Microsurgical two-stage reconstruction of the thumb. Case report

A 40-year-old patient presented with traumatic amputation of the thumb and index finger. The second metacarpal bone fragment was transposed to lengthen the first metacarpal bone. A free flap from the lateral forearm was used to reconstruct the thenar region. Later, the second free toe-to-hand transfer was done from which he made a good recovery, achieving active flexion and extension in all joints.

Tire explosion injuries to the upper extremity

Several articles have been published that bring attention to the destructive potential of tire explosions. Although the severity of tire explosion injuries to the head and neck region is well established, only one previous article has reported injuries to the upper extremity. Fourteen patients with upper extremity tire explosion injuries have been treated by us from 1980 to 1988. Each injury was caused by single-piece wheel assemblies, as opposed to multipiece wheel assemblies, which have traditionally been associated with the injury. Three representative patient reports are discussed. Prevention of this injury can be achieved by increased public awareness, formal industrial safety training, tire servicing with dedicated equipment including restraining devices or barriers, complete evaluation of wheel/tire serviceability before tire mounting, separation of servicing of single and multipiece wheels, and complete tire deflation before servicing.

Carpometacarpal joint injuries of the fingers

Injuries to the carpometacarpal joints are uncommon and are sometimes overlooked on initial radiographs. Their recognition depends on a careful physical and radiographic examination that may require trispiral tomograms and CT scans. Most injuries can be treated successfully by closed reduction and percutaneous fixation of the joint(s) using Kirschner wires. Chronic joint injuries can also be effectively treated, and if surgery is required, an arthrodesis will restore stability and eliminate discomfort.

A 22-year-old man with a swollen left hand after a motor vehicle accident

The following case is presented to illustrate roentgenographic and clinical findings of a condition of interest to the orthopaedic surgeon and emergency room physician. The initial history, physical examination, and pertinent roentgenographic findings are found on this page. The final clinical diagnosis is presented on the next page.

Biomechanical comparisons of unidirectional and bidirectional Kirschner-wire insertion

Peak axial loads on entry and peak pull-out loads were measured for Kirschner-wires (K-wire) inserted into canine metacarpals. The wires were placed using a standard, unidirectional drill and using an oscillating, bidirectional drill that reversed spin direction every 120 degrees. Seven trocar-tip wires were compared with seven diamond-tip wires using each drilling method. The trocar-tip wires demonstrated equal peak axial loads on entry when drilled at comparable speeds unidirectionally and bidirectionally. Pull-out load of the trocar tip after bidirectional insertion was less than that for unidirectional insertion but was still in the clinically useful range. The diamond-tip wire exhibited higher peak axial load on entry and lower peak pull-out load when drilled bidirectionally. Bidirectional insertion of a trocar-tip K-wire offers fixation characteristics comparable with those with unidirectional insertion and will potentially reduce the risk of soft-tissue damage associated with winding-up and avulsion of vital structures on the spinning shaft of a unidirectional driver.

Pivot osteotomy for the correction of malunion of metacarpal neck fractures

A new configuration of osteotomy has been developed which combines the principles and benefits of opening and closing wedge osteotomies without the degree of shortening associated with the closing wedge osteotomy and the tension imposed on the soft tissues by the opening wedge osteotomy. It is ideally suited to the correction of angular malunions in the long bones of the hands. Ten osteotomies of malunions of the metacarpals have been performed in nine hands giving good correction of the malunion in all cases.

Holding power of cortical screws after power tapping and hand tapping

Paired equine third metacarpal bones were drilled and tapped for 4.5 mm and 5.5 mm cortical screws. Tapping was done by hand or with an air-driven reversible orthopedic drill. Screws were inserted and subjected to extraction forces to failure of the osseous threads or the screws. There was no difference in holding power of either screw size between hand-tapped and power-tapped holes.

Comparison of two grafting methods in 4.0-mm drill defects in the third metacarpal bone of horses

In 6 horses, bilateral metacarpal vertical series of three 4.0-mm unicortical drill holes were made. At random, one of each series of 3 holes was filled using a sternal 4.0-mm cancellous bone cylinder or a slurry of cancellous bone injected into the hole or left as an empty control. All horses had lateral metacarpal xeroradiographs at monthly intervals. Three horses (6 metacarpi) were examined post mortem after 4 months and 3 others after 6 months. Immediate through 4-month post-operative xeroradiographs demonstrated increased density in the holes with cancellous cylinders and no difference could be seen between the untreated controls and holes injected with slurry. From 5 months, no radiographic difference could be seen between the treatment groups. No consistent histological difference between treatment groups could be detected. In conclusion, no justification for clinical grafting of 4.0-mm unicortical dorsal metacarpal drill holes could be found.

[Plastic surgery of combined cutaneo-osseous defects of the hand]

The article analyses modern methods for the restoration of of defects in the metacarpal bones, based on microsurgical techniques. A case is described in which a new method for one-stage reconstruction of the hand in combined traumatic defect in the first and second metacarpal bones and an extensive defect in the soft tissues on the back of the hand was used. The hand was reconstructed by means of a vascularized complex autograft on a common vascular pedicle which included two separate fragments of the scapula and a fascial flap of the scapular region. With the application of the described method successful functional rehabilitation of the injured hand was achieved in a short period. A good cosmetic effect of the plastic repair was also noted.

Imaging rounds. Bizarre parosteal osteochondroma

The following case is presented to illustrate the roentgenographic findings of a condition of interest to the radiologist and orthopaedic surgeon. Initial history, physical findings, and roentgenographic examinations are presented along with the final histologic and roentgenographic differential diagnosis.

Hand reconstruction with allograft demineralized bone: twenty-six implants in twelve patients

A long-term study of 26 phalangeal or metacarpal defects that were reconstructed with allogeneic demineralized bone implants demonstrates healing comparable to that which follows autogenous bone grafting. Average follow-up was 54 months. Five patients had multiple enchondromas (Ollier's syndrome), five children had congenital hand deformities, and all of these had previously had bone grafts harvested for associated craniofacial reconstructions. With the use of demineralized bone implants, tourniquet and operative times were significantly reduced and potential donor site morbidity was eliminated. Further, regional anesthesia was used more frequently and hospitalization time was reduced. There were no postoperative complications. Demineralized bone implants have been particularly useful in patients who previously had refused bone grafting.

Distal metacarpal sequestration in a bison

A 2-year-old 400-kg female American bison was admitted for evaluation and treatment of an open fracture of the right metacarpal bones 3 and 4. Radiography revealed osteolysis of the distal metaphysis and epiphysis, with extensive bony callus formation along the dorsoproximal and proximomedial aspects extending distally to the proximomedial aspect of the proximal phalanx. Evidence of periosteal or bony proliferation at the fracture site or along the distal segment of the third and fourth metacarpal bones was not visible, suggesting that the distal fracture fragment was becoming a sequestrum. Treatment consisted of soft tissue debridement and placement of the limb in a full-limb cast. The cast was changed every 4 weeks until the sequestrum was removed and the bone healed. It is rare for the distal half of a long bone to sequester following fracture. Additionally, it is remarkable that the sequestrum served as a buttress, which prevented collapse of the bone until the sequestrum was replaced by functional bony callus.

Surgical treatment of dorsal cortical fractures of the third metacarpal bone in thoroughbred racehorses: 53 cases (1985-1989)

Between January 1985 and May 1989, 53 Thoroughbred horses (mean age 3.2 years) were surgically treated for dorsal cortical fractures of the third metacarpal bone (MC III). All horses were treated with cortical drilling through the fracture line (osteostixis). Diagnosis of the fractures was confirmed by xeroradiography. Lifetime racing records were obtained for all horses. Forty-seven horses returned to racing after surgery (89%). The mean time between surgery and the first race was 6.8 months. Horses had a mean of 10.9 starts before surgery and 16.1 starts after surgery. The mean earnings per start before surgery was $6,459 and after surgery was $5,685. Of the 47 horses that raced after surgery, 70% raced at the same class or improved. Complications related to surgery were seen in 10 horses. Two horses had a second fracture of MC III at the same site, and were again treated by osteostixis, after which both horses returned to competition. Fractured drill bits were left in the MC III of 4 horses. One of these horses had catastrophic failure of MC III. Two horses developed subcutaneous infections and 2 horses had catastrophic failure of MC III in the surgically treated limb. Osteostixis appears to be an effective treatment for returning horses affected with dorsal cortical fractures to racing.

[Distraction of the first metacarpal bone for thumb reconstruction]

After amputation of the thumb good functional results can be achieved by lengthening the first metacarpal bone, if a suitable technique is used. Since 1987 we have treated six patients in this way. In all of our patients the thumb was mechanically stable and sensitive after lengthening, thus improving the patients' ability to use their hands for grasping. Other advantages include the relative simplicity of the method, the fact that no experience of microsurgery is necessary and that the surgery does not result in soft tissue damage. In most cases treatment is on an outpatient basis. Between the various operations the patient can be reintegrated into his professional and social life. The period of absence from work (about 12 weeks) is relatively short when the severity of the injury is taken into consideration. Distraction of the first metacarpal bone cannot be considered an alternative to replantation but represents a complementary procedure in accordance with the modern management of severe hand injuries.

Foreign-body osteitis of the metacarpal bone

Foreign-body granulomas in the hand can appear secondary to an unrecognized foreign material. In a six-year-old boy, an extensive sterile osteitis of the second metacarpal bone appeared adjacent to a wood splinter.

One-stage key pinch and release with thumb carpal-metacarpal fusion in tetraplegia

One-stage key pinch and release with carpal-metacarpal fusion, extensor pollicis longus tenodesis, and motor transfer to flexor pollicis longus were analyzed for functional results in tetraplegic patients. Eighteen patients (21 hands)--all with International Classification OCu:4 hand function or worse--were studied. Average follow-up was 42 months. All patients experienced significant increase in functional ability and thought the surgery was highly beneficial. Average pinch strength was 3.3 kg, whereas it had been nonmeasurable preoperatively. Both activities of daily living and pinch strength correlated with tetraplegic functional level. The patients with higher preoperative functional level had better postoperative activities of daily living scores and pinch strength. Sixteen hands had solid fusions, and patients with fibrous nonunions showed no decrease in pinch strength, pain, or functional limitations when compared with the patients who had solid fusions. Six hands showed degenerative changes at one or more adjacent joints, but this was not related to results.

Follow-up of 28 horses with third metacarpal unicortical stress fractures following treatment with osteostixis

The results of 31 intracortical dorsal metacarpal stress fractures in 28 horses following unicortical osteostixis were reviewed. The incidence was predominately in the middle third of the lateral aspect of the left metacarpus, and males were affected more commonly. Approximately half of the surgical procedures were performed with the horse in the standing position. The mean times to return to training and racing were 4.25 and 6.9 months respectively. There was no correlation between time taken to return to racing and position of surgery. Complications experienced included lack of suture removal and one case with a seroma.

An unusual association of the windblown hand with upper limb hypertrophy

An eight-year-old boy presented with a congenital windblown hand deformity associated with partial hypertrophy of that arm. Many of the classical features of the windblown hand syndrome described in previous papers were absent. In this case, the primary cause of the ulnar-drift deformity was an anomalous epiphysis at the base of the second metacarpal. Surgical correction was readily obtained by osteotomy at the base of the metacarpal combined with soft tissue re-alignment.

[Description of a vascularized bone graft taken from the head of the 2nd metacarpal bone]

The authors describe a new vascularised bone graft from the distal part of the second metacarpal. They report an anatomic study on 20 cadavers which demonstrates the existence of two dorsal first web arteries (superficial and deep). The existence of free anastomosis between the two arteries is demonstrated. The vascularisation of the bone graft relies upon the deep first web artery which lies against the lateral aspect of the bone. The operative procedure is described and the authors stress the necessity to transfer the vascularized bone graft with a large soft tissue pedicle.

Clinical analysis and evaluation of the function of replanted and revascularized parts of the upper limb

During the past four years, we have attempted to replant and revascularize 57 hands and fingers in 43 patients. The total success rate was 81%. Replantation of hands severed cleanly (guillotine type) and those with slight local crush injuries had the highest success rate. As for hand function, amputations at zones III and IV with end-to-end suturing of the tendons and nerves presented the highest degree of function when evaluated objectively and subjectively. All patients presented a high degree of satisfaction with the outcome of the operation.

Biodegradable implant materials in fracture fixation

Based on our experiences in paediatric traumatology treated conservatively or with metallic implants, we looked for alternative fixation possibilities in the field of biodegradables. We designed a new driving system for screws consisting of an indwelling screw driver which transduces the torque force over the whole length of the thread. With this technical approach, the head and the neck of the screw as the most friable point for the fracture of the implant could be avoided. In 48 calves aged 6 weeks we performed a comparative study with either conservative treatment (repositioning and casting) or osteosynthesis with biodegradable screws made from polylactate acid or metallic screws (AO type) after an oblique osteotomy at a 45 degrees angle to the axis of the right metacarpal bone. Results from 1 to 6 weeks postoperatively were compared and good to excellent results obtained in equal amounts for PLA and steel screw osteosynthesis, whereas conservative treatment was only successful in one third of the cases. Clinical, radiological and histological follow-up proved the feasibility of biodegradable osteosynthesis in the growing skeleton. For clinical evaluation in children, the resorption time of biodegradable materials has to be lowered to 3 to 6 months.

Standing musculoskeletal surgery

Indications for performing orthopedic surgery on the standing horse include inability to tolerate general anesthesia, risk of worsening an injury during recovery from anesthesia, and cost. The surgeon should be aware that performing surgery in the standing horse can be more demanding and require more experience than the same procedures when the time and convenience of general anesthesia are available. Improved sedatives and analgesics have allowed more latitude because the horses now are more tolerant than when older agents were used. Common sense should be applied to each situation before the decision is made to do a procedure, because every horse and problem is unique.

Transmetacarpal replantation of the right hand onto the left

Successful replantation of four fingers with the distal palm of the right hand onto the left hand is reported.

First metacarpal osteotomy for carpo-metacarpal osteoarthritis

The results of basal osteotomy of the first metacarpal in the treatment of carpo-metacarpal osteoarthritis have been analysed from two small studies, one retrospective and one prospective. Assessment included clinical examination, standardised radiography and computerised pinch-grip analysis. Surgery reduces the subluxation at the first metacarpal base and provides good pain relief and restoration of function in the majority of cases. It is concluded that this relatively simple technique produces very good results without reducing power grip.

[Sandblaster or alumina-coated 316 L stainless steel for implantable material in orthopedic surgery. Study on metacarpal bone of sheep]

We have carried out a study in sheep of the behavior of bone in the presence of two materials, 316 L stainless steel with a surface roughened by sandblasting, and the same type of steel, plasma-coated with alumina. Twelve nails of each type were implanted into the medullary cavities of previously fractured metacarpal bones. The samples were removed after 90 days for six animals and after 180 days for six others. The functional study and the radiographic analysis, as well as the growth of bone around the implants as assessed with a light microscope and with microradiography, did not show any significant difference between both types of temporary implants.