[Complex regional pain syndrome versus chronic regional pain syndrome (Hand-Finger Syndrome)]. / Komplexes regionales Schmerzsyndrom versus chronisches regionales Schmerzsyndrom (Hand-Finger-Syndrom).

Dystrophy is a main factor of CRPS. A large number of patients do not develop dystrophy but, instead, they suffer from pain with limitation in movement, possible paraesthesia and/or swelling. This is then a chronic regional pain syndrome or (shoulder-arm-) hand-finger syndrome. These patients should never be confronted with the diagnosis Morbus Sudeck or algodystrophy, which are today also well known among non-professionals, to avoid pushing them into a status of constant severe invalidity. Histories, clinical examination, as well as a good personal understanding of the patient are indispensable. Knowing that pain, or the extent of pain, remains subjective until today, the clinical diagnosis depends on the absence of side differences in: a) the circumference of soft tissues of both upper extremities; b) the callosity of the palm; c) the bone-density. These three parameters allow verification of the consequences of the pain complaints (indirect pain verification). It is essential to find the cause for their suffering and to treat it as far as possible: 1) Too long and inappropriate immobilisation (patient's suffering not considered sufficiently). These patients can recover quickly when the right diagnosis is made in good time. 2) Limitation of movement due to scar, neuroma, or elongation pain: a) bizarre functional disabilities can develop; b) due to the patient's complaints, one or several operations would finally be performed, which will not lead to an improvement but rather to an aggravation of the pain; c) socially-induced purposeful pain increase, the typical statement of the patient will be: "I can't stand it any longer". Patients who are socially over-burdened, or have psycho-social problems, may experience a decline of performance or a post-traumatic stress disorder. Several patients will be introduced as illustrations for each of the relevant groups.

[The Mantero technique for flexor tendon repair - an alternative?]. / Die Beugesehnennaht nach Mantero - eine Alternative?

PURPOSE: Regaining free tendon gliding after reconstruction of flexor tendons is essential to restore full function to the affected finger. Mantero et al. described a pull-out suture technique for the repair of flexor digitorum profundus (FDP) lesions in zone 1, allowing early postoperative active mobilisation and thus minimizing the risk of tendon adhesions. In a retrospective study we examined the results after Mantero tendon repair and compared these with the results after different reconstructive procedures in the literature. METHODS AND MATERIAL: Between 1995 and 2001, the FDP tendon in zone 1 and distal half of zone 2 distal to the chiasma respectively the flexor pollicis longus (FPL) tendon were reconstructed in 96 patients using the Mantero technique. 87 (90 %) patients, with a male to female ratio of 2 : 1, were re-examined an average of 43 (4 to 84) months postoperatively. We evaluated the isolated function of the finger joints, the total range of motion of the affected finger and grip strength and compared all values to the contralateral healthy side and assessed the functional results according to the Buck-Gramcko score and the patients' satisfaction according to the DASH score. Special attention was directed to the influence of the patients' age, gender, art of trauma, accompanying injuries or level of the lesion on the postoperative results. Furthermore, we evaluated whether clinical results depended on which finger was injured. RESULTS: 71 % (n = 62) of all injuries were found in the distal zone 2 or distal zone Th 2 in the thumb. While 81 % (n = 70) were caused by a clean cut, 10 % (n = 9) were due to a circular saw injury and 9 % (n = 8) due to a crush injury. The average DASH score value was 5.4 (0 to 37.5) with excellent and good results according to the Buck-Gramcko score in 90.8 % (n = 79) of all patients. Only the patients' age (> 50 years vs. < 20 years) and the digit involved (little finger vs. index, middle and ring fingers) had a significant influence on the postoperative results. Aside from superficial skin necrosis in 10 % of all cases, in which no further operative therapy was necessary, no other complications occurred. Interestingly, no ruptures of the sutured tendons were found, although active mobilisation was initiated immediately. Compared to the literature, the 90,8 % excellent and good results are equivalent to those of other studies concerning reconstruction after flexor tendon injuries using the Mantero technique and tend to be better than other reconstructive procedures. CONCLUSION: Based on our results, we consider the Mantero technique to be a good alternative to other forms of flexor tendon reconstruction in zone 1 and distal zone 2. Advantages include the possibility of immediate postoperative mobilisation and placing a secure tendon suture, even if the distal tendon stump is very short.

[Repeat interventions after decompression of the carpal tunnel]. / Rezidiveingriffe nach Karpaltunnelspaltung.

If after carpal tunnel release, symptoms continue or progress, or if new ones appear, they must be examined thoroughly and differentiated. Such symptoms may hint at incomplete splitting of the retinaculum flexorum, a more proximally located nerve compression (faulty diagnosis or double-crush syndrome), a general or a new disease, a previously unrecognized or a new hypertrophic synovialitis, a hypertrophically contracted scar, or a neuroma. Iatrogenic lesions have frequently been reported. A second follow-up operation is indicated only after all findings, including the neurophysiological assessment, have been taken into consideration: scar, neuroma resection, revision and neurolysis of the median nerve at all levels. The most difficult question is the coverage of the nerve in the scar tissue with thin and well-vascularised tissue. Various types of flaps using muscle or subcutaneous or synovial tissue have been suggested.

The synovial flap as treatment of the recurrent carpal tunnel syndrome.

After an exact definition of the recurrent carpal tunnel syndrome, its treatment, as described in the literature, is presented. To cover the median nerve isolated from the extended scar tissue with a thin and well-circulated tissue, the author proposes and demonstrates the synovial flap. The follow-up of 27 cases operated since 1979 with a follow-up time between 1 month to 14 years shows 6 excellent, 16 good, 3 satisfactory and 2 bad results.

[Chronic entrapment syndromes of the tendons]. / Chronische Engpasssyndrome der Sehnen.

The chronic entrapment syndromes of the tendons of the hand are: stenosing tendovaginitis of the flexor and extensor tendons, the trigger wrist, and the intersection-syndrome. Pathogenesis, symptoms, diagnosis and differential diagnosis are presented. The focus is on the localization of the individual disease and its particularities. Therapy and possible complications are discussed subsequently.

[The accessory tendon of the flexor pollicis longus]. / Die akzessorische Sehne des Flexor pollicis longus.

The slender accessory tendon of the flexor pollicis longus muscle is described. It is found in 10 to 54% of the cases of trigger thumb, but approximately in the same frequency in the normal thumb too. A literature review of the incidence and genesis is presented.

[Synovial flap repair in treating recurrent carpal tunnel syndrome]. / Die Synovialislappenplastik zur Behandlung eines Karpaltunnelsyndrom-Rezidivs.

In 1980, we presented the synovialis flap plasty for the treatment of carpal tunnel syndrome recurrence. Since May 1979, we performed 41 secondary procedures, and among them 14 synovialis flap plasties. The results were very good in three patients, good in eight, satisfactory in two, and poor in one, but this patient with the poor result reported subjective improvement.

[Abductor pollicis longus-repair in treating basal thumb joint arthrosis]. / Die Abductor pollicis longus-Plastik zur Behandlung der Daumensattelgelenkarthrose.

Between 1987 and 1990, we operated 32 hands of 30 patients for basal joint arthrosis. After extirpation of the trapezium, a part of the abductor pollicis longus is pulled through and wrapped around the flexor carpi radialis, similar to the Lundborg method. This creates a tendinous web, which supports the first metacarpal bone. Patient assessment revealed good to very good results with only one dissatisfied patient; the objective evaluation showed two thirds good and one third poor results, comparable to those of alternative methods of creation of a tendon web with the flexor carpi radialis (Weilby) or the extensor carpi radialis longus (Necking and Eiken). The essential point is a permanent distance between the base of the first metacarpal bone and both the scaphoid and the base of the second metacarpal bone under normal conditions as well as under loading.

[Results of follow-up examinations of treatment of Mantero flexor tendon injury in zone 1 and distal zone 2]. / Nachuntersuchungsergebnisse der Behandlung der Beugesehnenverletzung nach Mantero in Zone 1 und der distalen Zone 2.

We did follow-up examinations of flexor tendon sutures of 161 digits in 151 patients treated according to the Mantero-technique. They revealed that the urgence différée still has its merits today. The results of the sutures in zone 2 correspond to those of zone 1, if only one tendon is affected (zone 2.1), while they are clearly inferior, when two tendons are involved (zone 2.2).

[Intersection syndrome]. / Zum Intersection-Syndrom.

The causes, symptoms and therapy of intersection syndrome are discussed, cases presented and the literature reviewed. If intersection syndrome does not respond favorably to conservative treatment, we perform synovialectomy and incision of the thick fascia of the abductor pollicis longus muscle.

Flexor tendon suture in zone 1 and distal zone 2 by the Mantero technique.

A series of 161 digits with flexor tendon division in zones 1 and 2 have been reviewed after management by the method described by Mantero. The concept of "urgence différée" (delayed primary suture) is still valid. In zone 2, we distinguish between division of tendons, where only profundus is divided (zone 2.1) and, where both profundus and superficialis are divided (zone 2.2). Results from zone 2.1 are comparable to results from zone 1. Overall, our results are of the order of those achieved by management according to Kleinert, but we would maintain that the Mantero technique is easier to perform and more confortable for the patient.

[The "open palm" technique in Dupuytren's contracture]. / Die "Open-Palm"-Technik bei der Dupuytrenschen Kontraktur.

The authores reports on the "open-palm-technique" used in those patients in whom after excision of the Dupuytren's tissue and passive maximal extension of the fingers the skin in the palm cannot be closed without undue tension. Postoperative complications such as hematoma accumulation and edema can be avoided by this method. Neither the length of treatment nor the duration of incapacity is prolonged by this technique.

On the treatment of enchondroma.

We recommend simply removing an enchondroma without filling the cavity with cancellous bone or plaster-of-Paris. This method can also be applied to other benign bone conditions, such as aseptic necrosis.

[Post-traumatic ulnar nerve irritation and paralysis as a compression syndrome under the palmar carpal ligament]. / Die posttraumatische Ulnarisirritation und -parese als Kompressionssyndrom unter dem Ligamentum carpi palmare.

The palmar carpal ligament is defined as the distal border of the fascia antebrachii. It is proposed that this name is not used for the region of the fascia antebrachii proximally to this structure or for parts of the retinaculum distal to this structure, i.e. in the hypothenar region. The palmar carpal ligament has been found to be a cause of posttraumatic irritation of the ulnar and median nerve at the wrist proximal to the carpal tunnel or Guyon's canal.

[Peritendinitis calcarea of the hand, a case report]. / Peritendinitis calcarea an der Hand, ein kasuistischer Beitrag.

The authors present three cases of peritendinitis calcarea in the extensor tendons of the wrist and the flexor tendons of the fingers. The symptoms were gout-like pain attacks and local inflammation. In the X-rays calcification was seen within the tendon sheath. The symptoms and the calcification disappeared spontaneously in a few months. In these rare cases there is no indication for surgery.

[Malignant soft tissue tumors of the hand: report of 2 malignant fibrous histiocytomas and 2 extraskeletal myxoid chondrosarcomas]. / Maligne Weichteiltumoren der Hand: Bericht über zwei maligne fibröse Histiozytome und zwei extraskelettale myxoide Chondrosarkome.

The authors discusses two malignant tumors of the soft tissue of the hand: the malignant fibrous histiocytoma and the extraskeletal myxoid chondrosarcoma. With each tumor two patients were involved. One patient with malignant fibrous histiocytoma required amputation at the fourth and fifth carpometacarpal joints, one patient with extraskeletal myxoid chondrosarcoma amputation in the proximal third of the forearm. Both remained free of metastases. Also the other two patients after surgical excision and amputation in the third metacarpal bone respectively, are free of recurrences or metastases till now.

[Kaplan's anastomosis in the little finger]. / Die Kaplan-Anastomose am Kleinfinger.

The connection between the dorsal branch of the ulnar nerve and the proper digital nerve of the little finger--described by Camper 1760 and by Kaplan 1963 more proximally--is shown in the little finger of four patients.