Bipartite scaphoid with proximal pole osteonecrosis in a patient with Holt-Oram syndrome.

The Holt-Oram syndrome features a spectrum of upper limb abnormalities, including an abnormal shape of the scaphoid. Our report concerns a 19-year-old man with Holt-Oram syndrome and flattening and sclerosis of the proximal pole of a bipartite scaphoid. The initial ossification centre in the scaphoid was located distally at 8 years of age. By age 13, a pair of ossific centres were present. After an automobile accident at age 18, the proximal pole became sclerotic and then began to fragment over a 22-month period. Computed tomography confirmed the presence of two poles of the scaphoid and sclerosis and fragmentation of the proximal pole.

David R. Boyd Lecture in Trauma Care and Emergency Medical Systems: upper extremity injuries--past, present, and future.

Since its recognition as a subspeciality soon after World War I, hand surgery has evolved into a highly specialized and sophisticated field of medicine. Enormous advances have been made in the diagnosis and treatment of disorders of the upper limb; primary tenorrhaphy and the application of microsurgical techniques for revascularization, replantation, and free tissue transfer are among the most important innovations. This article reviews the history of flexor tendon surgery and reconstructive microsurgery up to the present time, and makes some predictions for the future direction of these, and other, areas of hand surgery.

Greig cephalopolysyndactyly syndrome: altered phenotype of a microdeletion syndrome due to the presence of a cytogenetic abnormality.

A male had several features of Greig cephalopolysyndactyly syndrome (GCPS) and significant developmental delay. He was found to have a de novo chromosomal deletion of chromosome no. 7 involving p13; this resulted in loss of the zinc finger gene, GLI3, which is the candidate gene in this syndrome. Modification of the CGPS phenotype in a sporadic case emphasizes the importance of searching for a chromosomal origin of this autosomal dominant disorder. Detection of a chromosomal deletion in these patients may be associated with a poor prognosis from the standpoint of cognitive development, and the potential for other structural abnormalities not normally associated with GCPS.

The abductor digiti minimi flap: its use in revision carpal tunnel surgery.

One of the few muscles or myocutaneous flaps in the hand available to cover soft-tissue defects without compromising significantly the hand's function and appearance is the abductor digiti minimi muscle. A technique that harvests the abductor digiti minimi flap with a small skin island from the hypothenar eminence allows direct closure of the skin following ADM transposition and makes it possible to directly monitor the blood supply to the muscle. This skin island is much smaller than others previously reported.

Toe phalangeal grafts in congenital hand anomalies.

The results of 73 toe phalangeal grafts were reviewed in order to determine the effects of age and operative technique on subsequent growth of the transferred phalanx. Minimum length of follow-up care for inclusion in the study was 1 year (mean, 42 months). Physeal openness and growth of transferred phalanges were determined from standard x-ray films. Physeal openness rates were 94% for those operated on before 1 year of age, 71% for those 1-2 years of age, and 48% for those older than 2 years of age. Mean growth rates were 1.0 +/- .2 mm, 1.0 +/- 0.6 mm, and 0.5 +/- 0.5 mm per year, respectively, for these three age groups. Extraperiosteal dissection of the transferred phalanx, tendon and collateral ligament reattachment, and patient age under 12 months had a statistically beneficial effect on maintaining physeal openness.

Fingertip and nail bed injuries.

Nail bed and fingertip injuries are commonly seen in the Emergency Department. Each of these injuries must be evaluated carefully not only for the acute situation but for the possible long-term effects. Nail bed injuries must be appropriately diagnosed and treated initially because a secondary repair is often unsatisfactory. Fingertip injuries must provide the patient with a sensitive fingertip with sufficient length for effective use of the finger. The initial care and treatment are vital for the best patient outcome.

Evaluating the injured hand.

Evaluation of the injured hand is undertaken to assess an acute injury, to diagnose chronic injuries prior to reconstruction, to evaluate function, and to evaluate disability. This article discusses the special evaluation method for each of these categories.

The repair of nail deformities with the nonvascularized nail bed graft: indications and results.

Twenty-four cases of nonvascularized nail bed grafting to correct nail deformities were reviewed. The highest success rate in improving the appearance of the deformed nail, 86%, was achieved when the split-thickness nail bed graft of sterile matrix was used to correct a nail deformity caused by a sterile matrix injury; the same procedure used to correct a nail deformity caused by a germinal matrix injury had a 0% success rate. Donor site morbidity occurred in 25% of split-thickness nail bed grafts and 100% of full-thickness nail bed grafts. The split-thickness nail bed graft of sterile matrix, if used in properly selected patients, will consistently improve the appearance of the deformed nail.

Improvement in motor function after brachial plexus surgery.

Motor functional recovery of 52 patients with brachial plexus surgery followed up for more than 2 years was evaluated. Fifty-eight surgical procedures were done, including autologous nerve grafting (38 cases), neurolysis (14 cases), and neurotization (6 cases). Overall results, evaluated according to the 0 to 5 formula of the Medical Research Council, were as follows: good, 58%; fair, 15%; and poor, 27%. Good results were evident in 58% of patients with nerve grafts and in 64% of those with neurolysis. In patients with neurotization, no good recovery and only one fair recovery were seen. Patients with open injuries showed good recovery, whereas the group with closed injury showed good recovery in only 48%. Patients with closed injuries caused by traffic accidents showed a worse recovery than those caused by other means. Patients with closed injuries and nerve grafting done within 3 months of injury or neurolysis within 6 months showed better recovery.

A new dynamic splint for postoperative treatment of flexor tendon injury.

This dynamic splint lessens resistance to finger extension and increases the arc of motion through full passive flexion of the injured fingers. Rubber bands run from the tips of the injured fingers under a spring-loaded roller bar at the metacarpophalangeal joint level to a coiled lever at the distal flexor surface of the forearm. The wrist is positioned in 45 degrees of flexion with 40 degrees to full flexion of the metacarpophalangeal joints and full flexion to full extension of the interphalangeal joints. We retrospectively compared patients treated in the new and traditional splints. Patients with coexisting fractures, extensor tendon injury, and insufficient follow-up were excluded. By use of Strickland's modified criteria in evaluating 36 patients treated in the new splint, 35 of 46 fingers with zone II tendon injury (76.1%) had excellent and 11 (23.9%) had good total active motion; none had fair or poor results or ruptures. Results were significantly better than after treatment in the traditional splint.

Lateral arm composite tissue transfer to ipsilateral hand defects.

Different applications in the use of the ipsilateral lateral arm free flap in 29 patients treated in our unit from November 1983 to December 1984 are described. The flap was used in both elective and emergency reconstruction with a success rate of 96.5%. This flap is elevated from the same limb as the injured hand, permitting the entire operative procedure to be performed with the patient under a single regional block anesthesia, both flap and recipient sites being prepared synchronously in a bloodless field.

Bioprosthesis in hand surgery.

In 1965, Carpentier coined the term bioprosthesis to distinguish the characteristics of glutaraldehyde-treated porcine heart valves from untreated or synthetic valves. Observation that the valves functioned normally but were not incorporated by the host has stimulated interest in similarly preserved materials for use in hand surgery. This report outlines work that was initiated to learn the effects of glutaraldehyde treatment on tendon and a reticular substitute. In over 56 experiments with a chicken model, experience with glutaraldehyde-treated tendon grafts shows no acute rejection. There is good function clinically by 8 weeks with proximal fibrous ingrowth seen histologically. By 12 weeks, distal ingrowth has occurred. There is no ingrowth into the tendon graft within the fibro-osseous tunnel. Mechanical testing of the implant system shows a peak load at failure of 1.86 +/- 0.43 pounds and at 24 weeks it is 6.53 +/- 2.6 pounds. The failure site at time zero was distal. By 12 weeks, the distal attachment strengthened and the proximal attachment failed at a greater load. An interpositional substance with potential uses in hand surgery has been prepared by glutaraldehyde treatment of mammalian pericardium. Possible uses include interposition between fractured phalanx and the extensor tendon. This has been evaluated in feasibility studies in a rabbit model.

Evaluation of glutaraldehyde-treated tendon xenograft.

Glutaraldehyde-treated flexor tendon xenografts were implanted in 62 adult White Leghorn chickens. Animals were evaluated for implant integrity, function, mechanical tests, and histology serially to 24 weeks. Implant function improved dramatically throughout the 24 weeks. Gross examination at death showed intact proximal and distal attachments in all but two animals. The amount of fibrous ingrowth into the proximal end of the implant increased throughout the 24 weeks. Distal fibrous ingrowth also occurred, but at a slower rate. At no point was lateral ingrowth into the tendon seen within the fibro-osseous tunnel. Excision of the sheath and pulley system significantly limited tendon gliding by allowing vigorous formation of adhesions. Mechanical testing revealed that the distal attachment strengthened with time and that the proximal attachment became the failure point. Glutaraldehyde-treated mammalian tendon xenografts allow for fibrous ingrowth and may become incorporated by the host. In this animal model, it has allowed the xenograft to function as a tendon graft. Further studies are planned before clinical trials are undertaken.

Hemangioma of the median nerve: a report of two cases.

Two cases of intraneural hemangiomas are described. Both lesions produced compression of the median nerve and required multiple excisions. In one case, interfascicular nerve dissection failed to produce a cure, while the other patient remains free of recurrence after excision of the involved median nerve and sural nerve grafting.

Management of acute flexor tendon injuries in the hand.

Success in treatment of acute flexor tendon injury demands careful assessment of the wound and patient, thorough knowledge of the relevant anatomy and physiology of tendons and tendon healing, meticulous and gentle surgical technique, and careful supervision during a controlled postoperative exercise program. With conscientious attention to the principles and techniques outlined, most complications can be minimized and a good clinical outcome can be achieved.

Perichondrial resurfacing arthroplasty in the hand.

A retrospective study of 36 perichondrial resurfacing arthroplasties, 16 metacarpophalangeal (MP) joints, and 20 proximal interphalangeal (PIP) joints with a minimum follow-up of 3 years was conducted to further define indication and contraindication of this procedure. The overall results for MP joints were 56% good, 25% fair, and 19% revision, and for PIP joints, 55% good, 15% fair, and 30% revision. All arthroplasties for healed pyarthrosis failed. Concomitant tendon repair was a cofactor in the high failure rate. Patient age had a direct influence on the outcome of the arthroplasty. In MP joint arthroplasties, 100% of patients in their 20s had good results and 75% in their 30s had good results. In PIP joint arthroplasties, 75% of patients in their teens and 66% in their 20s had good results. Good results were not recorded in MP or PIP joints for patients older than 40 years of age. Perichondrial resurfacing arthroplasty should be considered contraindicated in the treatment of arthropathies resulting from healed pyarthrosis, systemic diseases with joint involvement, concomitant tendon reconstruction, and age over 40 years. The procedure is indicated and can be utilized in the treatment of traumatic arthritis of the MP and PIP joints of the hand in young individuals.

Current state of flexor tendon surgery.

Successful restoration of function after flexor tendon injuries continues to present a challenge to the treating surgeon. Primary repair of tendon and associated injuries is the treatment of choice in clean wounds in all zones of the hand. In cases of untidy wounds or when associated injuries preclude primary repair, delayed primary or secondary repair may be performed. Tendon grafting in one or two stages is reserved for late secondary cases in which scarring of the bed, loss of pulleys, permanent retraction of the tendon ends, or joint contractures prevent direct repair. Meticulous attention to detail such as adequate exposure, careful opening and closing of the sheath, gentle handling of the tendons, a secure, smooth tendon juncture and proper postoperative splinting is essential for a successful outcome of direct repair. Tendon grafts done as a secondary procedure require the same attention to minutiae for an adequate functional outcome.