Crush injuries of the fingertip are the most common hand injuries seen in children. Many involve fracture of the distal phalanx, whereas others result in either crush alone or complete or partial ...fingertip amputation. The need for nail removal and nail bed repair after crush injury to the fingertip has long been a matter of debate. In our study comparing the outcome of nail removal and formal nail bed reconstruction versus simple evacuation of the subungual hematoma via trephination after fingernail crush injuries, simple nail trephination was equal to, or superior to, removal of the nail and nail bed repair with significantly lower cost (Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg Am 1999;24:1166-1170).
Although cubital tunnel syndrome has been described as the most common entrapment of the ulnar nerve, there is still considerable difficulty identifying the exact location of the pathologic ...compression of the nerve and deciding on the correct surgical or nonsurgical treatment. The most commonly recommended surgical techniques include simple (in situ) decompression, decompression with medial epicondylectomy, anterior subcutaneous transposition, and anterior submuscular transposition of the ulnar nerve at the elbow. It is important to understand the pitfalls and possible complications of these commonly used treatments.
Background: Fractures of the hook of the hamate are rare. Nonoperative management has historically been immobilization in a short arm cast (SAC) without thumb immobilization with a high reported ...incidence of nonunion. The high prevalence of nonunion following nonoperative treatment may be secondary to motion at the fracture site. The transverse carpal ligament’s attachment to the hook of the hamate results in movement at the fracture site during thumb motion. Methods: A cadaveric study using 8 fresh frozen cadaver arms amputated at the mid-humeral level was performed. Computed tomography (CT) imaging was used to assess the bony anatomy and assure no preexisting fractures were present. Osteotomy of the hook of the hamate was performed through a skin incision proximal to the hook of the hamate and the transverse carpal ligament. Each arm was then mounted in a jig designed to hold and stabilize the arm and hand in supination. CT scans were performed without cast immobilization with the thumb in extension and abduction, with SAC without thumb carpometacarpal joint immobilization, and SAC with thumb carpometacarpal joint immobilization. Results: Motion of the fractured hook of the hamate was found to occur in all noncasted specimens, greatest with base fractures. SAC without thumb immobilization had little to no effect in eliminating fracture motion. SAC including the thumb reduced fracture motion in all specimens. Conclusions: Previous poor experience with nonoperative management of fractures of the hook of the hamate may be partially due to inability to adequately immobilize the fracture fragment. Fracture motion of the hamate hook occurs during thumb movement, likely from traction on the fracture fragment by the transverse carpal ligament.
Upper limb defects occur in approximately 3.4 per 10,000 live births. Major thumb defects represent 16% of these upper limb defects (Tay SC, Moran SL, Shin AY, et al. The hypoplastic thumb. J Am Acad ...Orthop Surg 2006;14:354-366). Embryologically, hand development begins by the fifth week. This occurs simultaneously with the growth and development of the cardiovascular, neurologic, and hematopoietic systems. Therefore, congenital anomalies seen in the hands of infants may indicate significant anomalies in these other systems, requiring a comprehensive physical evaluation. Although the cause of 40% to 50% of congenital hand anomalies is unknown (Gallant GG, Bora FW. Congenital deformities of the upper extremity. J Am Acad Orthop Surg 1996;4:163-171), several others have traced this to specific genetic mutations. Others are due to a variety of teratogenic effects (Sadler TW. Langman's Medical Embryology. 10th ed. Philadelphia: Lippincott Williams &Wilkins, Chapter 9, 2006:125-142). For the clinician, this paper has been organized to identify possible corresponding syndromes that may accompany specific thumb deformities.
Paraplegic patients rely almost exclusively on their upper extremities for weight-bearing activities such as transfers and wheelchair propulsion. Eighty-four paraplegic patients whose injury level ...was T2 or below and who were at least one year from spinal cord injury were screened for upper extremity complaints. Fifty-seven (67.8%) had complaints of pain in one or more areas of their upper extremities. The most common complaints were shoulder pain and/or pain relating to carpal tunnel syndrome. Twenty-five (30%) complained of shoulder pain during transfer activities. Symptoms were found to increase with time from injury. As the long-term survival of spinal cord injured patients continues to improve, an increased awareness of the complications of the weight-bearing upper extremity is necessary to keep these patients functioning in society.
A reader-friendly, how-to guide on reconstructive plastic surgery from international experts Reconstructive Plastic Surgery: An Atlas of Essential Procedures edited by esteemed authors, educators, ...and surgeons Robert X. Murphy Jr. and Charles K. Herman is a comprehensive resource detailing head-to-toe surgical procedures for a broad range of conditions. The senior editors have more than 50 years of collective surgical experience and expertise training hundreds of medical students and plastic surgery residents. A distinguished and diverse group of contributors from more than 15 countries and five continents share clinical pearls throughout the book. Sixty-seven chapters organized in five sections start with head and neck chapters detailing cleft palate defects and repair, followed by functional rhinoplasty, neoplasms, and trauma. Section two encompasses breast reduction/reconstruction techniques and other breast deformities; and management of trunk ulcers, deep wounds, and defects. The hand and upper extremity section details reconstructive techniques for infections, trauma, and Dupuytren's contracture. The final two sections cover a wide spectrum of nerve-related conditions and syndromes, followed by burns, melanoma, and vascular anomalies. Key Features * High-quality illustrations and intraoperative photographs enhance understanding of step-by-step operative procedures * More than 30 procedural videos provide hands-on guidance on how to perform specific steps in reconstructive plastic surgery * A broad range of reconstructive techniques cover trauma, tumor resection, burns, congenital deformities, and degenerative conditions * Consistent chapter formatting includes a clear and concise introduction, discussion of pertinent anatomy, surgical indications, operative techniques, complications, and long-term results This highly accessible yet comprehensive procedural guide is must-have reading for medical students, plastic surgery residents, and early-career plastic surgeons. It will also benefit veteran reconstructive plastic surgeons looking for a robust refresher with an international perspective.
Active ranges of motion of the joints of the hand are well documented, but there is little data reporting the functional ranges of motion required to perform activities of daily living. ...Electrogoniometric and standard methods were used to measure both active and functional ranges of motion of the metacarpalphalangeal and interphalangeal joints during 11 activities of daily living. In the fingers, only a small percentage of the active range of motion of the joints was required for functional tasks. Functional flexion postures averaged 61 degrees at the metacarpalphalangeal joint, 60 degrees at the proximal interphalangeal joint, and 39 degrees at the distal interphalangeal joint. In the thumb, functional flexion postures averaged 21 degrees at the metacarpalphalangeal joint and 18 degrees at the interphalangeal joint using only 32% of the available flexion. Active thumb metacarpalphalangeal joint motion was found to be bimodal in the study group.
We studied six patients (twelve upper extremities) who had quadriplegia at the sixth cervical level. Our purpose was to evaluate how the loss of terminal extension of the elbow adversely affected the ...ability of the patient to perform transfers with a sliding board and so-called depression raises (lifting of the body with use of the extended upper extremities to reduce the pressure on the ischial tuberosities). Function of the triceps muscle was considered to be absent in eight upper extremities and present in four. A flexion contracture of the elbow was simulated with use of a specially fabricated, hinged elbow brace. Terminal extension was progressively limited, in 5-degree increments, until the patient was no longer able to perform the transfer or the depression raise. The mean flexion contracture at which the patient could not perform the transfer or the depression raise was approximately 25 degrees when function of the triceps was absent and approximately 50 degrees when function of the triceps was intact. The results of this study emphasize the importance of maintaining the full range of motion of the elbow in a patient who has high-level quadriplegia. In a patient who has quadriplegia at the sixth cervical level who otherwise would be independent with regard to transfer skills and mobility in bed, a flexion contracture of the elbow of approximately 25 degrees or more can result in the loss of a functional level and render the patient as dependent as one who has quadriplegia at the fifth cervical level.
Fresh anatomic specimen forearms were studied using a mechanical device, the axis finder, to locate the axis of rotation. The relationship of the axis to the membrane was demonstrated directly using ...a small jig. The axis of rotation of the forearm is constant and independent of elbow flexion or extension. It runs from the center of the radial head to the center of the distal ulna. All fibers of the interosseous membrane cross the axis of rotation near their distal insertion into bone. This relationship of the ligaments to the axis of rotation is similar to those of the ankle, knee, and thumb joints. The membrane does not limit forearm rotation and can provide little stability if the bony ring is disrupted.
Dr. Glueck is Orthopaedic Resident, Department of Orthopaedic Surgery, University of Kentucky, Lexington, KY. Dr. Gellman is Voluntary Clinical Professor, Department of Orthopaedic Surgery, ...University of Miami, FL, and University of Arkansas, Little Rock, AR.
None of the following authors or the departments with which they are affiliated has received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article: Dr. Glueck and Dr. Gellman.
Reprint requests: Dr. Gellman, Broward Hand Center, Suite 305, 3100 Coral Hills Drive, Coral Springs, FL 33065-4137.
Juvenile rheumatoid arthritis is a multifaceted disease. Average age of onset is 6 years, with peaks between 1 and 4 and between 9 and 14 years. Girls are affected more frequently than boys. Nonsteroidal anti-inflammatory drugs are the standard first line of therapy. Second-line therapy of antirheumatic drugs may be used early for progressive disease. Intra-articular corticosteroid injections should be considered to preserve joint mobility and muscle strength when medical treatment fails to control synovitis or when marked functional impairment exists. Historically, surgery has been a last resort, but in appropriate patients, it should be considered soon after failure of conservative management. However, when possible, reconstructive surgery should be delayed until completion of skeletal growth.
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