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Dysplasia epiphysealis hemimelica is a rare benign osteochondromatous disorder which develops in childhood mostly on the epiphyses of the bones in the lower extremities. While the tarsal bones are often involved, it is very rare in the carpus. Four patients are reported. Two were treated operatively with good results. In consequence of the experience of Lamesch, an excision was not performed in the other two cases. The patients were followed up for many years with the findings of some reduction in size and figure. Therefore, it is recommended not to operate this special tumour as long as no functional disturbances will occur.

The development of hand surgery in the three German-speaking countries is reported with special reference to the contributions in the literature. The formation of national and supra-national societies and the first meetings are part of the description of the modern hand surgery, written from the standpoint of the author. In this review article, the collection of the most important bibliographic data is of particular value.

Background: The rapid development of hand surgery in general has influenced the treatment of congenital malformations of the hand and forearm. Methods: The current indications and techniques for reconstruction of congenital malformations of the hand and forearm are reviewed. Results: Of the new techniques in the operative treatment of congenital malformations of the hand and forearm, the microsurgical procedures have to be mentioned first. The use of vascularized transplantation of toe and toe joints to thumb and fingers as well as the treatment methods for proximal radioulnar synostosis and congenital forearm pseudarthrosis have special indications. The different procedures of callus distraction, distraction transposition, and transverse soft-tissue distraction facilitating the separation of narrow syndactylies have to be known. Syndactyly separation without skin grafts must be discussed critically. Conclusions: Congenital malformations of the hand and forearm are rare. Knowledge of the optimal corrective techniques and experience are mandatory to improve functional long-term results.

The aim of this article is to show that the well-known Tinel sign is realiy a Hoffmann-Tinel sign. The translation of the two papers of Hoffmann, published in the same year that Tinel wrote his article (1915), is completed by a short biography of Paul Hoffmann.

In congenital malformations the lengthening of partially aplastic digits, by on-top plasty of a bone graft or the bony stabilization of finger stumps consisting of soft tissues without skeletal elements, is extremely difficult. The usual bone graft, taken from the iliac crest or the fibula, will undergo resorption and will have disappeared a few months postoperatively. Experience has shown that the proximal toe phalanx will with-stand any resorption if it is taken whole, covered by its periosteum. Another advantage is the possibility of the construction of a new joint between the metatarsophalangeal articular surface of the toe phalanx and the distal end of the recipient bone in the hand, which is usually covered by cartilage. Flexor and extensor tendons exist in most cases. Between 1976 and 1988, 69 transplantations of proximal toe phalanges were performed in 43 children. The indications were: boneless digital stumps or partial absence of digits in symbrachydactyly and ring constriction syndrome. Follow-up examinations of 40 patients with 63 transplanted phalanges at an interval of 36 months (12 to 160 months) has shown a 100% take of the bone graft provided it had not been split and the periosteum was undamaged. The earlier in life the operation was performed, the more postoperative growth was recorded. A joint construction was attempted in 46 digits with variable results; active mobility ranged from 0 degrees to 90 degrees. With the use of a tendon interposition, there is a less degree of shortening of the toes.

Dysplasia epiphysealis hemimelica is a rare benign osteochondromatous disorder which develops in childhood mostly on the epiphyses of the bones in the lower extremities. While the tarsal bones are often involved, it is very rare in the carpus. Four patients are reported. Two were treated operatively with good results. In consequence of the experience of Lamesch, an excision was not performed in the other two cases. The patients were followed up for many years with the findings of some reduction in size and figure. Therefore, it is recommended not to operate this special tumour as long as no functional disturbances will occur.

Report of the hand surgical treatment in two musicians, which enabled them to continue with their occupation. A young cellist was no longer able to play his instrument due to a painful scar at the pulp of his left index finger. The surgical treatment, performed only after a period of hesitation, consisted in scar excision and reconstruction of a normal pulp by a palmar advancement flap. Following a fracture of the distal radius, healed in 35 degrees dorsal angulation, a violinist was not able to flex his wrist maximally as required for playing in high octaves. This was again possible after a corrective osteotomy with interposition of a corticocancellous bone graft from the iliac crest and an intensive program of postoperative excercises. The important role of the cooperation of the patient, particularly in the rehabilitation, is emphasized.

The results of 226 arthrolyses of the proximal interphalangeal joints of ring and small fingers in patients with Dupuytren's disease are presented in a retrospective study. 52% of cases involved first operations, 48% were operations of recurrent diseases. Proximal interphalangeal joints of small fingers were more frequently affected than those of the ring fingers. Arthrolysis was carried out stepwise in Buck-Gramcko's technique. In 13% of the cases an additional temporary transarticular Kirschner wire fixation was carried out. The results were graded according to extension deficits and the distance from fingertips to distal palmar crease. The average pre-operative extension deficit was 65 degrees. The average extension deficit three months after operation was 35 degrees. The post-operative distance from fingertips to distal palmar crease was 2.5 centimeters. Ring fingers yielded better results than small fingers. A temporary transarticular Kirschner wire fixation did not lead to better results. In unfavourable cases however, this fixation seems to be indicated. Complications occurred in 27% of the cases, mainly involving wound healing.

From 1983 to 1990, 30 free toe transplantations were performed in 30 children suffering from congenital malformations of the hand. Especially the two severe forms of symbrachydactylia presented major indications. In addition to toe transplantation onto the ulnar ray, lengthening of the radial ray was frequently necessary. Whereas 25 transplantations were successful, there were one necrosis and four partial necroses of the toe. In the monodactylous form, all 15 children with successful transplantation showed good and very good functional results. Children suffering from the peromelic form could gain a grip function which could not have been achieved by prosthetic supply alone. The basal joint of the thumb is of major importance since most of the mobility of the two fingers is achieved in this joint. This is true even if the thumb has to be surgically formed. If there is no carpometacarpal joint, a toe transplantation should not be performed since the mobility in the toe joints would be severely limited.

The aim of this article is to show that the well-known Tinel sign is really a Hoffmann-Tinel sign. The translation of the two papers of Hoffmann, published in the same year that Tinel wrote his article (1915), is completed by a short biography of Paul Hoffmann.

The results of 175 high-resolution computed tomography (CT) scans of the hand and wrist are analysed and compared to the results of conventional radiographs. Advantages of the procedure can be demonstrated when assessing pathological changes within the complex three-dimensional structure of the hand and wrist, and in the analysis of articular surfaces. In some cases, fractures and dislocations of the distal radioulnar joint and the carpal bones were missed in conventional radiographs. In cases of scaphoid fracture and nonunion, CT scans give valuable additional information surpassing the possibilities of conventional radiographs. For instance, bone healing after bone grafting can be better evaluated with a CT scan. Furthermore, preoperative planning is simplified, when tumors and cysts of the carpal bones can be located precisely using computed tomography.

Transposition of the extensor indicis seems to be the most common procedure for reconstruction of the ruptured or severed extensor pollicis longus (EPL) tendon. From 1959 to 1988, we performed 115 extensor indicis transpositions in 34 open EPL injuries and 81 subcutaneous EPL ruptures. The open injuries involved failed primary repair (n = 6) or untreated tendon injuries (n = 19). The subcutaneous ruptures occurred after distal radius fractures or other closed injuries of the wrist (n = 62), arthrosis or rheumatoid synovialitis (n = 8). Forty-seven patients returned for follow-up examination six months to 18 years after operation. The evaluation included twelve parameters involving thumb, index finger and overall hand function as well as subjective patient assessment. We found significant loss of motion and strength only in two cases, where the tension of the transposed tendon was obviously inadequate. A certain loss of independent index extension was without functional impairment. Although several authors prefer EPL reconstruction with an intercalated tendon graft, we recommend the extensor indicis transposition as a simple procedure with predictable satisfactory results.

Fractures of the hook of the hamate are rare injuries of the hand. They are caused by direct trauma to the palm, however there are some cases without history of trauma. While physical examination is often suspicious of fracture, standard X-ray films can fail to demonstrate the fracture. Bone scans show an increased uptake in the ulnar region of the wrist. The carpal tunnel view or computed tomography confirm the diagnosis. Operative treatment is recommended. Simple excision of the hook, bone grafting or internal fixation are possible procedures. The diagnostic problems are demonstrated in two case reports.

Between 1986 and 1990 distal radioulnar arthrodesis with segment resection of the distal ulna (Sauvé-Kapandji Operation) was performed in 31 patients with posttraumatic changes of the distal radioulnar joint; 26 patients could be examined after 10 to 44 months. At the time of examination, all patients had bony fusion between distal radius and ulna; forearm rotation improved by 60.5%, 55% of the patients had significant pain relief. Grip strength also improved postoperatively, though never reaching values of the healthy hand. Two patients developed a bony regeneration, which was successfully reoperated upon in one case, 81% of the patients reported an improved wrist function.

Results of long-term follow up of 66 patients with ischemic contracture of the forearm and hand, all surgically treated in the "Unfallkrankenhaus Hamburg)) between 1961 and 1982, are presented. Whereas ischemic contracture of the forearm flexors resulted mainly from fractures, ischemic contracture of the intrinsic muscles of the hand was most often seen after pressure injuries. All patients in this study presented to us with fully established ischemic contractures. Muscle and nerve damage was retrospectively evaluated according to operative notes, and the degree of damage could be classified into four groups. Most frequently, neurolysis, scar excision and muscle-sliding operations were performed; furthermore, tendon lengthening, tendon transpositions, wrist arthrodesis and nerve grafting were indicated. Results were judged according to twelve separately measured functions, each measurement giving a possible score of three to six points. Muscle-sliding operations result in an improved score regardless of ischemic contracture stage. For a stage 2 contracture, a 20 point improvement can be expected. In stage 1 contracture--presenting with extension deficiency of four or more points--, complete recovery can be expected following a muscle-sliding operation. For isolated muscle injuries, tendon lengthening is recommended. For stage 2 contracture, the transposition of superficial to deep flexor tendons results in the same score as a muscle-sliding operation; however, the transposition procedure should be reserved for special indications. In stage 3 contracture, the muscle-sliding operation is the treatment of choice, with secondary procedures such as tendon transpositions and nerve grafts often being necessary. In stage 4 ischemic contracture, muscle-sliding operations may improve extension deficiency; however, wrist arthrodesis, especially in combination with extensor tendon transpositions, may be beneficial. No experience with free muscle transplantation was made during the study period.

While there is general agreement that pollicization is indicated in cases of complete thumb aplasia and Grade IV hypoplasia (floating thumb), there is continued discussion about the optimal management of lesser grades of hypoplasia, and of the five-fingered hand. In our opinion, the quality of a reconstructed thumb is determined by the quality of the digit from which it is made. Thus attempts at salvage of Grade III hypoplastic thumbs have been predictably disappointing. The absence of a carpometacarpal joint, portions of the metacarpal, and much of the intrinsic and extrinsic musculature, as well as metacarpophalangeal joint instability severely limit the resulting reconstructed thumb. Both functionally and cosmetically it will be inferior to a thumb achieved by ablation of the poorly functional digit and pollicization of a more normal index finger.

A search of the relevant literature concerning various procedures done to the distal ulna in post-traumatic conditions has shown that several terms are inappropriate to the procedures they describe. This paper tries to clarify the situation and help in correct citation.

The results of nine different methods for treating patients with lunate necrosis were investigated in a retrospective study. The study included seventy-eight of eighty-two operated patients with an average follow-up of five years and thirteen of thirty-five patients conservatively treated were examined at an average follow-up time of nine years. Treatments used were: shortening of the radius, lengthening of the ulna, pisiform transposition, prosthetic replacement, tendon interposition arthroplasty, STT-arthrodesis (scaphotrapezio-trapezoid arthrodesis), denervation of the wrist, wrist arthrodesis, and conservative therapy. The most important criteria for rating the results were pain relief, range of motion, grip strength, and X-ray findings. In the early stages of lunate necrosis with a minus variant of the ulna the best results were obtained by shortening of the radius. In intermediate stages good results could be achieved by tendon interposition arthroplasty. Denervation and STT-arthrodesis can be performed at any stage of the disease and may be combined with other methods. Despite some good results, a search for even better operative methods should continue, because the available techniques, especially in cases of advanced necrosis, do not always lead to satisfactory results.

At the present time there exist two internationally accepted classifications for the grouping of malformations of extremities: The anatomically and clinically orientated classification by Swanson (1976) and the anatomically and genetically founded classification by Temtamy (1966) and Temtamy and McKusick (1969 and 1978). In the introduction, the phylogeny and ontogeny of the extremities are considered. Under the aspect of phylogeny and ontogeny the groups I Failure of formation of parts, II Failure of differentiation (separation) of parts, III Duplication and VI Congenital constriction band syndrome of Swanson's (1976) classification are discussed. It is found that this anatomically founded classification is largely confirmed in the use of latest morphogenetic criteria and that only few modifications may be called for. In the light of present-day genetic knowledge the use of new classifications published in the literature, for example that of the cleft hand, appear doubtful, as they are based on mere by clinical criteria.

Schwere Quetschungen der Hande stellen Verletzungen dar, die selten ohne bleibende Folgen ausheilen. Diese entstehen nicht nur durch die unmittelbare Gewebszerreisung, sondern zu einem wesentlichen Anteil auch durch bindegewebige Organisation des Odems, welches immer nach einer Quetschung auftritt. Die resultierende Fibrose fuhrt zu narbigen Verklebungen der Gleitflachen der Sehnen und der kleinen Gelenke, so das Bewegungseinschrankungen bestehen bleiben. Neben der unmittelbaren Behandlung der Frakturen und Wunden ist daher die Verhinderung oder Beseitigung eines Odems der wichtigste therapeutische Schritt. Hierzu ist ein exakt anzulegender Kompressionsverband notwendig. Bei der Erstversorgung stehen der primare Wundverschlus und die Frakturstabilisierung im Vordergrund. Anhand von Beispielen wird das Vorgehen unter besonderer Berucksichtigung der Hautprobleme geschildert und auf sekundare Wiederherstellungsmasnahmen hingewiesen.

Die Behandlung der Knochen- und Gelenkinfektionen ist sowohl nach offenen als auch nach geschlossenen Frakturen der Hand grundsatzlich gleich: operative Freilegung zur Entfernung von Eiter, Nekrosen und Sequestern, Einlegen von Septopal-Ketten, innere und asere Immobilisation, gute Weichteildeckung. Nach Ausheilung der Infektion folgen dann Entfernung der Ketten, Defektuberbruckung durch Knochenspan, erneute Osteosynthese und gegebenenfalls Wiederherstellung von Sehnen und Nerven. Durch diese Masnahmen last sich meistens eine Amputation von Fingern vermeiden und ausreichende Funktion erhalten.

Carpal instabilities are caused by traumatic injuries to the bones and ligaments of the wrist joint, or by chronic overstretching of the ligaments due to inflammatory or degenerative diseases; an important factor in their development is the anatomical shape of the bones and their articular surfaces. According to their location, they are classified as radial (lateral), medial, and proximal carpal instabilities. The different types are described, especially with regard to their radiological signs; static and dynamic instabilities are distinguished. The common therapeutic strategies are reconstruction of ligaments, intercarpal arthrodesis, or correction osteotomy of the radius.

The results after treatment of 197 non-union of scaphoid fractures are reported. The operative technique of Matti-Russe, called also Russe I, has proved successful in cases in which the fracture is located in the middle or distal third of the scaphoid or where there is a viable small proximal fragment. Bone healing depends more on the age of the pseudarthrosis than on the age of the patient. In 86% of 83 cases the technique of Russe I was successful and in this group the period between accident and treatment was no longer than two years. After a period of more than four years after the accident the success rate is only 54%. The combination of the technique of Russe I with styloidectomy of the radius diminishes the number of good results. The operative technique known as Russe II assumes a good blood supply of the distal fragment of the scaphoid. In 15 cases, after resection of the necrotic small proximal fragment of the scaphoid, a fungiform bonegraft from the iliac crest was placed in the cavity and the success rate was 80%. The findings after palliative treatment of 43 non-unions of the scaphoid are based on subjective criticisms by the patients. The denervation of the wrist and the wrist arthrodesis were done in 28 cases. After resection of the necrotic proximal fragment, a tendon interposition arthroplasty was performed in nine cases, and in six cases a prosthesis for the proximal part of the scaphoid was implanted.

The authors report two cases in which a damaged median nerve or its branches were covered with an abductor digiti minimi muscle flap. This muscle has enough volume to protect the critical region of a damaged nerve at the wrist against stress by pressure.

The ligaments of the wrist and the bony configuration--beside muscles and tendons--are responsible for stability in the wrist joint, which is impaired in certain pathological conditions: unstable fractures of the scaphoid, scapholunate dissociations, perilunate fracture-dislocations, malunited Colles' fractures, Kienböcks disease, rheumatoid arthritis and posttraumatic laxity of ligaments. The differentiation between dorsal and palmar instability is made by radiological examination and measuring of the scapholunate, capitolunate and radiolunate angles. The understanding of normal anatomy and (post-)traumatic conditions is facilitated by the concept of dynamic action of the ligaments and the bones of the wrist as articular and extraarticular slings.

In this study the results of digital arthrodeses with intraosseous wiring and Kirschner-wire were compared with other operative techniques. The report is based on 309 operations performed between 1979 and 1982. The indications were mostly traumatic and posttraumatic joint lesions. Here the best results were obtained with the technique of intraosseous wiring and Kirschner-wires. On an average, it took seven weeks to full radiological and clinical bony union. Also the functional results after digital arthrodeses with different techniques were studied. With a mean total active range of motion of 76.8% compared with normal, this technique showed good results. Compression screw arthrodeses, tension-band arthrodeses and digital arthrodeses with crossed Kirschner-wires were performed only for special indications during the period covered by the report.

By uncontrolled application without indication of a photoactive drug methoxypsoralen (Meladinine) which is sold only on prescription a 20-year-old man sustained a large burn injury of 71% of body surface. Because he was admitted to the hospital relatively late, a life-threatening condition developed as it is well known after large body burns. Adequate intensive care including artificial respiration and proper local treatment to prevent infection were decisive for successful treatment.