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Seventy-three patients with rheumatoid arthritis had tenosynovitis of the tendon sheath of the extensors of the fingers (ninety-three hands). Forty-one hands had ruptures of extensor tendons which were repaired at operation in addition to the dorsal tenosynovectomy. The hands in which dorsal tenosynovectomy was done prophylactically showed no rupture except in two in which errors in a Darrach procedure accompanying the tenosynovectomy allowed attrition of tendons on the roughened ulnar stump. Our present indications for prophylactic tenosynovectomy are: (1) persistent dorsal tenosynovitis despite adequate medical treatment; (2) extensor tendon rupture; and (3) recurrent dorsal tenosynovitis. Tendon rupture is considered an urgent indication for operation because further ruptures may thus be prevented.

The experience in treating 100 patients with Dupuytren's contracture is reviewed. Clinical characteristics, indications for surgery, types of incisions and operations, attendant complications and their effect on results are presented. Partial fasciectomy through a longitudinal incision with one or more Z-plasties as required, is preferred; transverse incisions have a higher incidence of complications and poorer end results.

Mit 40,4% ist die Hand der bei Arbeitsunfallen am haufigsten betroffene Korperteil. Hautdefekte erfordern plastisch-chirurgische Masnahmen. Die genaue anatomische Diagnose ist Voraussetzung fur die korrekte Wahl der freien oder gestielten Hauttransplantate, die zur Wiederherstellung am besten geeignet sind. Die Indikation an der Fingerbeere (Abb.1) und palmaren Seite der Finger werden anhand eines Gefrierschnittes und an der Streckseite (Abb. 4) auf der Basis einer Unterscheidung in Zonen (Finger I und Handrucken II) aufgezeigt. Klinische Falle dienen zur Veranschaulichung der dargestellten Prinzipien.

A large proportion of hand surgery deals with flexor tendons and considerable effort is put forth to unite severed flexor tendons. The surgical and biologic repair often leaves the tendon bound down in scar tissue along its course or at the site of injury with little or no motion being transmitted to the interphalangeal joints.

Summary The need for skilled surgeons trained in the proper techniques of hand surgery has been emphasized in this survey of the reconstructive procedures used in radial nerve paralysis of the upper extremity. The most useful transfers have been found to be transfers of the pronator teres into the extensor carpi radialis brevis, the flexor carpi ulnaris into the extensor digitorum communis, and the palmaris longus into a rerouted extensor pollicis longus.

As documented by dissection of twelve cadaver hands, the palmar cutaneous branch of the median nerve may be injured by a transverse incision at the wrist, while the terminal fibers of this branch, passing through the substance of the transverse carpal ligament on their way to the palmar skin, may be injured by longitudinal division of the ligament. To avoid such injury during decompression of the carpal tunnel, a curved longitudinal incision located on the ulnar side of the axis of the ring-finger ray and extending through the skin, subcutaneous tissue, and the ligament is recommended, followed by elevation of a radial flap keeping all three tissue layers and the palmar cutaneous branch intact.

ALTHOUGH restorative hand surgery is correctly regarded as having been developed primarily in military centers, repair of flexor tendons, one of the most frequent and difficult problems in civilian practice, was not significantly influenced by war experience. The frequency of flexor-tendon lacerations, the relatively long amplitude of tendon motion required to flex a digit, and the nonselective nature of the healing process have been responsible for discouraging results and for the increased attention that flexor-tendon repair has received in the postwar period. Now, some twenty years since injuries of flexor tendons and digital nerves have become more important than the . . .

Summary Little is yet known about function, disease, and the efficacy of surgery in the rheumatoid hand. Subjective assessment methods have been reviewed but found to lack definition and precision and are difficult to quantify. The concept of the objective assessment of hand function at the digital level is emphasised and the value of cybernometer * measurements before and after corrective hand surgery is clearly demonstrated. Only by measuring the forces of the individual digits can the function of the hand be shown to improve in a quantitative fashion to the greater benefit of both patient and surgeon. Parts 2 and 3 of this study will be published in subsequent issues of The Hand. .

SUMMARY The use of Silastic sheeting to prevent adhesions in the hand is discussed, with four case reports. It is felt that judicious use of this material at primary or secondary operation may offer a significant benefit with regard to the final functional result, and the rate of attaining such a result, in the surgery of the hand.

Summary Successful reconstruction of the stiff hand is one of the most demanding and frustrating aspects of hand surgery. Good results are the product of a carefully planned, diligently followed conservative and operative approach.

1. Chronic distress rarely follows a well-performed primary amputation. The proximal nerve ends are probably best dealt with by clean division and recession into mobile, well-nourished tissues. 2. One workmanlike remodeling of a badly constructed stump is advisable, with concurrent resection of any neuromata found. Further procedures of this type are worse than useless. 3. Percussion or massage of the tender area seems to promise much, and many patients discover this of their own accord. The trauma inherent in daily use of the hand is probably helpful in abolishing hypersensitivity and phantom-limb sensation. 4. When well-conceived local treatment fails to relieve, it is vital to turn without delay to the autonomic nervous system. If sympathetic block fails to relieve, it is useless to carry out sympathectomy. High chordotomy should relieve pain if done in time, but procrastination may leave the patient without prospect of relief except through the drastic medium of leukotomy.

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Summary The place of neurovascular island pedicles in reconstructive hand surgery is outlined. The concept of tactilegnosis in the hand is mentioned and the island pedicle flaps related to this concept. The types of neurovascular island pedicles are described. Their donor sites and their many indications are detailed. The technique of the neurovascular island pedicle flap is described. In conclusion, it can be stated that neurovascular island pedicles by their versatility and excellent blood and nerve supply have a widening place in the improvement of hand function. Their early use following median nerve repairs in adults is advocated.

Twenty-eight cases of glomus tumor of the hand have been studied from various aspects including a review of the pertinent literature, clinical manifestations, treatment, and the incidence of this lesion in relation to other hand tumors and to glomus tumors occurring extramanually. These interesting and unusual lesions often are not palpable, frequently not visible, and usually not detectable on roentgen examination. Nonetheless, the diagnosis can be readily made if there is awareness of the characteristic triad of symptoms: pain, tenderness, and cold sensitivity. Meticulous complete excision, the only recommended treatment, should result in complete cure.

An anomalous distribution of nerve supply to the hadn is fairly common. According to standard textbooks of anatomy the median nerve divides into 2 parts approximately at the distal border of the flexor retinaculum. However, the site and pattern of termination of the median nerve may also vary. Three cases of unusual and high distal branching of the median nerve are presented and its importance in hand surgery is discussed.

SUMMARY Primary flexor tendon repair will provide superior functional results at all levels of injury: the forearm, the carpal tunnel, the palm, and distal to the superficialis tendon. Repair of injuries to the flexor tendons in the fibro-osseous tunnel (distal palmar crease to the proximal interphalangeal joint crease) is a controversial subject. Flexor tendon graft is the established and accepted method of treating these injuries. Improved technique in primary tenorrhaphy in the flexor digital sheath has produced results at least equal to those with flexor tendon graft. The technique of primary flexor tenorrhaphy is described. We do not advocate or suggest that primary tendon repair is indicated in most flexor lacerations in the „no man's land“ area unless a specially trained hand surgeon capable of performing primary tenorrhaphy is available. If this surgeon is not available, the wound should be cleansed, the skin sutured, and the patient referred to a specialist for tendon graft. Ill advised attempts at primary tenorrhaphy in this region will result in contracted scarred fingers, which may at best be impossible to restore even with a staged tendon graft procedure.