Giovanni Battista Monteggia (1762-1815).

Giovanni Battista Monteggia was born in Laverne on the 8th of August 1762. Monteggia started his education in the School of Surgery at the Hospital Maggiore in Milano in 1779.This hospital was called "Big House"and it is one of the oldest medical institutions in Italy. He passed exam in surgery in 1781. Monteggia was promoted to assistant at surgery in Maggiore hospital in 1790. He was among the first who gave a complete clinical description of polio. He described traumatic hip dislocation and special forearm fracture which was named after him. Strictly speaking, a Monteggia fracture is a fracture of the proximal third of the ulna with an anterior dislocation of the radial head. Monteggia became a member of the renewed Institute of Science, Literature and Art in Milano in 1813.

Open Dislocation of the High Ankle Joint After Fibular Graft Harvesting.

The free microvascular fibula and soft tissue transfer has become a widely used method for reconstruction of different regions. Donor site morbidity for free fibula microvascular flaps has generally been reported to be low, or at least acceptable. We describe the case of a patient who underwent vascularized free fibula graft harvest for mandibular reconstruction. After 21 months, he had sustained an open dislocation of the left high ankle joint during recreational sports activity. We did not found such case in the published data.

Evaluation of reversal osteofixation using K-wires in digital replantation.

INTRODUCTION: Modified, reversal technique of fixation in digital replantation using K-wires was analyzed. The results obtained from the standard technique and reversal technique of fixation using K-wires were compared. OBJECTIVE: The aim was to compare the results of osteofixation using K-wires in digital replantation when either standard or reversal, modified technique was used. METHODS: A retrospective study included 103 replanted fingers in 72 patients. The first group included standard fixation using K-wires and the second group included fixation using K-wires, but with a modified technique. Modification consisted of the opposite order of moves during the phalanges fixation compared to the standard technique: first, K-wire was introduced intramedullary in the proximal phalanx and the top of the wire was drawn out through the skin in proximal part of the finger or hand. Second, distal part of the wire was introduced in the phalanx of the amputated part of the finger intramedullary until the wire entered the cortex. RESULTS: Duration of bone healing after digital replantation was shorter in cases where reversal technique was used in comparison with standard technique (7.2 weeks compared to 7.5 weeks). CONCLUSION: The comparison of standard and reversal technique of phalangeal fixation with K-wires in digital replantation shows that both techniques are useful. Reversal technique expands the choice of operative techniques for bone fixation during the replantation. It shows some advantages and enables avoidance of vein injuries.

Replantation of upper extremity, hand and digits.

Replantation is defined as reattachment of the part that has been completely amputated and there is no connection between the severed part and the patient. In Boston in 1962 Malt successfully replanted a completely amputated arm of a 12-year-old boy. Komatsu and Tamai reported the first successful replantation of an amputated digit by microvascular technique. There are no strict indications and contraindications for replantation. It's on surgeon to explain to the patient the chances of success of viability, expected function, length of operation, hospitalization and long rehabilitation protocol. Survival and useful function in replantation of upper extremity amputations is questionable. Success depends on microvascular anastomoses, but the final function is related with tendon, nerve, bone and joint repair.

Fractures of the scaphoid, diagnosis and management--a review.

The scaphoid is vitally important for the proper mechanics of wrist function. Fracture of the scaphoid bone is the most common carpal fracture. Among all wrist injuries the incidence of scaphoid fracture is second only to fractures of the distal radius. Scaphoid fractures are significant because a delay in diagnosis can lead to a variety of adverse outcomes that include nonunion, delayed union, decreased grips strength, range of motion and osteoarthritis of the radiocarpal joint. To avoid missing this diagnosis, a high index of suspicion and a through history and physical examination are necessary, because initial radiographs are often negative. Regardless of the technique of bone grafting, there will almost always be some loss of motion even if the fracture unites.

[Relevant factors in the treatment of digital nerve injury of the hand].

INTRODUCTION: In his work the orthopaedic surgeon deals with a large number of peripheral nerve injuries, especially of the upper extremity. Most of these injuries involve the hand (30%). OBJECTIVE: The aim of the study was to analyze the influence of some factors (age, aetiology, level of injury, associated injuries) on surgical treatment outcome of digital nerve injury of the hand. METHODS: At the Department for Microsurgery 72 hospitalized patients were operated on due to the injury of common palmar digital nerves and proper palmar digital nerves. All operations were performed within the first 48h after injury and primary neurosuture was done in all. Beside the evaluation of demographic parameters, we also assessed aetiology of injury, associated injuries, level of injury, as well as the vascular status of the injured finger. Functional recovery was measured by the Medical Research Council (MCR) scale (S0-S4). RESULTS: We found a statistically significant difference in sensory recovery according to age and aetiology of injury (p < 0.05). Better results of sensory recovery were detected in cases with undamaged artery or where anastomosis was done, but without statistical significance. There was no statistical significance difference regarding the level and associated injuries. CONCLUSION: Two major factors in the recovery of digital nerve function are patient's age and mechanism of injury. Having in mind the limited degree of recovery, the patient should be precisely informed preoperatively on the nature of injury and realistically expected results.

[Digital nerve injury of the hand-epidemiologic and clinical analysis].

The aim of this study was to show the significance of epidemiologic factors of digital nerve injury and their social influence. 108 patients were operated with primary suture within first 48 h after injury. We record factors as sex, age, etiology, dominance and level of injury. Results of sensory recovery were measured by Medical Research Council scale (MCR). Males predominantly sustain this injury (83.3%) and we seen more frequently in the young adults. Average age is 34.7 years (from 16 to 70). These injuries rarely isolated and most of them are in the zone II (48.1%). The full recovery we have only in nine patients. Digital nerve injury of the hand are more often found in young mail adults who are work active. They are out of work even six months, and sometimes even more. Some of these injuries leaves permanent disability which have a socio-economic importance.

Free fibula and corticocancellous bone grafting for salvage of a war-injured forearm.

The treatment of a complex forearm injury inflicted by a wartime mine explosion is presented in this study. Apart from the soft tissue damage, a 4-part fracture of the radius and loss of 19 cm of the ulnar diaphysis were present along with lesions of the median and ulnar nerves. The radial pulse was intact. The first formal treatment of the wounding consisted of extensive soft tissue and bone debridement and external fixation of radius with an additional intramedullary K-wire. After wound closure was obtained, a free vascular fibula grafting of the ulna and corticocancellous bone grafting of the radius were performed. Bone union of both the radius and ulna was subsequently achieved and 9 years after the injury, the patient has full flexion and extension of the elbow, full pronation and 70% of supination. Motion of the wrist is limited because of an ulnar plus variant of the distal radioulnar joint. Hand function is still limited by chronic low-moderate median nerve palsy, but the ulnar nerve has recovered completely. The patient is able to pinch, has full finger extension and can make a fist. He is satisfied that he made the correct decision in not having an initial amputation for his injury.

[Radiographic signs of scaphoid union after bone grafting: the analysis of inter-observer agreement and intra-observer reproducibility].

INTRODUCTION: The diagnosis of radiological union of scaphoid bone after bone grafting requires clear evidence of bony trabeculae traversing the graft from the proximal to the distal pole on at least two of four standard scaphoid views. This sign is the only objective assessments of union. Radiographs of the scaphoid taken 18 weeks after operation, however, can be difficult to interpret. This fact led us to question whether radiographs of scaphoid at 18 weeks provide reliable and objective indication of union. OBJECTIVE: Our study was, therefore, designed to determine the reliability of the radiographic diagnosis of scaphoid union after bone grafting by testing the degree of inter-observer agreement and reproducibility. METHODS: Out of 30 sets of the scaphoid bone radiographs after bone grafting taken 18 weeks after operation, 15 of good quality were selected. Each set included four views: postero-anterior, lateral, semi- pronated and semi-supinated. Seven observers were tested: three orthopedic consultants, three residents and one consultant in radiology. Each was presented with 15 sets of radiographs designated from 1 to 15 and each was asked to answer the question: "Are there trabeculae crossing the fracture site?" Possible answers were 'yes' or 'no'. Eight weeks later, the same 15 sets of radiographs were marked in alphabetic order from A to K and presented to the same seven observers. Data was then analyzed and expressed in terms of interobserver agreement in pairs and intra-observer reproducibility. Calculation was done by kappa statistics so that the degree of disagreement was taken into account and allowance was made for chance agreement. Kappa values can vary from -1.0 (complete disagreement) through 1 (chance agreement) to +1 (complete agreement). RESULTS: For all 15 sets of radiographs, the degree of agreement between each pair of observers was illustrated in Table 2. It demonstrated the level of agreement between each pairs of seven observers. The overall median kappa coefficient for inter-observer agreement was 0,46. This value corresponded to "moderate" strength of agreement. Median kappa coefficient for consultant was 0.62, but median kappa coefficient for residents was 0.43. The degree of agreement between the opinions of each observer at his first and at his subsequent reviews of the same set of radiograph after 8 weeks was presented in Table 3. The overall median Kappa coefficient for the intraobserver agreement for all seven observers was 0.54. The ability of seven observers to reproduce their own opinion regarding trabeculae crossing the fracture line was poor to use it for assessment of bone union. CONCLUSION: Our conclusion is that radiographs taken 18 weeks after scaphoid grafting cannot be reliable and reproducible for assessment of bone union.