Results after replantation and revascularization in the upper extremity in children.

The rates of survival of the amputated part and the functional outcomes were studied retrospectively after seventy-three replantations and eighty-nine revascularizations in the upper extremity in 120 children. All operations were performed between January 1974 and December 1988 after partial and complete amputations at various levels. The ages of the patients ranged from three days to sixteen years. The average duration of follow-up was thirty-six months (range, fourteen months to seven years) for the patients who had had a replantation and thirty months (range, fourteen months to eight years) for the patients who had had a revascularization. The rate of survival of the amputated part was significantly higher (p < 0.0002) after revascularization (seventy-eight parts [88 per cent]) than after replantation (forty-six parts [63 per cent]). There was no association, for either group, between survival and the preoperative duration of ischemia, the level of the injury, the digit that had been injured, the number of arteries that had been repaired, or the use of venous grafts. The rate of survival after replantation of completely amputated parts was 72 per cent (twenty-eight of thirty-nine parts) when the amputation had resulted from a laceration injury and 53 per cent (eighteen of thirty-four parts) when the amputation had resulted from a crush or an avulsion injury. The rate of survival after revascularization of incompletely amputated parts was 100 per cent (all forty-five parts) when the injury had been the result of a laceration and 75 per cent (thirty-three of forty-four parts) when it had been the result of a crush or an avulsion. We did not find any relationship between the age of the patient and the rate of survival of the amputated part after revascularization; however, there was a significantly higher rate of survival (p , 0.02) after replantation in children who were less than nine years old (77 per cent [twenty-four of thirty-one parts]) compared with the rate in those who were nine to sixteen years old (52 per cent [twenty-two of forty-two parts]). The viability of the digit was in jeopardy after twenty-nine (40 per cent) of the seventy-three replantations and nineteen (21 per cent) of the eighty-nine revascularizations. Immediate reoperation resulted in the salvage of only two of the twenty-one replanted parts and six of the twelve revascularized parts that had a reoperation.(ABSTRACT TRUNCATED AT 400 WORDS)

Biomechanical analysis of the effectiveness of in-line skating wrist guards for preventing wrist fractures.

The purpose of this investigation was to determine the effectiveness of commercially available wrist guards in preventing wrist fractures. Forty arms were harvested from 20 cadaveric specimens. The forearms from each cadaver, one with a wrist guard and one without a wrist guard, were then fractured using an instron Servohydraulic Material Testing System. The group of forearms tested to failure without wrist guards failed at an average force of 2245 N, while the group tested with wrist guards fractured at an average force of 2285 N, revealing no statistical difference. Similarly, observed fracture patterns were not noted to be different in the two groups. The in-line skating wrist guards tested were not effective in preventing wrist fractures under the experimental conditions of our study.

Synovial chondromatosis in the radiocarpal joint.

A rare case of synovial chondromatosis involving the radiocarpal joint is described. Histologic examination revealed a cartilaginous loose body and mildly inflamed synovium. Histologic differentiation of this condition from synovial chondrosarcoma can be difficult because of the frequent finding of nuclear atypia. Surgical excision is recommended.

Distal ulna resection, extensor carpi ulnaris tenodesis, and dorsal synovectomy for the rheumatoid wrist.

We conclude from this study that distal ulna resection coupled with stabilization by ECU tenodesis is a highly useful technique with a reproducibly successful outcome for DRUJ destruction resulting from rheumatoid arthritis. In this series, like those noted previously, alleviation of pain, preservation of wrist mobility, prevention of tendon rupture, and improved function have been consistently observed. Moreover, with adjunctive dorsal synovectomy this combined procedure has proved applicable to cases demonstrating not only mild but also moderate stages of radiocarpal disease, thereby avoiding the more extensive and less desirable surgical alternatives of complete wrist arthrodesis or total wrist arthroplasty. Recognizably, the long-term benefit of this surgery depends on maintaining stability of both the reconstructed radioulnar joint and the synovectomized radiocarpal joint. Although the data reported herein strongly support the efficacy of the tenodesis in preserving distal ulna stability and similarly indicate a favorable influence on maintenance of radiocarpal architecture, one must be cognizant that progressive radiocarpal deterioration is a characteristic, albeit somewhat unpredictable, manifestation of the chronic rheumatoid process, and is the principal factor apt to compromise an initially satisfactory result. In such cases demonstrating excessive carpal malalignment preoperatively and for those with an unremitting postoperative course of ulnar translocation or volar subluxation, additional radiocarpal stabilization, preferably by arthrodesis, is essential to salvage the benefits of distal ulna resection and ECU tenodesis.

Complications of common carpal injuries.

Interest in the diagnosis and treatment of common disorders of the carpus has intensified in recent years. Although newer nonoperative and surgical procedures have developed to improve outcome, complications and their treatment remain a challenging problem. To address complications of the more common carpal injuries, we have chosen fractures of the scaphoid, scapholunate ligament injuries, carpal fracture dislocations, and fractures of the hook of the hamate for discussion.

Complications of flexor tendon injuries.

Despite the many advances in the surgical and rehabilitative management of flexor tendon injuries, problems of adhesion, contracture, and rupture continue to limit the restoration of function in a significant number of cases. This article reviews the most frequent complications after flexor tendon injuries. The treatment options for these problems, including the authors' methods of choice, are discussed.

Lunotriquetral injuries in the athlete.

The athlete with an LT injury typically presents with ulnar-sided wrist pain after a high-energy impaction of the wrist. Reagan's LT ballottement test and Kleinman's shear test help the examiner identify these injuries. A thorough radiographic examination includes standard PA and lateral radiographs. Magnetic resonance imaging or arthrography can be performed, but the sensitivity of these imaging studies varies. The palmar portion of the LT interosseous ligament, dorsal radiocarpal ligament, and dorsal intercarpal ligament play the most significant roles in LT stability. Lunotriquetral injuries without instability respond well to immobilization. Arthroscopy is valuable in staging and determining treatment but requires a thorough radiocarpal and midcarpal examination. Acute LT injuries with instability are treated with arthroscopic-assisted reduction and pinning. If desired, this procedure can be incorporated with an open ligament repair through a volar approach. Chronic LT tears without instability can also be treated arthroscopically. Treatment of the chronic LT tear with instability depends on the degree of collapse. Treatment in the athlete includes ligament reconstruction with capsulodesis or, rarely, intercarpal LT arthrodesis.

Percutaneous and arthroscopic screw fixation of scaphoid fractures in the athlete.

The authors prefer to treat nondisplaced acute scaphoid fractures in the athlete on an individualized basis. Percutaneous or arthroscopic-assisted fixation are valuable techniques to employ when prolonged immobilization is a concern. Return to athletic competition has been rapid using these methods. Morbidity has been minimal, and there have been no nonunions to date at the authors' institution.

Compartment syndrome of the leg after plantaris tendon harvest: a case report.

A case of lower extremity compartment syndrome following plantaris tendon harvest for use as an upper extremity tendon graft is described. Compartment syndrome seems to be a rare complication after plantaris harvest, but expedient management is required to avert adverse sequelae. Exploration of the course of the plantaris tendon may be a viable alternative to the traditional lateral approach in attempting to reverse the condition.

Continuous peripheral nerve block in replantation and revascularization.

Continuous infusion of a local anesthetic by means of a percutaneous forearm catheter and an infusion pump was studied for its utility in achieving sympathetic blockade following replantation and revascularization of the digits. The efficacy of the technique was demonstrated by cold stress testing. When the technique was used in 55 patients who underwent digital replantation or revascularization, 53 of 57 replanted digits (93 percent) and 25 of 26 revascularized digits (96 percent) survived. The analgesia obtained from the nerve block benefited patient comfort during hospitalization, and normal sensibility in the uninjured digits returned promptly after discontinuing the anesthetic in all but one patient. The reported study indicates that continuous peripheral nerve block by means of an indwelling forearm catheter is a safe and effective adjunct in preventing neurogenically-mediated vasospasm.

The effect of ice application versus controlled cold therapy on skin temperature when used with postoperative bulky hand and wrist dressings: a preliminary study.

Skin temperature of the hands of 12 volunteers was monitored. The hands were placed in bulky dressings and treated with a standard ice bag (group I) or a new cooling blanket (group II). The contralateral hands served as controls. The mean difference in skin temperatures between group I and controls was 1.5 degrees F, while the difference between group II and controls was 13 degrees F. Temperatures of the controls did not decrease with time. Newer cooling devices appear to be more efficacious than standard ice bags in accurately and significantly lowering skin temperature when used with traditional bulky hand dressings.

Treatment of flexor tendon injuries: surgeons' perspective.

Medical researchers continue to explore the flexor tendon's response to injury and repair. In recent years, hand surgery and therapy publications have focused on the biomechanics of suture techniques and the benefits of early postoperative motion on surgically repaired flexor tendons. Laboratory and clinical studies have shown that stronger suture techniques can withstand the strain of immediate active motion without a significant risk of tendon rupture or gap formation. Newly proposed therapy techniques and anatomic studies defining the effects of wrist and digital position on tendon excursion share the goals of achieving early motion and reducing restrictive adhesions. Clinical studies have evaluated the various imaging modalities used to diagnose postoperative adhesions. Other clinical surveys have detailed the use of pedicled autograft and allograft tendons in staged reconstruction. Histologic and immunologic researchers have concentrated on cellular activation patterns following tendon injury and the effects of pharmacologic agents, such as hyaluronan and aprotinin, on tendon healing and adhesion formation.

Left-hand dominance and hand trauma.

To investigate the relationship between hand dominance and the risk of major hand injury, the case records of 125 patients who had been treated for digital amputation were retrospectively reviewed. A second group of 116 patients treated for minor hand trauma was similarly evaluated. The incidence of left-hand dominance among the digital amputation group was 35%, and among the minor trauma group the incidence was 11%. The left-handed were more likely to have an amputating injury of their dominant hand than were the right-handed (70% compared with 51%, respectively). The most common mechanism of amputating injury was by power saw. The present data suggest that left-handed individuals have a relative risk of sustaining an amputating injury that is 4.9 times greater than the right-handed individuals, while minor hand trauma occurs at rates proportional to the distribution of left handedness within the population. Additional safety measures and the redesigning of tools, assembly lines, and workstations are recommended to help decrease the incidence of serious hand injury among left-handed individuals.

Evaluation of suture caliber in flexor tendon repair.

This biomechanical study investigated the effect of suture caliber variation on tensile strength in 3 types of 2-strand flexor tendon repairs. Each type of repair was constructed with 5-0, 4-0, 3-0, and 2-0 braided polyester suture. Linear distraction was performed on 120 repaired human cadaveric flexor digitorum profundus tendons until tensile failure occurred. Ten trials of each repair construct were tested. Analysis of variance revealed significant main effects of caliber and technique. Mean repair strength increased as suture caliber increased. A 4-0 suture was 66% stronger than a 5-0 suture, a 3-0 suture was 52% stronger than a 4-0 suture, and a 2-0 suture was 51% stronger than a 3-0 suture. The technique effected repair strength only with the larger 2-0 and 3-0 suture calibers, which tested the technique's capacity to hold the tendon.

Corticosteroid injections for trigger digits: is intrasheath injection necessary?

Ninety-five patients with 107 trigger digits were divided into 2 groups and studied prospectively to evaluate steroid injection placement and efficacy. In 1 group, an attempt was made to deliver 1 injection into the tendon sheath at the A1 pulley. In the other group, 1 injection infiltrated the subcutaneous tissues overlying the A1 pulley. Radiopaque dye provided contrast to the injection medium, and postinjection x-rays identified the true delivery site of the steroid solution. Of the 52 digits into which intrasheath injection was attempted, 19 digits (37%) received all the injection within the sheath, 24 (46%) received medication into both the sheath and the subcutaneous tissues, and 9 (17%) received no medication within the tendon sheath. The results were analyzed to determine whether injection placement influences the efficacy of steroid injection. The confirmed all-sheath injection group exhibited a 47% good response, the mixed sheath and subcutaneous group had a 50% good response, and the all-subcutaneous group had a 70% good response. The results of this study suggest that true intrasheath injection offers no apparent advantage over subcutaneous injection in the treatment of trigger digits.

Replantation in children.

The authors have replanted 162 parts in 120 children over the past 15 years. The youngest patient, undergoing successful replantation, was aged 7 months, 3 weeks. Unlike an adult, any child suffering a traumatic amputation should be considered for a possible replantation. Replantation should consist of minimal bone shortening to preserve epiphyseal plates, with repair of all severed structures. Longitudinal K-wires usually provide adequate fixation. Our survival rate for complete replantation in children under the age of 16 years is 77%. Long-term study showed that continued skeletal growth occurred and the digit attained 81% of normal longitudinal length at maturity. Recovery of sensibility in the replanted digit is nearly as good as for isolated digital nerve repair. Patient and parent satisfaction is high when replantation is successful, with uniform approval of the extensive effort required.