular fractures or fracture dislocations of the proximal interphalangeal joint.

Intra-articular fractures or fracture dislocations of the proximal interphalangeal joint are difficult clinically because the bone and soft tissue structures are small and intricate. Suboptimal treatment of intra-articular fractures typically leads to functional impairment of the hand. This article reviews the current methods of treatment, together with the senior author's experience in treating difficult proximal interphalangeal joint fractures and dislocations. Besides conservative treatments, surgical treatments include open or closed reduction with traditional Osteosynthesis, such as K-wires, screws or plates. Among recent developments are the percutaneous application of thin cannulated compression screws and novel dynamic external fixators. After a preferred minimally invasive treatment with stable reconstruction of the articular surface, sufficient aftercare is necessary to improve surgical outcomes.

[Infection of the hand: evaluation of a two-stage therapy]. / Handinfektionen: Evaluation eines zweizeitigen Therapieregimes.

INTRODUCTION: Infections of the hand are common diseases in hand surgery departments. The correct diagnosis and subsequent treatment is difficult and is often underestimated. In literature different and often conflicting treatments are recommended. The present study retrospectively analysed our two-stage surgical treatment. PATIENTS AND METHODS: 60 patients (mean age: 51 years, 38 male, 22 female) were studied retrospectively on the basis of the diagnosis hand infection (ICD L03.-). In all patients, a rapid and radical surgical debridement without wound closure was performed. An antibiotic therapy was initiated. We investigated how often wound closure during a second-look operation, following a period of open wound treatment with antiseptic dressing was successful possible. Furthermore, the patients were followed up in our outpatient clinic. RESULTS: A successful secondary wound closure was possible after on average 38.7 h and in 92% of the patients. 8% of patients required further surgical treatment. These patients presented with either an existing disease or a delayed presentation with initial antibiotic treatment. Antibiotic therapy was performed on an average for 8.7 days. Altogether for 85% of the 58 patients examined in our outpatient clinic the therapy could be terminated after 3 weeks with a full recovery of function of the injured hand and with full force measurements. The inability to work was on average 16 days. DISCUSSION: The two-stage surgical treatment, with radical debridement and open wound dressing in our collective is an adequate treatment for infections of the hand. It is a safe procedure, that allows for combination with an antibiotic therapy by which a rapid restoration of function of the injured hand is possible.

[Abductor digiti minimi muscle flap for defect coverage of the hand]. / Die M.-abductor-digiti-minimi-Lappenplastik zur Defektdeckung im Handbereich.

OBJECTIVE: Defect coverage of the ulnar aspect of the hand, wrist and hypothenar with an abductor digiti minimi muscle flap and split skin graft. INDICATIONS: Soft tissue defects of the ulnar aspect of the hand, wrist and hypothenar. Osteomyelitis of the fifth metacarpal bone. CONTRAINDICATIONS: Large defects > 3 × 5 cm, complex hand trauma, injuries of the ulnar artery or within the area of the pedicle. SURGICAL TECHNIQUE: Marking of the flap's rotational radius, using the pisiform bone as the center point. Ulnar skin incision and exposure and detachment of the distal flap pole, which is located at the level of the metacarpophalangeal (MCP) joint. Dissection of the abductor digiti minimi muscle flap up to the vascular pedicle in the area of the pisiform bone. Transposition and fixation of the flap onto the defect after opening of the tourniquet. Coverage of the muscle flap with a split skin graft. Wound closure of the donor side. POSTOPERATIVE MANAGEMENT: Palmar cast splinting in intrinsic-plus position for 10 days physiotherapy. Scar care and compression glove for 3 months. RESULTS: In total, 9 patients showed good results with a reliable defect coverage due to a constant anatomy and easy preparation.

Posterior interosseus nerve vs. medial cutaneous nerve of the forearm: differences in digital nerve reconstruction.

Digital nerve defects are common in hand trauma and for primary or secondary nerve reconstruction, the autologous nerve graft remains the gold standard. This study compares the regeneration results and donor side morbidity of either the posterior interosseus nerve (PIN) graft or the medial antebrachial cutaneous nerve (MACN) graft. 16 patients (group A, age 43 ± 13 years) with digital nerve defects were treated with a PIN graft and 12 patients (group B, age 40 ± 15 years) received a MACN graft. The average nerve gap was 22 mm in each group. After a follow-up of 15 ± 8 months in group A, S4-sensibility were measured in 9 cases, S3+ in 5 cases and in 1 case S2 and S0. Up to an inconspicuously scar in projection of the fourth extensor-tendon compartment, there was no significant donor side morbidity. In group B, a S4-senibility has been obtained in 4 cases, S3+ in 5 cases, S3, S2 and S0 in each 1 case after a follow-up of 16 ± 11 months. Regarding the donor side morbidity, almost all patients complained about a disturbing scar formation and unpleasant paresthesia at the forearm down to the rascetta. Neuroma-associated pain has been detected in 4 cases. Although there has been no significant difference in terms of nerve regeneration, we recommend the use of the PIN graft for digital nerve reconstruction, since harvesting this nerve is fast and easy and without any donor side morbidity compared to the MACN graft.

Noncontact electrosurgical grounding--a useful and safe tool in the initial surgical management of thermal injuries.

BACKGROUND: Electrosurgical instruments - one of the useful and most-used instruments within the surgeon's armamentarium - are potentially dangerous by causing unanticipated direct burns; fire occurring as a result of electrosurgical instruments and electromagnetic interference with a pacemaker, defibrillator, or cardiac monitoring device. METHODS: The Mega 2000 Patient Return Electrode System produced by Megadyne Medical Products is a noncontact electrode designed to provide adequate electrical return to facilitate function of electrocautery devices. We used this noncontact device in 67 patients (28 women, 39 men) with large burns during their stay in our burn unit and in 11 of these patients (4 women, 7 men) for escharotomies during admission in our burn care. RESULTS: The device functioned well in all cases, no additional cutaneous burns on the patients' body were noticed. CONCLUSION: This paper is a review of our experience with this noncontact electrosurgical grounding in burn surgery highlighting its advantages comparing with the conventional electrosurgical instruments.

[Mechanical ventilation in toxic epidermal necrolysis]. / Beatmung bei Toxisch Epidermaler Nekrolyse.

INTRODUCTION: Toxic epidermal necrolysis (TEN) is associated with a high mortality. The need for mechanical ventilation is associated with an increased mortality in TEN patients. This study investigates the impact of the timing of initiation of the mechanical ventilation on the survival of TEN patients. PATIENTS, MATERIALS AND METHODS: A retrospective study of 26 TEN patients was carried out. Primary (on admission (group A) and secondary ventilation (>1 day after admission (group B) were analysed for an association with mortality. RESULTS: 8 patients did not require mechanical ventilation. 18 patients needed mechanical ventilation. In group A 8 patients with an epidermolytic body surface area (BSA) of 73 ± 16% and a mean SCORTEN of 3.2 ± 1.1 were analysed. In group B 10 patients with an epidermolytic BSA of 76 ± 19% and a mean SCORTEN of 3.8 ± 0.9 were evaluated. Statistical analysis showed an increased mortality in all mechanically ventilated compared with non-ventilated TEN patients (Odds ratio: 2.0; 95% CI: 1.26-3.17 p = 0.013). CONCLUSIONS: Mechanical ventilation in TEN patients is associated with an increased mortality rate, but the timing of initiation of mechanical ventilation does not affect the patient survival rates.

[Self inflicting behavior in patients with borderline personality disorder : retrospective analysis of principles of plastic surgery therapy]. / Selbstverletzungen bei Menschen mit Borderline-Persönlichkeitsstörung : Retrospektive Analyse plastisch-chirurgischer Therapieprinzipien.

One symptom of Borderline personality disorder is self inflicting behavior, especially cuts and thermal injuries in the upper extremity. Due to the complex underlying psychiatric disease, surgical treatment of these injuries can be tedious and frustrating; therefore it is sometimes necessary to differ from classical plastic surgery principals and to favorite a more conservative approach. In every case, close cooperation with psychiatrist is inalienable.

[Results after revision surgery for carpal tunnel release]. / Ergebnisse von Karpaltunnel-Revisionseingriffen.

PURPOSE: The aim of this study was to assess the clinical results of revision surgery due to persistent neurological disturbances after carpal tunnel release. PATIENTS AND METHOD: In a previous study we showed the reasons for persisting neurological symptoms after carpal tunnel release on the basis of the intraoperative findings in 200 patients who underwent revision surgery in the years 2001 - 2003. We classified them into four groups (1: incomplete release of the retinaculum flexorum, 2: traction neuropathy, 3: real recurrent carpal tunnel syndrome, and 4: nerve lesions). 122 of these patients have been investigated regarding the clinical results using two questionnaires in the year 2004. We used the DASH questionnaire as well as an additional self-assessment questionnaire asking about remaining symptoms of median nerve irritation and the subjective results of revision surgery. The completely filled-out forms were assigned to the four groups, analysed and the results compared with each other. RESULTS: Within group 1 (incomplete release), 78 % reported only one persistent neurological symptom, 89 % described a benefit from revision surgery and 84 % were satisfied with a median DASH score of 11. Within group 2 83 % complained about at least one persistent neurological problem and only 60 % reported on an improvement following revision surgery. The DASH score within group 2 averaged 30. 87 % of group 3 patients reported of an improvement following the revision operation (DASH score 24), whereas this was the case for only 55 % (DASH score 37) of group 4 patients. CONCLUSION: The incomplete release of the flexor retinaculum is the most common reason for revision surgery. In most of these patients the clinical symptoms can be resolved with revision surgery leading to a very high satisfaction of the patients. A similarly high satisfaction can be expected following revision surgery of a true recurrent carpal tunnel syndrome although in most patients a significant degree of functional deficit will remain. Revision surgery due to fibrotic adhesions of the median nerve, leading to a traction neuropathy, or iatrogenic nerve lesions during the primary surgery will definitely lead to unsatisfactory overall results.

[The dorsal flag flap for alternative skin coverage for defects of the thumb tip: case reports]. / Der dorsale fähnchenlappen zur alternativen defektdeckung an der daumenkuppe: fallberichte.

PURPOSE: This case report describes the use of the dorsal flag flap in contrast to its standard indication (dorsal and palmar defects of the proximal finger phalanx) for defect coverage of the thumb tip in three patients. PATIENTS AND METHOD: In 2006, defects of the thump tip were covered with a dorsal flag flap in three male cases. After 6 - 9 months a clinical evaluation was performed with special focus on pain, aesthetic aspect, sensibility and function. RESULTS: Primary wound healing without complications was observed in all cases. No functional impairments or pain have been reported, the aesthetic aspect was satisfying for the patients. All flaps showed an intact protection sensibility (in terms of pressure and pain perception). The subjective shortcoming of the sensitivity like numbness was not distracting to any of the patients. CONCLUSION: The dorsal flag flap is a good alternative for covering tissue defects at the thumb tip compared to local flap grafts or neurovascular long-distance flaps with satisfying results.