Digital artery damage associated with closed crush injuries.

This retrospective study describes closed finger crush injuries in seven patients (eight fingers) in which each finger sustained a loss of blood supply. Clinical findings included numbness, decreased two-point and sharp/dull sensation, cyanosis or pallor, and decreased capillary filling. Fractures, especially transverse fractures near the proximal interphalangeal joint or distal interphalangeal joint, were usually present and often showed longitudinal crush fracture lines. Exploration and revascularization were carried out in seven fingers, all of which survived. The only finger not explored progressed to necrosis and amputation. Crush injuries to the fingers, especially those associated with displaced fractures, should be carefully evaluated for symptoms and signs of ischaemia.

Percutaneous release of the common extensor origin for tennis elbow.

Thirty patients (32 elbows) who had surgery for tennis elbow were examined. Symptoms were present an average of 18 months before surgery. The operation was done percutaneously through an incision just distal to the lateral epicondyle, through which the common extensor origin was released. The followup period was 6 to 61 months, with an average of 26 months. Twenty-nine elbows had good or excellent results. In these 29, the pain was relieved an average of 9 weeks after surgery. Three elbows did not improve significantly, and treatment was considered a failure. The grip strength improved from an average of 60% of the opposite side before surgery to 90% after surgery.

Reflex sympathetic dystrophy: treatment with long-acting intramuscular corticosteroids.

In an 8-year period, 69 patients with reflex sympathetic dystrophy, who were followed at least 1 year, were treated with active exercises and injections of long-acting methylprednisolone. Of these, 22 patients did not respond to this treatment and 47 patients obtained significant improvement. All 47 were relieved of night and rest pain. Proximal interphalangeal motion improved from an average of 39 degrees to an average of 75 degrees. Grip strength was an average of 7 lb. before treatment and 29 lb. after treatment.

Clinical evaluation and temperature monitoring in predicting viability in replantations.

Experiences with temperature and clinical monitoring in a series of 111 patients with 188 revascularized digits were reviewed. Criteria for abnormal temperature monitoring were defined. Monitoring of only clinical parameters showed a sensitivity of 1.00 and specificity of .97, but this technique was time-consuming and required experienced interpretation of subtle clinical changes. Temperature monitoring gave a sensitivity of 1.00, while the specificity was only .61. Drops in temperature were frequently not associated with vascular problems. Review of digits with abnormal clinical or temperature monitoring showed five patterns of abnormality. The first three groups had either abnormal clinical or temperature monitoring, but all fingers survived without reexploration. The fourth and fifth groups showed abnormalities in both clinical and temperature monitoring; all but one finger were found to be nonviable. Combined clinical and temperature monitoring was highly effective in early prediction of vascular compromise, with a sensitivity of 1.00 and a specificity of .99. The authors recommend the use of temperature monitoring. If a temperature drop occurs, monitoring of the clinical parameters can then be done. If both temperature and clinical monitoring yield abnormal results after a specified time, intervention should be carried out.

Compression syndromes in reflex sympathetic dystrophy.

Over an 8-year period we treated 93 cases of reflex sympathetic dystrophy. The initial treatment consisted of long-acting intramuscular corticosteroids and active exercises. Twenty-two patients who did not respond significantly to this treatment had carpal tunnel syndrome. In addition, five had cubital tunnel syndrome, one had ulnar tunnel syndrome, and one had a herniated disk of the cervical spine. All nerves were decompressed with significant improvement in the patient's condition. Pain was relieved in all except three who had mild pain. Motion of the proximal interphalangeal joint improved from an average of 35 degrees before operation to 76 degrees after operation. Grip strength improved from an average of 4 pounds to 27 pounds.

Technical factors related to Herbert screw fixation.

We reviewed 24 patients treated for an acute fracture or a nonunion of the scaphoid bone using the Herbert screw. Mean follow-up in 22 patients who returned for examination was 17 months. The overall union rate was 67% for both acute fractures and nonunions. Fracture healing correlated strongly with technical factors of the procedure. The fracture failed to heal in seven of nine cases with poor scaphoid realignment, inaccurate jig placement, or improper screw length for a nonunion rate of 78%. Conversely, without these technical problems, 14 (93%) of 16 fractures achieved union. Applying Herbert's criteria, a satisfactory rating for clinical function was achieved in 59% of all patients and for patient satisfaction in 68% of all patients. Although the postoperative immobilization period was reduced using the screw, the final functional result in our nonunions was similar to that reported for the Russe bone grafting procedure. Appropriate modifications of the standard technique and recognition of equipment limitations may improve union rates.

Central slip tenotomy for chronic mallet finger deformity.

Twenty patients with chronic mallet finger deformity were treated with central slip tenotomy. Seventeen patients had normal passive motion at the distal joint preoperatively. In them the average extensor lag was 37 degrees before the operation and 9 degrees after the operation. The average recurvatum at the proximal interphalangeal (PIP) joint was 10 degrees before the operation; postoperatively the extensor lag was less than 2 degrees.

Pathologic anatomy of the forearm: intersection syndrome.

Intersection syndrome of the forearm is a common painful condition that is infrequently diagnosed. It presents with pain and swelling in the area where the muscle bellies of the abductor pollicis longus and extensor pollicis brevis cross the common wrist extensors. The etiology is not well understood, but operative treatment of 13 patients has shown that the basic pathologic abnormality is stenosing tenosynovitis of the sheath of the common radial wrist extensors.

Ulnar tunnel syndrome.

Ulnar tunnel syndrome or compression of the ulnar nerve at the wrist is of two distinct types. In the first type compression is at the level of the pisiform with involvement of both sensory and motor fibres. In the second type compression is distal to the pisiform with involvement of the motor fibres only.

Intramedullary fixation for fractures of the hand.

Twenty-seven fractures in 22 patients were treated with an intramedullary rod, introduced through the fracture fragments, without violating the joint surfaces. Twenty-six fractures united. There was one nonunion and one migration of the pin into the joint; there were no infections. Advantages of this procedure are (1) that it is quicker and easier to perform than a procedure requiring Kirschner wires or plates, (2) no special equipment is needed, and (3) motion can often be started as early as 10 days after the operation.

Anatomic repair of boutonnière deformity.

Seven patients were operated on four to 26 weeks after sustaining a traumatic boutonnière deformity. The operation recommended is excision of 3 mm of central slip followed by end-to-end repair of the tendon. The postoperative average motion for the group was 7 degrees to 89 degrees at the PIP joint and 7 degrees to 51 degrees at the DIP joint.