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Abstract: In forensic pathology, forensic onychology studies fingernails and toenails for medicolegal purposes. It mainly deals with DNA profiling from nails, toxicological analysis for detecting poisons, and the collection of trace evidence present under the nails. Injuries to fingernails and their interpretation for medicolegal purposes are the neglected areas of this study. We have discussed the most common types of fingernail injuries and their significance. We found that their notification has significant value in drowning cases, defense wounds on the palm, self-inflicted cuts, burns, electrocution, blunt trauma, physical assault, sexual offenses, and other issues like torture. We emphasize the examination of fingernails in the autopsy and medicolegal clinical examination for better administration of law and justice., Competing Interests: Conflicts of interest: None., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

This brief report is a retrospective review of three cases of iatrogenic digital ischemia and clinical outcome at six months. Hand injuries are one of the most common injuries that occur in the working population. Iatrogenic digital ischemia is a rare condition that can be avoided by proper wound management. After the correct initial treatment is provided, it is important to apply the wound dressing correctly to avoid iatrogenic trauma or ischemia. Currently, there is no consensus regarding the best treatment for these injuries. Our aim is to remind clinicians of this rare condition, and to highlight prevention and treatment strategies., (Copyright © 2021 The Authors. Published by Elsevier Inc. All rights reserved.)

Closed rupture of the thumb flexor tendon pulleys is rare and, to our knowledge, the MRI findings associated with this injury have not been described in the radiology literature. The injury can result in nonspecific clinical and physical exam findings and advanced imaging may be crucial to diagnosis. A familiarity with the normal anatomy of the flexor mechanism of the thumb and the imaging appearance of pathology is therefore necessary. We report a case of a 31-year-old female nurse with ruptures of several of the thumb flexor pulleys and the corresponding findings on MRI., (Copyright © 2019 Elsevier Inc. All rights reserved.)

The aim of the study was an ultrasound assessment of distal interphalangeal (DIP) joint enthesopathy in patients with nail psoriasis. Altogether, 72 patients with nail psoriasis (41 with psoriasis and 31 with psoriatic arthritis) and 30 people in the control group participated in the study. In total, 1014 nails were examined. The thickness of DIP digital extensor tendons in the groups of patients with psoriasis (Ps) and psoriatic arthritis (PsA) was correlated with the nail bed thickness (r = 0.316, p = 0.027 vs. r = 0.402, p = 0.031, respectively) and with the thickness of the nail matrix in patients with psoriasis (r = 0.421, p = 0.012). The linear regression model showed the tendon thickness in Ps patients to be affected by the nail bed thickness, duration of psoriasis and the thickness of the nail matrix, whereas in PsA patients it was found to be significantly affected by duration of psoriasis and of arthritis, the nail bed thickness, CRP concentration and the swollen joint count. Our findings may indicate the role of the nail-tendon apparatus changes in the PsA development and they emphasise the justifiability of US examinations in patients with psoriasis direct assessment of morphological changes in nails as potential predictors of PsA development.

Background: The success of replantation following traumatic amputation is determined by the quality of the vascular anastomoses. The purpose of this study was to assess the vascularity of injured arteries from traumatically amputated digits using arteriographic and histopathological analysis., Methods: 25 amputated digits were included in the study. Crush and avulsion injuries were evaluated according to the Venkatramani classification. The amputated arteries were dissected under a microscope, and the arterial route determined with a transducer. Arteriography using fluoroscopy was evaluated by a radiologist. The area thought to be damaged was dissected and 2-mm slices taken for histopathological examination, and scored using the parameters of fibrin accumulation, oedema, separation, and bleeding., Results: Arterial flow was observed in 6 of 7 in the avulsion group. In the crush group, arterial flow was observed in 11 of 16 cases. On histopathological examination in all cases there were 2 or more findings of either oedema, fibrin formation, bleeding or hernia. These findings were more common in the crush group then the avulsion group., Conclusions: The intravascular introduction of radio contrast agents to amputated digit prior to replantation may give further information particularly in avulsion amputations.

Dislocations of the carpometacarpal (CMC) joints are uncommon and are frequently missed on standard radiographs of the hand. Dislocations could be dorsal or palmar; dorsal dislocations are seen more frequently. Palmar dislocations can be either ulnopalmar or radiopalmar. Stable CMC dislocations could be successfully treated conservatively, while unstable dislocations are mostly treated operatively. The purpose of this report is to present a patient with an isolated ulnopalmar dislocation of the fifth CMC joint, satisfactorily treated with closed reduction and casting., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: The management of finger deep burns is still problematic for the surgeon. Due to the fineness and the thickness of the subcutaneous tissue, after excision there is an important risk of exposure of the underlying tissue like bone, nerve or tendons. Local flaps (random pattern flap and pedicle flap) allowed ensuring a good quality covering with a tissue with many advantages (good thickness, sensitivity). On the contrary of all other techniques, flaps can be used independently from the vascular quality of the wound bed. Despite those advantages, the literature is poor to report the experience of flap in the management of finger deep burn., Material and Methods: We report our experience in the use of such technique with a series of 49 flaps. The cohort consisted of 34 patients (22 men and 12 women) who were treated in our unit between 2003 and 2012., Results: Of the 49 flaps made, 71,4% were homodactyl flaps. 22,5% were heterodactyl flaps and 6,1% were intermetacarpian (second space) flaps. The rate of success was 87,8%. We reviewed 16 patients out of 34 patients operated, 20 of the 49 flaps performed (40,8%). The patients were reviewed by an independent surgeon. The average follow-up at this consultation was 4,25±2,46 years. The monofilament test was positive for 17 flaps (85% of cases). For the Weber's test, we found a normal perception threshold for 11 flaps (55%), with an average test at 2,8mm (2-4mm). Normal motricity was found at the donor site in 14 of the 16 patients evaluated for 18 of the 20 revised flaps (90% of cases). In terms of cosmetic result, the average overall score obtained at the patient's own evaluation was 0.85. That obtained by the evaluator was equal to 0.55, with no significant difference (scale range from 0 best results to 5 worse results)., Discussion: Hand and finger burns are frequent and benefit from rapid, high-quality coverage, enabling early mobilization to combat secondary stiffness problems. The high success rate of our series, as well as the quality of the functional and cosmetic results obtained, demonstrate the reliability and the interest of the digital flaps., (Copyright © 2017 Elsevier Ltd and ISBI. All rights reserved.)

A 45-year-old female patient presented to clinic with an almost completely embedded ring in the volar aspect of her right ring finger, with complete reepithelialisation over the superficial aspect of the ring. We present this unusual case of an embedded ring after an insect bite on the patient's ring finger. The patient had worn the ring for the previous 5 years without removing it and did not report any discomfort or traumatic injury. We discuss this case in the context of previously reported cases of an embedded ring, a rare presentation in itself, highlighting the key differences in both this patient's aetiology and the risk factors associated with the presentation., (© 2017 Medicalhelplines.com Inc and John Wiley & Sons Ltd.)

Fingertip amputation is the most common amputation encountered by hand surgeons. Treatment decisions are multifactorial, based on mechanism, level of injury, tissue loss, associated injuries, and patient preference, among others. In this article, we present use of the thenar flap in combination with bone graft and split-thickness nail bed graft to address the tripartite loss of distal phalanx, soft tissue, and nail bed. This method allows for a full-length and functional reconstructed fingertip that is aesthetically satisfactory and does not require microsurgical techniques., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

History A 34-year-old man without underlying medical conditions came to the emergency department for evaluation of persistent pain over the volar portion of his right fifth finger after a fall during a football match 3 days before. At physical examination, the injured finger was swollen and purple. Passive and active flexion of the proximal and distal interphalangeal joints were compromised, without interphalangeal instability. Radiography was performed in the emergency department, and the patient was released with a diagnosis of a fifth digit sprain. After the senior radiologist (V.M.C.) reviewed the radiographs, the patient was called back for assessment with ultrasonography (US) on the same day. US was performed with an Aplio 500 unit (Toshiba Medical Systems, Tokyo, Japan) using a multifrequency linear array 7.2-18.0-MHz PLT-1204BX transducer focused at the level of the flexor tendon. The patient was sitting in front of the examiner, with the hand lying palm up on the examination bed. No abnormality was observed during color Doppler US.

High-pressure paint injection injury is an uncommon but well-described injury. The histologic features of long-term paint injection injury with retained material are less recognized. A 46-year-old male presented clinically as "recurrent giant cell tumor of tendon sheath." The right index finger demonstrated fusiform enlargement by a pigmented mass with diffuse infiltration into the soft tissue of the hand. Histologically the tumor showed multiple giant cells in a fibrotic stroma extending into the dermis. There were multiple types of foreign material including diffuse brown black pigment, weakly optically polarizing foreign material and white inclusions with a "train track" appearance. The cells were positive for CD68 and negative for S100 antigen. Further investigation revealed that the patient had a history of high-pressure paint injection injury to his digit 6 years prior. Foreign material injected under high pressure into tissues may result in a pseudo-neoplastic foreign body granulomatous reaction that can mimic giant cell tumor of tendon sheath. Our case demonstrates that this reaction can be florid and can have slow growth over years. A high index of suspicion, a good clinical history and careful examination can distinguish these 2 entities., (© 2017 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Rationale: Slowly progressive hand ischemia is mostly associated with medical illness such as vasculitis, and in patients with smoking history, Buerger disease is often considered first. However, despite the very low incidence of vascular anatomical anomalies, they can lead to hand ischemia. And if there is no consideration for them, proper treatment cannot be selected., Patient Concerns: A 42-year-old male smoker presented with a slowly progressing 5th fingertip necrosis following blunt trauma., Diagnoses: Angiography revealed congenital hypoplasia of ulnar artery, and excluded Buerger disease or hypothenar hammer syndrome., Interventions and Outcomes: We reconstructed the necrotic fingertip using a 2nd toe pulp free flap to reflect the patient's need., Lessons: In this case report, the authors emphasize that the possibility of anatomical anomaly should be considered as a cause of the ischemia. Vascular imaging should be undertaken to investigate the cause of ischemia of the hand.

Embedded ring injury is a rare condition often associated with mental illness or cognitive disorders. Clinical presentation varies from simple oedema to serious neurovascular deficits. We report the unusual case of a 69-year-old woman presenting with two embedded ring injuries. The rings had been in place for over 20 years, however she had no past medical history of psychiatric or neurological disorder. A non-invasive approach was decided to treat the patient by simply cutting the rings allowing to resolve the situation without further morbidity., (Copyright © 2016 Elsevier Masson SAS. All rights reserved.)

The volar V-Y flap is used in transverse or dorsal oblique amputations in fingertip injuries; however, its use is contraindicated in patients with volar oblique amputations and cannot advance distally enough to cover the defect. The aim of this report is to describe a technique of double V-Y flap to cover fingertip defects in which a simple V-Y flap is not enough. This technique allows advancement between 30% and 50% farther than the original, simple V-Y flap. Report of cases a series of fingertip amputation covered with this technique. This technique was performed in 7 patients between 25 and 64 years old, with transverse, volar and dorsal oblique defects in the fingertip. The advancing of the flap was between 3 and 5 mm. There were no infections or necrosis of the flaps. In all patients there were acceptable aesthetic results with 2-point discrimination between 4 and 6 mm in the proximal flap and up to 10 mm in the distal flap with a minimum follow-up of 6 months. With this double V-Y flap, we have seen a good coverage even in volar oblique amputation. In addition, it is possible to advance up to 5 mm more with this second V-Y flap without compromising the vitality of the flap. It is a simple and reproducible technique that can be used on any finger, with good results, without flap necrosis.

The foremost goal of managing a mutilated hand is provision of adequate skin coverage. The most suitable method is free tissue transfer. The specific role of volar surface requires replacement tissue to have similar texture for aesthetically satisfactory and functionally acceptable outcomes. Hand surgeons must approach mutilating hand injuries with the recognition that no 2 injuries are ever the same. The injured hand must be evaluated on the individual demand and characteristics of hand use. Optimal function and aesthetic outcomes require appropriate selection of skin coverage. Lost tissues must be replaced like with like tissue., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Background: Most microsurgeons believe that smoking and severity of injury adversely affect the outcome of digital replantation surgery. As countermeasures, several pharmacologic agents have been used for the perioperative period. The purpose of this retrospective study was to examine whether the rate of necrosis is appreciably different across smokers versus nonsmokers with prostaglandin E1 therapy., Methods: The authors' study subjects included 144 patients (184 digits) who underwent replantation or revascularization between August of 2013 and August of 2015.The primary outcome was the incidence of total necrosis after replantation surgery, and the secondary outcomes were the rate of overall necrosis, proportion of total necrosis to overall necrosis, and total success. Intravenous administration of prostaglandin E1 was performed at the rate of 120 μg/day for 7 days after surgery in all patients. These outcomes of each injury type were compared between smoking and nonsmoking groups., Results: Among the 184 injured digits, the incidence of total necrosis in smokers (23 percent) was higher than that in nonsmokers (17 percent), although no significant difference was shown (p = 0.36). The adjusted odds ratio was 1.17 (95 percent CI, 0.51 to 2.69). Similarly, there was no significant difference in the secondary outcomes between the two groups., Conclusion: The authors' retrospective study found no significant difference in the formation or extent of necrosis after replantation or revascularization between smoking and nonsmoking groups when all patients were treated with prostaglandin E1., Clinical Question/level of Evidence: Risk, II.

Background: Tuberculosis is a common problem in Turkey, and cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis. Herein, the authors describe a case of cutaneous tuberculosis (lupus vulgaris) occurring after contact with a sheep., Case: A 15-year-old boy was admitted to Marmara University School of Medicine Pendik Training and Research Hospital (Istanbul, Turkey) with delayed wound healing on the left index finger and left axillary lymphadenopathy. His medical history was unremarkable except for a wound incurred when he slaughtered a sheep 3 months before. One month after this injury, the patient developed enlargement of the left axillary lymph node on the side of the wounded extremity, and the wound turned a dark black color. The biopsy specimens obtained from the wounded skin and lymph nodes showed granulomatous reaction, but acid-fast bacilli (AFB) could not be shown with Ehrlich-Ziehl Neelsen staining. The patient tested positive in an interferon-gamma release assay. Computerized tomography scans of the thorax were normal, and early morning gastric lavage specimen was negative for AFB. The wound and axillary lymphadenopathy disappeared after institution of anti-tuberculosis therapy., Conclusion: Tuberculosis infection must be considered in chronic skin lesions with granulomatous reaction occurring in countries with high prevalence of tuberculosis.

Aim: The aim of this study is to evaluate the use of one-stage debulking procedure to separate the fingers after flap reconstruction for degloving injury of the hand., Patients and Methods: From January 2009 to June 2014, 15 patients with degloving injuries of the hand were treated at the Kaohsiung Chang Gung Memorial Hospital. Among the 15 patients, 11 sustained degloving injury of the fingers; free flap reconstruction was performed in three patients, and a pedicle flap was used in eight. Four patients sustained complete degloving injuries of the hand; reconstruction was performed with an anterolateral thigh pocketing procedure. One-stage debulking procedure was performed for debulking of the flap and interdigitation from the flap envelope., Results: After the 12-month follow-up and rehabilitation, the fingers could move independently and perform in opposition with the thumb. Protective sensation was also regained. The patients with degloving injury of the fingers could return to daily activity and work after 1-year follow-up, while those with complete degloving injury of the hand could return to daily activities and work after 18-month follow-up., Conclusion: The use of ALT pocketing procedure is simple for salvage of complete degloving injury of the hand. One-stage debulking procedure provides thin and durable skin coverage for hand after reconstruction. The fingers can also be separated from the envelope of a bulky flap for independent movement to fulfill functional and aesthetic requirements., (Copyright © 2016 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

The article describes the experience of reconstructive and restorative operative treatment of patients with, defects of the skin of the fingers at the daily surgical hospital. It is shown that surgeons applying standard instruments and having additional training in hand surgery, using a technique non -free skin plastic flap on a temporary pedicle and using inpatient technology, get cosmetic and functional results compared to-those of treatment in hospitals. Cited in -the article data on the direct and separate treatment outcomes, quility of life of patients, the estimated non-specfic and organ-specific method, clearly show that non-free skin plastic flap on a temporary pedicle - a reliable and effective method of restoration of the skin fingers defects which can be accompanied wit the use of resource-saving technologies in health care.

We report the case of a patient who presented with an apparent acute avulsion of the ring finger flexor digitorum profundus (FDP), or jersey finger. At surgery, the FDP to the ring finger was found to be absent; also absent were the lumbrical to the ring finger and the A5 pulley. Absence of the FDP was confirmed with postoperative imaging. Although absent profundus tendons have been previously reported, none have involved the FDP to the ring finger. However, various reports have described abnormal connections between the ring and little finger flexor tendons., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Capnocytophaga canimorsus is a gram-negative bacillus present in the oral cavities of 22% to 74% of healthy dogs. Capnocytophaga canimorsus has unique virulence factors that enable it to evade the human immune system and cause life-threatening sepsis following a dog bite. We report a previously well 68-year-old woman who presented with septic shock and multiorgan failure following a seemingly minor dog bite to the finger. The patient required intensive care treatment, intravenous antibiotic therapy, and multiple surgical procedures including amputation of the affected finger. The septicemia and coagulopathy that ensued resulted in gangrene and amputation of additional fingers and toes. The purpose of this report is to raise awareness of this organism among hand surgeons when faced with a patient presenting in septic shock and minimal signs at the site of a dog bite., (Copyright © 2016 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Climbing athletes frequently suffer from pulley ruptures, as the shear stress on the finger flexor tendon pulley system is extremely high, especially in the 'crimping position'. Studies showed that surgery only has to be performed in a multiple pulley rupture situation (grade IV injuries). This case describes a complication that appeared after performing a 'bone-encircling' technique recommended for climbers (modified 'one-and-a-half-loop' technique). Simultaneously with resumption of full-strength training after surgery and rehabilitation, the dorsolateral cortex of the proximal phalanx, to which the tendon transplant (palmaris longus tendon surrounding bone and flexor tendon of the finger) is entangled, developed an osteitis and atrophy. We investigated two athletes with the same complaints and symptoms., (2015 BMJ Publishing Group Ltd.)

Purpose: To examine the outcomes and complications associated with revision proximal interphalangeal (PIP) joint arthroplasty., Methods: An analysis of 75 consecutive revision PIP joint arthroplasties in 49 patients, performed between 1998 to 2012, was performed. The mean age at the time of surgery was 58 years. Thirty-two patients had a history of prior PIP joint trauma, and 18 patients had rheumatoid arthritis. There were 12 constrained (silicone) implants and 63 nonconstrained implants (34 pyrocarbon and 29 metal-plastic)., Results: Over the 14-year period, 19 (25%) fingers underwent a second revision surgery. Second revision surgeries were performed for infection, instability, flexion contracture, and heterotopic ossification. The 2-, 5-, and 10-year survival rates were 80%, 70%, and 70%, respectively, for patients requiring a second revision for PIP joint arthroplasty. Worse outcomes were seen with postoperative dislocations, pyrocarbon implants, and when bone grafting was required. Two operations were complicated by intraoperative fractures, but neither required stabilization. Sixteen patients undergoing revision surgery experienced a postoperative complication, including 2 infections, 1 postoperative fracture, 3 cases of heterotopic ossification, and 10 PIP joint dislocations. The volar approach and the use of a pyrocarbon implant was associated with increased rates of heterotopic ossification, whereas preoperative instability increased the rates of PIP joint dislocation following revision. At a mean of 5.3 years (range, 2-10 years) follow-up, 98% of patients had good pain relief but decreased PIP joint total arc of motion., Conclusions: Proximal interphalangeal joint arthroplasty in the revision setting represents a challenge for surgeons. Revision arthroplasty was associated with a 70% 5-year survival but with a high incidence of complications. Instability was associated with worse outcomes. In this series, silicone and metal-polyethylene implants had lower rates of implant failure and postoperative complications than ones made from pyrocarbon., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: The correct diagnosis of an A3 pulley rupture is challenging for musculoskeletal radiologists. An A3 pulley rupture should in theory influence the shape of the proximal interphalangeal joint volar plate (VP) and the amount of bowstringing at level of the VP during finger flexion. The purpose of this study was to perform MRI with metric analysis of the VP configuration and VP bowstringing in cadaver fingers in the crimp grip position and to determine cut points for A3 pulley rupture., Materials and Methods: MRI in the crimp grip position was performed in 21 cadaver fingers with artificially created flexor tendon pulley tears (fingers with A3 pulley rupture n = 16, fingers without A3 pulley rupture n = 5). The distances of the translation of the VP relative to the middle phalanx base, the distances between the flexor tendons and the VP body, and the distances between the flexor tendon and bone (TB) were measured., Results: Statistical analysis showed significantly lower VP translation distances and significantly higher VP tendon distances if the A3 pulley was ruptured. A2 TB and A4 TB distances did not differ significantly in specimens with and without A3 pulley rupture. The optimal cut points for A3 pulley rupture were a VP translation distance <2.8 mm and a VP tendon distance >1.4 mm., Conclusion: Reduction of the VP translation distance and augmentation of the VP tendon distance are suitable indirect signs of A3 pulley rupture.

In this manuscript, these authors have utilized years of clinical experience to suggest rehabilitation modifications for Zone III flexor tendon injuries. - VictoriaPriganc, PhD, OTR, CHT, CLT, Practice Forum Editor., (Copyright © 2015 Hanley & Belfus. Published by Elsevier Inc. All rights reserved.)

Background: Metacarpal fractures are among the most common fractures of the hand. They may lead to loss of function if treated improperly. These injuries can be treated conservatively. However, if significant shortening, rotational deformity and angulation occur, surgical treatment is required. In this article, results of metacarpal fractures treated with open reduction and internal fixation with mini plates were presented., Methods: We retrospectively reviewed the clinical and radiologic records of twenty-nine consecutive patients with 37 metacarpal fractures treated by open reduction and internal fixation with low profile mini plate fixation between 2006 and 2013. Surgical treatment with dorsal approach was planned for cases with unacceptable shortening, rotational deformity, and angulation. Early active motion was begun in all cases postoperatively. Patients were permitted to use their hands in daily activities four weeks after surgery. For objective assessment, total range of joint motion was measured. Rotational deformity of the fingers was assessed. Grip strength and quick DASH scores were compared with the uninjured side. Metacarpal shortening was evaluated radiologically, and angulation was measured., Results: Mean age was 35.1 years (19-61 years) and mean follow-up period was 32 months (6-39 months). While mean operation time was 8.48 days (2-23 days), mean shortening was 7.58 (2-30) mm. In cases with radiologically documented union, mean angulation in the posteroanterior plane was 8.13 (0-42) degrees preoperatively and 3.55 (0-28) degrees postoperatively. In lateral X-rays, mean angulation was 8.22 (0-39) degrees preoperatively and 3.66 (0-28) degrees postoperatively. Mean quick DASH score was 3.6 (0-11.4). Mean grip strength measurements by Jamar hand dynamometer were 41.05 (±8.3) kg for fractured hands, 44.7 (±9) kg for normal hands. No significant relationship was found between normal hand and fracture hand by Mann-Whitney U test., Conclusion: As in general fracture treatment principles, goals in metacarpal fracture treatment are obtaining an anatomical and stable reduction, fracture union and beginning early movement to avoid loss of function. Open reduction and low profile titanium plate application in metacarpal fractures is the choice of treatment in suitable cases as it meets the above mentioned treatment principles.

We describe reconstruction of a nail unit defect in the finger using a free composite flap taken from the great toe, comparing the outcome in patients in whom neurorrhaphy between the dorsal digital nerve of the great toe and the dorsal branch of the proper digital nerve of the injured finger was performed to those in which no nerve repair was made. From January 2002 to March 2009, 47 patients with traumatic fingernail defects were treated. Twenty-two patients before February 2005 had no nerve repair and subsequently 25 patients had nerve repair. The mean size of the germinal matrix and sterile matrix defects was 9 × 8 mm, and the mean size of the nail bed flaps was 9 × 9 mm. The mean length of the arteries used for the flap was 2.2 cm. Outcomes were rated. In the nerve repair group, full flap survival was achieved in 24 patients. At the mean follow-up period of 25 months, there were 12 excellent, seven very good, four good, and two fair results. In the comparison group without nerve repair, there were seven excellent, four very good, four good, five fair, and two poor results. Donor site morbidities were similar in both groups. The use of a free composite flap taken from the great toe is a useful technique for reconstructing nail unit defects in the finger. Innervated nail flap reconstructions tended to show better outcomes than those in which no nerve repair was performed. There is no difference in function or donor site between those in whom the nerve was repaired compared with those in whom it was not repaired., (© The Author(s) 2014.)

Background: The regrowth of amputated appendage extremities and the distal tips of digits represent models of tissue regeneration in multiple vertebrate taxa. In humans, digit tip injuries, including traumatic amputation and crush injuries, are among the most common type of injury to the human hand. Despite clinical reports demonstrating natural regeneration of appendages in lower vertebrates and human digits, current treatment options are suboptimal, and are complicated by the anatomical complexities and functions of the different tissues within the digits., Results: In light of these challenges, we focus on recent advancements in understanding appendage regeneration from model organisms. We pay special attention to the cellular programs underlying appendage regeneration, where cumulative data from salamanders, fish, frogs, and mice indicate that regeneration occurs by the actions of lineage-restricted precursors. We focus on pathologic states and the interdependency that exists, in both humans and animal models, between the nail organ and the peripheral nerves for successful regeneration., Conclusions: The increased understanding of regeneration in animal models may open new opportunities for basic and translational research aimed at understanding the mechanisms that support limb regeneration, as well as amelioration of limb abnormalities and pathologies., (© 2015 Wiley Periodicals, Inc.)

In the era of perforator flaps, lower-abdominal/inguinal perforator flaps such as superficial circumflex iliac artery perforator (SCIP) flap and superficial inferior epigastric artery (SIEA) perforator flap are becoming popular with its longer vascular pedicle and usefulness in various reconstructions. SIEA flap's region is innervated by the T12 nerve and the iliohypogastric nerve (IHN), but no sensate SIEA flap has been reported so far. In this report, we present a case in which a sensate SIEA flap innervated by the IHN was used for reconstruction of a finger soft tissue defect. A 55-year-old male suffering from the volar skin necrosis of the right ring finger underwent the volar soft tissue reconstruction using a free sensate SIEA flap because of hypoplastic SCIA. The SIEA flap included the IHN anterior branch, and neuroraphy was performed between the IHN and the third common digital nerve in an end-to-side manner after vascular anastomoses. The reconstructed volar skin could sensate 14 weeks after the surgery. At postoperative 6 months, Semmes-Weinstein test and moving 2-point discrimination revealed 3.64 and 8 mm in the proximal portion of the SIEA flap where the IHN was supposed to innervate. The IHN may be included in a SIEA flap, and a sensate SIEA flap may be a useful option when a SCIP flap is not available. Further anatomical and clinical studies are required to clarify anatomy and clinical usefulness of the IHN., (© 2014 Wiley Periodicals, Inc.)

We report the case of a 47-year-old man who presented with a pathologic fracture of the middle phalanx of the fourth finger. The treatment of this juxta-articular lesion close to the proximal interphalangeal joint was performed in 2 stages. First, a biopsy was carried out combined with fixation of the fracture by a Suzuki dynamic external fixator. After 6 weeks, a curettage of the confirmed enchondroma was performed with iliac crest grafting, leaving the external fixator for another 4 weeks. With a follow-up of 48 months, a satisfying functional result has been obtained with a remarkable remodeling of the painless proximal interphalangeal joint.

The extensor tendons in the dorsum of the hand lie relatively superficially, making open injuries to the extensor mechanism a common source of morbidity. These injuries can range from simple clean lacerations to complex open injuries associated with severe skin and soft tissue loss. Although many advances in the treatment of tendon injuries focused on the flexor tendon, the extensor tendon has begun to receive more attention in recent literature. Knowledge of modern repair techniques and rehabilitation protocols may improve patient outcomes. This Current Concepts article summarizes the treatment of open extensor tendon injuries with a focus on the recent literature., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: Pain reduction in the affected metacarpophalangeal joint (MP joint) by synovectomy, loose body extraction and resection of intraarticular scars., Indications: Synovitis in rheumatoid arthritis (RA) not responding to antirheumatic treatment, primary and secondary degenerative arthritis, osteochondral lesions, loose bodies, foreign bodies, capsular contracture, septic arthritis, posttraumatic arthralgia (old collateral ligament injury), intraarticular fractures., Contraindications: Established biomechanical changes in RA such as ulnar deviation and palmar subluxation with extensor tendon luxation of the MP joint. Advanced radiologic changes in degenerative arthritis. Joint instability in posttraumatic conditions. Fresh skin lesion near portals., Surgical Technique: Longitudinal traction of the affected finger in a Chinese finger trap. The joint is filled with Ringer solution. Placement of a radial and ulnar dorsal portal at joint space level, through the extensor hood, at the dorsal border of the collateral ligaments. Diagnostic arthroscopy. In case of insufficient visibility (i.e., bulky synovitis in RA) "blind" shaving in the dorsal recess at first. Completion of synovectomy under sight. If necessary additional ablation of synovial tissue by a radiofrequency (RF) electrosurgical system. Use of arthroscope (1.9 mm) with a 30° angle of vision and shaver (aggressive cutter; 2.0 mm). Low-suction drain, soft padded dressing., Postoperative Management: Immediate postoperative mobilization for the full range of finger movement., Results: In 106 MP joint arthroscopies from 2009-2011, very high patient satisfaction was achieved. Best results were obtained in RA, even in advanced radiologic changes (Larsen stages 1-3). Only in Larsen stage 4 results were rated lower. In early stages of degenerative arthritis (Kellgren-Lawrence 0-2), patient satisfaction was also very high, however decreased rapidly with increasing degree of radiologic changes. The results in posttraumatic cases are promising.

Purpose: To retrospectively evaluate the effectiveness and safety of using a distal ulnar artery perforator (DUAP)-based bilobed free flap (BFF) for the repair of complex digital defects in the hand., Methods: We retrospectively studied 15 patients who sustained traumatic digital defects with complicating tendon and phalanx exposure and were hospitalized for repair using a DUAP-based BFF. Main outcome measures included patients' self-assessed physical appearance, total active motion, and 2-point discrimination., Results: The flaps survived and the wounds healed with primary intention in all patients except one who experienced partial flap necrosis of the distal margin and required treatment with a second skin graft. Patients were observed for a mean of 13 months. The physical appearance and texture of the repaired fingers were assessed as good with minimal scarring. Total active motion and 2-point discrimination were 113° to 255° (contralateral, 255° to 275°) and 6 to 11 mm (contralateral, 5 to 8 mm), respectively., Conclusions: Use of the DUAP-based BFF is a feasible, effective, and safe treatment alternative for repairing complex digital defects with favorable aesthetic and sensorimotor outcomes., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

We report a new method of flexor tendon repair in zone II using a standard modified Kessler technique combined with a vascularized dorsal fascial flap from the finger pedicled on a dorsal cutaneous branch of the proper digital artery, which is placed as a mechanical barrier between the flexor digitorum superficialis and profundus tendons. The functional outcomes of 14 patients (Group A) with flexor tendon repairs in zone II by this new technique were compared with those of 32 patients (Group B) with flexor tendon repairs in zone II using a standard modified Kessler technique only. Patients in Group A had a higher proportion of excellent results (on the modified Strickland system) and more movement in the distal interphalangeal joint than the patients in Group B., (© The Author(s) 2013.)

Nineteen fingertip amputations with exposed bone were treated with a semi-occlusive dressing. The quantity and quality of the regenerated soft tissue was examined. In all 19 fingers there was sufficient uncomplicated healing such that secondary surgical procedures were not needed. At follow-up 6-18 months after the injury, soft tissue thickness around the bone of the distal phalanx measured 6.0 mm (SD 1.6) on the palmar aspect (opposite side 7.0 mm (SD 0.8)) and 4.2 mm (SD 1.7) distally (opposite side 4.5 mm (SD 0.8)). The two-point discrimination was 4 mm (SD 2) (opposite side 3 mm (SD 1)). The skin healed almost without scarring and the dermal ridges reformed. The regeneration of the soft tissue thickness to almost 90% of its former extent is higher than we expected., (© The Author(s) 2013.)

The treatment of traumatic partial injuries of the flexor tendons of the fingers is seldom published. The only published clinical series states that the therapeutic approach depends on the existence or absence of a preoperative trigger. We hypothesized that the therapeutic attitude mainly depends on the percentage of the injured cross-section. Our retrospective series included 36 partial lesions of 31 fingers in 29 patients. The average age was 42 years, there were 19 men. We noted 8 lesions in zones I, 21 in zone II and 2 in zone III. The average percentage of the injured cross-section was 35% and ranged from 10% to 90%. If the lesion was less than 50% (29 tendons), a tangential resection was performed. If the lesion exceeded 50% (seven tendons), a direct suture was performed, supplemented by a running suture. At a follow-up of 34 months, the average pain on a visual analogue scale was 0.7. The average percentage of strength compared to the contralateral side was 93%. The Quick DASH score was 6.2. The range of motion averaged 214° with extremes ranging from 90° to 260°. We observed no cases of hypertrophic callus, neither through the MRI nor through the ultrasonography. Complications such as trigger finger, pseudoblocage or rupture were not observed. Based on our results, in case of partial injury of a flexor tendon, we propose to perform a tangential resection in cross-section lesions up to 50%, and a suture for those which exceeded 50%., (Copyright © 2014 Elsevier Masson SAS. All rights reserved.)

The number of the suicides is increasing all around the world. In this study, the cases autopsied between 2000 and 2007 in The Konya Branch of Forensic Medicine Council were retrospectively investigated. Fifty-seven shotgun suicides were determined. The cases were evaluated in terms of their demographic characters, site of entrance wound, the type of the cartridge used, shooting distance, the place of incident, the place of death, motive for suicide, and the presence of previous suicide attempts. The most preferred site of entrance wound was the head with 34 cases (59.7%). Of 34 cases in which the entrance wound was on the head, there was indirect mandibular fracture in 16 cases (47.1%). In 11 cases (19.3%), there observed small ecchymosed abrasions on the finger surfaces, which are thought to have resulted from the trigger kicking back during triggering or the finger having been stuck between the trigger and the trigger guard. It is concluded that there is a need for a legal regulation that makes obtaining of shotguns more difficult and the people who have them are to be educated not to keep them in easily accessible places.

The severity of high-pressure injection injuries to the hand is often underappreciated on initial presentation. These injuries require urgent and thorough surgical débridement. Despite the advances in our understanding of this injury type and the decline in amputation rates, the risk of long-term morbidity with diminished function and chronic symptoms remains high, and the role of systemic steroids in treatment is uncertain. Functional outcome of the hand and upper extremity following high-pressure injection injuries depends on a number of factors, including the magnitude of the initial wounding force, the chemical properties and volume of the substance injected, the presence of secondary infection, and the timing and thoroughness of débridement. Further investigation is required to determine the relative significance of these factors and the effectiveness of steroids in treatment.

A volar advancement flap based on V-Y concept for fingertip reconstruction is described. The crescent flap utilises curved incision to preserve fingertip contour and distal digital crease. Satisfactory outcome was achieved in two patients who underwent fingertip reconstruction using this technique. Its advantages are technical simplicity, minimal donor morbidity, and may be used in situation where conventional V-Y incision is unsuitable.

We present the case of a 22-year-old man with third- to fourth-degree flame burns to all fingers of the right hand. After removing the necrotic tissues and amputating the carbonized distal segments of each finger, we covered the injured thumb with a paraumbilical tubular flap and covered the other fingers with an abdominal wall marsupial flap. Fifty days after injury, all the wounds healed, and the remaining fingers were salvaged. Four months after injury, the grip strength and the first web span of the right hand was 23.6 kg and 53°, and the patient could fulfill almost all the activities of daily living., (Copyright © 2013 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Upper limb second to fourth digit ratio (2D:4D) has been shown to be dependent on prenatal androgen exposure. A longer relative fourth digit to second digit is indicative of increased intrauterine testosterone exposure prenatally and the converse is also true for oestrogen exposure. The 2D:4D ratio has implications in the sporting, academic, financial and sexual arenas. The purpose of this study was to examine the association between smaller finger length ratios (2D:4D) and boxers fractures, in both men and women, by comparing the 2D:4D ratios in 150 boxers fractures and comparing them to matched controls. Boxers fractures are an injury classically incurred during acts of aggression and we postulated that this cohort of patients would have a smaller 2D:4D ratio in comparison to the normal population mean ratio., Methods: One hundred and fifty radiographs from patients with boxers fractures secondary to aggressive actions were analysed and the 2D:4D ratio was calculated. A further 150 X-rays from patients not involved in aggressive activities were used as a control group and the 2D:4D ratio was calculated in the same manner. We then performed statistical analysis to compare the 2D:4D ratios between our two groups., Results: As predicted, the 2D:4D in males was smaller than females in all of the groups. However, our results showed that those presenting with a boxers fracture due to an aggression related injury had a statistically significant smaller 2D:4D ratio when compared to the normal population., Conclusion: Boxers fractures are injuries that typically occur from an aggressive act. It is well documented that a low 2D:4D ratio is reflective of an increased prenatal exposure to androgens, particularly testosterone. We have shown that boxers fractures are associated with a smaller 2D:4D ratio than the normal population, thus suggesting that persons exposed to high levels of prenatal androgens are more likely to exhibit aggressive tendencies in adulthood. Our results suggest that smaller digit ratios may predict a predisposition to acts of aggression, and as such result in an increased likelihood of sustaining an injury such as a boxers fracture. This relationship seems to be present independently of gender., (Copyright © 2013 Elsevier Ltd. All rights reserved.)