Goro Inoue

Dislocation of the extensor tendons over the metacarpophalangeal joints

Twenty-seven patients who had received treatment for dislocation of the extensor tendons over the metacarpophalangeal joint were reviewed. Sixteen patients had traumatic dislocations, seven had spontaneous dislocations, and four had congenital dislocations. The long finger was most frequently affected. The other fingers were affected almost equally. Displacement of the extensor tendon always occurred in the ulnar direction in the long and ring fingers. The index and little fingers exhibited different patterns of dislocation: two patients had ulnar dislocation of both the common and proprius tendons, and the remaining five patients had divergent dislocation of the two tendons. Nonsurgical treatment was undertaken in six cases. Surgery was performed in 21 cases. No recurrent dislocations were reported in any of the patients. Based on our experience, patients seen within 2 weeks of injury initially should be treated with splinting of the involved metacarpophalangeal joint. Chronic dislocations should be treated with a primary repair of the defect in the sagittal band. When the sagittal band is absent or deficient, the tendon must be stabilized using a loop procedure with a tendon slip.

Resurfacing of skin defects of the hand using the arterialised venous flap

In 22 patients an arterialised venous flap, with arterial blood only flowing through the vein of the flap, was used to cover skin defects of the hand. There were 17 complete successes, four partial successes and one complete failure. The main indications for use of the arterialised venous flap are to cover extensive skin loss with exposed bone or tendon where conventional flaps cannot be applied and to reconstruct the digital arterial defect where both revascularisation and skin coverage are needed.

Corrective ulnar osteotomy for malunited anterior Monteggia lesions in children: 12 patients followed for 1-12 years

We reviewed 12 children, mean 5 (1-12) years, after corrective osteotomy of the ulna, combined with open reduction of the radial head for malunited anterior Monteggia lesions (Bado type I). A simple corrective osteotomy was used in the first 6 patients (group A) and a posterior angular osteotomy was used in the second group of 6 patients (group B). All osteotomies healed uneventfully, but 3 patients had a persistent dislocation of the radial head. Children who had been treated with an angular osteotomy had the best clinical outcome).

Management of acute perilunate dislocations without fracture of the scaphoid

A retrospective review of 14 cases of acute perilunate dislocations without fracture of the scaphoid managed by three different forms of treatment was conducted at an average follow-up of 29 months. Treatment included closed or open reduction with cast immobilization only (n=2), closed reduction followed by percutaneous K-wire fixation of the carpus (n=4), and open reduction with repair of the torn scapholunate ligaments and K-wire fixation of the carpus (n=8). Based on Cooney’s clinical scoring system, there were five excellent, five good, two fair and two poor results. The patients without ligamentous repair did as well as those with ligamentous repair when the scaphoid was reduced anatomically and stabilized with K-wires. In the latter, however, the scapholounate relationship was maintained more consistently. We believe that open reduction through a dorsal approach, direct repair of the scapholunate ligaments, and K-wire fixation of the carpus is a reliable method for obtaining satisfactory clinical and radiographic results in the management of acute perilunate dislocations without fracture of the scaphoid.

Arterialized venous flap for treating multiple skin defects of the hand

An arterialized venous flap, with arterial blood flowing only through the vein of the flap, was used in each of five patients to cover multiple digital skin defects caused by trauma or burns. Four flaps survived completely, and one showed 30 percent partial necrosis. Although this procedure will require additional refinement, it permits a certain range of motion of the involved digits prior to flap division and inset.

Osteochondritis dissecans of the elbow managed by Herbert screw fixation.

Seven patients (eight elbows) with osteochondritis dissecans were treated with cancellous bone grafts and internal fixation of the fragment using a Herbert screw. Average follow-up was 32 months. All patients were pain-free and returned to previous sporting activities. The postoperative range of motion of the elbow increased by an average of 18 degrees. Radiographs showed complete reossification of the capitular cyst and normally contoured joint surface.

Herbert screw fixation for scaphoid nonunions: An analysis of factors influencing outcome

A retrospective review of 160 cases of scaphoid nonunion treated by internal fixation using a Herbert screw with bone grafting was conducted at an average followup of 24 months. Definite radiographic union was achieved in 90% of cases. Based on Cooneys clinical scoring system, 80 cases had an excellent result, 37 had a good result, 33 had a fair result, and 10 had a poor result. Failure of union was related to the existence of avascular changes of the proximal fragment, instability of the fracture fragment, the prolonged delay in surgery, and the location of the fracture site. In the united scaphoids, the lengthy period of postoperative immobilization, the existence of osteoarthritis, and the prolonged delay in surgery were significant factors in the patients functional outcome. Overall, the results do not support the view that a residual flexion deformity of the scaphoid is less likely to yield a satisfactory outcome, although it seems worthwhile to correct excessive angulation at the time of repair to promote an anatomic union, thereby preventing early arthritis. A bone graft with internal fixation using a Herbert screw and a shorter period of immobilization may give a satisfactory functional result when the nonunion is treated before the onset of arthritic changes in the wrist.

Closed reduction of mallet fractures using extension-block Kirschner wire.

Summary Fourteen cases of mallet fingers with a displaced large fracture fragment and/or a subluxated distal phalanx were treated by closed reduction using extension-block Kirschner wire. The follow-up evaluations took place after a mean of 9 months. The results according to Crawfords criteria were eight excellent, four good, one fair, and one poor. This technique is simple, is easier than other techniques for reduction of mallet fractures, and is associated with a low morbidity.

Proximal row carpectomy in perilunate dislocations and lunatomalacia.

Proximal row carpectomy was performed in 13 wrists with old unreduced perilunate dislocations and in 4 wrists with Kienböcks disease. One failure was converted to wrist arthrodesis, and 2 patients were lost to follow-up. The remaining 14 patients were reexamined after 11 (3-19) years. Average ranges of wrist motion were 37 degrees of dorsiflexion, 30 degrees of palmar flexion, 5 degrees of radial deviation, and 24 degrees of ulnar deviation. Grip strength averaged two thirds of the uninvolved hand. Pain relief was achieved in 12 patients, who all returned to their previous occupations. The results according to Cooneys criteria were 1 good, 8 fair, and 5 poor.

Nonoperative treatment of camptodactyly

Twenty-four patients with camptodactyly of their small fingers were treated with a dynamic splint. Most of the patients could extend the proximal interphalangeal (PIP) joints within a few months by using the dynamic splint 24 hours a day. After almost full extension of the proximal interphalangeal joint was achieved, splinting for 8 hours a day produced good final results. However, after the splint was removed, contracture tended to recur. Although further studies are needed to determine the optimum termination of treatment, in our opinion it should be when the growth plate is closed, and longitudinal growth of the finger no longer occurs.