Role of emergency reconstruction of fingers by the "reposition-flap" technique. Report of eight cases

Following replantation failure, fingertip reconstruction was performed as an emergency "reposition-flap" procedure in seven patients (eight fingers). This technique was intended for amputations distal to the DIP joint in long fingers, and IP joint in the thumb. Pulp was excised on the amputated segment, and the remaining bone and nail bed were reattached to the proximal stump with Kirschner wires. Pulp was reconstructed with a local advancement and sensitive flap. Trophicity and nail regrowth as well as mobility and strength were satisfactory in five cases. MRI examination showed revascularization of the distal bone fragment in four cases. This procedure is an alternative to amputation after replantation failure when patients do not accept finger shortening. The more distal the amputation, the better is the result.     

Replantation of degloved skin of the hand

The treatment of a degloving injury is one of the most difficult problems in hand surgery. Various reconstructive procedures have been adopted in the past years, all with poor results. Between 1988 and 1995, nine patients with degloving injuries of the hand and fingers were treated by microsurgical replantation. The injury involved the thumb in three patients, the ring finger in three patients, the little finger in one patient, and multiple fingers in two patients. Successful complete revascularization was obtained in seven patients. In one case a superficial necrosis of the replanted thumb skin occurred with good preservation of the subcutaneous layer. In one patient with a degloving injury involving multiple fingers, revascularization was achieved only in the middle finger, and the first ray was secondarily resurfaced by a free flap from the foot. In our experience revascularization of the degloved skin does represent the best solution and must be managed as an emergency procedure. Coverage obtained in this way offers the best cosmetic result and allows early mobilization with good recovery of joint movement. Reestablishing sensibility is more difficult. It is not always possible to suture the nerves damaged by the trauma, and even when a careful primary nerve anastomosis is performed, the results often are unsatisfactory, probably because of the avulsive mechanism of nerve injury.     

Salvage replantation of two fingers from a nonreplantable midpalm

To achieve better functional results following mutilating multidigital trauma, every effort should be made to maximize the ultimate function of the hand, and the plan of replantation should be guided accordingly. All usable parts should be salvaged from the amputated nonreplantable areas. A patient is reported in whom two fingers taken from the nonreplantable midpalm were used to reconstruct the thumb and ring fingers, ultimately improving the overall quality of the patient's life.     

Benign esophageal stricture caused by diffuse severe esophagitis presenting as ascending fibrosis: report of a case

It is generally accepted that replanted digits surviving at least 1 week following surgery rarely succumb to ischemic necrosis. Presented here are 2 patients who experienced late digital replantation failure. The first patient is an 8-year-old boy who had his index finger replanted at the proximal phalangeal level. After 16 days of viability, the replanted digit became swollen and subsequently necrosed. The second patient is a 35-year-old man with a history of smoking and intravenous drug use who underwent replantation of his avulsed thumb at the metacarpophalangeal joint. The replanted thumb was viable at the 2-week follow-up, but began to show ischemic changes at 3 weeks and eventually required revision amputation at the interphalangeal level. Both of these patients demonstrate late digital replantation failure--an unusual and poorly understood phenomenon. A discussion of possible risk factors and potential pathophysiology is presented.     

New concepts in arthroplasty of the hand and wrist

Clinical trials with cemented polyethyiene and metal total joint arthroplasties were initiated in 1973. Replacements have been developed for the wrist, carpometacarpal joint of the thumb, metacarpophalangeal joints of the thumb and fingers, and the proximal interphalangeal joints of the fingers. Results, evaluated by pain relief and joint stability, were excellent at all sites. Motion, however, averaged only 50% of normal. Significant problems included abnormal posture in the wrist, roentgenographic evidence of loosening in the finger metacarpophalangeals, extensor lag in the metacarpophalangeal of the thumb, and lack of motion in the proximal interphalangeal joint of the finger.     

Molecular cytogenetic characterization of breakpoints involving pericentric inversions of human chromosome 9

Thirty consecutive patients with amputation or devascularizing injuries of the thumb or two or more fingers proximal to the PIP joint were reviewed. Replantation or revascularization had been done in 27 patients, in 24 successfully. Three patients had primary amputation. The distribution of calculable costs was dominated by those for sick leave (49%), operation (26%) and ward costs (20%). Out-patient care, physiotherapy and travel together constituted only 6%. The cost of a successful replantation was equal to 1.6 times the mean annual salary of these patients and that of primary amputation about half as much. Mobility, power and performance of a standardized grip test were better for the successfully replanted or revascularized patients. Subjective evaluation of 23 parameters of function, cosmesis and quality of life did not disclose any differences. All patients except three had returned to their original work within 2 years.     

Management of the amputated thumb

Two cases are described, one of replantation of an amputated thumb, the other of late reconstruction by toe transfer. A possible reason for the good results in thumb replantation is mentioned, and the advantages of toe transfer in thumb reconstruction are discussed. Suggestions are made as to the course of action to take when confronted with a patient with an amputated thumb.     

Formation and migration of avian primordial germ cells

A retrospective review of 22 patients who sustained snowblower injuries to the hand was performed. There were 17 men and 5 women, ranging in age from 20 to 68 years (average age, 39.7 years). Fifty percent were manual laborers, 25% were unemployed, 15% were office workers, and 10% were not categorized. The dominant hand was involved in 86% of patients. In all patients, injuries occurred during an attempt to unclog manually the snowblower of wet snow. Patients were evaluated initially in the emergency room, where their wounds were irrigated and debrided, subungual hematomas drained, and nail bed lacerations repaired. Patients with more extensive injuries were taken to the operating room for definitive treatment including open or closed reduction of fractures, fingertip replacement as composite grafts or skin grafts, revision amputations, tenorrhaphies, and digital nerve repairs. All injuries occurred distal to the metacarpophalangeal joints. Only 1 patient sustained an injury to the proximal phalanx. Ten patients injured only 1 finger, 6 patients injured 2 fingers, and 6 patients injured 3 fingers. The middle and ring fingers were most commonly injured (39.6% and 33.3% respectively), followed by the index and little fingers (16.7% and 8.3% respectively), and the thumb (2.1%). Phalangeal fractures were the most common type of injury, occurring in 29.2% of patients, and usually involved the distal phalanx. This was followed in frequency by nail bed injuries (22.9%), amputations (22.9%), tendon lacerations (14.6%), soft-tissue avulsions (6.3%), and digital nerve injuries (4.2%). Snowblower injuries can involve bone, soft tissue, nail bed structures, nerves, and tendons, and may even result in amputation of one or several fingers. These injuries are localized to the distal portions of the fingers. The middle and ring fingers are most commonly involved, with relative sparing of the thumb. Fractures are the most frequent injury, followed by nail bed injuries and amputations. Snowblower injuries are often managed as open fractures with intravenous antibiotics; irrigation and debridement; and repair of bone, soft tissue, and nail bed structures.     

Individual finger forces acting on a grasped object during shaking actions

Individual finger grip forces acting on a hand-held object were examined during shaking tasks with a five-finger precision grip. The subjects (n = 13) shook a force transducer-equipped grip object (mass = 400 g) in vertical, horizontal, and mediolateral directions at an average movement speed of 33 cm/s (moderate) and 66 cm/s (fast). In addition, grip forces were examined while the subjects (n = 10) held the object in front of the body and walked or ran in place. It was found that the grip forces for all the fingers changed temporally and spatially coupling with the acceleration of the object resulting from shaking. The results suggest that grip force control is accomplished in an active and anticipatory fashion. Regardless of the shaking direction and speed, among the four fingers the absolute grip force in the index finger was largest, followed by the middle, ring, and little finger forces. The index finger therefore plays a primary role in grip force control during shaking. The percent force contribution by each finger varied depending on the direction of shaking. Contributions of the ring and little fingers were larger when shaken in the horizontal and mediolateral directions than they were in the vertical direction. The results suggest that different finger co-ordination is required in relation to shaking direction. Changes in shaking speed from moderate to fast changed the grip forces for all the fingers. During walking and running, grip force control similar to that during active vertical shaking was required to hold the object safely in the hand.     

Factor analysis of finger ridge-counts in Blacks and Whites

Finger ridge-counts of an American White, American Black and an African Black sample were subjected to factor analysis. The analysis was carried out using correlation matrices computed from 10-ridge counts, each finger being represented by its largest count, and from 20 ridge-counts, using both radial and ulnar counts for each finger. The 20 count analysis was much more informative, demonstrating the relative independence of the radial and ulnar sides of the fingers. Moreover, the radial and ulnar counts themselves generally resulted in two factors reflecting counts on the ulnar digits and the median digits. The independence of the thumb was also demonstrated. There was considerable intersample consistency, although some evidence of sex and race variation was observed.     

The treatment of older adult patients with acute myeloid leukemia by triple infusion chemotherapy

This retrospective study analyzed 202 toe-to-hand transplants performed over the last 20 years at the Davies Medical Center, San Francisco (USA). The overall success rate was 97%. Toe transplants for finger reconstruction yielded optimal functional and cosmetic results due to their anatomical similarity to fingers. The great toe was preferably used for thumb reconstruction, whereas the other toes were used for reconstruction of the long fingers. Early reconstructions, multiple simultaneous toe transplants, and interventions combining toe transplantation with free flaps seemed to be advantageous because of shorter rehabilitation and comparable results.     

Donor site morbidity in cross-finger flaps

As relevant literature is scarce, this study was undertaken to assess the donor site morbidity of cross-finger flaps. It included 23 patients who had undergone reconstruction of a finger defect with a cross-finger flap. Any additional trauma to the donor finger was an exclusion criterion. Split thickness skin grafts were employed for donor site closure in 13 cases, full thickness skin grafts were used in 10 cases. Follow-up time averaged 83 months. Active and passive total range of motion of the donor finger and maximal pinch grip strength in kilopascals were measured. Both parameters were compared to the corresponding finger of the other hand. The donor site scar was evaluated for instability and pain in the donor finger was determined subjectively with a visual analogue scale. Cold intolerance and the cosmetic appearance of the donor site were also assessed.Active total range of motion of the donor fingers averaged 156°. Average active total range of motion of the contralateral control fingers was 173.6°. There was a significant difference between the donor fingers and the control fingers (p=0.03) but not between split thickness and full thickness grafted donor sites (p=0.91). Grip strength was significantly impaired in the donor fingers (p=0.03), but there was no significant difference between split thickness and full thickness grafted donor sites. Subjective cosmetic evaluation by the patients revealed significantly better results for full thickness grafted donor sites. Donor finger pain averaged 2.4 with a range of 0–8. Five of the 13 patients with split thickness grafted donor sites and two of the 10 patients with full thickness grafted donor sites mentioned cold intolerance.In conclusion, the cross-finger flap is a secure and valuable option. There is, however, significant donor site morbidity. Our results suggest that alternative solutions should also be considered and if a cross-finger flap is employed, donor sites should be closed with full thickness grafts.     

Distal thumb reconstruction with a great toe partial-nail preserving transfer technique

The great toe partial-nail preserving transfer technique is another modification for distal thumb reconstruction in composite defects at or below the interphalangeal joint of the thumb. Noting the size difference of the nail width between the great toe and thumb, the authors dissected only a thumb nail width and skin flap from the great toe, leaving the remainder of the medial skin flap and nail of the great toe at the donor site. A total of 25 cases between 1993 and 1996 were performed using this technique, and the mean follow-up period was more than 12 months. The reconstructed thumb had a better cosmesis with a more natural appearance. At long-term follow-up, the thumb nail width decreased an average of 1.8 mm, but the pulp volume was almost the same as that of the normal contralateral side. The average static 2-point discrimination was less than 9.0 mm. In cases with preserved interphalangeal joint, an average of 48 degrees of range of motion with key-pinch of 80 percent of that of the normal contralateral thumb was achieved. The final appearance of the donor site with partial nail looks like a brachymetatarsia.     

Upper extremity replantation: current concepts and patient selection

Dramatic advances in replantation and microsurgery have somewhat altered the criteria we use in selecting patients to be candidates for upper extremity replantation surgery. We suggest that contraindications for such replantation are: presence of associated life-threatening injuries; serious anesthetic risk; preexisting medical or psychiatric problems; previous injury or disease of the amputated part; warm ischemic time greater than 6-8 hours for extremities or greater than 10-12 hours for digits; and single-digit amputations (except thumb, for grasp). Replantation is feasible when: amputated part is properly preserved; injury type is sharp amputation, mild to moderate crush, or selected avulsion, and amputation is proximal to the DIP joint. Careful preservation of the amputated part, not in dry ice, is mandatory. On an individual basis, the decision to attempt replantation rests on the prediction that the patient may have better function with such surgery than with a prosthesis.     

Decision making in detecting abnormal Semmes-Weinstein monofilament thresholds in carpal tunnel syndrome

Both hands of 39 patients who had symptoms of pain and/or numbness in one or both hands were tested by two hand therapists using the full kit of Semmes-Weinstein monofilaments (SWMFs). The SWMF thresholds were obtained for the thumb, the index finger, and the long and small fingers. These thresholds were classified as normal or abnormal based on four decision rules and two criterion measures. Decision rules were based on whether SWMF 2.83 or 3.22 would be the best limit of normality, and whether the small finger should be used for within-subject comparisons. The criterion measures were the highest threshold of all three radial digits and the highest threshold of the long finger alone. Intertherapist agreement on normality was fair to moderate (kappa = 0.22-0.51), varying according to decision rules and criterion measures. Reliability was higher when the additional comparison with the small finger was omitted. High accuracy in identifying cases of carpal tunnel syndrome (CTS) was possible, but accuracy varied moderately between testers and greatly according to decision rules and criterion measurements. The best overall accuracy (81%-82% sensitivity and 57%-86% specificity) was achieved when SWMF 2.83 was used as the upper limit of normality and the small finger was used for within-subject comparison, and when data from the long finger alone were used for decision making.     

Centrifuge Modeling of Unstable Infiltration and Solute Transport

Unstable flow can result in the formation of fingers during infiltration into dry soil. Centrifuge modeling is a potentially useful tool to study the relationship between finger size, spacing, and velocity. It can also be used to investigate solute transport in such fingers. Physical properties of the fingers are obtained for three tests conducted at elevated acceleration levels. A fourth test was conducted at 1g. The physical parameters compare well with theoretical predictions. To assess solute transport in fingers, a known concentration of solute was introduced after the fingers had formed. The resulting breakthrough curves were analyzed using the two-region model as well as the advection dispersion equation with appropriate initial and boundary conditions. Although the two-region model is physically more plausible, it was found to match the extensive tailing observed in the breakthrough curves only marginally better than the advection-dispersion equation.     

Spatio-temporal properties of the pattern of evoked phantom sensations in a left index amputee patient

In a left index finger amputee, appropriate stimulation of skin areas of the remnant left fingers or left lower face evoked veridical sensations as well as sensations localized to the phantom finger. Five months after the amputation, there was a systematic correspondence between positions of digital and facial stimuli and positions of stimuli felt on the phantom. More than 3 years after the amputation, orderly maps of the phantom index on the ipsilateral fingers were still detected. By contrast, poorly organized facial maps were present only contralaterally to the amputation. The maps on the remnant fingers are likely to acquire stability because they are systematically activated during manipulations performed with the mutilated hand. The disorganization of facial maps may be related to their irrelevance for behavioral control in everyday life conditions.     

Clinical experience and indications of the free serratus fascia flap: a report of 21 cases

The free "serratus fascia" flap as a free flap was first described by Wintsch and named a free fascia flap of gliding tissue; however, it has not yet been given a distinct name. The particular advantages of this flap consist of an easy access and a low donor-site morbidity without functional deficit. Additionally, it may be designed very variably and molded even three-dimensionally as a tendon wraparound flap or folded to fill up cavities. In our clinic, we used this flap in 21 patients for distinct indications and in 7 patients as a vascular graft in fingers or great toe with a minimal adjacent layer of gliding tissue around the vessels for the treatment of cold intolerance after finger replantation or severe finger or toe trauma. In the other cases, this versatile flap served for the coverage of traumatically exposed tendons or bones at the extremities, covered with a skin graft. Eighteen flaps survived completely, whereas 3 flaps developed partial or superficial necrosis. Only once did a major complication by unintentional sacrification of the long thoracic nerve during flap harvesting occur, resulting in a wing scapula. We recommend this flap for defect cover at sites where a thin vascularized gliding layer for defect cover is needed, especially in distal extremities with exposed tendons or nerves, and present the current indications in discussing our experiences.