Purpose: The management of Dorsal Fracture Dislocations of the PIP joint is challenging, especially for the unstable ones. Complications are common and often lead to functional disability. Many treatment methods have been described in the past, illustrating that no optimal solution has been found. In the Hemi-Hamate autograft technique, introduced by Hastings in 1999, a reconstruction of the volar lip joint surface and stabilization of the joint is achieved. This autograft can be seen as a model of a non vascularised bone-cartilage composite graft. The purpose of the present retrospective study was to evaluate the long term results of the hemi-hamate autograft technique in unstable PIP fracture-dorsal dislocations with special reference to posttraumatic degenerative arthritis common in non vascularized joint transfers.

Materials and Methods: We report the results of 9 patients operated between November 2002 and March 2008 and with a minimum follow up of 26 months. The mean follow-up time was 56 months. There were 6 men and 3 women with a mean age at operation of 45 years (23–66). All fractures were unstable with comminution of the volar lip. In 3 patients the dominant hand was involved. The middle finger was injured in 4 patients, the ring finger in 4 and the little finger in 1 patient. All patients were treated with the operation technique described by Hastings and reanalyzed by Williams. The volar base of middle phalanx was debrided and reconstructed by a pre-sized autograft harvested from the dorsal side of the homolateral hamatum, and fixed with mini screws. A standard rehabilitation program was used postoperatively. Clinical (ROM, grip strength), radiographic and subjective outcomes (VAS) were examined in all patients.

Results: At the last follow up, the injured finger had an average active ROM at the MCP joints of 97o (90o–115o) at the PIP 69 o (45 o –95 o) and at the DIP 59 o (30 o –90 o). The extension lag in the PIP joints were mean 10 o (0 o –30 o). Grip strength of the injured hand was mean 89% of the uninjured contralateral side. On radiographs, severe arthritis in the treated PIP was found in 2 of 9 patients. Another 2 patients had degenerative arthritis in several PIP. The average subjective score of patient’s satisfaction was 85 (20–100) in a scale 0–100 (100 best).

Conclusions: The Hemi-Hamate autograft technique is a technically demanding operation but an alternative to arthrodesis or primary joint arthroplasty in the treatment of Fracture-Dorsal Dislocations of PIP joint. Our results are good and comparable to previously reported results (Williams 2001). Some deterioration will occur regarding joint osteoarthritis but a high degree of subjective patient satisfaction was found. Further studies and methods to decrease the osteoarthritis would be preferential.

Introduction: The choice of whether to use absorbable or non-absorbable suture in the closure of wounds following hand or upper limb surgery is usually surgeon dependent. In our unit both continuous absorbable subcutaneous suture and interrupted non-absorbable suture are utilised. The use of absorbable sutures offers a potential advantage to the patient and clinician in not requiring a clinic appointment for suture removal. The quality and aesthetic appearance of hand and upper limb surgical scars are of great importance to patients. Few studies have compared the aesthetic appearance of scars following the use of absorbable and non-absorbable suture in hand and upper limb surgical wound closure.

Method: 50 consecutive patients having undergone day case hand surgery between August 2007 and May 2008 with absorbable suture wound closure were identified along with 50 consecutive patients over the same time period who underwent non-absorbable wound closure. Each was sent a questionnaire comprising a visual analogue scale (VAS) for wound satisfaction, a validated 6 point patient scar assessment tool and the short version of the Disabilities of the Arm, Shoulder and Hand questionnaire (QuickDASH).

Results: 100 patients were contacted by post and 70 responses were received (37 absorbable, 33 non-absorbable). Both groups had undergone a similar spectrum of procedures including carpal tunnel decompression, Dupuytrens fasciectomy, excision of lesions and trigger finger release. Age, sex and QuickDASH scores were not significantly different between groups. Mean VAS was not significantly different between groups (Non-absorbable group 82.4 (95% CI 74.7–90.2) Absorbable group 80.4 (95% CI 71.9–89.0)). No significant difference was found between groups in terms of pain, itching, scar colour, stiffness, thickness or irregularity.

Conclusion: No significant difference in aesthetic appearance of scars exists following the closure of hand and upper limb wounds with either absorbable or non-absorbable suture. Either suture material can be used with confidence with respect to aesthetic outcome.

Traditionally open extensor tendon injuries in zones III to V (PIP to MP joints) have been treated with repair and immobilization in extension for 4 to 6 weeks. Early controlled motion protocols have been successfully used in zones VI and VII of the extensors. An early controlled mobilization protocol combined with strong repair for zones III to V extensor tendon lacerations was studied prospectively.

From 1999 to 2003, 27 extensor tendon lacerations in 26 patients, mean age 34 years (range 14–70), were treated using dynamic extension splinting. Inclusion criteria were zone III to V, complete lacerations involving the extensor mechanism and possibly the dorsal capsule (without associated fractures or skin deficits) in patients without healing impairment. All injuries were treated in the emergency department with a core Kessler-Tajima suture and continuous epitendon suture. After an initial immobilization in a static splint ranging from 5 days (for zone V) to 3 weeks (for zone III), controlled mobilization was initiated with a dynamic splint that included only the injured finger. The patient was weaned off the dynamic splint 5 weeks after the initial trauma. The patients were treated in an outpatient basis and did not attend any formal physiotherapy program.

The mean follow up was 16 months (range 10–24 months). No ruptures or boutoniere deformities were observed and no tenolysis was necessary. The mean TAM was 242deg for the fingers and 119deg for the thumbs. The mean grip and pinch strength averaged 85% and 88% that of the contralateral unaffected extremity. 77% of the patients achieved a good or excellent result in Miller’s classification. The mean loss of flexion was found to be greater than the mean extension deficit.

The protocol described above was found to be safe, simple, functional, cost effective and reproducible for zone III to V simple extensor tendon injuries. Success is based on strong initial repair, close physician observation and a cooperative patient. The addition of physiotherapy for patients with flexion deficits in the period immediately after dynamic splinting may ameliorate results.

Aim: To study the carpal geometry in patients with symptomatic scaphoid non-union without arthritis or with early arthritic changes. Method: The preoperative x-rays of 58 patients were retrospectively reviewed and x-rays of 35 of those fulfilling strict criteria for true projections were digitized and measured using CAD methodology. Patients’ mean age was 31,3 years and mean time from fracture 50,4 months. The measured variables concerned the carpal height, possible displacement of the carpal bones and carpal instability. The Herbert and Fisher classification was used and two subgroups concerning the absence (14) or presence (21) of early arthritic changes were created. Results: 62,5% of the patients (including patients without radiologicaly obvious arthritis) were presented with increased radial height and radial inclination, 28% with an affected carpal height, 17% with ulnar translocation of the wrist and up to 48% (varying according to the method of measurement) with a DISI pattern of instability. No statistically significant differences could be established between the morphological groups or between the two subgroups concerning early arthritis. Conclusions: Carpal geometry in scaphoid non-union although altered does not seem to change significantly with the appearance of early arthritis and thus treating non-union with early arthritis with osteosynthesis and bone grafting seems justified. In view of our findings it seems appropriate to supplement this procedure with distal radial osteotomy or with temporary lunate stabilization in selected patients.

The most common management of open injuries of the extensor tendons in Zones III to V (PIP to MP joint) is tendon suturation and digit immobilisation in extension for 4 to 6 weeks. Dynamic splinting and early mobilisation has been already successfully tested in the treatment of extensor tendons injuries in Zones VI to VII. In the current study we performed a protocol, including strong suture technique of the lacerated extensor tendon in Zone III to IV in addition with early mobilisation.

From 1999 until 2002, 23 lacerated extensor tendons (Zones III – V) in 22 patients were managed at the Orthopaedic Department of the Univercity of Ioannina. The mean age of the patients was 36 years old (14 – 70 years). The principle treatment has taken place at the emergency room and included suture of the lacerated central slip, using the Kessler-Tajima technique, plus continuous suture of the epitenon. Injuries of other structures (lateral bands, sagittal band, joint captule) were also managed by suturing. After a period of 5 days (Zone V) to 3 weeks (Zone III) of immobilisation in a static splint, injured digit mobilisation started using a dynamic extensor splint until the 5th week after injury.

The mean follow up was 7 months (3–24 months). There have been no ruptures of the extensor mechanism nore permanent digit deformities. Minimal (until 30o) loss of MP flexion or DIP extension has been regarded in 5 patients. The grip strength has been affected in 4 patients, and the grip strength between the 1st and 2nd digit (“the key pinch strength”) has been affected in 12 patients, compared with the contralateral hand. No further operation for tenolysis has been necessary.

Satisfactory results have been obtained, by early mobilisation using dynamic splinting, in the treatment of open injuries of extensor tendons in Zones III – IV under the following conditions: using strong suture technique, a co-operative patient and weekly examination of the patient. Using a dynamic splint only for the injured digit is better accepted by the patient.

The symptomatic non-union of the scaphoid, if left untreated, will eventually lead to established arthritis and by that time important alterations in carpal geometry will have occurred. The aim of this paper is to study the carpal geometry in patients with symptomatic scaphoid non-union without arthritis or with early arthritic changes.

The pre-operative x-rays of 58 patients were retrospectively reviewed and x-rays of 35 of those fulfilling strict criteria for true projections were included (32 posteroanterior and 31 lateral views). Patients’ mean age was 31.3 years and mean time from fracture 50.4 months. The x-rays were digitized and measured using CAD methodology. The measured variables concerned the carpal height, possible displacement of the carpal bones and carpal instability. The non-unions were classified according to the Herbert and Fisher classification and were further categorized in two subgroups concerning the absence (14) or presence (21) of early arthritic changes in the radio-carpal or in one of the mid-carpal articulations (patients with established or generalized arthritis were excluded).

In total (and varying according to the method of measurement) up to 28% of the patients were presented with an affected carpal height, up to 17% with ulnar translocation of the wrist and up to 48% with a DISI pattern of instability. 62.5% of the patients (including patients without radiologicaly obvious arthritis) had increased radial height and radial inclination. After statistical analysis (ANOVA and regression analysis) no significant differences have been found between the morphological groups or between the two subgroups concerning early arthritis. A tendency of the lunate to translocate both in the coronal and the sagital plain simultaneously was found and the measurement methods were correlated.

In conclusion the carpal geometry in scaphoid non-union although altered does not seem to change significantly with the appearance of early arthritis and from this point of view treating non-union with early arthritis with bone grafting and osteosynthesis or even with additional radial osteotomy seems justified.

In late cases of brachial plexus palsy or when nerve reconstruction was not that beneficial, pedicled or free neurotized muscles i.e. latissimus dorsi are used to restore or enhance important functions i.e. elbow flexion or extention.

During the last three years, 43 patients with brachial plexus injuries were operated in our Clinic to reconstract the paralysed extremity. In nine of them, the ipsilateral latissimus dorsi was transferred as pedicled neurotized muscle to restore elbow flexion (seven patients) and elbow extension (two patients). Two patients had free latissimus dorsi transfer, which was neurotized directly via three intercostals. The neurovascular pedicle was dissected proximally up to the subclavian vessels and posterior cord, and the muscle was raised from its origin to its insertion and tailored to simulate the shape of biceps or triceps. Then it was passed via a subcutaneous tunnel on the anterior or posterior arm. The reattachment was done with Mitek anchors on the clavicle and the radial tuberosity (elbow flexion) or on the posterior edge of the acromion and the olecranon (elbow extension). The arm was immobilized in a prefabricated splint, which was removed after six to eight weeks.

After the first three months all patients had a powerful elbow flexion or extension. One of the free muscle transfers started to have elbow flexion after eight months and he is still progressing. In one patient skin necrosis and infection occurred near the elbow. The patient after IV antibiotics needed another operation to restore the distal insertion, using fascia lata.

Ipsilateral latissimus dorsi, if strong enough (at least M4), is an excellent transfer for elbow flexion or extension restoration or enhancement, in late cases of brachial plexus paralysis. Contralateral latissimus is an option when the ipsilateral is weak but it takes more time to function since there is a waiting period for reinnervation.