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The fracture-dislocation at the base of the fifth metacarpal is analogous to Bennett's fracture of the thumb (Fig. 13-1 A). Because of the obliquity of the fracture line, the obliquity of the metacarpal hamate joint, and the pull of the extensor carpi ulnaris, this fracture-dislocation tends to be unstable and to displace, much in the same fashion as the first metacarpal in a Bennett's fracture and with similar functional impairment.

If union with deformity occurs at the distal radius, it can be of sufficient magnitude to cause an unacceptable deformity or loss of function. Sometimes the problem is confined to the radiocarpal joint. In these instances, it is important to restore radial length and distal radial angulation in both the anteroposterior and lateral planes. Adequate joint congruity must be present before corrective osteotomy. Otherwise, such an effort is likely to be in vain because of posttraumatic or degenerative arthritis.

A violent force that impacts the proximal phalanx against the metacarpal head may split the phalanx. If this happens and the base of the proximal phalanx is fractured into two major fragments that are displaced, one must perform an open reduction and internal fixation to restore the congruity of the articular surface. The metaphysis is reconstructed with one or more 1.5 or 2.0 mm minicortical lag screws. The reconstructed metaphysis is then secured to the diaphysis by plate fixation. Although open fractures are not discussed until Chapter 39, the case illustrated in Figures 23-1 A-M provides an excellent opportunity to demonstrate how a displaced intraarticular split fracture of the base of the proximal phalanx is managed as part of the overall reconstruction of a seriously injured hand.

Distal radioulnar arthrodesis with ostectomy of the distal ulna is an excellent method of stabilizing the distal radioulnar joint and the ulnar side of the carpus. It is also useful in distal ulnar bone loss with the ulnar head intact ((Fig. 43-1 A) (Fig. 43-1 B) (Fig. 43-1 C) (Fig. 43-1 D) Fig. 43-1 E-J) or distal radioulnar instability (Figs. 43-2 A-H). Rotation then occurs through the distal ulnar defect. The interosseous membrane must remain intact to prevent dorsal dislocation of the distal portion of the proximal ulnar fragment, which could cause skin pressure, irritation, and even rupture of the extensor carpi ulnaris. When performing this procedure, the proximal and distal bone ends at the site of the distal ulnar ostectomy are waxed, and periosteum is secured over the bone ends. A portion of the pronator quadratus is brought into the defect. These maneuvers help stabilize the distal end of the proximal ulna and also prevent reestablishment of osseous continuity at the distal ulnar ostectomy site.

Skin cancer, the most common malignancy in white patients, is rare in black populations. Seventeen black patients have been diagnosed and treated for basal cell carcinoma in the past 20 years at the University of Mississippi Medical Center. Ten of them have died, six of various types of cancer. Of the seven living patients, one had two cancers at the time of study: a new basal cell carcinoma and generalized lymphoma. The majority of patients had some degree of mixed racial ancestry, with medium to light brown skin, a history of heavy sun exposure, and lesions appearing on the head or neck. Highly significant depression of cellular immunity was demonstrated in these patients by T-cell assay. Altered tumor surveillance is implied as an etiological factor in basal cell carcinogenesis in black patients.

Ptosis of the larynx and/or base of the tongue resulting from extirpation on the hyomandibular complex is a major factor in the production of chronic aspiration. A simple technic of laryngeal suspension, equally applicable in primary reconstruction or as a secondary procedure, is described. A modification of the method can be adapted for glossoptosis.

Silastic implants have been inserted to augment the malar regions via a transoral approach in 7 patients with satisfactory results. No implants have been removed because of infection. The problem of fluid accumulation about the implants and the use of triamcinolone for its treatment in one case is described. The major advantages of this technique are: ease of exposure; safety for the facial and infraorbital nerves; the ability to place the implant medial to the infraorbital nerve; and avoidance of further external scarring.

Summary One hundred sixteen cases of basal cell carcinoma of the medial canthal region are reviewed. Radiation therapy and surgical excision offer similar results in terms of recurrence, complications, function, and cosmesis. Preservation or reconstruction of the lacrimal drainage system or both should be attempted whenever possible without compromising adequate tumor removal.

To the Editor.— I read the recent article on the management of dog bite wounds (1980;244:2327) and the resulting letters (1981;246:833-834). As a plastic surgeon, much of my experience with such injuries has come in patients who have been treated initially by someone else and then had either an outright infection or an unsatisfactory result. Most of the errors in dog bite treatment do not come from a failure to trim the skin edges properly but from the failure to take into account the length of a dog's tooth. The teeth carry the inoculum deep into the wound, and it is a failure to treat contamination at these depths that frequently results in clinical infection. When I treat a dog bite, I take care to anesthetize it well enough that I can explore and locate the path and then irrigate it well. I close most of them primarily and infection

Summary One hundred sixteen cases of basal cell carcinoma of the medial canthal region are reviewed. Radiation therapy and surgical excision offer similar results in terms of recurrence, complications, function, and cosmesis. Preservation or reconstruction of the lacrimal drainage system or both should be attempted whenever possible without compromising adequate tumor removal.