Ralph W. Coonrad

Impacted Fractures in the Proximal Portion of the Proximal Phalanx of the Finger

1. A ten-year-follow-up of sixty-eight patients with impacted fractures in the proximal third of the proximal phalanx in the hand (forty-one in children, twenty-seven in adults) revealed that two of six children over age ten had malunion with loss of significant flexion and extension of the proximal interphalangeal joint; of seventeen adults, nine had malunion and seven, first seen more than five weeks after injury, had angulation of 25 to 70 degrees with significant loss of both flexion and extension at the proximal interphalangeal joint. 2. The commonest causes of malunion were immobilization of the digit in insufficient flexion at the metacarpophalangeal and proximal interphalangeal joints, permitting loss of reduction and acceptance of oblique rather than true lateral roentgenograms for evaluation of angulation in fractures of the proximal phalanx, both before and after reduction. 3. Impacted fractures of the proximal portion of the proximal phalanx in the hand are more common in children than in adults. In younger children, residual angulation of 30 degrees or less should remodel without significant disability. 4. Uncorrected angulation of 25 degrees or more in the adult or older child usually results in loss of both flexion and extension of the proximal interphalangeal joint, aside from any adherence of tendon apparatus adjacent to the fracture site. 5. Fractures of the proximal phalanx in the hand should be immobilized with the wrist in functional extension, the metacarpophalangeal and proximal inter phalangeal joints flexed to a functional position and with the finger tip positioned three to four centimeters from the palm. 7. An open-wedge osteotomy with bone graft from the distal end of the radius or of the ulna is described for early malunion; and, transverse osteotomy with internal fixation may be necessary for older deformities and when osseous shortening is indicated.

TRAPPING OF THE POSTERIOR TIBIAL TENDON AND INTERPOSITION OF SOFT TISSUE IN SEVERE FRACTURES ABOUT THE ANKLE JOINT

Two cases of trapping of the posterior tibial tendon, in one of which there was associated trapping of the posterior tibial nerve, and two cases with interposition of a reflected portion of the deltoid ligament within the medial aspect of the joint space, are presented as complications of severe fracture-dislocation of the ankle joint, requiring open reduction. Failure to achieve anatomical reduction in fractures about the ankle is probably the largest cause of poor end results. It is suggested that any patient with fracture-dislocation of the ankle1 in which there is severe medial ligamentous injury and disruption of the mortise, which cannot be reduced by initial closed manipulation, be considered a candidate for early open surgical reduction. True anteroposterior roentgenograms of the ankle joint are necessary for any critical evaluation of mortise alignment.

Tendon Grafting of the Flexor Profundus in the Presence of a Completely or Partially Intact Flexor Sublimis

Disagreement exists over late treatment of the divided flexor digitorum profunidus tendon in the finger when the sublimis remains completely or partially intact. Arthrodesis or tenodesis of the distal interphalangeal joint can restore stability of the distal segment of the finger, but strength, dexterity, and mobility are riot necessarily restored. Restoration of the profundus tendon by free grafting has been recommended, under certain conditions, by Pulvertaft, Jaffe arid Weckesser, arid others. Our experience during the past ten years with late profundus grafting in the presence of a completely or partially intact sublimis is reported. The material includes results and indications for selection of this procedure.

GIANT-CELL ARTERITIS--AN ACUTE HAND SYNDROME.

Giant-cell arteritis is essentially an inflammatory condition often resulting in partial or complete vascular occlusion which is capable of resolution. The disease may occur as an acute of chronic focal process or as a widespread systemic disease. Temporal artery involvement has been described more commonly; extremity lesions heretofore have usually been described only at necropsy. This report presents three cases of an acute, painful process involving the radial, ulnar, and median arteries. A preoperative diagnosis of giant-cell arteritis was made in the last of the three cases described. These three cases are presented to draw attention to this acutely painful hand syndrome, which undoubtedly is widely seen and seldom recognized. Resection of the portion of the artery involved, when possible, had given relief where other measures have failed.

Marie-Strümpell arthritis; follow-up study of roentgenographic, physical, and orthopaedic therapy.

From clinical observations it appears that the roentgen irradiation affects the cellular changes of Marie-Strumpell arthritis, but we have no evidence that. it affects the associated ossifying process once it is under way. In a series of 100 patients with Marie-Strumpell arthritis, treated by roentgenotherapy plus corrective measures, the results, based on relief of pain, range of motion, and roentgenographic changes, indicate that the therapy can be expected to give approximately the same relief from pain during any stage of the disease. Increase in range of motion can be expected in a fair percentage of the mild and moderately advanced cases. Although there is relief from pain, a decrease in range of motion and further ossification may occur. In the mild or moderately advanced cases, the process can be arrested and in some instances cleared by the roentgenotherapy. Of the forty-seven patients in the mild and moderately advanced groups, fifteen showed roentgenographic clearing of the bone changes; twenty-four sholved no change or advance in the disease; only seven showed advance with additional ossification. Comparison with the advanced group of thirty-two patients shows that roentgenographic improvement can be expected in the earlier cases more frequently than in the advanced cases, where the changes are no longer reversible.

Unusual Case of Multiple Abnormalities of Bone with Malignant Degeneration

A bone disease different from any disease commonly recognized was found in one patient observed by us. The pathological changes were a combination of those found in fibrous dysplasia, multiple enchondromatosis, and hemangiomatosis, with final evolution into osteogenic sarcoma.