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This paper describes and discusses some of the clinical applications of the posterior interosseous forearm flap in hand reconstruction, including the fact that larger areas of skin than previously reported can be used safely. It is based on a series of 21 patients, 50 anatomical dissections and 10 injection studies.
Devastating hand injuries often require multiple microvascular reconstructions. We report a patient in whom two flaps were used for late reconstruction of a devastating hand injury involving devascularization of the right hand, severely comminuted fractures of the hand and forearm, and multiple tendon avulsions. We believe the sequential vascular connection of free flaps offers the best method of reconstruction in this severe case, allowing composite tissue transfer, monitoring of the osseous flap, and optimal positioning of the two free tissue transfers.
The manifestations of injuries caused by wringer washing machines were examined in 24 children with a total of 26 injured extremities. The extent of injury was almost always determined at admission and delays of four hours or more from injury resulted in longer hospitalization. The majority of the injuries were minor, but 11% of the injured limbs had skin loss necessitating skin grafting and one patient had progressive vascular compression necessitating fasciotomy. Compression was used as treatment in 23% of the cases. The standards of therapy continue to be antiseptic wound care, elevation, and early coverage of areas of skin loss. The use of compression could not be shown to be either beneficial or harmful.
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PURPOSE OF THE STUDY: Epicondylalgia is a frequent condition although the cause and appropriate treatment remain a subject of debate. We present our experience with surgical treatment based on the hypothesis that the condition results from excessive tension on the deep aponeurosis of the carpal and digital extensors. MATERIAL AND METHODS: Between 1996 and 1998, sixteen patients underwent surgical treatment of epicondylalgia unresponsive to medical treatment. There were six men and ten women, men age 43 years, two underwent bilateral procedures. The dominant side was involved in 75% of the cases. For ten patients, heavy manual work led to epicondylalgia. For two others it was related to sports activities. Mean duration of medical treatment prior to surgery was 16 months. A double deep transverse fasciotomy of the extensor carpi radialis brevis (ECRB) was performed in all cases, alone for 3, and associated with section of the Fröhse arcade in 5, supinator fasciotomy in 9, and complete section of the superficial head of the supinator in 4. For five recent cases, double fasciotomy of the extensor digitorum communis (EDC) was also performed. The epicondyle was left intact as were all tendons. All patients were reviewed at a mean 20 months. The Roles and Maudsley classification was recorded. Motor force was measured comparatively with a Jamar dynometer. RESULTS: Outcome was excellent in 7 cases, good in 7 and acceptable in 4. All patients improved. Outcome was excellent in 2 cases and fair in 3 cases with double fasciotomy of the EDC. The period of work loss was 3 months on the average. Forty-six percent of the patients resumed their former activity at 6 weeks. Muscle force was globally reduced 21.5% compared with the contralateral side (range 0-60%). DISCUSSION: This surgical technique is based on the hypothesis that epicondylalgia results from excessive tension on the epicondylar area leading to enthesitis or aponeuritis, or both. Deep fasciotomy allowed distension and clinical improvement in all cases. Associated deep fasciotomy of the EDC in addition to the transverse fasciotomy of the ECRB and supinator appears to improve functional outcome.
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A forearm flap based on radial artery (Chinese Flap) is one of the most often used flaps in reconstruction of posttraumatic tissue defects within upper extremity. It may be used as free flap or pediculated one. Long vascular pedicle allows easy transposition of the flap within upper extremity. Microsurgical techniques do not have to be employed. Flap anatomy enables one stage reconstruction of majority of posttraumatic defects both during acute or planned operations. The material includes 10 patients. Satisfactory functional results have been achieved in all cases.
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The incidence of various fractures resulting from falls onto the outstretched hand in a Transkeian population was compared to that in a British population. Large differences were found, fractures of the distal humerus being much more common in Transkei, as were 'juvenile Colles' ' fractures. Fractures of the clavicle and radial head were correspondingly less common and fractures of the scaphoid were not seen in Transkei. Possible reasons for these differences are discussed.
Although upper-extremity injuries alone are usually not life-threatening, they can produce significant immediate or long-term morbidity, especially if there is an associated nerve injury. The diagnosis of an arterial injury may be readily apparent, but the excellent upper-extremity collateral circulation may create palpable distal pulses despite a significant proximal arterial injury. Therefore, a high index of suspicion and the liberal use of arteriography are necessary to avoid missing these injuries. Compression of the brachial plexus by a hematoma can produce a serious neurologic deficit. Prompt evacuation of the hematoma may significantly reduce the deficit, another fact that supports an aggressive surgical approach in these patients. The long-term results of upper-extremity vascular injuries are usually determined by the extent of any associated nerve injuries.
BACKGROUND: Hypothenar hammer syndrome (HHS) is a cause of vascular insufficiency to the hand and may be manifest as Raynaud's phenomenon. The cause is trauma to the vulnerable portion of the ulnar artery as it passes over the hamate bone, which may result in thrombosis, irregularity or aneurysm formation. AIM: This review was undertaken in order to clarify the features of HHS that may differentiate it from hand-arm vibration syndrome. METHODS: A tiered review of world literature was undertaken using Medline and EMBase as the primary search engines. Fifty-two relevant articles were critically reviewed. CONCLUSION: Colour and temperature changes occur more diffusely in HHS than in classical Raynaud's phenomenon and the absence of the triphasic colour change may alert clinicians to the diagnosis, which may be confirmed by Allen's test. Doppler or arteriographic studies are required for confirmation. It is important to recognize the possibility of HHS in the occupational setting as a potentially curable cause of Raynaud's phenomenon, distinct from hand-arm vibration syndrome. The possibility exists of HHS occurring as a result of repeated hypothenar trauma from vibrating tools, in which case the nature and magnitude of the individual episode of trauma may be more important than the weighted acceleration level of vibration exposure.
The authors illustrate an original method of osteosynthesis concerning shaft fractures in children: Stable Elastic Nailing. They elaborate the physiopathological basis and specify all details of this technique. The results of this treatment as well as its limits are considered through personal experience of 217 femurs, 42 tibias, 36 humerus, 84 fore-arms and 96 supracondylar fractures of the humerus. We essentially proceeded for a comparative analysis with other methods of osteosynthesis or conservative treatment, illustrating the net superiority of stable elastic nailing in their indications according to the recommended technique.
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Twenty-four cases of complex trauma of the upper limb, with soft tissue damage including at least loss of part of an artery and the overlying skin, were recorded and treated in the Hand Emergency Unit at the Timone Hospital in Marseilles. These cases were dealt with globally in a single staged operation with careful wound care, bone stabilisation when this was deemed necessary, arterial shunt and repair of the soft tissues. To cover the exposed arterial shunt, the choice of coverage technique depends on the site of the lesion, on the extent of soft tissue damage, and also on the reliability of the flap and its residual scar. The authors analyse their series and present their indications.