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Hand surgery is a combination of microsurgery, osteosynthesis, nerve and tendon surgery focusing on the most essential organ in daily life and in societal interactions: the human hand. A discipline as important and highly specialized as hand surgery must be based on scientific studies and milestones from the past. Our work accompanies the video with english subtitles that was displayed in part during the opening ceremony of the 58th Congress of the Deutsche Gesellschaft für Handchirurgie (DGH, German Society of Hand Surgery) in Munich (President of the conference, Univ.-Prof. Dr. R. Giunta). This paper presents the development of hand surgery from its historical origins, focusing on and introducing important characters from the times of Hippokrates, the Middle Ages, the Renaissance, the 18th and 19th centuries, as well as the two World Wars. In summary, progress of hand surgery is linked to the advances in anatomy, tendon surgery, nerve surgery and closely connected to the necessity of specialized care for upper limb injuries during and after World War II. A well-founded understanding of history and an insight into the development of our specialization underlines the importance of our daily work as hand surgeons and creates new incentives for the future development of hand surgery.This contribution is published in honor of Ulrich Lanz on occasion of his 80th birthday in november 2020., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Workplace violence (WPV) by patients and visitors is a hazard in many emergency departments (ED), with serious consequences for both staff and patients. Patients with a migratory background seem to be prone to being involved in WPV. We therefore reviewed all reports of ED staff who experienced WPV over a 4-year period (2013⁻2016). We analyzed data on the reasons for the incident, the time of day, the manner of violence, the consequences, and the migratory background of the aggressor. In total, 83 cases of WPV were reported over a four-year period. The average age of the violent person was 33.1 years; in 35 cases (42.0%), aggressors were younger than 30 years old, 53 (63.8%) were male, 49 (59%) were of Swiss nationality, and 35⁻40% had a migratory background. The odds ratio of people originating from a low- to middle-income country versus those originating from a high-income country was 1.8. Furthermore, 45.8% of the patients arrived by ambulance ( n = 38) and 19 patients (22.9%) were self-presenting. Most cases (92.8%) involved verbal aggression, but in more than half of the cases, physical assault (56.6%) was also reported. In addition, 43 (51.8%) of the events occurred during the night. Results also showed that 42 (50.6%) of patients who were involved in WPV were under the influence of alcohol and 29 (34.9%) suffered from psychiatric disorders. Security personnel and police were involved in 53 (63.9%) and 47 (56.6%) cases, respectively. Twenty patients (24.1%) were sedated and 16 (19.3%) were restrained. In 18 cases (21.7%), the psychiatrist ordered compulsory hospitalization in a psychiatric institution. Taken together, WPV is a relatively common event in our ED and persons with a migratory background are involved more often relative to their frequency of ED visits.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Purpose: The purpose of this study was to evaluate outcome and structural integrity after arthroscopic repair of large subscapularis tendon (SSC) tears at 2 to 4 years' follow-up., Methods: Between January 2006 and October 2008, 52 consecutive patients underwent arthroscopic repair of Lafosse type III and IV SSC ruptures. A total of 46 patients (38 men and 8 women) with a mean age of 62 years (range, 45 to 81 years) were available for final follow-up. Clinical findings were assessed for all patients preoperatively and postoperatively, including range of motion, the lift-off test, the belly-press test, the Constant score, and the modified University of California, Los Angeles score. Subscapularis muscle strength by use of the bear-hug test and external rotation were compared in both shoulders postoperatively. Patients were evaluated with plain radiographs and magnetic resonance imaging or computed tomographic arthrography before surgery. Postoperatively, radiographic examination was completed by use of magnetic resonance imaging or computed tomographic arthrography in 39 patients (85%). Patients completed the subjective shoulder value and rated their satisfaction at final follow-up., Results: The mean follow-up period was 35.3 ± 9.6 months (range, 23 to 57 months). An isolated lesion was detected in 13% of patients; a lesion of the SSC and supraspinatus tendon was found in 37%; and a lesion of the SSC, supraspinatus tendon, and infraspinatus tendon was detected in 50%. At latest follow-up, the mean Constant score significantly improved from 46.4 points to 79.9 points and the modified University of California, Los Angeles score improved from 15.1 points to 31.5 points (P < .001). Subscapularis strength was 92% and external rotation was 96% of the nonoperative shoulder. All outcome scores were similar between Lafosse type III and IV SSC ruptures. Radiographic evaluation showed a rerupture rate of 11%. The coracohumeral distance increased from 9.7 mm to 10.1 mm postoperatively (P = .086). The subjective shoulder value improved from 51% to 88% (P < .001), and 98% of patients were satisfied or very satisfied., Conclusions: Arthroscopic treatment of large to massive SSC ruptures results in significant clinical improvements, excellent maintenance of muscle strength, and durable tendon integrity at 2 to 4 years' follow-up., Level of Evidence: Level IV, therapeutic case series., (Copyright © 2013 Arthroscopy Association of North America. Published by Elsevier Inc. All rights reserved.)

After lesions of the peroneal nerve or damage of the tibialis anterior muscle a lack of active dorsiflexion leads to a drop foot deformity. Ober (1933) described a transfer of the posterior tibialis tendon to the dorsum of the foot to restore active extension of the foot. The aim of this retrospective study was to evaluate the results of this method and to compare our results with those in the literature.Between 1992 and 2004 we performed a posterior tibialis tendon transfer in 16 patients with an average age of 40 years. 10 patients suffered from complete peroneal nerve palsy, which was due to a traumatic lesion (n=8) or iatrogenic damage (n=2). 3 patients had an incomplete peroneal nerve palsy caused by iatrogenic lesion (n=2) and lumbar disc herniation (n=1). 3 patients demonstrated a malfunction of the anterior tibial muscle following a compartment syndrome. 14 patients were available for a clinical follow-up after an average of 64 months. Clinical assessment included the hindfoot, muscular strength, pain, limitation of function and subjective satisfaction. The clinical result was evaluated using the Stanmore score (0-100).8 patients were very satisfied and 2 were satisfied with their results, 4 patients were not satisfied. 11 patients had no pain. The active dorsal ankle extension averaged - 5.7° (10 to - 30°). The Stanmore score revealed an average of 62 points with an excellent result in 2, a good result in 5, a fair result in 2 and a poor result in 5 patients.Transfer of the posterior tibial muscle to restore active dorsiflexion of the foot is a therapeutic option. As it is known from the literature objective results were mostly fair, but there was a high degree of satisfaction among the patients., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background: The Scarf osteotomy was described as a technique to correct a metatarsus primus varus in primary hallux valgus surgery, but it is unclear whether the technique could correct recurrent hallux valgus when an initial procedure failed to provide any or an adequate lateral displacement of the metatarsal head., Questions/purposes: We asked whether the Scarf osteotomy could reduce pain, improve the AOFAS score, reduce the deformity, and prevent further recurrence when used as a revision procedure., Patients and Methods: Of 41 patients (45 feet) we treated for failed initial operations, we retrospectively reviewed 35 (39 feet) who underwent a Scarf osteotomy. We administered a VAS for pain and the AOFAS score preoperatively and postoperatively. Preoperative and postoperative radiographs were taken to assess the hallux valgus angle [HVA] and intermetatarsal angle [IMA]. The minimum followup was 24 months (mean, 42 months; range, 24-89 months)., Results: The mean VAS for pain improved from 5.9 to 0.4 points. The mean AOFAS score improved from 56 to 90 points. The radiographic evaluation showed improvement of the mean HVA from 30 degrees to 8 degrees and improvement of the IMA from 13 degrees to 4 degrees. Complications included one asymptomatic recurrence with a 20 degrees -HVA, one overcorrection with a 3 degrees-varus deformity, and pain attributable to irritation caused by screws in five patients., Conclusions: As a revision procedure the Scarf osteotomy clinically and radiographically corrected recurrent hallux valgus recurrence in most patients., Level of Evidence: Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Ischemic muscle contracture after a compartment syndrome of the forearm and hand may result in severe loss of function. In addition to the established muscle contracture, a loss of nerve and vessel function can often be found. The clinical appearance depends on the involved muscles respectively compartments. Even though each case requires individual analysis of the clinical situation, the combination of Tsuge's classification with Holden's classification provides a more or less systematic approach to treatment that can be adapted to each case according to the severity of the contracture of the joints and muscles, the degree of nerve and vessel damage, the function of the remaining muscles and nerves, and the availability of other functioning muscles for reconstruction.

Purpose: The aim of this study was to assess the clinical results of revision surgery due to persistent neurological disturbances after carpal tunnel release., Patients and Method: In a previous study we showed the reasons for persisting neurological symptoms after carpal tunnel release on the basis of the intraoperative findings in 200 patients who underwent revision surgery in the years 2001 - 2003. We classified them into four groups (1: incomplete release of the retinaculum flexorum, 2: traction neuropathy, 3: real recurrent carpal tunnel syndrome, and 4: nerve lesions). 122 of these patients have been investigated regarding the clinical results using two questionnaires in the year 2004. We used the DASH questionnaire as well as an additional self-assessment questionnaire asking about remaining symptoms of median nerve irritation and the subjective results of revision surgery. The completely filled-out forms were assigned to the four groups, analysed and the results compared with each other., Results: Within group 1 (incomplete release), 78 % reported only one persistent neurological symptom, 89 % described a benefit from revision surgery and 84 % were satisfied with a median DASH score of 11. Within group 2 83 % complained about at least one persistent neurological problem and only 60 % reported on an improvement following revision surgery. The DASH score within group 2 averaged 30. 87 % of group 3 patients reported of an improvement following the revision operation (DASH score 24), whereas this was the case for only 55 % (DASH score 37) of group 4 patients., Conclusion: The incomplete release of the flexor retinaculum is the most common reason for revision surgery. In most of these patients the clinical symptoms can be resolved with revision surgery leading to a very high satisfaction of the patients. A similarly high satisfaction can be expected following revision surgery of a true recurrent carpal tunnel syndrome although in most patients a significant degree of functional deficit will remain. Revision surgery due to fibrotic adhesions of the median nerve, leading to a traction neuropathy, or iatrogenic nerve lesions during the primary surgery will definitely lead to unsatisfactory overall results.

Aseptic osteonecrosis of the head of metacarpal is a rare disease with an unknown aetiology. It was first described by Mauclaire 1927. We now report on the treatment of 2 patients with Mauclaire's disease via transplantation of the calotte of the head of the 2nd metatarsal. At 26 and 30 months, respectively, after surgery both patients were free of complaints in activities of daily live and had free function of their fingers. There was no discomfort in the resection area at the 2nd metatarsal. Based on this experience, the method seems to be a recommendable option in young adults. A prerequisite is that the base of the proximal phalanx be intact.

Objective: To evaluate the clinical and electrophysiological results of 26 patients treated with either a hypothenar fat flap or a synovial flap to prevent recurrent scar compression of the median nerve after previously failed carpal tunnel decompression., Methods: A total of 26 patients underwent flap coverage as a result of a nerve tethering attributable to a position within scar; 15 were covered by a synovial flap and 11 by a hypothenar fat flap. Only patients in whom the median nerve was significantly enveloped in scar tissue were included. All candidates underwent a thorough clinical examination and nerve conduction test. The pre- and postoperative nerve conduction tests and the results of the two groups were statistically compared., Results: The reduction rates of brachial nocturnal pain and pillar pain were 25 and 25%, respectively, in the synovial flap group and 64 and 37%, respectively, in the hypothenar fat flap group. The reduction rates of a positive Tinel's sign (25%) and a positive Phalen's test (13%) were lower in the synovial flap group compared with hypothenar fat flap coverage (55% Tinel's sign, 46% Phalen's test). Thenar atrophy and paresthesia were reduced in 44 and 62%, respectively, in the synovial flap group and in 46 and 64%, respectively, in the hypothenar fat flap group. The overall patient satisfaction (73%) and the Disabilities of the Arm, Shoulder and Hand score (31 points) appeared superior in the hypothenar fat flap group compared with the synovial flap group (56%; 37 points). Nerve conduction tests demonstrated a significant improvement when comparing the pre- and postoperative measurements in both groups. Distal motor latency decreased in the hypothenar fat flap group from 6.81 ms to 4.92 msec (P = 0.01; mean value) and in the synovial flap group from 6.04 ms to 4.43 msec (P < 0.001; mean value)., Conclusion: Coverage by an ulnar-based hypothenar fat flap appeared to produce superior clinical results compared with coverage with synovial tissue from adjacent flexor tendons, although conclusive statistical evaluation of clinical outcomes was not possible. Further studies to confirm this are warranted.

Background: Ulna shortening osteotomy is a common procedure for the surgical treatment of ulna impaction syndrome, but it is still associated with complications such as rotation malalignment, and delayed or non-union due to of incomplete closure of the osteotomy gap., Methods: We have developed a 7-hole titanium compression plate that provides fixation of the ulna before the osteotomy is carried out. With this plate, which has been in use for 4 years, a shortening of up to 10 mm is possible using two gliding holes, with the compression holes enabling the closure of the osteotomy gap. We report the results of 70 patients undergoing 70 ulna shortening procedures, with a follow-up of between 5 and 18 months. Two patient groups underwent follow-up clinical examination as well as completing the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for evaluation., Results and Conclusions: There was no occurrence of delayed or non-union. The DASH score averaged 19 points in the prospective and 23 points in the retrospective group, representing a good functional result with only minor impairment. This study indicates that ulnar shortening using this gliding compression plate and performing an oblique osteotomy is associated with a minimal complication rate and highly satisfactory clinical outcome.

Background: Septic arthritis of the wrist is correlated with a high morbidity. To show diagnostic and therapeutic options we reviewed the patients treated with wrist infections at our institution for one year., Methods: The data of ten patients who were treated for septic arthritis of the wrist in 2003 and 2004 were collected in a retrospective survey. Etiology, risk factors, microorganism and resistance data were recorded., Results: Six infections were of an iatrogenic nature (four following surgery, one joint puncture and one joint injection). In nine cases there was a single arthritis of the wrist. One patient had oligoarthritis. In four cases Staphylococcus aureus, in one Proteus mirabilis and in one Pseudomonas aeroginosa were identified. In four cases, no microorganism could be identified. Two of the patients suffered from diabetes mellitus, one had rheumatoid arthritis. There was no significant elevation in the white blood cell count with 9.2 (4.5 - 12.5) x 10 (9)/L. Arthroscopic debridement and synovialectomy could be performed in one case. In the other cases open surgery was necessary. In four cases partial bone resection was required. Local antibiotics were installed in eight cases. All infections healed. In nine patients the joint was immobilized with an external fixation device. All patients received systemic antibiotics. Four wrists ended in an arthrodesis, one in a four-corner fusion. On average, two (1 - 6) surgical interventions were necessary per patient. The six patients without an arthrodesis had a range of motion in extension/flexion of 30-0-24 degrees., Conclusion: Surgical treatment is sufficient in septic arthritis of the wrist. However, an early diagnosis and therapeutic intervention are essential to avoid a permanent disability.

Objective: Prosthetic joint replacement to reduce pain and maintain function of the proximal interphalangeal joint., Indications: Symptomatic arthritis of the proximal interphalangeal joint with preservation of the collateral ligaments, sufficient bone support, and intact or at least reconstructable extensor tendons., Contraindications: Lack of stability, e. g., as a result of rheumatoid arthritis or destruction of the ligaments caused by an accident. Nonreconstructable extensor tendons. Florid or chronic infection. Lack of patient compliance., Surgical Technique: Dorsal approach to the proximal interphalangeal joint. A triangular tendinous flap with pedicle, based distally on the insertion of the medial band, is lifted up, leaving the lateral bands intact. The joint surfaces are resected while maintaining the palmar plate and the collateral ligaments. The trial prosthesis is fitted, its position is checked, and the final unconstrained prosthetic components are inserted using a press-fit technique. The dorsal aponeurosis is reapproximated., Results: 20 patients were treated for posttraumatic or idiopathic arthritis with 24 pyrolytic carbon PIP prostheses, and a follow-up examination was carried out after an average of 15 months (6-30 months). Surgical management was changed from arthroplasty to arthrodesis in three cases. For the remaining prostheses, an average range of motion of 50 degrees was achieved for the proximal interphalangeal joint. On the visual analog scale (VAS; 0: no pain, 10: incapacitating pain), the patients suffered few symptoms (VAS: 0-3). 80% of patients said they were satisfied with the outcome of the operation. In three cases (one infection, two dislocations) the prostheses had to be removed and arthrodesis performed. Migration of the distal components was observed on the radiographs in five cases, and of the proximal components in four cases, although this did not have any effect on the functional parameters. The development of a painless noise ("squeaking") was noticed in nine out of 21 prostheses. However, as with prosthetic migration, this did not cause any functional deficits.

Purpose/background: This retrospective analysis focused on a comparison of long-term results in patients who underwent resection of the trapezium with subsequent arthroplasty and tendon suspension using either the abductor pollicis longus (APL) or the flexor carpi radialis (FCR) tendon., Method and Material: Based upon a positive history along with a clinical and radiological examination, 20 patients underwent suspension arthroplasty using the APL tendon (APL group) and 21 patients suspension arthroplasty using the FCR tendon (FCR group) after trapeziectomy. In both groups mean age (APL group: 60.4 +/- 5.3; FCR group: 61.7 +/- 6.8 years), pain severity according to the Visual Analogue Scale (VAS; APL group: 6.7 +/- 1.9; FCR group: 6.9 +/- 1.7), severity of arthrosis in the thumb carpometacarpal joint according to the Eaton-Littler classification (APL group: 3 +/- 0.7; FCR group: 3.2 +/- 0.6) and time interval from onset of symptoms to surgery (APL group: 27 +/- 8.1; FCR group: 41.5 +/- 14.1 months) did not significantly differ. Each patient of both groups was treated surgically and reviewed by one experienced hand surgeon. Both groups received the same standardized postoperative treatment., Results: In the APL group the mean operative time was significantly shorter (31.7 +/- 9.5 min) than in the FCR group (48.7 +/- 7.9 min). The follow-up period from surgery to the final examination was similar in both groups (APL group: 23.1 +/- 12.2; FCR group: 31 +/- 17.6 months). At the time of the final examinations, no statistically significant differences were found when analyzing the results of the DASH score (APL group: 20.1 +/- 15.1; FCR group: 29.3 +/- 15.7), the self-administered hand ability score (APL group: 1.7 +/- 0.6; FCR group: 2.1 +/- 0.6) and the VAS (APL group: 1.1 +/- 1.6; FCR group: 0.8 +/- 1.5). The time period from surgery to the offset of postoperative pain was also comparable in both groups (APL group: 5 +/- 1.8; FCR group: 5.3 +/- 2.5 months). The range of abduction in the first carpometacarpal joint after arthroplasty, parallel and perpendicular to the dorsum of the hand, was also similar in both groups (APL group: 63.4 +/- 14.3 degrees /62.1 +/- 11 degrees ; FCR group: 67.8 +/- 12.7 degrees /66 +/- 12.1 degrees ). However, patients enrolled in the APL group revealed significantly better results compared to patients in the FCR group regarding grip-strength, key and pinch grip (APL group: 23.9 +/- 9.7/6.6 +/- 2.4/6.2 +/- 2.8 kg; FCR group: 17 +/- 7.2/4.5 +/- 1.5/3.6 +/- 1.5 kg)., Conclusion: Both techniques led to highly satisfactory results as seen in DASH and VAS data together with a near normal range of abduction in the first carpometacarpal joint in all enrolled patients. However, in direct comparison the APL procedure is technically easier to perform with significantly shorter surgery time recorded and significantly higher values in all force parameters compared to the FCR procedure.

Carpal tunnel release (CTR) is regarded as a common and successful operative procedure in hand surgery. However, an increasing number of patients with complications have been referred to our hospital. This retrospective investigation was undertaken to clarify the reasons for persisting or recurrent symptoms in 200 patients who underwent secondary exploration during a 26 month period at a single institution. In 108 cases, the flexor retinaculum was found to have been released incompletely. In 12 patients, a nerve laceration had occurred during the primary intervention. In 46 patients, symptoms were due to the nerve being tethered in scar tissue. The re-exploration revealed circumferential fibrosis around and within the median nerve in 17 patients and a tumour in the carpal tunnel in four patients. In 13 patients, no specific reason was found for recurrence of symptoms. We conclude that CTR seems to be a widely underestimated procedure and revision surgery could be largely avoided by reducing technical errors during the primary operation.

Forty-eight patients underwent a total number of 113 non-vascularized free toe phalanx transplantations for congenital short digits between 1975 and 2003, a mean number of 2.3 transplanted phalanges per patient. The mean age at the time of initial surgery was 3.6 years (range 6 months to 21 years). The follow-up time ranged from 4 months to 14 years with a mean of 6 years. Sixty-four phalanges showed radiographically measured growth, 22 phalanges showed signs of resorption, while 27 phalanges showed neither growth nor resorption. Resorption increased with patient age. Three patients developed donor site problems. The optimum timing for initial surgery is as early as possible because of the safer and greater growth potential and less resorption of the transplanted phalanges. Non-vascularized free toe phalanx transplantations offer a simple and safe method of lengthening with a significant improvement of hand function.

We report on a six-year-old girl with bilateral carpal tunnel syndrome with familial accumulation. Parents and one grandmother had positive history for CTS, treated by surgical decompression. Following neurologic and radiologic evaluation and after failed conservative treatment in a plaster cast, open carpal tunnel release was performed in a two-stage procedure. Postoperatively symptoms diminished and now six months after surgery, all complaints disappeared completely.

Purpose: To define both the underlying pathology and diagnostic criteria in lunates presenting with conspicuous signal pattern in MRI., Materials and Methods: The retrospective evaluation of 2940 MRI examinations revealed 203 patients with signal alterations of the lunate. All MRI examinations were performed on 1.5-Tesla platforms using dedicated surface coils and an intravenous contrast agent. To establish a definitive diagnosis, a total of 252 MRI examinations (49 follow-ups), 22 CT examinations and 4 arthroscopic studies were obtained in addition to the obligatory conventional radiographs., Results: Incorporating all clinical data, radiographs and MRI examinations succeeded in assigning a diagnosis in 136 signal-compromised lunates (67.0 %), whereas additional diagnostic procedures or follow-up examinations were required for the definitive diagnosis in 57 cases (33.0 %). The most frequent entities were 51 cases of Kienbock's disease (25.1 %), 47 cases of ulnolunate-(triquetral) impaction syndromes (23.2 %) and 44 cases of intra-osseous ganglion cysts (21.7 %). Other pathologies included 23 degenerative, 19 traumatic and 10 inflammatory changes as well as 9 congenital conditions. For MRI assessment of the altered lunate, the most important parameters were location and morphology as well as involvement of the articular and osseous structures of the carpus., Conclusion: The lunate may be affected by different pathological states of the wrist. In total, only one quarter of the signal-compromised lunate represented Kienboeck's disease.

Although midcarpal wrist arthrodesis is recognized as a standard procedure to treat scapholuate advanced collapse (SLAC) and scaphoid nonunion advanced collapse (SNAC) of the wrist, little has been reported about patients with bilateral involvement and the number, cause, and results of failed cases requiring conversion to total wrist arthrodesis. This study investigated the results of 20 patients with bilateral procedures and of 22 patients who underwent total wrist fusion after failed midcarpal arthrodesis out of an overall group of 907 patients treated by this method during a 12-year period. Of these, 16 bilateral and 20 converted cases were reexamined after an average of 48 months and 42 months, respectively. Patients after bilateral midcarpal arthrodesis experienced a pain reduction by an average of 54% of the preoperative pain values at rest and by 56% at stress on the visual analog scale (scale range: 0 to 100) and from intolerable (3.7) to pain only during stress (1.9) on the verbal scale (scale range: I to 4). A mean arc of wrist extension and flexion of 53 degrees on the right and 49 of the left wrist was preserved. The mean DASH score was 45 points and 70% of the patients felt impaired only during certain activities. Total arthrodesis reduced pain in 18 of 20 reexamined wrists by 67% of the previous values after the failed partial arthrodesis at rest and by 46% at stress on the visual analog scale andfrom intolerable pain (3.7) to pain only during stress (2.1) on the verbal scale. Seven of the 20 reexamined patients noted complete pain relief at rest and two also under stress conditions. The DASH score averaged 39 points. A mean Krimmer score of 46 points and a mean Buck-Gramcko and Lohman evaluation of 6 points represented a satisfactory result. Grip strength of the operated hand averaged 53% of the opposite side. Subjectively, 30% felt impaired only during certain activities, 55%felt considerably and 15% strongly limited in daily life. However, all but two patients were satisfied with the secondary total wrist fusion as pain was considerably reduced. Midcarpal arthrodesis reliably reduced pain and preserved valuable wrist mobility thus improving daily activity and quality of life also in bilateral carpal collapse. In the rare cases when midcarpal arthrodesis failed, total wrist arthrodesis markedly improved the complaints in most patients, but in contrast to other studies complete pain was seldom.

Purpose: Osteoid osteoma is a painful benign bone tumour and very rare in the hand and wrist. Diagnosis may be very difficult and often is made after multiple previous diagnostic errors., Methods and Patients: From 1992 until 2003, 22 patients (11 men, 11 women) were operated on because of an osteoid osteoma of the hand or wrist in our hospital. The mean age was 30 years, ranging from 14 to 62 years. We retrospectively analysed patient records. A clinical examination with X-ray control was performed in 14 patients. Five patients were questioned by phone; three patients were lost to follow-up., Results: The mean time interval between onset of symptoms and surgical removal of the tumour was approximately two years. Symptoms were often non-specific; clinical findings varied according to localisation of the tumour. Conventional X-rays did not always show typical pathological findings. Bone scanning and gadolinium-enhanced MRI proved to be very sensitive in detecting the pathological process. High-resolution CT-scan demonstrated the nidus exactly. Usually, operative removal of the nidus resulted in immediate pain relief. At follow-up, 18 patients were free of pain. However seven patients had had a revision operation; in four of those, osteoid osteoma recurred once again., Conclusions: In our opinion, it is important to consider osteoid osteoma as a possible cause of otherwise unexplained pain of the hand or wrist. If there is clinical suspicion, we recommend the early use of gadolinium-enhanced MRI as a sensitive screening method. Thus, it should be possible to shorten the time interval until correct diagnosis is established.

The eccrine carcinoma is a rare tumour originating from the sweat glands. They are mainly located in the palm of the hand and the sole of the foot, the digits, the head and the trunk. We report on a now 68-year-old male, who underwent partial amputation of the thumb at the level of the proximal phalanx due to an eccrine carcinoma in 1990. In the following years, three local recurrences were excised. After the exclusion of metastases an amputation at the MP I level was performed at our institution. To restore grip function, we performed a distraction of the first metacarpal bone followed by deepening of the first web space. So far, there are no defined treatment recommendations due to the rarity of the tumor. In some cases, metastatic disease has been reported, and in most cases, a high rate of local recurrence. After diagnostic biopsy, we recommend staging to exclude metastatic spread of the tumor followed by aggressive local surgical treatment.

Background: The diagnosis of a chondrosarcoma of the hand can be difficult for the surgeon as well as for the pathologist. The histological criteria for differentiation between chondrosarcoma and chondroma are not well-defined. Nevertheless, distinguishing the two entities is clinically relevant, as chondrosarcomas of the hand, despite their low tendency for metastatic spread, require a prompt and more radical treatment than chondromas., Method and Material: From 1996 to 2003, we treated four patients with a histologically diagnosed chondrosarcoma of the metacarpal bones and phalanges. Two patients were female and two male with a mean age of 42 years. The duration between the first clinical symptoms and first surgery ranged from two months to 30 years. Three out of four patients underwent primary treatment in other institutions, always under the histologic diagnosis of a chondroma. The mean follow-up ranged from nine months to seven years., Results: The histological diagnosis of chondrosarcoma was followed by ray resection in three cases. Two tumors were grade 1 and two tumors grade 2. During follow-up, the patients showed no local recurrence and no metastatic spread., Conclusion: Since the differentiation between chondroma and chondrosarcoma is difficult, a good cooperation between surgeon, radiologist and pathologist is required. Despite the low metastatic potential of chondrosarcomas of the hand in comparison with other sites, ray resection or digital amputation is recommended to avoid local recurrence. In cases with only local excision, close follow-up is recommended.

Ulnar instabilities of the carpus are rare findings depending on a dissociation of the lunotriquetral (LT-) junction. They are frequently not recognized or confused with ulnocarpal complaints of other origin due to missing typical clinical or radiological indications. The central structures are the os triquetrum and its connections to the os lunatum, the distal carpal row, radius and ulna. The most important causes are injuries, but degeneration, ulnar impaction syndrome or the ulna plus variant can also be involved. The symptoms are ulnar-sided pain, sensations of instability and weakness as well as "clunking" sensations in the ulnar wrist. Clinical examination may reveal tenderness in the LT-interval, between the ECU- and FCU-tendons, and displacement of the triquetrum on palpation. The LT-interval is rarely extended in conventional X-rays. A VISI position of the os lunatum is found in instabilities of higher degree. A distinct diagnosis is only achieved by arthroscopy. Conservative treatment consists of 4-8 weeks of arm immobilization. Diagnostic arthroscopy can be combined with débridement and/or closed reduction of the LT-interval with consecutive percutaneous k-wire fixation. If a repair of the LT-ligament is not possible, reconstructive methods are indicated. They include extrinsic tenodesis with part of the extensor carpi ulnaris tendon, ligamentoplasty or osteoligamentous autografts. The role of lunotriquetral arthrodesis is considered to be controversial, due to a high rate of non-fusions. Simple correction of the LT-dissociation does not resolve the static instability of the proximal row (VISI-position of the lunatum). In these cases, salvage procedures such as limited arthrodesis of the wrist, proximal row carpectomy or complete arthrodesis are indicated.

The most common cause of an arthritically damaged distal radioulnar joint is a malunion of a distal radius fracture. Therapeutically, ulnar head resection, hemiresection-interposition-technique, Kapandji-Sauvé procedure and implantation of an ulnar head prosthesis have been described. None of these procedures is able to restore the complete function of the joint. Therefore, anatomical reconstruction of the joint in acute or secondary correction osteotomy for malunited fractures of the distal radius should be performed to avoid the development of the arthrosis. Numerous clinical studies have demonstrated a similar reduction of the clinical symptoms for all procedures. Therefore, classification of the different procedures has to consider the number of complications. Biomechanically, partial resection of the distal ulna will destabilize the distal radioulnar context and clinically may lead to painful radioulnar and/or dorsopalmar instability of the distal ulnar stump. Biomechanically and clinically, this complication, next to secondary extensor tendon ruptures, has to be expected far more often following complete resection of the ulnar head than in the alternative procedures. We do not see any remaining indication for complete resection of the ulnar head. Clinical results and the occurrence of painful instability of the distal ulnar stump have been reported almost identically for the hemiresection-interposition technique and the Kapandji Sauvé procedure. Therefore, both procedures appear to be equally suitable for the treatment of painful arthrosis of the distal radioulnar joint. In patients with a preexisting instability of the distal radioulnar joint, or a major deformity of the radius or the ulna, we prefer to perform the hemiresection-interposition-technique. In these conditions we consider the remaining contact of the triangular fibrocartilage complex with the distal end of the ulna a biomechanical advantage to reduce the risk of secondary instability. Biomechanically as well as clinically, replacement of the ulnar head using a prosthesis has been shown to either avoid or solve the problem of instability. We therefore consider ulnar head replacement the treatment of choice in secondary painful instability following resection procedures at the distal end of the ulna. Primary ulnar head replacement should be considered in special indications until long-term follow-up results are available.

This is a report on eight cases of a rare congenital malformation in the upper extremity, consisting of a unilateral muscular hyperplasia. In addition to the hand, all segments of the upper extremity may be affected. The hyperplasia is always unilateral, preferably on the right hand side, in combination with accessory muscles. Hereditary dependence or association with other malformations has not been observed. Six of eight patients were male. Shoulder and arm function were normal in all cases. Ulnar drift of the fingers in the metacarpophalangeal joints (six of eight patients), flexion contractures of the metacarpophalangeal joints (six of eight patients) and extension contractures of the wrist (three of eight patients) to various degrees were seen. A prominence of the second and third metacarpal head with an enlarged space between them gave the affected hands a very typical appearance (six of eight patients). Deformities and functional limitations requiring surgical treatment were present in six patients. In all cases, accessory muscles were found intraoperatively and resected. The macroscopic and microscopic appearance of the muscle specimen did not differ from normal muscular tissue. In all cases, additional procedures were necessary to improve the overall function. Nevertheless, the reconstructive efforts did not lead to an entirely normal hand function or appearance. The malformation we describe can clearly be distinguished from other malformations such as arthrogryposis multiplex congenita, Freeman-Sheldon syndrome or macrodactyly. Up to now, only two other reports were found in the literature showing characteristics similar to those in our own cases. Four similar cases were observed by Benatar. From a pathomechanical point of view, a disturbance in the muscular balance seems to cause the deformities and functional limitations. This imbalance could be related to accessory muscles which are not opposed by defined antagonists or to an unbalanced hyperplasia of normally developed musculature. Surgical intervention should begin early to prevent joint stiffness. Splinting and hand therapy should precede surgical intervention. Surgical treatment should aim to restore the muscular balance by resection of accessory and hyperplastic musculature. In some cases, muscle transpositions and joint releases may have to be performed. Postoperative splinting and intensive hand therapy are mandatory to preserve the results.

Introduction: The indication and treatment of malunited fractures of the distal radius in the growing skeleton differ from those for adults. The literature results are scarce. In this study we examined the results of surgical correction following fractures of the distal radius in infants., Materials and Methods: Seven infant patients with malaligned fractures of the distal radius that demonstrated significant functional deficit and poor prognosis for spontaneous recovery were treated with surgical correction. Two of them were treated because of growth disturbance from post-traumatic closure of the distal radial physis., Results: All seven osteotomies healed with acceptable radiologic alignment. After an average follow-up period of 3 years and 1 month (range 10 months to 8 years and 4 months), patients had an average range of wrist motion (ROM) of 131 deg in extension and flexion (93% of the contralateral side, 130% of presurgical situation); 65 deg in ulnar and radial deviation (94% of the contralateral side, 122% of presurgical situation); and 177 deg in pronation and supination of the forearm (97% of the contralateral side, 115% of presurgical situation). The average grip strength of 71.4 kPa was nearly equal to the other side with 72.8 kPa. The average postoperative angulation of the distal radius was 12 (range 10-17) deg, the radial inclination 20 (range 12-30) deg, and the ulnar variance was -0.6 (range -3 to +2) mm. According to the Fernandez point score system as well as the scale of Fernandez, there were five excellent results and two good results. The patients described low disability on the DASH scores, with a median of 4 (range 0-41) points., Conclusions: Surgical correction for malunited fractures of the distal radius provides good and excellent radiological and functional results in the growing skeleton. It should be considered immediately if there is poor remodeling capacity and disabling loss of function.

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.

Purpose: Midcarpal fusion is a reliable treatment for posttraumatic carpal collapse in the short or midlong term. The long-term results remain, however, unclear. The objective of this study was to assess the long-term clinical outcome but also the incidence of an arthrosis of the radiolunate joint or an ulnar translocation after excision of the scaphoid., Method and Material: 37 patients after midcarpal fusion were reexamined after an average follow-up of 97 months clinically and radiologically., Results: The average range of motion from extension to flexion was 62 degrees, the average grip strength changed from 69 % of the opposite side before surgery to 80 % after surgery. Pain in the verbal analogue scale improved from 2.7 preoperatively to 1.7 postoperatively. The Krimmer wrist score was 72, whereas 28 patients (76 %) reached a good or excellent result. The mean DASH score was 24 points. At the X-rays, ten patients (27 %) showed an arthrosis of the radiolunate joint and/or an ulnar translocation. Differences in clinical results between the groups with or without X-ray pathology were not statistically significant. From 107 patients with a midcarpal fusion in the time of interest, seven (6.5 %) had to be converted into wrist arthrodesis because of ongoing pain., Conclusion: Also in the long-term the motion-sparing midcarpal fusion offers a functional advantage over wrist arthrodesis.

Objective: In literature the diagnostic value of MRI for detecting lesions of the carpal ligaments and the TFCC is judged controversially. The aim of the following study is to determine the diagnostic accuracy of direct MR arthrography for depicting and staging of intraarticular lesions of the wrist., Material and Methods: One day before undergoing arthroscopy, 125 patients suffering from wrist pain were examined with direct MR arthrography in a prospective and blinded study. A mixture of contrast medium (iodine-containing contrast medium and gadopentetate in relation 200 : 1) was injected into both radiocarpal and midcarpal joints. The following sequences were acquired on a 1.5T scanner: coronal T1-weighted SE, coronal fat-saturated T1-weighted SE, coronal T1-/T2*-DESS-3D, and sagittal T2*-weighted MEDIC. MRI results were compared with arthroscopic findings using statistical analysis (SEN = sensitivity, SPE = specificity, PPV = positive predictive value, NPV = negative predictive value, ACC = accuracy)., Results: In comparison to arthroscopy as the accepted diagnostic gold standard, the following results were found for MR arthrography. Detection of TFCC lesions: SEN 97.1 %, SPE 96.4 %, PPV 97.1 %, NPV 96.4 %, ACC 96.8 %. Detection of complete tears of the scapholunate ligament: SEN 91.7 %, SPE 100 %, PPV 100 %, NPV 99.1%, ACC 99.2%. Detection of partial tears: SEN 62.5 %, SPE 100 %, PPV 100 %, NPV 94.8 %, ACC 95.2 %. Detection of cartilage defects: SEN 84.2 %, SPE 96.2 %, PPV 80 %, NPV 97.1 %, ACC 94.4 %. In total, only three lesions of the lunotriquetral ligament were present., Conclusion: Direct MR arthrographic imaging is well suited for detecting intraarticular lesions of the wrist. The presented diagnostic results of MR arthrography are superior to the results of unenhanced MRI reported in the literature. Direct MR arthrography as a reliable diagnostic tool is strongly recommended if lesions of the scapholunate ligament and the triangular fibrocartilage complex are suspected. In contrast, an attitude of caution must be adopted in diagnosing lesions of the articular cartilage of the wrist.

The arthrotically destroyed distal radioulnar joint will lead to painful limitation of forearm rotation. Alternative treatment options are the hemiresection-interposition arthroplasty or the Kapandji-Sauvé procedure. The aim of our study was to evaluate the clinical and functional results following the hemiresection-interposition arthroplasty in non-rheumatoid patients. The most common posttraumatic cause of the arthrosis was the malunited distal radius fracture. In a retrospective study we examined 36 of 51 patients with a mean age of 53 years after an average follow up of 34 months clinically, radiologically and using the DASH questionnaire. The average preoperative pain measured 7.8 on the visual analog scale and was reduced statistically highly significant (p < 0.01) to 3.9. Whilst pronation increased statistically not significantly from a mean of 74 degrees to 76 degrees (p = 0.428), supination improved significantly from 54 degrees to 69 degrees (p - 0.012). The average grip strength increased statistically highly significant (p<0.001) from 40% to 64% compared to the unaffected side. Patients' satisfaction with the result averaged 6.9 on a visual analog scale. Using a modified Mayo-wrist score, six patients were rated to have an excellent, eleven patients a good, ten patients a satisfactory and four patients a poor result. The average DASH score measured 35. In 21 patients radioulnar impingement was found. This appeared to be painful in 14 patients and required revision surgery using the ulnar head prosthesis in five patients. In three patients, secondary ulnar shortening had to be performed due to a remaining painful impaction of the distal ulna against the lunate and triquetrum. Comparing our clinical results with the reported results following the Kapandji-Sauvé procedure from the literature, there was no evident superiority of either of the procedures. There is a need for a functional evaluation following the Kapandji-Sauvé procedure to compare the remaining functional impairment following both procedures. In conclusion both procedures have to be classified salvage procedures and therefore the indication should be limited to the arthrotically destroyed distal radioulnar joint.

The acute compartment syndrome of the forearm and hand leads to severe muscle necrosis and nerve damage if the diagnosis is not recognized. The resulting ischemic contractures and paralyses require a distinctive regime of therapy. Therefore,physiotherapy and occupational therapy are of main importance. In mild cases exclusively nonoperative treatment is possible. The goal is to exercise the function of the remaining muscles, mobilize the joints, and stretch muscle scars. Severe forms need surgery. To reach the best starting point for the operation, extensive preoperative active and passive exercises as well as splint therapy are required. Postoperatively, this regime has to be continued to retain a favorable outcome. The treatment approach is demonstrated with a case report.

Aim: In our goal-oriented society the demands for a forearm with full function are increasing. Functional deficits are not acceptable even if they persist only for a limited period of time. Therefore a rising number of surgical corrections of malunited forearm fractures in the pediatric patient has been performed during the last years. However literature about indication, technique and outcome in these patients is rare. For that reason we report our experience about surgical correction of malunited fractures of the forearm in 14 children., Methods: Fourteen patients with an average age of 13 years at the time of surgical correction of a malunited fracture of the forearm were included. Seven had a deformity of the shaft, five at the distal forearm without and two with growth disturbance. Malunions without growth disturbance were corrected with an osteotomy and plate fixation. Those with growth disturbance were first treated with callus distraction. Previous to and 24 (3 to 100) months after surgical correction the patients were examined clinically and radiologically. Range of motion was noted. Additionally to the range of motion, grip strength and pain (VAS) were documented. Patients with correction of the distal forearm were asked to fill out the DASH questionnaire., Results: In all groups a significant increase of the range of motion was noted in pro-/supination of 61 per cent to 85-0-80 degrees. In patients with distal correction additionally the range of motion in extension/flexion of the wrist improved 30 per cent to 70-0-65 degrees and in ulnar/radialduction 22 per cent to 30-0-35 degrees. At follow-up the grip strength following distal corrections was 98 per cent of the opposite side. The patients had no pain (VAS < 3 points). The median subjective functional result was excellent with a median DASH score of 3.5 points., Conclusions: Our results show that potent techniques for surgical correction of malunited forearm fractures in the growing skeleton are available. These techniques allow excellent functional outcome.

The treatment of hand surgery patients suffering from chronic pain requires an interdisciplinary procedure. An imbalance between nociception and antinociception can be seen as a reason for the chronification of pain. The complexity of the problem of chronic pain patients is marked by a wide variety of symptoms. Full diagnostic assessment to detect or to exclude other organic diseases is required. Rehabilitation to improve function and reduce pain intensity has priority. Our therapeutic strategy consists of intensive physiotherapy and analgesic drugs as well as a series of blockades with buprenorphine (Temgesic) of the ganglion stellatum (GLOA). This specific therapy achieved an improvement of the function of the upper extremity and a reduction of pain intensity. The majority of patients were satisfied with the outcome.

Despite the important observations that have been made concerning biomechanics and function of the wrist joint in recent years, the surgeon is still confronted with a huge number of delayed posttraumatic disorders of this joint. In the past, total wrist fusion was the leading salvage procedure, whereas today several salvage procedures are available to solve these problems. Partial wrist fusions are supposed to stabilize the carpus, immobilize destroyed articulating surfaces while allowing motion in the unharmed parts of the wrist. Acknowledging pathobiomechanical laws, they have been used for a growing number of indications with a large benefit. The patients profit of better functional results than can be observed in patients with total arthrodesis of the wrist. Furthermore, partial wrist fusion provides a more stable situation and the absence of pain for a longer period of time. However, further studies evaluating the clinical outcome of these salvage procedures are necessary and to be expected in the near future.

Between December 1994 and December 1996, 26 patients with a scapholunate ligament injury (three with SLD 1. degrees, 16 with SLD 2. degrees and 7 with SLD 3. degrees ) underwent an operation for dorsal capsulodesis in the Klinik für Handchirurgie, Bad Neustadt/Saale. Mean follow-up was 24 months (16 to 37 months). Follow-up criteria were range of motion, grip strength, pain relief, and X-ray findings. Clinical outcome was evaluated using a personal questionnaire, the DASH- and a modified Cooney-Score. Although significant reduction of joint mobility compared to the opposite site was found in all cases (E/F 32 %, U/R 19 %), the reduction of pain was 30 %. Grip-strength was not altered. Thus, 86 % of the patients were satisfied with the result obtained. On X-ray, the scapholunate angle was raised in the SLD 3. degrees -group by 12 degrees postoperatively; in the group with dynamic instability, X-ray findings were normal. Overall, 19 % (5/26) needed further operations due to persistent pain.

Purpose: Evaluation of the outcome of preoperative intermittent pneumatic soft tissue distraction (IPD) in patients with severe contractures in Dupuytren's disease with special regards on recurrent deformities., Method: In a prospective study, nine patients with Dupuytren's contracture grade III and IV according to the classification of Tubiana were treated with a preoperative intermittent soft-tissue distraction using a pneumatic extension device followed by a standardized operative correction and follow-up program. Sixteen fingers were involved: grade I and II four fingers, grade III and IV twelve fingers. Nine fingers - grade III and IV seven fingers - in six patients had a recurrent deformity., Results: The preoperative reduction of contracture simplifies the surgical treatment. Preoperatively using the IPD, the flexion contracture was reduced between 5 and 60 degrees. With an average of 29 (10 to 60) degrees, the improvement was greater in fingers with severe contracture (grade III and IV according to Tubiana) than in fingers with a minor contracture averaging 10 (5 to 25) degrees. In fingers with recurrent deformity, the reduction of the flexion contracture averaged 27 (5 to 60) degrees. There were no complications leading to break off of the distraction., Conclusion: The intermittent pneumatic distraction is a good alternative to the method introduced by Messina for preoperative soft-tissue distraction in patients with severe Dupuytren's contracture.

Two cohort populations consisting of 13 patients with an un-united fracture of the distal radius in whom the distal fragment had more than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion and ten patients with an un-united fracture of the distal radius with a smaller distal fragment were compared. There were no preoperative differences with respect to age, gender, interval between injury and index procedure, preoperative amount of radius tilt, ulnar inclination and ulnar variance, or the preoperative function. Independent of the size of the distal fragment in all patients the distal radius was restored to gain bony union and realignment with preservation of some wrist motion. The length of the follow-up period averaged 30 months for the small fragment group compared with 22 months for the large fragment group. Bony union was achieved in 22 patients. One patient out of the large fragment group failed to heal the fracture and had wrist fusion. At the follow-up examination there were no significant differences in the radiological and clinical outcome between the two groups. No differences were seen on total range of motion of forearm supination and pronation with an average of 135 degrees in the large fragment group and 145 degrees in the small fragment group. Wrist motion revealed no significant differences in the flexion-extension arc, averaging 90 degrees in the large fragment group and 83 degrees in the small fragment group. Total range of motion of radial and ulnar deviation of the wrist was similar, averaging 39 degrees in the large fragment group and 43 degrees in the small fragment group. Grip strength averaged 59% compared with the opposite limb for the large fragment group and 67% for the small fragment group. We believe that the results of reconstruction of un-united fractures of the distal end of the radius for patients in whom the distal fragment had less than 5 mm of subchondral bone supporting the articular surface distal to the site of the nonunion are comparable to the results for patients with a larger distal fragment. Therefore, we believe that surgeons should try to preserve even a small amount of wrist motion and reserve wrist fusion as a final resort.

Purpose. Evaluation of effectiveness of capsuloligamentous release in severe PIP joint contractures in Dupuytren's disease. Method. Prospective study to compare the clinical outcome of eleven patients with severe contracture of the PIP joint due to Dupuytren's disease, in whom an additional capsulotomy was performed to reduce a residual flexion contracture of the PIP joint of 20 degree and more after release and excision of all diseased fascia, with the outcome of 32 patients with severe contracture of the PIP joint due to Dupuytren's disease, in whom the PIP joint contracture could be reduced by fasciectomy alone. Preoperatively all patients had a severe flexion contracture (60 degrees or greater) of one PIP joint. All patients underwent standardized operative treatment and postoperative extension splinting program for six months. Follow-up examinations included assessment of active range of motion at two, four, ten, 16 and 24 weeks after surgery. Results. In the noncapsulotomy group, preoperative contracture averaged 70.6 degrees and intraoperative residual contracture averaged 2 degrees. In the capsulotomy group, preoperative contracture averaged 78.6 degrees. Intraoperative residual contracture averaged 61.8 degrees before and 2 degrees after capsulotomy. At the final follow-up examination, PIP joint flexion contracture averaged 15 degrees in the noncapsulotomy group compared to 16 degrees in the capsulotomy group. Conclusion. Residual flexion contracture of a PIP joint after release and excision of all diseased fascia in Dupuytren's disease can be reduced by capsuloligamentous release. The data of this study showed no significant differences in the outcome at the final follow-up examination between patients with and without capsulotomy. Therefore, we recommend capsulotomy as treatment of residual flexion contracture of the PIP joint in Dupuytren's disease.

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.

Malunion of forearm fractures located in the distal third will remodel satisfactorily providing the child is less than twelve years of age. Complete correction of gross deformity cannot be anticipated in diaphysial fractures when the child is over five years of age. Malunion of fractures of the forearm in children can lead to permanent functional disability with limitation of forearm rotation. In the case of functional disability, there is an indication for corrective osteotomy at the age over twelve in malunion of a fracture located in the distal third and already after age five in gross deformity of fractures to the midshaft of the forearm.

Significant progress has been made in the understanding of carpal kinematics and posttraumatic disorders of the wrist. The importance of stabilization of the scaphoid is well known. More and more ligament injuries of the proximal carpal row have been diagnosed in cases of severe arthrotic changes. Long-standing scaphoid nounion or scapholunate ligament injuries can lead to progressive carpal collapse due to a break of the continuity of the proximal carpal row. SLAC-wrist (scapholunate advanced collapse) and SNAC-wrist (scaphoid nonunion advanced collapse) after missed fusion of scaphoid fractures should be differentiated. Severity of degenerative changes is classified into three stages. Salvage procedures preserving wrist mobility, like midcarpal fusion, are preferable to total wrist fusion because of the functional benefit. With complete excision of the scaphoid and fusion of the midcarpal joint, all arthritic joint surfaces are eliminated and motion is preserved in the radiolunate joint which is usually spared of degenerative changes.

The ulnar impaction syndrome is proven to be a common source of ulnar sided wrist pain. Ulna-shortening osteotomy represents a successful therapy for this kind of problem, both congenital or posttraumatic positive ulnar variance. Positive variance resulting from a distal radius fracture needs correct dorsal and radial angulation of the radius. In case of congenital positive variance arthroscopic debridement for decompression of the TFCC should be performed first. The adequate correction of the length is the major problem. Disorders of the distal radioulnar joint may result due to overcorrection. Oblique osteotomy using 7-hole-plates is our preferred treatment.