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The rare occurrence and the difficulties in diagnosis make partial and total luxations of the scaphoid to a problematic chapter in hand surgery. The main part in diagnosis lies in the correct interpretation of the X-ray pictures from which the different formes of displacement may be recognized. These include isolated luxations of scaphoid in palmar, radial or dorsal directions, varying degrees of scapho-lunate subluxations and luxations and the special type of isolated subluxation of the scaphoid bone. In the first part of the paper the diagnostic criteria and in particular the radiologic signs are described. Most important is the recognition of the alteration in the shapes of the scaphoid bone due to its tilting on several axes and the overlapping of its outline with that of the adjacent bones. The displacement of the whole carpal region can extend as far distal as the metacarpals. A diastasis of the scaphoid and lunate is typically due to rupture of the ligaments between these bones and the radius.

Treatment with DEBRISORB, a new topical agent formed by three dimensional network of dextran polymers in porous hydrophilic beads, was used in 26 cases of infected wounds in the hand. These were of traumatic and postoperative origin, often with remaining necrotic areas and in a few cases with a considerable oedema. The special effect of DEBRISORB was in absorbing the exudate and in reducing the inflammation and swelling of the discharging wounds. Within a few days secretion was diminished and healthy granulation tissue appeared. For covering the defects we employed local transposition flaps, direct flaps and split-skin grafts without complications. Local treatment with DEBRISORB is an effective method to clean infected wounds, to reduce inflammation and oedema, and is useful as treatment before grafting.

A comparison of results in flexor tendon repair is of value only if standard methods of measurement and recording are used. The function of the involved finger(s) can be judged by measurement of the distance between the finger tip and the distal palmar crease, the total maximum flexion at all three finger joints (composite flexion), the lack of extension as an aggregate of the minimum angles which can be achieved at each of the three finger joints (composite extension deficit), and the total amount of movement (composite flexion minus composite extension deficit). Each of these measurements graded according to a scale of values (table 2 and 3); the sum of these values gives a final classification (excellent, good moderate and poor). In a series of 157 follow-up examinations with 223 fingers with flexor tendon repair this method of recording the results of flexor tendon repair was evaluated.

Follow-up examination is reported of 24 patients with post-traumatic arthritis treated by 29 finger joint implants. The average follow-up time was 35 months. It could be shown that implant arthroplasty in painful, unstable finger joints stiffened in an unfavourable position represents a quite reasonable method of treatment. Necessary essentials, however, are sufficient function of the tendons, skin areas without twoo extensive cicatrical changes, precise operative procedure and adequate postoperative treatment.

This case report of a chondroid syringoma (t. h.) arising in a finger is of interest because of the unusual site, its usual location being the region of the head and neck. Characteristically it is benign, slow growing and compresses adjoining structures. In skin lesions generally histological confirmation of the diagnosis is essential in order to exclude malignancy, but particularly when the site of the lesion is an unusual one.

Reconstruction of the thumb following amputation injuries: In this review of the different methods of thumb reconstruction following traumatic amputation, the procedures applicable in the primary care of the hand are first mentioned and demonstrated: replantation of a thumb, cover of a distal amputation with a neurovascular flap and salvage of a thumb with intermediate segmental loss. In most instances the thumb reconstruction is performed as a secondary procedure. The indication and the selection of the method depend upon the level of amputation, the dominance of the injured hand, and the presence of other injuries to the same hand as well as age, sex, occupation, and intelligence of the patient. There are several different operative methods: 1) Deepening of the first web space (phalangisation of the first metacarpal) by means of a Z-plasty with proximal transposition of the insertion of the adductor pollicis muscle. 2) Lengthening of the first metacarpal with a bone graft either as Gillies cocked hat procedure or as interposition following distraction of the osteotomized two parts of the metacarpal in one stage or as continuous distraction (Matev). --Both methods are performed often in combination and are indicated in loss of the thumb at the base of the proximal phalanx or at the MP-joint in the non-dominant hand or in unskilled workmen. 3) Osteoplastic methods with bone graft, tube pedicle and neurovascular island flap have the risk of absorption of the bone graft and therefore more limited indications. These are given in unskilled manual workers with no other injured digits and in multiple loss of digits where toe transfer is not appropriate. 4) Transposition of another intact or partially amputated digit on a neurovascular pedicle. The two different operative techniques depend upon the presence or loss of the first metacarpal and the thenar muscles. The indication is given in amputations at any point proximal to the base of the proximal phalanx in either hand of most women, children and skilled workers. 5) Free toe transfer is indicated if there is not any other finger or part of a finger available and the first metacarpal is preserved. In exceptional cases a free transfer of a digit of the contralateral hand is possible.

There are three major facts which differentiate injuries in children and adults: 1. The size of the hand and its anatomical structures which require finer instruments and a meticulous -- almost microsurgical -- operative technique. 2. The better healing and better regeneration following injuries which lead usually to a better functional result. 3. The relationship between scars and growth: a scar will not grow in the same way as normal skin, so that contractures may occur some years after the injury even in areas of the hand where in adults scar contractures may never occur. In this lecture, presented at the 17th Annual Meeting of The German Speaking Society for Surgery of the Hand in Tübingen, several cases demonstrate the general principles and special details in the operative treatment of soft tissue injuries in children. For the skin the correct placement of incisions in reconstructive surgery and the conversion of wounds into suture lines which will not lead to scar contractures are mentioned. Some cases with correction of existing scar contractures and prevention of new ones are shown (fig. 1 to 12). For flexor tendon injuries some of the satisfactory results after primary repair and secondary reconstruction are demonstrated. Also in nerve injuries the better regeneration in children will lead to good functional results following nerve grafting. In irreversible nerve damage tendon transfers are employed by the same technique as in adults (fig. 13 to 15). For the operative treatment of ischemic contractures of the forearm and the hand the different procedures are mentioned. The importance of the intrinsic test (PARKES) for the diagnosis of the contracture of the interossei is stressed (fig. 16 and 17). A case of thumb reconstruction in a four year old girl by transposition of the index finger on a neurovascular pedicle shows that in smaller children complicated reconstructive procedures can give excellent results (fig. 18).

The commoner and more important congenital deformities of the hand are reviewed, considering their clinical picture, indications and optimal age for intervention, operative technique, postoperative care, and results. It is stressed that the value of many of the procedures can be assessed only after several years, and often only at the end of the growing period. The following malformations are discussed: 1. Syndactyly: There are many patterns of deformity; fusion of fingers of unequal legnth and distal bony fusion with convergence are absolute indications for early separation (six months of age); in uncomplicated cases operation can wait until the second year of life. Correctly placed skin incisions are of great importance for the prevention of scar contractures; a zig-zag incision forms long triangular flaps for cover of the sides of the fingers, splitting up areas of full-thickness skin graft; the commissure is formed from either two triangular flaps or a single dorsal rectangular flap...

Description of two cases of badly injuried hands, where the grasp-function has been restored. In one case, the traumatically amputated thumb was reconstructed in the conventional way, transposing the index finger on its neurovascular bundle. The other case demonstrates the use of modern microsurgical methods in substituting a freely transplanted toe with microvascular anastomoses for four lost fingers. Resulting function was satisfactory in both cases.