Love thy neighbour--a case report of fingertip necrosis following neighbour strapping.
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Adult↗
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Central slip tenotomy for the treatment of chronic mallet finger: an anatomic study.
PURPOSE: Tenotomy of the central slip, described by Fowler, can clinically improve chronic distal interphalangeal joint (DIP) extensor lag secondary to mallet finger (terminal tendon disruption). The goal of this study is to evaluate the potential of central slip tenotomy to restore DIP joint extension. METHODS: A mallet deformity was reproduced in 15 fresh-frozen cadaver fingers after the extensor tendon insertion was sectioned over the DIP joint. A suture anchor inserted at the terminal insertion was then secured to the extensor tendon over the middle phalanx to reconstruct the extensor mechanism. A 500-g weight attached to the proximal extensor tendon applied extensor tension. Central slip tenotomy was then performed. DIP extensor lags before and after tenotomy were recorded. RESULTS: After sectioning of the terminal tendon over the DIP joint the average amount of extensor tendon lag produced was 45 degrees. After central slip tenotomy was performed the average amount of extensor lag correction was 36 degrees (range, 30 degrees-46 degrees). CONCLUSIONS: Several clinical studies have shown that central slip tenotomy is an effective treatment for chronic mallet finger but may not fully restore DIP joint extension. Our data suggest that patients with a pre-existing extensor lag of greater than 36 degrees may not achieve full extension from central slip tenotomy, although extensor lags of up to 46 degrees may be corrected.
Adult↗
Extensor mechanism slide for the treatment of proximal interphalangeal joint extension lag: an anatomic study.
PURPOSE: We describe a technique for correction of proximal interphalangeal joint (PIP) extensor lag secondary to angulation and/or shortening of proximal phalanx fractures. METHODS: Proximal phalanx fracture malunions with 2.5 mm of shortening, 5.0 mm of shortening, and apex volar angulation of 40 degrees were simulated in 15 cadaver fingers, creating PIP extensor lags. The metacarpophalangeal (MCP) joint was pinned in neutral. Transection of the ulnar and radial sagittal bands, the extensor digitorum communis (EDC) insertion on the MCP joint capsule, and the juncturae tendinae then was performed. The PIP extensor lag before and after each of the earlier-noted releases was recorded. The MCP joint then was freed and MCP hyperextension was recorded. With the MCP joint in neutral position the sagittal bands then were reapproximated with sutures and MCP extension was measured. RESULTS: The 2.5 mm of axial shortening, 5.0 mm of axial shortening, and 40 degrees of apex volar angulation fracture models produced an average extensor lag of 6.2 degrees , 25.8 degrees , and 42.5 degrees , respectively. Maximal correction of PIP extensor lag required transection of both sagittal bands, EDC insertion on the MCP capsule, and the juncturae tendinae with an average residual extensor lag of -0.8 degrees for the 2.5-mm shortening model, 0.7 degrees for the 5.0-mm shortening model, and 3.2 degrees for the 40 degrees -angulation model. The MCP joint hyperextension increased by 20 degrees to 30 degrees after the releases but decreased to only 1.8 degrees if the sagittal bands were reapproximated to the EDC tendon at their new resting position with the MCP joint in neutral position. CONCLUSIONS: In the cadaver model the PIP extensor lag can be improved substantially by transection of the sagittal bands, release of the EDC insertion on the MCP capsule, transection of the juncturae tendinae, and reapproximation of the sagittal bands to the EDC tendon.
Aged↗
Innervated reverse island flap based on the end dorsal branch of the digital artery: surgical technique.
Fingertip or pulp loss of the fingers is observed frequently in unskilled workers. To reconstruct a sensate fingertip or pulp we designed the innervated reverse island flap based on the end dorsal branch of the digital artery, which was harvested from the dorsum of the middle phalanx. The sensation of the fingertip or pulp was re-established through coaptation of the proper branches of the digital dorsal nerves to the digital nerves. Three fingertip or pulp defects were reconstructed with this technique. All patients achieved satisfactory functional and cosmetic results. The mean follow-up time was 7.7 months. The average size of the flaps was 1.6 x 1.8 cm. The average static 2-point discrimination and moving 2-point discrimination of the flaps were 4.6 mm and 3.0 mm, respectively. The technique we applied seems to be an excellent option for 1-stage reconstruction of fingertip or pulp defects.
Adolescent↗
Innervated reverse dorsal digital island flap for fingertip reconstruction.
PURPOSE: Various methods of fingertip reconstruction with a sensory flap have been reported. Digital island flaps or cross-finger flaps have to be used for large defects; however, the digital artery is sacrificed when creating conventional homodigital island flaps and 2 surgeries are required for the cross-finger flap. We describe our experience with an innervated reverse dorsal digital island flap that does not require sacrifice of the digital artery. METHODS: We used innervated reverse dorsal digital flaps for fingertip reconstruction in 8 patients. The flap was supplied by the vascular network between the dorsal digital artery (the terminal branch of the dorsal metacarpal artery) and the dorsal branch of the digital artery. Venous drainage was through the cutaneous veins and the venous network associated with the dorsal arterial network. The flap was designed on either the dorsal proximal or the dorsal middle phalangeal region. The flap was harvested with the dorsal branch of the digital nerve (for the dorsal middle phalanx), the dorsal digital nerve (for the dorsal proximal phalanx), or the superficial branch of the radial nerve (for the thumb), which was anastomosed to the distal end of the digital nerve. After flap transfer the donor site was covered with a full-thickness skin graft. RESULTS: Of the 8 flaps, 6 survived completely, 1 had partial epithelial skin necrosis, and 1 showed central compression skin necrosis. Three flaps showed congestive changes from the first to the fifth day after surgery, which resolved by massage. All patients achieved satisfactory recovery of sensation; the static 2-point discrimination ranged from 3 mm to 5 mm and the Semmes-Weinstein test results ranged from 0.036 g to 0.745 g. CONCLUSIONS: The innervated reverse dorsal digital island flap provides another option for homodigital tip coverage. The advantages are that the digital artery is not sacrificed and only 1 surgery is needed. A disadvantage is the potential for venous congestion for the first 4 or 5 days after surgery.
Adult↗
Vascularized bone blocks from the toe phalanx to solve complex intercalated defects in the fingers.
PURPOSE: Vascularized bone transplants resist infection and allow rapid healing but keeping small bony segments vascularized, as needed for a finger defect, is a challenge. The purpose of this article is to present a cohort of patients with traumatic intercalated compound bony defects in the fingers that were reconstructed by a vascularized toe phalanx (or part of a phalanx) in a single stage. METHODS: Eight patients were treated with an intercalary vascularized bone graft that included a part of the proximal phalanx (3 patients), most of the middle phalanx (4 patients), or a portion of each phalanx (1 patient) of a second toe (totaling 9 bone blocks). There was an associated soft-tissue defect in each patient, an infection in 6 patients, and cartilage loss in 4 patients. The toes were pedicled on the proper digital artery (6 patients) or a segment of the first dorsal metatarsal artery (2 patients). A mean length of 12 mm of vascularized bone was transferred. The associated skin island varied from a minimum of 2 x 1 cm to a maximum of 5 x 3 cm. Bleeding from all of the bone surfaces was evidenced once the clamps were released. The homolateral digital nerve and the contralateral neurovascular pedicle of the toe were kept in place. The toe defect was treated by soft-tissue arthroplasty or arthrodesis. No toe was amputated. RESULTS: Radiologic bony union was evident at 4 to 6 weeks, except in 1 patient with an acute infection whose distal union failed to unite at 6 weeks because the infection recurred. Finger length loss averaged 3 mm. All patients returned to their preoperative occupation. CONCLUSIONS: In this group of patients the toe phalanx reliably maintained its vascularization, allowing us to solve compound osteocutaneous defects in the fingers in a single stage. Donor site morbidity was minimal.
Adult↗
Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations.
PURPOSE: Surgical intervention may be necessary to treat unstable dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint of the hand. One method of stabilization is open reduction and internal fixation (ORIF). The purpose of this study was to assess the outcomes of ORIF for unstable dorsal fracture-dislocations of the PIP joint using mini-screws via a volar approach. METHODS: A retrospective chart review with clinical follow-up evaluation was performed on 9 patients who had ORIF for unstable dorsal fracture-dislocations of the PIP joint. The fracture fragment(s) from the middle phalangeal base were reduced and secured using mini-screws. RESULTS: A clinical evaluation was performed at an average of 42 months after surgery. The average arc of motion for the involved PIP joint was 70 degrees (range, 55 degrees -90 degrees ). The average PIP joint motion in the 2 patients with 1 fracture fragment was 85 degrees , and the average PIP joint motion for the remaining 7 patients was 65 degrees . One joint was subluxated with an intra-articular screw. Nine patients had an average flexion contracture of 14 degrees . Seven patients had no pain, and 2 had pain only with heavy activity. CONCLUSIONS: Open reduction and internal fixation of unstable dorsal PIP joint fracture-dislocations using mini-screws can be considered if the fracture fragment(s) can accommodate the screws. The procedure attempts to restore the concave contour of the middle phalangeal base and permits early protected range of motion. The procedure should be approached cautiously, especially in the presence of comminution. Proximal interphalangeal joint range of motion is usually compromised; 8 of our 9 joints had a residual flexion contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.
Activities of Daily Living↗
The multiple monoblock toe-to-hand transfer in digital reconstruction. a report of ten cases.
Ten hands with multiple traumatic finger amputations or congenital agenesis underwent reconstruction by monoblock transfer of multiple toes. Eight patients underwent monoblock transfer of the great and second toes, one patient received the great toe and the metatarsophalangeal joint from the second toe with the same vascular pedicle, and another patient the great, second and third toes as a block. Only part of the great toe was ever taken, while the second toe was totally or partially taken. The surgical technique and the outcome are detailed in this work, with a mean postoperative follow-up of 6 years.
Adolescent↗
Prostacyclin analogue (beraprost) relief of cold intolerance after digital replantation and revascularization.
Cold intolerance frequently occurs after successful digital revascularization and replantation. A series of 11 patients with cold intolerance 6 to 24 months after digital revascularization/replantation were treated daily for 2 weeks with beraprost, a stable prostacyclin analogue. That pain was reduced in 9 of 11 cases after treatment and digital thermography showed significantly increased surface temperature after the 2-week course of beraprost. These findings support the use of beraprost to relieve symptoms of cold intolerance under these clinical conditions.
Adult↗
External fixation of closed metacarpal and phalangeal fractures of digits. A prospective study of one hundred consecutive patients.
Stable and undisplaced phalangeal and metacarpal fractures treated with strapping or functional splinting and controlled active exercises offer from about 70 to 80% of good results. The goal of treatment of closed unstable and displaced fractures should be to achieve similar or better outcome. External fixation combines the simplicity of time-honoured fixation with K-wires and an external frame to increase rigidity. This combination was used in a prospective study of 100 consecutive patients with closed fractures of the proximal and middle phalanges and the distal three-quarters of the metacarpal bones. Good clinical results (TAM > or = 230 degrees) were obtained in 76% of isolated phalangeal fractures, in all metacarpal fractures and in 89% of multiple fractures.
Adolescent↗
The S-Quattro in the management of acute intraarticular phalangeal fractures of the hand.
Intraarticular phalangeal fractures of the hand are difficult and challenging to manage. Dynamic external fixation devices offer the advantages of allowing distraction of the impacted fracture and early joint mobilization. We present our study of 100 patients with a variety of fractures who were treated with the S-Quattro technique over a 6-year period, with an average follow-up of 10.5 months. The mean active range of motion regained was 92 degrees for proximal interphalangeal joints (81 fractures), 82 degrees for distal interphalangeal joints (10 fractures), 91 degrees for metacarpophalangeal joints (6 fractures) and 80 degrees for interphalangeal joints of the thumb (3 fractures). Only nine patients complained of mild or moderate pain. Postoperative radiographic appearances were satisfactory in all but five out of the 100 patients. This device is a simple and effective technique for the management of these difficult fractures. It offers advantages in terms of versatility, ease of application, good tolerance by patients, few complications and good outcome.
Adolescent↗
Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results.
Many operative and non-operative treatments of dorsal fracture dislocations of the proximal interphalageal (PIP) joint have been described. Return of good joint function requires anatomical reduction of the articular fragments and restoration of joint congruity and a stable functional arc of motion, with the fixation construct stable enough for early mobilization. To prevent recurrent dorsal subluxation, the attachments of the ligamentous palmar restraints and the bony buttress provided by the palmar lip of the middle phalanx base must be restored. Open reduction and internal interfragmentary screw fixation using 1.5 or 1.3mm screws was employed in 12 fingers in 10 patients with unstable dorsal fracture dislocations of the PIP joints of Schenck grades III and IV. At an average follow-up of 8.7 months, all patients in this series achieved good to excellent results and an average total active interphalangeal motion of 132 degrees (range 105 degrees -165 degrees). Additional benefits over non-operative techniques included improved patient comfort and simplified nursing care and therapy supervision.
Adolescent↗
Reconstruction of fingertip defects with the neurovascular tranquilli-leali flap.
For many years, bipedicled palmar advancement flaps were used rarely in fingers because they sacrificed the dorsal branches of the digital arteries, risking dorsal skin necrosis. In 1995, a short bipedicled neurovascular VY advancement flap raised distally to the PIP flexion crease, which spared the dorsal blood supply, was described by Elliot et al. (1995). This paper includes an anatomical study on 28 fresh cadaver fingers to evaluate the advancement potential of this flap. It also reviews 22 fingertip reconstructions in 22 patients using this flap. The mean advancement of the flap in the cadaver study was 14 (range 10-16) mm. This procedure gave good clinical results in respect of healing, sensibility, bone cover and appearance. Complications occurred in four fingers (18%), viz. two infections, one neuroma and one stiff proximal interphalangeal joint. Our study suggests that this flap can be used to treat fingertip defects of a size of approximately half of the pulp of the distal phalangeal segment of the finger.
Adolescent↗
Irreducible palmar dislocation of the distal interphalangeal joint.
A case of a child with rare palmar dislocation of the ring finger distal interphalangeal joint requiring open reduction is presented and the literature discussed.
Child↗
[Heterotopic digital transplantation in an 80-year-old man].
The authors report a case of amputation of the first, second and third fingers of the left hand in an 80-year old man. As the thumb was not replantable, a pollicization by hetero-replantation of the index was performed as an emergency. With a 1-year follow-up, the functional result was satisfactory. Analysis of the case report again shows that in the case of thumb amputation, hetero-replantation according to the principles of "finger-bank" is the solution of choice and demonstrates its feasibility in the elderly. The authors discuss the recovery of sensation.
Aged↗
[Thumb reconstruction in emergency, not including replantation].
Many articles have discussed secondary thumb reconstruction but only few have been devoted to acute reconstruction. We propose to artificially separate four circumstances: (i) the thumb is preservable without associated trauma of the fingers. The rule is not to burn the bridge of secondary reconstruction; (ii) the thumb is preservable but a neighboring finger is seriously injured and functionally condemned. The finger has to be used as a "bank" to borrow the necessary anatomical structures for reconstruction of the thumb; (iii) the thumb is not preservable and the lesions of a neighboring finger allow to use it for a pollicization. The difficult decision is between the immediate transposition or maintenance for secondary pollicization. Only finger devascularization is a clear indication for acute pollicization; (iv) Finally when the thumb is not preservable and there is no associate finger injury, it is difficult to assess and inform sufficiently the patient to take a decision. Secondary thumb reconstruction is the best choice.
Amputation, Traumatic↗
[The treatment of digital nerve defects by the technique of vein conduit with nerve segment. A randomized prospective study].
OBJECTIVE: This study aims to compare the results of treating digital nerve defects with autologous sural nerve grafts as compared to using a vein conduit with interposition of a posterior interosseous nerve segment. METHODS: This study is a clinical, prospective, randomized and blinded trial, comparing digital nerve defects treated by two different surgical techniques. It included a total of 50 digital nerves (25 patients in each treatment group), with a mean follow up of 10.2 (SD 1.4) months. In addition, the impact of five different factors (type of surgery, size of nerve defect, patient's age, type of lesion and lesion age) on the final outcome were evaluated. RESULTS: In respect of the sensory assessment, the static two point discrimination score was 6 mm for both groups . According to the Al-Ghazal Scoring Method, the autolougus sural nerve graft group scored a mean (sd) of 7.7 (1.9) points, while vein conduit with interposition of a posterior interosseous nerve segment group scored 6.9 (2.1). Under multivariate analysis, both patient's age and lesion age proved to be important independent factors, having influenced almost all results. The group treated with vein conduit with interposition of a posterior interosseous nerve segments showed fewer complications than the group treated using sural nerve. CONCLUSION: Based on the results obtained, we concluded that the sensory scores were equal in both groups. We also concluded that the vein conduit and posterior interosseous nerve graft procedure offered some advantages in terms of the complication rate.
Adolescent↗