Delayed treatment of persistent radial nerve paralysis associated with fractures of the middle third of humerus: review and evaluation of the long-term results of 52 cases.

This study was undertaken to determine the efficacy of delayed surgical treatment in cases of persistent radial nerve paralysis after fractures of the middle third of the humerus. We have limited this study to patients who had absolutely no functional recovery of the radial nerve 3 to 4 months after middle third humeral fractures. The fractures were treated by a variety of orthopaedic methods, conservative and surgical, in other departments and hospitals. Surgical exploration of the radial nerve was carried out 3 to 4 months after primary orthopaedic treatment. The outcome of this study concurs with data in the literature in showing that delayed nerve surgery (neurolysis or nerve grafts) in the absence of functional recovery of the radial nerve after humeral fracture can be useful in achieving good functional recovery and subjectively satisfying results.

Replantation of large segments in children.

If one looks at the final results obtained in children, one should conclude that replantation of large segments is more often indicated in children than in adult patients. Nevertheless, the more common components of crush or avulsion and the frequent severe associated lesions must restrain the surgeon's enthusiasm when indicating replantation of a large segment in children. The possible dramatic consequences of a late revascularization syndrome can be easily foreseen as an outcome of replantation of a large segment in children. Moreover, the problem of growth must be faced from the start, programming secondary surgery either for soft tissue assessment (skin retraction treatments, tendon lengthening, muscle sliding) or for bone lengthening. The final outcome being a functional arm, special care has to be taken in nerve repair integrated with possible secondary tendon transfers to compensate the functional deficit. With all these limitations in indications, care in emergency, and correct timing and planning for secondary surgery, the final functional results of macroreplantations in children will certainly be improved.

A new prosthesis for the metacarpophalangeal joint. Study of materials and biomechanics.

This report discusses the Daphne prosthesis for the metacarpophalangeal joint on the basis of the mechanical, chemical and biological performance of the materials employed. The Daphne prosthesis is a mobile device. The main body is made of a new generation polymethylmetacrylate, while the hinge is made of AISI 316 L stainless steel. Biocompatibility tests were performed on the materials employed. Systemic toxicity, cytotoxicity and contact tests have given favourable results. Mechanical engineering tests have been used to investigate the performances and reliability of the selected materials. The polymethylmetacrylate used in Daphne behaves in a ductile fashion. No mechanical failures were encountered in fatigue tests after 10 million cycles.

Radial forearm fasciocutaneous free flap as a solution in case of Noma.

The authors describe a case of Noma or Cancrum Oris, an oral gangrenous disease, features more frequently found in children from developing countries. The clinical features, its ethiopathogenesis, and its particular link with different geographic and economic areas of the world, its clinical evolution as well as surgical treatment are all discussed. Underlined is the functional and organic aspect of this disease, in particular the distortion of the face, which commonly involves the full thickness of the cheek skin and bone, mandibular ankylosis and craniofacial dismorphisms, and the modern approach in reconstructive microsurgery. The authors report a case of a patient affected by Noma, with a very evident left face dismorphism, where we found a brilliant solution using a left radial forearm fasciocutaneous free flap, appropriately shaped.

Idiopathic tumoral calcinosis associated with congenital malformation of the hand. Case report.

The authors describe a case of tumoral calcinosis of the hand in a three-year-old child, involving the digits and carpus, and associated with ectrodactyly. The clinical features, diagnostic imaging procedures, particularly radiography and MRI, and therapeutic approach, in most cases radical excision, of this rare soft tissue tumour are discussed.

The treatment of chronic flexion contractures of the proximal interphalangeal joint.

A method of treatment of chronic flexion contractures of the PIP joint is presented, with the results obtained in 19 patients treated between 1989 and 1992 after a follow-up of from 6 to 53 months. The flexion contractures, with an extension deficit which ranged between 70 and 90 degrees, had been present for a period of between 2 months and 24 years. Our treatment program involves the surgical release of the unreducible PIP joint followed by the use of static and/or dynamic splints. Surgery is performed using a midlateral approach; the accessory collateral ligament and the flexor sheath are incised and, after the volar plate and check-rein ligaments have been excised, forced hyperextension is applied. The main collateral ligaments are carefully spared and freed from the condyle if there are any remaining adhesions. In our 19 patients, complete extension of the finger was achieved in 11 cases (57.9%); in the remaining 8 cases (42.1%) the residual extension deficit ranges from 10 to 15 degrees. In our experience this combined surgical and rehabilitative approach had led to consistently good results with minimal complications.

Reverse dorsal digital island flap.

The anatomic and clinical bases for a reliable and versatile homodigital flap for covering difficult distal dorsal and dorsolateral wounds of the long fingers are presented. This one-step procedure, which uses the dorsal skin of the first or second phalanx transposed as a reverse island flap, preserving the collateral nerve and artery to the fingertip, has proved valuable in salvaging the severely injured digits of nine patients (for a total of 12 flaps). It would seem to be a relatively simple way of achieving early recovery because it does not require distant flap reconstruction, the immobilization of adjacent digits, or homodigital flaps that might jeopardize an already injured finger. Furthermore, it reduces the time of hospitalization and improves patient welfare.