Articular fractures of the digits: a prospective study

We report a prospective study of 92 articular fractures of the digits. The treatment protocol was based on functional stability and acceptable alignment rather than on joint congruity. 54% of patients had good results, with 22% fair and 24% poor results being recorded. These results are similar to reports of treatment of finger fractures in general and suggest that for articular fractures of the digits, stability and alignment are more important factors than joint congruity in determining short-term outcome. Compound fractures and those associated with comminution, significant soft tissue damage and marked displacement at presentation have a worse prognosis.

Hand function after digital amputation

127 patients with amputated thumbs or fingers between the level of the DIP and MP joints were followed up at regular intervals until one year after injury. Sensory disturbances subsided rapidly except for numbness which was still present in 50% at one year. Range of movement was regained early. Although pronation and supination improved to 70% only a few months after injury, it took a year for power grip and key pinch to regain 70%. Further analysis showed that power grip was worst in amputees of multiple fingers, thumb, and the middle finger through the proximal phalanx. For key pinch, almost all were impaired to a level of 50% to 60%. Multiple finger amputees also had decreased pronation, and thumb amputees had decreased supination. Other factors were not significant. One-quarter had to change their jobs and one-fifth showed concern with the appearance.

Mycobacterium fortuitum infections of the hand. Report of five cases

Five cases are reported of infection due to Mycobacterium fortuitum involving the hand following contaminated injection or traumatic wounds. Synovectomy, debridement, or amputation together with prolonged chemotherapy using kanamycin or amikacin were required. Doxycycline and sulphamethoxasole also seemed to be the effective antibiotics for this organism. A high index of suspicion is important in order to obtain the correct diagnosis.

Reinnervation of denervated skeletal muscles by grafted dorsal root ganglion

We examined whether or not the cervical dorsal root ganglion (DRG) of the rat, when isografted and connected to the distal stump of the severed common peroneal nerve, could survive, project axons to the denervated leg muscles, and exert beneficial influences to delay the degeneration of the denervated muscles. Rats in which the muscles were similarly denervated but no DRG was grafted served as the control. After a postoperative period of 72 to 286 days, histological study showed that nerve cells at the superficial part of the grafted DRG survived. Indirect electrical stimulation via the distal stump of the common peroneal nerve produced no contraction of the muscles, indicating that no functional neuromuscular contacts had been reestablished. Direct stimulation of the denervated muscles did elicit contraction, and the isometric twitch and tetanic tensions were significantly much higher in the experimental rats with a grafted DRG than in the control rats. Cholinesterase-silver staining indicated the presence of axons in the denervated muscles, but the axons did not terminate on endplates. Compared with the control muscles, the experimental muscles had significantly more axons, and had atrophied less as indicated by muscle wet weight and histological appearance. These results indicate that the sensory axons can delay the weakening and atrophy of muscles after denervation. We suggest that the sensory axons may exert certain trophic influence on the denervated muscle fibers, though the actual mechanism is unknown.

Partial weight bearing after operations for hip fractures in elderly patients

Factors affecting a patient's ability to carry out partial weight bearing after operation for hip fracture were studied in 100 patients. Seventy-six were able to do so. Significant factors included the muscle power of the good limbs and the mental state, whereas age, body-weight and type of operation were not significant. Logistical regression analysis showed that it was possible to predict a patient's partial weight bearing potential by simply testing the left hand grip and the 'Set' test score.

A comparison of arterial and venous flaps

The survival rate and elastic properties of the anterior abdominal skin flap in Sprague-Dawley rats were studied in three groups of animals. In group 1 where the flaps were supplied by a normal artery, arterial flaps (1A) had better survival rate and elastic properties than venous flaps (1B). In group 2, where the flaps were supplied by an artery with diminished perfusion pressure, the arterial flaps (2A) still had slightly better results than venous flaps (2B). However, in group 3 where the flaps were supplied by a vein, venous flaps (3B) had better results than arterial flaps (3A).

Sequential fractures of both hips in elderly patients--a prospective study

Thirty-five patients with sequential fractures of both hips were studied prospectively. The second hip fractures occurred more commonly if the patients were institutionalized, if they suffered from concomitant neurologic diseases such as previous stroke or Parkinsonism, or if there was biochemical evidence of osteomalacia. Twelve patients sustained the contralateral hip fracture within 12 months of the first one. There was a significant correlation between biochemical evidence of osteomalacia and early occurrence of the second hip fracture. Although rehabilitation was difficult for such patients, it was possible with a longer period of intensive physiotherapy; only three patients were not able to walk upon discharge from the hospital after the second hip fracture.

Acute carpal tunnel syndrome caused by pseudogout

Acute carpal tunnel syndrome caused by pseudogout occurred in a Chinese patient. The radiological findings mimicked those of synovial chondromatosis. Such radiological findings were very unusual. Diagnosis of such conditions may be difficult, since the clinical features may be confused with those of gout and infection. Surgical release is the treatment of choice.

Effect of treated infection on microvascular anastomosis

The effect of established infection with penicillin-resistant Staphylococcus aureus on microarterial and microvenous anastomosis was studied in a rat experimental model. The infection was treated with wound debridement and systemic antibiotics at the time of the surgical procedure. It was found that the patency rate of microarterial repairs at 10-14 days was 95.1%. Veins were less resistant to infection than arteries. Two types of vein involvement were found. These were classified according to the degree of thrombosis resulting from endophlebitis. The patency rate of anastomoses performed on the more mildly infected veins was 56.5% and that on the more severely infected veins was 0%.

A prospective study on hip fractures in patients with previous cerebrovascular accidents

Of 1430 patients with proximal femoral fractures admitted into Queen Mary Hospital, Hong Kong from 1985 to 1990, 146 patients (10.2 per cent) had a history of previous cerebrovascular accidents. The fracture was on the hemiplegic side in 82 percent of patients. Most patients were treated by operation. Intensive physiotherapy was given to these patients for an average of 6 weeks. The prefracture walking ability was regained or even improved upon discharge in 60.9 per cent of patients. After an average follow-up of 21 months, 31 per cent had satisfactory walking and active daily activities. There was significant correlation of the performance upon discharge from the hospital with the walking ability at the final follow-up.

A study of function and residual joint stiffness after functional bracing of tibial shaft fractures

Ninety-eight diaphyseal tibial fractures were treated with custom made functional braces in 97 patients older than 14 years of age. The average follow-up period was 1.86 years, and 53 patients had more than two years' evaluation (average, 2.83 years). The majority of the patients did not have full range of movement in the ankle and subtalar joints when the brace was removed after fracture healing. Although the stiffness decreased with time, a significant number of patients were left with residual joint stiffness. At an average follow-up period of 1.86 years, 68.4% of the patients had normal ankle motion and 60% had normal inversion and eversion of the hindfoot. In patients with more than two years' evaluation, 75.5% had normal ankle movement and 71.1% had normal inversion and eversion of the foot. In the knee joint, the incidence of residual joint stiffness was small and the amount of stiffness was clinically insignificant. Patients with an abnormal walking pattern after fracture healing had a high incidence of ankle and subtalar joint stiffness.

A prospective study of 245 open digital fractures of the hand

We report a prospective study of 245 open digital fractures of the hand in 201 patients. Management followed clear guidelines set out in protocol. The incidence of infection (2.04%) and non-union (2.45%) was low. Proximal phalangeal fractures and comminuted fractures did worst and associated significant soft tissue injuries had a particularly deleterious effect on the outcome. A classification based on the different soft-tissue components involved is proposed. In fractures associated with simple lacerations or isolated digital nerve injury only, one can expect about 40% good results and about 25% poor results. Where extensor tendon injury or extensive skin loss are also present, there will be approximately 18% good results and 50% poor results. If there is also injury to the flexor tendon or more than one component of significant soft-tissue damage, about 80% will be poor and good results are rare.

Unstable phalangeal fractures: treatment by A.O. screw and plate fixation

A prospective study of fifty-two fresh traumatic unstable fractures of the proximal or middle phalanges of the hand in forty-seven patients was reviewed. All the fractures were fixed with A.O. miniature screws and plates. The overall results were not satisfactory and complications were frequent. Only 26.9% of the fractures had good results. Fractures associated with significant soft tissue injuries had very poor results. When the present series was compared with a comparable group of fractures fixed with Kirschner wires, there was no significant improvement in the results. The unsatisfactory outcome of this group of unstable fractures may be largely due to the frequent association with poor prognostic factors.

Tuberculosis of the lumbosacral junction. Long-term follow-up of 26 cases

Of 37 consecutive patients suffering from tuberculosis of the lumbosacral spine, 26 were reviewed after an average follow-up of 20 years. Those presenting at under 10 years of age usually had a discharging sinus or a pointing abscess and a visible kyphosis. In older patients, low back pain was the predominant presenting symptom. Neurological involvement was uncommon. Both operative and conservative treatment had resulted in fusion but all patients treated conservatively ended up with a kyphosis associated with trunk shortening. They had a higher incidence of back pain and more complications in pregnancy. Anterior debridement and fusion with a strut graft can reduce the incidence and size of kyphosis, but is technically demanding. Treatment remains difficult and requires individual consideration.

A splint for controlled active motion after flexor tendon repair. Design, mechanical testing, and preliminary clinical results

A splint for controlled active motion after flexor tendon repair is described. It incorporates a single core-coated elastic band passing around a palmar pulley and attached proximally to a spring wire. Its mechanical properties were tested against six other systems. The tension in various systems all rose near full extension. However, the palmar pulley, the spring wire, and the elastic band each could lower the tension significantly. When the bending moments at the interphalangeal joints were measured, all systems produced a peak during the latter part of extension. With the palmar pulley, spring wire, and elastic band, the rise was minimal and in fact, the bending moments diminished near full extension. Initial results in 28 flexor tendon repairs using this splint showed less flexion contracture when compared with 78 flexor tendon repairs using a standard rubber band anchored at the wrist.

Fracture of the tibial tubercle in the adolescent

We have reviewed 16 patients with avulsion fractures of the tibial tubercle, mostly boys who sustained left-sided injuries during sport. Two-thirds had type I or II injuries and were treated conservatively. Fractures involving the knee joint (type III) had internal fixation. The final results were good except for minor complications such as a prominent and uncomfortable tibial tubercle.

Evaluation of results in flexor tendon repair: a critical analysis of five methods in ninety-five digits

The development of an internationally accepted system of assessment of results after flexor tendon repair is important. In a prospective study of ninety-five digits, gross discrepancies were demonstrated between five popular methods of assessment: Buck-Gramcko, linear measurement, Grossman, American Society for Surgery of the Hand, and Strickland. The relative merits of each systems were studied and modifications for the Buck-Gramcko system are suggested.

Sequential Forearm Intravenous Regional and Infiltration Anaesthesia: Value for Haemostasis

Intravenous regional anaesthesia using 0.5% lignocaine with a forearm tourniquet is a satisfactory technique for operations on the distal forearm, wrist and hand. Since recovery of pain sensation is rapid, haemostasis after release of tourniquet becomes difficult and sometimes impossible. Local wound infiltration or metacarpal block with 1% lignocaine just before release of the tourniquet can allow subsequent haemostasis and wound closure to be carried out without causing pain. 55 patients received this sequential forearm intravenous regional and infiltrative anaesthesia. Subsequent haemostasis and wound closure could be carried out without pain in 51 patients (92.7%); three patients (5.5%) noticed mild discomfort but the operations could be finished without any additional anaesthetic agent. No complications were encountered with this modified technique.

Sequential forearm intravenous regional and infiltration anaesthesia: value for haemostasis

Intravenous regional anaesthesia using 0.5% lignocaine with a forearm tourniquet is a satisfactory technique for operations on the distal forearm, wrist and hand. Since recovery of pain sensation is rapid, haemostasis after release of tourniquet becomes difficult and sometimes impossible. Local wound infiltration or metacarpal block with 1% lignocaine just before release of the tourniquet can allow subsequent haemostasis and wound closure to be carried out without causing pain. 55 patients received this sequential forearm intravenous regional and infiltrative anaesthesia. Subsequent haemostasis and wound closure could be carried out without pain in 51 patients (92.7%); three patients (5.5%) noticed mild discomfort but the operations could be finished without any additional anaesthetic agent. No complications were encountered with this modified technique.

Post-traumatic oedema of the foot after tibial fracture

A total of 97 patients with diaphyseal tibial fractures treated with functional bracing were studied prospectively. Persistent ipsilateral foot swelling was present in 84.5 per cent of the patients. Most of the swellings subsided with time, but a small percentage of them persisted for a duration of 2 years or more after injury. The time for disappearance of the swelling in 50 per cent of the patients was 18.6 weeks. The development of oedema is not related to the age and sex of the patients, the configuration, type and level of the fractures, or the association of a fibular fracture. The bone healed quicker in those who did not have swelling of the foot. Once the swelling has developed, it seems to run its own course and its disappearance is not related to the age and sex, the configuration, type and level of fractures, the association of a fibular fracture, or the time for fracture healing. This complication does not have any adverse effect on the functional recovery of the patients.

Vitamin D status among patients with fractured neck of femur in Hong Kong

Vitamin D deficiency leads to secondary hyperparathyroidism initially and then to mild osteomalacia, both of which conditions may be aymptomatic and may predispose to bone fracture. To assess the importance of vitamin D deficiency in predisposing to fractured neck of femur, we studied the vitamin D status, dietary intake and socio-economic characteristics in 69 patients with fractured neck of femur (group A), 28 normal subjects with age above 60 (group B), and 101 normal volunteers (group C). Patients with fractured neck of femor had significantly lower levels of serum 25-hydroxy-cholecalciferol compared with subjects of groups B and C. There is no statistically significant difference in other biochemical parameters, including calcium, phosphate, and alkaline phosphatase. Patients with fractured neck of femur and with 25-hydroxycholecalciferol below 20 ng/mL were characterized by a home-bound and/or institutionalized life-style, smaller living place, and limited access to open space. To conclude, hypovitaminosis D is a common problem among elderly patients with fractured neck of femur in Hong Kong. The fact that such vitamin D deficiency is associated with muscle weakness may contribute to falls, and thus indirectly account for an increased rate of hip fractures over the normal control.

25-Hydroxycholecalciferol and insulin-like growth factor I are determinants of serum concentration of osteocalcin in elderly subjects with and without spinal fractures

Osteocalcin is one of the major proteins in the osseous matrix. To evaluate the determinants and thus the physiological control of osteocalcin production in normal and osteoporotic subjects, the serum levels of osteocalcin, 25-hydroxycholecalciferol (25-OH-D3), and insulin-like growth factor I (IGFI) were measured by radioimmunoassay in 44 subjects over 60 years old. Circulating osteocalcin, 25-OH-D3, and IGFI were 0.28 +/- 0.10 nmol/L (1.65 +/- 0.96 ng/mL), 70.5 +/- 25.1 nmol/L (28.3 +/- 10.1 ng/mL), and 23.8 +/- 12.0 nmol/L in 27 healthy controls respectively, as compared with 0.09 +/- 0.09 nmol/L (0.52 +/- 0.52 ng/mL), 48.2 +/- 19.9 nmol/L (19.35 +/- 7.91 ng/mL), and 16.56 +/- 6.96 nmol/L in 17 patients with spinal fractures. Significant correlation was found between osteocalcin and 25-OH-D3 level, as well as between osteocalcin and IGFI. The results show that IGFI and 25-OH-D3 are important determinants for serum concentration of osteocalcin in elderly subjects with and without spinal fractures.

Prognostic factors and progress for ambulation in elderly patients after hip fracture

A longitudinal study of the ambulation progress was done on 102 patients in the first 9 wk after an operation for repair of hip fractures. The time taken to achieve a stable walking pattern from frame to a cane was recorded for every patient. Results showed that 82.2% of the patients were able to walk with a cane at 4 wk postoperatively. Of the remaining 17.8% of the patients, 7.7% were able to walk with a cane at 6 wk whereas 10.1% were not able to walk with a cane at 6 wk. Several factors including the age, sex, mental state, the type of operation and the preoperative ambulation level of the patients were studied to predict the ambulation progress of the patients. The most important factors affecting the ambulation progress were the age and the preoperative ambulation level of the patient. Because of the general trend in the aging of the population, an increase in the number of hip fractures is expected. The result of this study may help in predicting the prognosis and provide guidance for restoring the function of the patients.