Journal of the American Society for Surgery of the Hand最新文献

Digital hypoplasia or aplasia can result from both longitudinal and transverse deficiencies. The indications for and technique of nonvascularized toe phalangeal bone grafts to stabilize and lengthen the soft-tissue sleeve of the digit is described.

Bacterial infections in the hand are most commonly caused by organisms present in the skin. Atypical infecting organisms of the hand are becoming more common, especially because more patients presenting with these infections are immunocompromised. Atypical infecting agents include mycobacterium, viral, and fungal organisms. The treating physician should recognize the presentation, be familiar with the course, and begin the appropriate antimicrobial and/or surgical treatments.

The distal radioulnar joint has a unique architecture that simultaneously allows a wide arc of forearm rotation but requires the coordination of a primary ulnoradial ligament and secondary supporting structures to maintain stability. Office examination must focus on correlating the mechanism of the original injury, details of the patient’s symptoms related to activity, and a manual stress examination for ulnoradial instability. Surgical reconstruction of the stabilizing ligaments is an appropriate strategy if the symptoms are attributable primarily to traumatic instability and the patient has failed nonsurgical treatment. Both the primary ulnoradial ligament and secondary capsular ligaments can be anatomically reconstructed with a free tendon graft. During the rehabilitation process, remodeling of the tendon graft must take place to achieve the simultaneous goals of joint stability and full motion. Patients can be expected to return to manual labor, sports, and other demanding activities after complete graft incorporation and a conditioning program.

Supination syndrome is a relatively common upper-extremity deformity in patients with incomplete recovery after severe brachial plexus injuries. It is a highly disabling condition because of the awkward positioning of the forearm and, hence, the hand. Historically, one surgical option has been to transfer the distal tendon of the biceps brachii muscle. However, the efficacy of this procedure often may be limited because of contractures of the interosseous membrane and proximal and distal radioulnar joint capsules. A second surgical option has been to perform a rotational osteotomy of the radius. This typically has been performed nonphysiologically by rotating the radius upon itself. A more physiologic approach would be to perform the osteotomy in a manner that allows rotation of the radius around the ulna, as it does in normal forearm pronation. Such an osteotomy has been developed and found to be quick and reliable, resulting in use of muscles not functional with the forearm in static supination and allowing for more effective staged tendon transfers.

The use of vascularized bone grafts to treat scaphoid nonunion has been proposed by various investigators. We examined the blood supply to the palmar surface of the distal radius in 40 fresh cadavers that were injected with a colored latex solution and determined that the radial portion of the palmar carpal arterial arch can serve as a pedicle for vascularized grafts. Scaphoid nonunions with a humpback deformity can be corrected by harvesting a wedge of vascularized bone from the palmar cortex of the distal radius, providing easier access to the scaphoid deformity compared with the use of dorsal distal radius vascularized grafts. We also review our series of 72 patients treated by this technique.

Although most radial head fractures can be managed nonsurgically or with open reduction and internal fixation, some are comminuted and cannot be treated successfully with these options. Radial head arthroplasty is indicated for unreconstructable displaced radial head fractures with an associated elbow dislocation or disruption of the medial collateral, lateral collateral, or interosseous ligaments. Metallic radial head implants have been shown to have superior resistance to valgus and axial stresses relative to silicone implants in biomechanical studies. The clinical experience with metallic radial head arthroplasty to date has been encouraging relative to earlier series with silicone devices. Newer modular prosthesis designs are easier to implant and incorporate improved sizing to better reproduce the anatomy of the proximal radius. Advances in implant design and materials can be expected to further improve the durability of these devices in the future.

Open fractures of the hand are a challenging problem for the hand surgeon because of the global nature of the injury. The soft-tissue envelope and skeletal structure are disrupted and often there is additional injury to the blood supply, nerves, and tendons. Furthermore, contamination of the wound is associated with an increased risk for infection. The surgeon must apply a systematic approach to the treatment of these injuries to minimize the risk for infection and scarring while re-establishing the skeletal architecture. Initially, open hand fractures require irrigation and debridement of contaminated and devitalized tissue. The soft-tissue envelope must be reconstructed before definitive skeletal reconstruction and bone grafting. Injuries to the blood supply, nerves, and tendons must be recognized and treated appropriately.