Complex injuries of upper extremity are among the most challenging cases for the treating physician, especially when comminuted fractures, neurovascular injuries or extensive soft tissue loss are accompanied with. Reconstruction of the skeleton is usually very difficult since plates, screws, or external fixation do not always provide sufficient stability. Recently, flexible titanium intramedullary nails that initially developed for pediatric trauma, were introduced in treatment of open and complex injuries of upper extremity.

From 1995 – 2001 20 patients (16 male, 4 female) with a mean age 28 years (15–60 years) were managed at our department with flexible titanium intramedullary nailing. 12 sustained forearm fractures, humeral ones, as well as 4 concomitant fractures of forearm and humerus.Nailing was performed either closed with image intensifier or open through the wound with minimal stripping. Postoperatively a splint was applied. Rehabilitation regime was adjusted to soft tissue care; when severe soft tissue wasn’t encountered, early mobilization of the arm was applied.

Union rate was conceivably high, in a relative short time. In 3 cases of segmental fractures of radius, nail removal and subsequent fixation with plate and screws due to nonunion of distal site, was necessitated.

Operative technique is simple, fast and reliable providing satisfactory reduction, stable fixation with minimal further tissue trauma and mostly early mobilization

In this report we present the results of the primary suture of the flexor tendons in zone II, in 198 patients who were operated in our department between 1998 and the first months of 2001. 142 were male from 16 to 65 years old and 56 were female between 14 to 60 years old. Children below 14 years old are not included in this report.

The majority of patients in this review reported an accident during dancing and late night activities. Patients with complex injuries such as fractures of phalanges, phalangeal dislocations and extensive soft tissue laceration were excluded. The majority of the patients operated immediately within the first 48 hours and only 28 patients (14, 5%) were operated with a delay ranging between 1 – 5 weeks. The suturing technique was variable in all cases. A Bruner (zig-zag) incision was utilized to facilitate. The tendon was sutured using a standard Kleinert technique and 4.0 nylon sutures as supportive sutures, 5.0 nylon sutures were used to suture the epitendon in a continuous fashion. A dorsal splint holding the wrist in 40° of flexion and the MP joints in 70° of flexion and PIPs and DIPs in extension was used postoperatively. Early mobilization was initiated (shortly after surgery, 3 – 4 days) and lasted 4 weeks. After this period the patient underwent a program of full active motion for an additional 4 weeks. They finally allowed to perform freely after a 12-week postoperative period.

We used the Kleinert score to evaluate the surgical results. According to this score results were found to be: Excellent in 80 patients (40%), good in 60 pts (30%), fair in 22 (12%) and poor in 16 pts (8%). Despite the satisfactory overall results we observed a high incidence of tendon ruptures (10%) in 20 patients and this may be related to poor follow up and rehabilitation conditions. No other complications (infection, hematoma formation, and skin slough) were observed in these patients.

Thoracic outlet syndrome (TOS) is characterized by a series of symptoms, which arise from the compression of the neurovascular bundle between the supraclavicular space and its entry to the axilla. The type and intensity of symptoms is relative to the site of compression and the anatomic structures involved.

Between 1990 and 2001, 42 patients were operated for thoracic outlet syndrome utilizing a supra-clavicular incicion (8 bilateral). 12 were male and 30 female. Ages ranged from 21 to 55 years (mean 31). The time interval between the onset of first symptoms and operation was 7 to 12 months in 16 patients and 1 to 4 years in 26 patients. All patients had neurologic symptoms with pain, paresthesias and numbness in the lateral neck, shoulder or arm. The duration and intensity of symptoms was variable. 12 of them had symptoms arising from the arterial compression. Preoperative evaluation included a formal clinical and neurologic examination, radiographs of the chest and cervical spine, Electromyography was often performed if a carpal tunnel syndrome was suspected. Angiography was performed in patients with vascular symptoms. MRI scan of the cervical spine and supraclavicular spaces were routine practice. Most of the patients had undergone prolonged conservative treatment including medication (muscle relaxants and analgesics), physiotherapy, exercises and cervical brace immobilization. This approach produced only temporary improvement or even aggravation of their neurologic complaints.

Intraoperativelly we found: Hypertrophy of the scalene muscle with aberrant or broad insertion on the first rib (31 pts), perineural fibrosis (5 pts), long type cervical rib (2 pts), fibromuscular bands between the 7 transverse process and the first rib (4 pts), vascular bridge pinching the lower trunk (4 pts). In four cases no obvious anatomic finding within the thoracic outlet affecting the brachial plexus could be found. The follow up period ranged from 6 months to 10 years (mean 6 years). Results were classified as excellent in 16, who were free of symptoms. Good in 12, who complained of mild symptoms on daily activities but were significantly improved. Poor in 6 who had persistent or aggravation of their symptoms. 4 patients from the poor results group were treated by 1st rib excision, on a later stage and experienced significant improvement.

The operative complications include one case of pneumothorax and a temporary dysfunction of the phrenic and XI cranial (accessory) nerve. No postoperative complications were found and the average hospitalization period ranged between 24 – 48 hours.