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To restore function of the ruptured extensor pollicis longus (EPL) tendon, two operative principles have been described: reconstruction of the original tendon using a tendon interposition graft or a tendon transposition operation, most commonly transposition of the extensor indicis. From 1992 to 1998, we reconstructed the extensor pollicis longus tendon using an interposition graft in 58 patients. 48 patients were available for follow-up after a mean of 31 months. The mean age of the 25 women and 23 men was 49 years. The time between tendon rupture and reconstruction ranged from one to 40 weeks. The tendon rupture occurred in 19 patients following a radius fracture, in 22 patients without history of trauma and in seven patients it was due to a sharp injury. Using the clinical score of Geldmacher and Köckerling, five patients achieved a very good, 35 patients a good and eight patients a satisfactory result. No patient had a poor result. According to the statistical analyses, these results were independent of the age of the patients, the origin of the rupture or the time interval between rupture and tendon reconstruction. The average DASH score measured 14. Considering our results, secondary reconstruction of the original EPL tendon appears to be a valuable alternative to the commonly performed tendon transpositions. It yields good clinical results with little remaining functional impairment and without the need to sacrifice another functional motor. We strongly recommend this technique in patients who require an independent and strong extension of the index finger in their profession (surgeons, musicians) and in patients with severe trauma that does not allow the sacrifice of another intact motor unit.

Deep frostbites of the fingertips mostly result in some form of amputation. To preserve functional length and to achieve good sensibility, we managed deep frostbites of five fingertips of a mountain climber with semiocclusive dressings. The method was described by Mennen and Wiese (1993) for the management of fingertip injuries. To our knowledge, the method has not been used so far in the treatment of frostbites. The two fingertips presenting only deep soft-tissue damage achieved a nearly normal recovery of pulp shape and sensibility. The three fingers with bone involvement required a long period of time for complete healing. In two of these fingers, additional bone shortening had to be performed.

Following replantation in childhood, growth disorders of the affected epiphysis can influence function and aesthetic appearance of the hand. In a retrospective study long-term results of replantation in the upper limb in childhood were analysed with respect to factors influencing further growth. 22 patients with 29 replanted fingers were reviewed clinically and radiologically after an average interval of ten years. An average bone growth of 93% compared to the contralateral non-injured side was found. With the epiphysis affected, bone growth was reduced to 86% of the contralateral side. Analysis of single phalanges showed a growth rate of 71 to 100% in phalanges distal to the amputation and also in phalanges initially severed. Potential factors influencing bone growth were assessed separately. Best results were achieved in straight injuries without epiphyseal affection. An influence of anoxia time or number of anastomosed vessels could not be found. Even though replantation in childhood affects growing bone, almost normal bone growth can be expected afterwards.

In a retrospective clinical study, thirty-six patients with a dorsal intraarticular fracture of the DIP-joint were examined. The fracture can be classified according to the size of the dorsal fragment as a mallet finger or as an intraarticular fracture with the tendency for dislocation. Subcutaneous tendon ruptures with a small dorsal fragment respond well to conservative treatment. Intraarticular fractures should be treated surgically. Anatomical reduction and joint stability are the treatment aims. In 21 patients, tension band wiring was performed, in eight cases percutaneous treatment with the "Hakendraht" was carried out.

Although experience in replantation surgery increased during the past 30 years, there are still problems remaining. Refinement of microsurgical operations and improvement in rehabilitation technique have lead to superior functional results. Beside clear indications as thumb loss or replantation in children there are only few absolute contraindications. A retrospective analysis of more than 300 replantation showed that there are still problems concerning exhaustive supply of replantation centres. Because time is one of the many critical components of successful preplantation improvements are necessary in extra- and intrahospital organization of replantation surgery.

Since the invention of microsurgical techniques the free toe-to-hand transplantation is an established method for reconstruction of hand function. The indication for this method following thumb and finger amputations as well as congenital defects with aplasia of the fingers and the thumb is discussed in comparison to alternative operations. The operative technique as well as the functional and aesthetic results that can be expected are described by presentation of clinical cases. Since 1992 we performed 18 free toe-to-hand transplantations for the above mentioned indications. Depending on the primary situation the elementary hand function with grip and pinch could be restored in all our patients using this method. Restoring sensibility next to length, mobility and strength in one operation has to be considered as an advantage compared to alternative methods.

Tenolysis of flexor tendons was performed in 48 fingers of 36 patients. After a mean follow-up to ten months, the total active movement (TAM) was improved from 79 degrees preoperative to 189 degrees postoperative in 84% of the fingers with a minimal improvement of 40 degrees. Following the classification of Buck-Gramcko, 80% (38) of the fingers showed an excellent, good, or fair result. In addition, the influence of nine factors (associated injuries or procedures) on the outcome was investigated. These results showed that there is a decrease in improvement when severity of trauma increases. Arthrolysis of PIP-joint showed no negative influence on the results. We are not able to establish a predictive score for flexor tenolysis from our results.

Fourteen patients with an amputation injury of four fingers are reported. Fifty-one of these 56 fingers were replanted with a survival rate of 88%. To achieve optimal results replantation of all fingers should be attempted. Dividing the operative procedure into a macrosurgical and a microsurgical part helps to economize both tourniquet time and total operative time. In case of arterial spasm or other difficulties to reestablish blood flow, a check list can be of great value. To achieve good results in such severe and difficult procedures a special organisation of replantation centers is needed.

Lacerations of arteries and nerves not only result in motor and sensory deficiencies. Trophic changes occur as well, more frequently after nerve injuries than after vascular injuries. The major progress in their treatment consists in primary repair of the injured structures in order to keep their loss of function as brief and as minimal as possible. Although the results after nerve laceration are still far from being ideal, there are strong indications that an improvement can be obtained with this treatment strategy. Alternatives to primary repair are discussed.

One year after rupture of the 5th flexor profundus tendon, a 45-year-old man showed signs of carpal tunnel syndrome. At surgery the proximal stump of the 5th flexor profundus tendon was found in the carpal tunnel. Due to an anomalous origin of the 4th lumbrical muscle from the profundus tendon of the 4th finger the proximal stump of the 5th flexor profundus tendon had withdrawn far proximally and in this way produced a carpal tunnel syndrome.

Transcutaneous PO2 measurement is a suitable means of confirming the healing of replanted fingers. The method allows continuous monitoring of blood circulation; therefore, failing blood circulation in replanted fingers can be detected early.

In six cases parts of the distal phalanx were replanted with arterial anastomosis alone without suture of a vein. With heparinisation venous haemorrhage continued for two to three days. After this time venous drainage was sufficient through new vessels and venous bleeding stops. This method is only a salvage procedure when venous congestion develops or with distal replants where venous repair is not possible.