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Comminuted low velocity gunshot fractures of the proximal phalanx were stabilized with an external fixator in 15 patients. This device was found to be useful. It allowed healing of the fracture in good alignment in 13 patients. And motion of the metacarpophalangeal joint was preserved.
Vasospasm may result in marked reduction of blood flow through injured or revascularized tissues. Neurogenic vasoconstriction is mediated through sympathetic pathways which may be blocked by long-acting local anesthetics resulting in optimal intravascular pressures and elevated flow. An experimental study performed on normal human volunteers has shown that distal sympathetic blockade using Bupivacaine protects the digital circulation against vasospasm elicited by a strong stimulus for a minimum of 7 to 8 hours. A catheter, placed adjacent to the median or ulnar nerve at the wrist level after digital microvascular reconstruction, facilitates continuous Bupivacaine sympathetic blockade. This technique has been used clinically and appears to improve the circulation of replanted or revascularized tissues and protects against vasospasm caused by a variety of stimuli.
A group of 49 patients with 74 injured digital nerves was studied more than 5 years following epineurial nerve suture. Three tests of return of sensibility were used: von Frey plastic filaments, a modified Weber two-point discrimination device, and a dynamic test--the plastic ridge. The correlation between two-point discrimination and tactilegnosis in the range of 8 to 12 mm was poor. The plastic ridge device detects the presence or absence of tactilegnosis in patients in the intermediate range of two-point discrimination between 8 and 12 mm. Of the factors studied, the patient's age at the time of nerve suture was found to be directly related to the return of sensibility by both two-point discrimination and ridge criteria.
Skeletal deformities of the denervated hand are subtle in their development and pose a more formidable problem than do primary deformities of Hansen's disease. Basic osseous changes consist of concentric, longitudinal, or the longitudinal varying methods of absorption. Knowledge of their pathogenesis provides the basis for their management. Prevention of deformity and conservative management of secondary complications are necessary to salvage as much of the hand as possible.
In fourteen cases transposition of either the second or fifth ray was used following traumatic amputation of one or both central digits, or in conjunction with surgical removal of either the middle or ring finger when it was rendered useless by trauma, involved with a malignancy, or congenitally hypoplastic. The operative technique consisted of osteotomies at the base of the metacarpals with internal fixation of the transposed ray. When the fifth ray was transposed, the level of division of the bone was such as to provide the appearance of a more normal length of the digit.
A common site for digital amputation is through the middle phalanx, with comminution of the distal or proximal interphalangeal joints. To circumvent delayed union and a stiff painful joint, a not infrequent sequele of standard fixation methods, 12 cases are presented in which a polypropylene peg has been employed for immediate stabilization, as the first stage of replantation. It provides rapid osteosynthesis, a painless stabilization of the finger in a functional position, permits early return of movement in adjacent joints, and prevents excessive shortening of the finger. No case has been complicated by infection or extrusion.
Tension-band arthrodesis was employed in 26 finger joints with various pathological lesions. This is a simple procedure based on the principles of compression osteosynthesis. Stability thus achieved makes immobilization of the hand unnecessary and allows full motion of all adjacent joints.
A technique of extending exposure in digital replantation using lateral incisions permits atraumatic exposure of adequate length of digital nerves, arteries, and veins, and excellent exposure for fashioning bone and debridement and repair of tendon. Increase in viability rates, the ability to repair two arteries per digit, the number of veins repaired per digit, and a higher overall arterial patency rate appear to be related to the improved exposure. Operative time was also significantly shorter.
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By careful technique the dorsum of the thumb can be used as a donor area to cover exposed bone of index fingertip amputations and, in certain cases, avulsions of the nailbed. In this procedure an oblique, radially based flap from the dorsum of the proximal phalanx is used.
A case of immediate pollicization of an amputated index finger is reported. The patient sustained accidental amputation of the entire thumb and index finger and subtotal amputation of the middle finger of her left hand. Two years following replantation of the index finger to the thumb position, the finger has limited motion but the patient has a functional replanted digit.
In 16 fingers in 12 patients, where profundus tendon reconstruction was contraindicated due to soft tissue and distal joint changes, the superficialis tendon was reconstructed in two stages using a round silicone rod from the distal interphalangeal joint to the lumbrical level in the palm and profundus-superficialis tenorrhaphy as the first stage. The proximal end of the pedicled superficialis was used as the graft in the second stage. Fifteen fingers obtained a satisfactory result; one was a failure when the rod protruded through the skin. Two patients required a third surgical procedure: one a tenolysis at the superficialis-profundus junction, the other reattachment of the graft distally.
Restoration of motion and appearance of the chronic boutonniere deformity is often accomplished by splinting. If the deformity persists following appropriate splinting, and if a full passive range of motion of the proximal interphalangeal joint is present, surgery may be recommended. Thirteen patients had surgical reconstruction over a 10-year period, with satisfactory improvement in all but one. This operation involves release of the transverse retinacular ligaments and reconstruction of the damaged central slip by using the local joint capsule and synovium attached to the base of the proximal phalanx.
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Features of the glomus tumor and the relatively recently described pacinian hyperplasia are described including signs and symptoms, differential diagnosis and treatment. The role of trauma as an etiology is proposed. A case is reported and discussed in which the patient had a glomus tumor and pacinian hyperplasia in an index finger, and a glomus tumor in the small finger of one hand. Treatment of both entities was surgical excision.
Clearer indications regarding when to replant an amputated digit can be obtained by comparing the functional capabilities of two similar groups of patients, one of which has had amputations and one of which has had replantations. This paper reports such a comparative study. Function was assessed by asking the patient to perform 10 tests designed to cover a broad spectrum of everyday activities, and grip strength was compared to that in a normal hand. Grip strength was appreciably greater in patients with replanted thumbs and multiple digits, and less so in those with replanted single digits. Based on our findings on the small, but intensively studied, number of patients assessed in this review, it would appear that thumbs should always be replanted if possible. In contrast, the functional analysis shows little necessity for replantation of a single finger. Multiple digital replantation assumes lesser functional value if one or more fingers remain that can oppose the thumb to provide prehension.