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Clinically most patients complain about ulnar sided wrist pain and limited forearm rotation following malunited distal radius fractures. Possible bony reasons consist of intraarticular incongruency, malalignment of the sigmoid notch of the distal radius or the ulna-plus-situation at the wrist level. A persisting luxation of the distal radioulnar joint (DRUJ) will present itself with complete loss of forearm rotation. The ligamentous or bony detachment of the triangular fibrocartilage complex (TFCC) will lead to instability of the DRUJ. Uncorrected, each of these components will lead to arthrosis of the DRUJ. The presence of arthrosis only allows salvage procedures for the DRUJ and will lead to functional loss. Reconstructive options consist of radius correction osteotomy, ulnar shortening osteotomy, reposition of a luxation and refixation of the TFCC. To chose the necessary reconstructive procedure, the individual pathological situation has to be analysed.

Lesions of the TFCC may have degenerative or post-traumatic causes. Distal radioulnar joint as well as the ulnocarpal joint can be affected. Patients present with ulnar-sided wrist pain especially in forearm rotation. Therapy depends on the degree of lesions and additional pathology. Wrist arthroscopy offers a certain diagnostic tool. In addition, adequate therapy can be realized. After failed arthroscopic therapy, ulnar shortening osteotomy reduces ulnar load significantly.

In our study, we present the data of eleven patients suffering from scarring of the median nerve, predominantly after open decompression of the carpal tunnel. Dysaesthesia in the palmar region and loss of grip strength prevented performing normal daily activities. All patients except one were relieved of the palmar discomfort and experienced an increase of grip strength allowing their return to work. The hypothenar fat flap has been shown to be a reliable source of local tissue to cover the median nerve. The sprouting of nerve fibers to the skin is prevented as well as median nerve readherence. We believe that the hypothenar fat flap provides sufficient regenerative conditions and coverage of the median nerve within the carpal tunnel in the surgical treatment of abundant scarring.

Background: One of the most common injuries in orthopaedics is the distal radius fracture. Malunion may lead to pain, limited motion, and loss of grip strength. Presently there is no consensus concerning the indications for corrective surgery after malunion. Studies concerning the biomechanics of the wrist in cases of malunited radius fracture can be helpful., Method: Analysis of the literature of the last ten years., Results: In laboratory studies, malalignment of the radius caused alterations of the distal radioulnar joint (anatomically: reduction of the radioulnar contact area, disruption of the deep portion of the dorsal radioulnar ligament, tightness of the triangular fibrocartilage complex; functionally: limited forearm pronation and supination). Further alterations have been found concerning the carpal kinematics, the force transmission through the wrist, the pressure distribution on the articular surface of the radius and the median nerve., Conclusion: Attempts should be made to obtain an anatomic reduction of all acute distal radius fractures. Posttraumatic disability of the wrist following malunion in radius fractures should accordingly be treated by a corrective osteotomy of the radius at the original fracture site.

Background: There is an increasing interest in the corrective osteotomy for the malunited distal radius fracture. Already in the seventies we developed an operative technique for the correction of the malunited Colles' fracture. The technique is based on a special plate, which facilitates precise restoration of the angulation of the joint surface and the length of the radius. The purpose of our study is to investigate the results of our method and to compare them with results in the literature., Patients and Methods: We examined retrospectively the patients with a malunited Colles' fracture corrected by our technique until August 1996. The investigated criteria were range of motion, grip strength, pain relief, and X-ray findings., Results: Until August 1996, we have performed 124 corrective osteotomies for malunited Colles' fractures; 115 were carried out by our technique; 91 of them could be examined. The mean follow-up time was 4.5 years. The range of motion has improved in all planes, especially for flexion. Grip strength increased but still remained below the level of the opposite side. On X-ray, average dorsal tilt of the radiocarpal joint was 24 degrees preoperatively and was reduced to an almost normal palmar tilt of 7 degrees. Ulnar-plus variance was reduced from 6 mm to less than 1 mm., Conclusion: Corrective osteotomy of the distal radius is of great benefit and leads to improved hand function and diminished pain. The use of our special plate facilitates this ambitious operation considerably.

Midcarpal fusion is a reliable treatment for advanced carpal collapse following scaphoid nonunion or scapholunate dissociation. It remains, however, unclear if the alignment of the fused carpal bones influences the redirection of load towards the lunate. The objective of this study was to assess the actual loading conditions after midcarpal fusion in patients by evaluating the patterns of subchondral bone mineralization in the distal articular surface of the radius. Nine patients, who were treated by midcarpal fusion with complete excision of the scaphoid, were examined after an average of 22 months postoperatively by means of CT osteoabsorptiometry. All patients showed peak mineralization in the lunate fossa of the distal articular surface of the radius. Six patients with correct carpal alignment had one large density maximum in the lunate fossa and none in the scaphoid fossa. Patients with incomplete correction of the radial translocation of the capitate, incomplete excision of the scaphoid, or incomplete correction of the extension position of the lunate, showed a second density maximum in the scaphoid fossa. These findings emphasize that a correct carpal alignment is necessary to achieve a complete unloading of the degeneratively altered scaphoid fossa.

A retrospective review of severe flexion contractures (60 degrees or more), involving 51 proximal interphalangeal joints in 40 patients with Dupuytren's disease, was performed. Thirty-two joints underwent aponeurectomy alone, 19 joints additional capsuloligamentous release. Mean follow-up was 12 months. No statistically significant difference was seen in the percentage of contracture correction in the capsulotomy group compared with the noncapsulotomy group.

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.

Midcarpal fusion represents a salvage procedure in cases of advanced carpal collapse, which unloads the scaphoid compartment and redirects the load to the intact lunate compartment of the radiocarpal joint. The aim of this study was to obtain further information about the loading conditions in the living subject by evaluating the pattern of subchondral bone mineralization in patients who have undergone midcarpal fusion of the wrist. Between 4 and 42 months after the surgery, 9 male patients were examined by means of computed tomographic osteoabsorptiometry. All of them showed peak mineralization in the lunate fossa of the radius. Six patients had only one large density maximum in this fossa and no corresponding maximum in the scaphoid fossa. In accordance with our expectations, loading after midcarpal fusion was found to be transmitted mainly through the lunate compartment, a result that was observed even after as little as 4 months, and that thus confirmed subchondral bone mineralization as a valuable parameter for assessment of long-term stress distribution.

The ulnar head represents a keystone for normal forearm function. A complex system of soft tissues stabilizes the radius and the ulnocarpal joint against the ulnar head which is an essential part of the distal radioulnar joint as well as the ulnocarpal joint. Injuries around the ulnar head can destabilize these joints leading to loss of congruity and secondary arthrosis. The different injury patterns can result in axial or transverse instability. Axial instability primarily affects ulnocarpal function, transverse instability the function of the distal radioulnar joint. The injury pattern determines the degree of bony and soft tissue lesions that will clinically present in a variety ranging from acute dislocation to chronic instability of the ulnar head. An early and exact diagnosis of the injured structures with their anatomical reconstruction is necessary to avoid secondary arthrosis that will result in functional impairment of the distal radioulnar and ulnocarpal joints.

A patient developed after an occupational trauma with fall on the ulnar edge of his right hand pain and swelling in the ulnar area with reduced sensation in the fourth and fifth finger. After examination performed by a neurologist, ulnar nerve-entrapment was diagnosed and operative treatment was indicated. The release of the ulnar tunnel showed a traumatic aneurysma of the ulnar artery compressing the superficial branch of the ulnar nerve. The tumor was removed and end-to-end anastomosis ensued. Four weeks after surgery, examination showed complete recovery. Various reasons of ulnar tunnel syndrome are discussed.

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.

Free muscle transplantation with motor innervation offers the possibility to add contractile elements to upper extremities with extensive loss of musculature due to direct trauma or untreated compartment syndrome (Volkmann's contracture). The functional cross section area and the mean resting fiber length determine the maximum power and the contracting amplitude of the donor muscle. Although considerably weaker than the finger flexors to be replaced, the gracilis muscle was the preferred donor muscle because of its neurovascular pedicle and the minimal donor site morbidity. In a series of 15 gracilis transplantations, all 13 muscles that survived regained function. Finger motion was dependent on the preoperative condition of tendons and joints. Even after complete loss of the flexor and extensor compartment a useful upper extremity could be restored, which was preferable to the only alternative-amputation.

The results of STT-fusion for treatment of advanced Kienböck's disease were investigated in a retrospective study. The follow-up included 25 of 28 patients, the average follow-up time was 39 months. Pain relief, range of motion, grip strength and X-ray findings were the most important criteria for rating the results. On the one hand, there was a decrease of range of motion, but on the other hand, grip strength improved markedly. Of course, one part of the decrease of pain is caused by the performed partial denervation of the wrist. However, the decrease of pain was impressive.

The distribution of subchondral mineralization of the distal articular surface of the radius was examined by CT osteoabsorptiometry in both wrists of twelve patients showing different stages of Kienböck's disease. The pattern of density distribution had already been demonstrated in previous studies to be an adequate parameter for assessing axial loading across the wrist joint in the patients. Contrary to the anticipated presence of predominant stress in the lunate compartment, some patients showed identical stress in the compartment of the scaphoid, and the balanced loading of both compartments, as before. Even when in early stages of the disease the lunate type of mineralization appeared more often, it was still not possible to demonstrate general excessive stress on the lunate. We have therefore concluded that the main stress in the scaphoid compartment might be a secondary effect, which is to be regarded as the expression of the advancing destruction of the lunate and consequent loss of load transmission through this compartment. This hypothesis is also supported by the fact that, in progressive stages of Kienböck's disease, the density maximum in the fovea lunata, generally present in healthy people, is absent. Furthermore, in patients with necrosis of the lunate, the total mineralization in terms of the maximal density values in the distal joint surface of the radius is in the majority of cases less than in the normal subject. In two cases, even the density maximum was absent from the fovea lunata of the contralateral wrist joint, without there being any clinical signs suggesting a possible lunate necrosis on this side. We interpret these pathological changes in the unaffected wrist joint as a further indication that we are dealing with a congenital predisposition which affects both wrist joints.

Because of the loss of mobility, scarring of the median nerve in the carpal tunnel can lead to chronic pain syndrome of the wrist joint, with reduced sensation, muscular dystrophy and severe limitation of the use of the hand. This syndrome most often appears following open carpal tunnel release. Nine patients with scarring of the median nerve in the carpal tunnel were treated with a hypothenar fat-pad flap. Eight of them showed a significant reduction in pain, with improved sensation, trophism and strength. The procedure is suitable as a salvage procedure for restoring a sliding pathway and for cushioning the median nerve in the presence of recurrent lesions in the carpal tunnel.

Camptodactyly is caused by an imbalance between the flexor and extensor forces at the proximal interphalangeal joint of the fingers. Although the etiology is not completely clear, the lumbrical muscle anomalies seem to play an important part in the pathogenesis of camptodactyly. The insertion of this intrinsic muscle often differs greatly from that described in anatomical textbooks. In our series, we transposed the lumbrical muscle and the superficial flexor tendon to the extensor tendon creating a better balance between extensor and flexor forces. Additionally, we performed skin-lengthening procedures and, if necessary, an arthrolysis of the proximal interphalangeal joint. In this study, we present a new classification of preoperative guidelines to ameliorate the operative treatment of camptodactyly.

Radial nerve palsy results in a lack of extrinsic extensors of the wrist, fingers and thumb. The degree of dysfunction depends on the level of trauma to the radial nerve. If the wrist is not stable there is a loss of prehensile grip. Patients have great difficulty picking up large or heavy objects. In high radial nerve palsy the loss of triceps function can cause additional problems. Based on our knowledge of anatomy and biomechanics, radial nerve function can be restored sufficiently. The indications, preoperative planning, technique of transposition and postoperative management are explained.

Radial nerve palsy results in a lack of extrinsic extensors of the wrist, fingers and thumb. The degree of dysfunction depends on the level of trauma to the radial nerve. If the wrist is not stable there is a loss of prehensile grip. Patients have great difficulty picking up large or heavy objects. In high radial nerve palsy the loss of triceps function can cause additional problems. Based on our knowledge of anatomy and biomechanics, radial nerve function can be restored sufficiently. The indications, preoperative planning, technique of transposition and postoperative managment are explained.

Tendon sheath infections and septic arthritis require early irrigation therapy in order to avoid permanent loss of function. In the thumb, infection of the sheath often leads to an acute carpal tunnel syndrome, necessitating open median nerve decompression. Differential diagnoses have to be taken into consideration: tuberculous synovialitis of the tendon sheath or finger joint is not yet extinct. The severely painful herpetic whitlow of the finger tip requires virostatic therapy. Operative measures are also not indicated in the acute calcium deposit, which as a rule resolves spontaneously within several days. Only its chronic recurrent form with or without pressure symptoms requires surgical intervention.

Primary or secondary flexor tendon surgery occasionally leads to damaged flexor pulleys. Insufficient pulley reconstruction causes loss of finger function by bow stringing of the flexor tendon. This paper reviews the anatomy and biomechanics of the flexor pulley system. Different techniques of reconstruction are discussed.

Computer-aided communication provides us with an easy way of exchanging different messages. Personal data (E-Mail) can be transferred as easy as pictures. News-groups would be intended to act as a forum where many people could interact and share information on issues related to the practice and the advancement of hand surgery. This paper explains the technique and the advantage of electronic communication. Using already existing computer-networks will enable us to start communication at once.

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.

The continuous extension of Dupuytren's contracture prior to aponeurectomy in severe cases, introduced by Messina, is presented. This technique demonstrates the possibility of reversing contractures; it simplifies the surgical treatment thereafter and avoids difficulties in blood circulation and sensibility. First results in ten patients are presented.

Free muscle transplantation with motor innervation is the only way to add contractile elements to upper extremities with extensive loss of musculature due to direct trauma or untreated compartment syndrome (Volkmann's contracture). The functional cross-sectional area and the mean resting fiber length determine the maximum power and the contracting amplitude of the donor muscle, respectively. Although considerably weaker than the finger flexors to be replaced, the gracilis muscle was the preferred donor muscle because of the consistent anatomy of its neurovascular pedicle and the minimal donor site morbidity. In a series of 15 gracilis transplantations, all 13 muscles that survived regained function. Finger motion was dependent on the preoperative condition of tendons and joints. Even after complete loss of the flexor and extensor compartment after direct trauma or infection, a useful upper extremity could be restored, which was preferable to the only alternative--amputation.

Long before the term 'handsurgery' was coined, surgery in the hand was performed. The development towards a surgical speciality, however, is closely bound to the name Sterling Bunnell. By the end of World War II he instituted hand centers, in which tissue specific surgery was replaced by region specific surgery. Introduction of microvascular surgery made an immediate and global repair of all injured structures possible and desirable.

Dupuytren's contracture is a disease of the connective tissue, especially of the palmar side of the hand. Today, by means of electron microscopy and histochemistry, several alternations specific of pathology of the disease can be shown, providing a better understanding. However, a revolutionary change of treatment is far out of reach. Dupuytren's diathesis can be influenced by none of today's known methods, and therapy is still empirical. Operative therapy is only indicated in functional impairment. Treatment should be done by well-trained surgeons and in case of extensive diathesis by carefully planning and longtime follow-up to avoid complications and eruption of the disease.

This case report represents a 56-year-old patient with macrodactyly of the right foot. This congenital anomaly was not treated surgically before. We resected the gigantic phalanges and metatarsals with preservation of the three main points for walking. The patient is now able to wear fitting shoes.

In case of the loss of one single muscle function in the hand, the possibility of a neurogenic cause should not be overlooked. The differential diagnosis includes: 1. Partial compression; 2. anatomical variation; 3. monofascicular rotational distorsion. Rotational distorsion of a nerve has previously been described by A. Wilhelm (1976). This type of compression syndrome occurs after repeated forceful muscle contractions and may involve for example either exclusively those fascicles in the main trunk of the median nerve, forming the anterior interosseous nerve or the deep branch of the radial nerve. We report a series of six patients in whom torsional nerve injury was found.

Longstanding unstable scaphoid nonunions inevitably lead to carpal collapse and symptomatic secondary arthrotic changes, ruling out reconstructive procedures to the scaphoid itself. Partial mediocarpal fusion, however, can preserve some wrist motion and markedly reduce or even eliminate wrist pain. By correcting the malalignment of the lunate and capitate, carpal height is restored. By excision of the scaphoid, its destroyed articular surfaces are removed. In 26 of 31 patients undergoing mediocarpal fusion, complete or at least significant reduction of wrist pain was observed. Average grip strength increased by 23%, whereas wrist mobility decreased by 33 to 40% with a relatively short follow-up of 14 months. Total wrist fusion remains the last line of defense.

Computed tomography was carried out in 32 patients with clinically equivocal soft-tissue lesions of the hand (24 times) and forearm (8 times). The CT scans were performed with the patients in standard positions; thin slices and zoom technique were used. All soft-tissue tumors were correctly diagnosed with regard to localization, size and infiltration of the surrounding tissue. The histological diagnosis was correct in tendon-sheath proliferations, deposits caused by metabolic disorders, epithelial and ganglion cysts, hemangiomas, lipomas and in one schwannoma. A malignancy was suspected and was proven to be correct in two cases. False-positive diagnoses of a malignant soft-tissue tumor were made in one case of an aggressive fibromatosis, in a rapidly progressive, ossifying myositis, and three times in the presence of postoperative scar tissue following the resection of a sarcoma. Finally, a case of proliferative myositis regarded as semimalignant was underrated by CT. The hand surgeon considered CT diagnostics to be very helpful in planning operations in an anatomically complex organ such as the hand.

A fibrous cord with a length of nearly 60 mm and a width of 3 mm consistency starts near the insertion of the abductor digiti minimi muscle at the ulnar border of the little finger. The fibers pass parallel to the longitudinal direction of the little finger and at the level of the osseous ridges on the palmar side of the flexion-extension axis of the finger joints. Proximally the cord receives fibers from the periosteum at the base of the proximal phalanx, from the ulnar end of the natatory ligament, and from the pretendinous fibers of the A1 pulley. Distally the digital cord has connections to the cutaneous ligaments of Grayson and Cleland. The cord also joins the flexor tendon sheath, the neurovascular bundles, and the skin. Sometimes these cords are involved in Dupuytren's contracture.

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.

From 1976 to 1976 in 44 fingers (41 patients) flexor tendons within the digital sheath (zone I and II) were repaired by direct suture. A modification of KESSLER's "grasping" suture was employed. In 21 fingers only the deep flexor and in 23 fingers both flexor tendons were divided; in these cases a repair of both tendons was carried out whenever possible. In cases of delayed repair, however, secondary changes of the gliding apparatus often prevented a repair of the superficialis tendon. Tenolysis was proposed in one half of the cases. It was done not earlier than 3 months after tendon suture. After division of both flexor tendons we obtained in cases with good preoperative conditions (21 fingers) 66% of good and excellent results, according to BOYES' classification, and 75% according to BUCK-GRAMCKO's classification.

Edema of the hand of no matter which cause prevents adequate active finger motion. Persistent swelling may lead to secondary shrinkage of collateral ligaments and fibrosis of paratenon. A custom made compression glove has proven to be an effective tool in reducing edema and preventing secondary damage. It has been useful in treating posttraumatic or postoperative edema and trophic disturbances of the hand.

Alteration of carpal morphometry after surgical release of the carpal tunnel was investigated in 22 patients with idiopathic carpal tunnel syndrome, using pre- and postoperative computed tomography. The morphometric evaluation showed an increase in carpal volume which was due to a palmar soft-tissue prolapse in 90% and to an increase of the carpal arch cross sectional area in about 10%. The carpal tunnel release caused a palmar opening of the canal most commonly at the pisiform bone. There was also a variation in form and an increase in volume of Guyon's canal. The results are discussed and related to the postoperative complaints.

In 246 hands in which the carpal tunnel was explored at operation, 29 variations in the course of the median nerve were found. Accessory branches at the distal portion of the tunnel were found in 18 hands, a high division of the median nerve in seven, and accessory branches proximal to the tunnel in four. Based upon these findings and including published reports of others, the variations were classified into four groups: I-variation in the course of the thenar branch; II-accessory branches at the distal portion of the carpal tunnel; III-high divisions of the median nerve; and IV-accessory branches proximal to the carpal canal. The thenar branch variations in 100 cadaver hands (Poisel) were extraligamentous in 46 percent, subligamentous in 31 percent, and transligamentous in 23 percent. The findings emphasize the importance of approaching the median nerve from the ulnar side when opening the carpal tunnel.

The method of transcutaneous PO2 measurement is suitable to record the differing oxygen supply, and thereby the blood supply of direct skin flaps. The increasing blood supply in the base as well as in the peripheral part of the flap up to the tenth postoperative day is characterized by increasing PO2 values. In clinical use the method is suitable for controlling of pedicle flaps, particularly with regard to the determination of the optimal time for division of the pedicle. In axial pattern flaps the production of ischemia by regular occlusion of the pedicle seems to accelerate vascularization from the bed of the transplant.