Immediate insertion of silicone rubber rods in fingers with cut flexor tendons

In 7 patients with cut flexor tendons of the hand, we did an immediate quantitative bacterial analysis of the wounds. These showed fewer than 10(5) bacteria per gram of tissue, so we inserted silicone rubber rods in 10 of these fingers. All healed without infection, and this shortened the reconstruction. In retrospect, we believe it best not to insert the rods primarily in crush injuries. However, this seems to be a safe, worthwhile measure for those patients with sharp injuries of the tendons.     

Treatment of finger avulsion injuries with innervated arterialized venous flaps

Complete degloving injury of the digits not amenable to revascularization may leave poor cosmetic and functional results. We used innervated venous flaps from the dorsum of the foot in two patients with traumatic finger degloving injuries. All the flaps successfully provided coverage over the denuded fingers. Good sensation and nearly full rage of motion of the fingers were obtained. There were no donor-site problems. The advantages of this flap are preservation of a major artery of the donor site, easy elevation without deep dissection, and providing a thin, nonbulky tissue and good sensation. The innervated arterialized venous flap is a useful method that provides functional and cosmetic coverage to the severe avulsion injury of the finger.     

Tendon disorders of the hand

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Make decisions on flexor tendon repair based on current evidence. 2. Perform some important tendon transfers after viewing Dr. Kozin's videos. 3. Inject local anesthesia for wide-awake flexor tendon repair after viewing the appropriate videos in the article. 4. Use relative motion extension splints for the postoperative management of extensor tendon injuries. SUMMARY: This article provides a practical, clinically useful overview of some of the current best techniques and evidence available to the plastic surgeon in the treatment of flexor and extensor tendon injuries, tendon transfers, trigger fingers, mallet fingers, boutonniere deformities, and De Quervain tenosynovitis. Twelve short movies and drawings emphasize important points of diagnosis and treatment of tendon disorders.     

Further experience in rehabilitation of zone II flexor tendon repair with dynamic traction splinting

A review of all flexor tendon repairs in the "no man's land" performed from January of 1985 to June of 1987 was done to evaluate the efficacy of our method of rehabilitation. There were 60 fingers (57 patients) with complete laceration of the flexor digitorum profundus and flexor digitorum superficialis tendons in zone II. Fingers with phalangeal fractures, joint injuries, or significant skin loss were excluded. Follow-up ranged from 12 to 48 months. Rehabilitation consisted of a 12-week protocol using the U.S. military combined regimen of controlled motion. Features from the technique of controlled active extension against rubber band passive flexion as well as those of controlled passive extension and passive flexion were incorporated. The palmar pulley modification of Kleinert's dynamic traction splint was utilized. Strickland's total active motion formula was employed to determine results. The results were classified into the four categories of excellent, good, fair, and poor. Fifty-two fingers (86 percent) were rated excellent, 4 fingers (7 percent) were rated good, 1 finger (2 percent) was rated fair, and 3 fingers (5 percent) were rated poor.     

Fingertip replantation using the subdermal pocket procedure

Restoration of finger length and function are the goals of replantation after fingertip amputation. Methods include microsurgical replantation and nonmicrosurgical replantation, such as composite graft techniques. To increase the survival rates for composite grafts, the subcutaneous pocket procedure has been used as a salvage procedure. The subdermal pocket procedure, which is a modification of the subcutaneous pocket procedure, was used for replantation of 17 fingertips in 16 consecutive patients. Eight fingertips experienced guillotine injuries and the other nine fingertips experienced crush injuries. Revascularization of one digital artery without available venous outflow was performed for six fingers, and composite graft techniques were used for the other 11 fingers. The success rate was 16 of 17 cases. The difference in success rates for guillotine versus crush injuries was statistically significant. Comparison of patients with arterial anastomoses and patients without arterial anastomoses also indicated a statistically significant difference. Thirteen fingertips survived completely. One finger, demonstrating complete loss and early termination of the pocketing procedure, was amputated on the eighth postoperative day. Two fingers were partially lost because of severe crushing injuries. One finger demonstrated partial loss of more than one quarter of the fingertip, which required secondary revision, because the patient was a heavy smoker. The pocketing period was 8 +/- 1 days (mean +/- SD, n = 6) for the fingers revascularized with one digital arterial anastomosis and 13.3 +/- 1.9 days (n = 10) for the fingers successfully replanted with composite graft techniques. The mean active range of motion of the interphalangeal joint of the three thumbs was 65 +/- 5 degrees, and that of the distal interphalangeal joint of the other 11 fingers was 51 +/- 11 degrees. The static two-point discrimination result was 6.4 +/- 1.0 mm (n = 14) after an average of 11 +/- 5 months of follow-up monitoring. Compared with other methods, the subdermal pocket procedure has the advantages of exact subdermal/subdermal contact, a shorter pocketing period, and more feasible observation. The method can offer an alternative salvage procedure for fingertip amputations with no suitable vessels available for microsurgical replantation.     

The timing of neovascularization in fingertip replantation by external bleeding

To overcome venous congestion in fingertip replantation with no venous anastomosis, the authors have used a salvage procedure that consists of continuous external bleeding through a stab incision on the paraungual area and dripping a heparinized saline solution at the incision site to maintain external bleeding. Because this method requires continuous bleeding for a certain period of time, it may be a great burden on the patient; therefore, it is most important to minimize the duration of bleeding. Many authors have studied the timing of the new venous channel formation of the flap. However, to our knowledge, a study on fingertip replantations has not yet been performed. From June of 1985 to November of 1999, the authors performed fingertip replantations on 144 fingers of 137 patients using our salvage procedure at Korea University Guro Hospital. Among the 144 fingers, 101 fingers of 96 patients were successfully transplanted, including those with partial necrosis. The authors reviewed the medical records of these 101 fingers retrospectively; they compared and analyzed the necessary duration of external bleeding according to sex, age, level of injury, cause of amputation, and the type of injury. The average period of the salvage procedure was 7.6 days. Regarding age, the shortest period (5.5 days) was required for patients younger than 10 years. On the basis of the types of injuries, the duration of bleeding was shortest for the guillotine injury group (5.9 days) compared with crush (8.2 days) or avulsion (8.0 days) injuries. Sex and level of injury did not make much difference in the duration of the procedure.     

Finger Tip Amputations—Review of Procedures and Applications

Repair of finger tip amputations depends upon the slope of transsection and how much of the tip has been amputated. Type 1 and 2 injuries are easily handled in the emergency room by local flaps with results acceptable by functional and economic criteria. Type 3 amputations with losses of less than 25 percent can be repaired by primary closure. Losses of 50 percent or over are best treated by local or “distant” flaps from the involved or adjacent fingers or palm. Each style of flap and technique has advantages and disadvantages.     

Extensor tendon injuries: acute management and secondary reconstruction

LEARNING OBJECTIVES: After reviewing the article, the participant should be able to: (1) Describe the anatomy of the extensor tendons at the level of the forearm, wrist, hand, and fingers. (2) Recognize variations in the anatomy. (3) Master the hand examination and define the relevant findings in acute injuries of the extensor tendon(s). (4) Delineate the techniques for extensor repair in both acute and secondary (delayed) management. SUMMARY: Extension of the fingers is an intricate process that reflects the combined action of two independent systems. The interossei and lumbricals constitute the intrinsic musculature of the hand. These muscles innervated by the median and ulnar nerves extend the proximal interphalangeal and distal interphalangeal joints and flex the metacarpophalangeal joints. The extrinsic extensors are a group of muscles innervated by the radial nerve, originating proximal to the forearm. The extrinsic digital extensor muscles include the extensor digitorum communis, extensor indicis proprius, and extensor digiti quinti. The digital extensors function primarily to extend the metacarpophalangeal joints, but also extend the proximal interphalangeal and distal interphalangeal joints. Normal extensor physiology reflects a delicate balance between these two unique extensor systems. In the injured hand, a functioning intrinsic system may potentially compensate for an extrinsic deficit. An understanding of the relevant anatomy and an appreciation for the complex interplay involved in extensor physiology is necessary to recognize and manage these injuries.     

Causes of Intraspecific Aggression in Alouatta palliata mexicana: Evidence from Injuries,Demography, and Habitat

Although howlers have been traditionally considered to be pacific, showing one of the lowest rates of aggression among primates, new evidence is emerging to question this image. We present data on injuries in Mexican mantled howlers (Alouatta palliata mexicana) in relation to different sociecological parameters. We censused howler populations in 19 forest fragments over a 17-mo period in the Los Tuxtlas Region, southern Veracruz, Mexico. We conducted detailed observations of scars, torn lips, broken fingers, mutilated tails and other visible injuries. We also collected data on the demography, biogeography and vegetation of each fragment in order to relate injury data to them. We censused 333 howlers, of which we exhaustively observed 254 for injuries. Four resident adult females (n = 108) and 29 adult resident males (n = 76) had injuries, while none of the solitary males (n=16), solitary females (n=1), juveniles (n=23) and infants (n=30) had them. We discuss possible interpretative scenarios for the distribution of injuries. Although some results suggest that food resource concentration may determine intergroup agonistic encounters, we propose that physical injury is primarily associated with male-male agonistic encounters during takeovers, and consequently it could indicate migration among troops.     

Combining structure-based design with phage display to create new Cys(2)His(2) zinc finger dimers

BACKGROUND: Several strategies have been reported for the design and selection of novel DNA-binding proteins. Most of these studies have used Cys(2)His(2) zinc finger proteins as a framework, and have focused on constructs that bind DNA in a manner similar to Zif268, with neighboring fingers connected by a canonical (Krüppel-type) linker. This linker does not seem ideal for larger constructs because only modest improvements in affinity are observed when more than three fingers are connected in this manner. Two strategies have been described that allow the productive assembly of more than three canonically linked fingers on a DNA site: connecting sets of fingers using linkers (covalent), or assembling sets of fingers using dimerization domains (non-covalent). RESULTS: Using a combination of structure-based design and phage display, we have developed a new dimerization system for Cys(2)His(2) zinc fingers that allows the assembly of more than three fingers on a desired target site. Zinc finger constructs employing this new dimerization system have high affinity and good specificity for their target sites both in vitro and in vivo. Constructs that recognize an asymmetric binding site as heterodimers can be obtained through substitutions in the zinc finger and dimerization regions. CONCLUSIONS: Our modular zinc finger dimerization system allows more than three Cys(2)His(2) zinc fingers to be productively assembled on a DNA-binding site. Dimerization may offer certain advantages over covalent linkage for the recognition of large DNA sequences. Our results also illustrate the power of combining structure-based design with phage display in a strategy that assimilates the best features of each method.     

A new strategy of fingertip reattachment: sequential use of microsurgical technique and pocketing of composite graft

Many methods have been used to reattach amputated fingertips. Of these methods, microsurgery has been accepted as the procedure of choice because the defining characteristic of a microsurgically replanted finger is that its surival in the recipient bed is predicated on functioning intravascular circulation. Although considerable progress has been made in the techniques for microvascular replantation of amputated fingers, the replantation of an amputated fingertip is difficult because digital arteries branch into small arteries. This is in addition to digital veins that run from both sides of the nail bed to the median dorsal sides, which are difficult to separate from the immobile soft tissue. Furthermore, even with the most technically skilled microsurgeon, replantation failure often occurs, especially in severe injury cases. Therefore, the technique is not the only protection against failure, and a new strategy of fingertip reattachment is needed. From March of 1997 to December of 1999, 12 fingers of 11 patients with zone 1 or zone 2 fingertip amputations that were reattached microsurgically but were compromised were deepithelialized, reattached, and then inserted into the abdominal pocket. All had been complete amputations with crushing injuries. Approximately 3 weeks later, the fingers were depocketed and covered with a skin graft. Of the 12 fingers, 7 survived completely and 3 had partial necrosis on less than one-third the volume of the amputated part. The complete survival rate was approximately 58 percent. The results of the above 10 fingers were satisfactory from both functional and cosmetic aspects. The authors believe that this high success rate was achieved because the deepithelialized finger pulp was placed in direct contact with the deep abdominal fascia, which was equipped with plentiful vascularity, not subcutaneous fat. In addition, the pocketing was performed promptly before necrosis of the compromised fingertip occurred. From the results of this study, it is clear that this new method is useful and can raise the survival rate of an amputated fingertip.     

Accidents in Childhood: A Report on 17,141 Accidents

The causes of injury to 17,141 children brought to the emergency department of a large pediatric hospital in one year were studied. The leading causes of injury were: falls, 5682; cuts or piercings, 1902; poisonings, 1597; and transportation accidents, 1368. Included in these are 587 falls on or down stairs, 401 cuts due to glass, 630 poisonings from household or workshop substances, 510 poisonings from salicylate tablets, and 449 accidents involving bicycles or tricycles. Other findings included 333 injuries to fingers or hands in doors, usually car doors; 122 instances of pulled arms; 384 ingestions and 53 inhalations of foreign bodies; 60 alleged sexual assaults, 58 chemical burns, 127 wringer injuries, and four attempted suicides. A rewarding opportunity in accident prevention exists for hospitals that undertake to compile and distribute pertinent source data.     

Innervated radial thenar flap combined with radial forearm flap transfer for thumb reconstruction

A radial thenar flap combined with radial forearm flap was used for the reconstruction of the ipsilateral thumb in four patients. Vascular supply of the combined flap was based on the radial artery and extending the vascular pedicle to the superficial palmar branch of the radial artery. The flap was sensated by the palmar branch of the superficial radial nerve. The size of the flap averaged 15 x 5 cm and the innervated region of the thenar eminence was an area approximately 5 x 3 cm located over the proximal parts of the abductor pollicis brevis and opponens pollicis muscles. The flap was transferred as a free flap in three patients and as an advancement flap in one patient. The flaps survived completely without complications. Satisfactory restoration of sensation was achieved in the flap area, as shown by 6 mm of average moving two-point discrimination. This combined flap may be a feasible reconstructive option for large palmar defects of the fingers such as degloving injuries.     

The PHD finger, a nuclear protein-interaction domain

The PHD finger is a common structural motif found in all eukaryotic genomes. It is a Zn(2+)-binding domain and its closest structural relative is the RING domain. Many RING fingers bind to E2 ligases to mediate the ubiquitination of proteins. Whether PHD fingers share a common function is unclear. Notably, many if not all PHD fingers are found in nuclear proteins whose substrate tends to be chromatin. Some PHD fingers bind to specific nuclear protein partners, apparently through the same surface that is used by RING domains to bind their cognate E2 ligases. New evidence also suggests that some PHD fingers bind to nucleosomes, raising the possibility that chromatin might be a common nuclear ligand of PHD fingers.     

Minimizing impairment in laborers with finger losses distal to the proximal interphalangeal joint by second toe transfer

Traditionally, toe-to-hand transfers have been reserved for thumb amputations or for use after severe mutilating injuries. The authors report their experience with the use of second toe-for-finger amputations with preserved or reconstructible proximal interphalangeal joints in manual workers. The aim of the procedure was to reduce impairment and to upgrade the hand from a functional and cosmetic standpoint. Fifteen second-toe wrap-around or variations were carried out on 11 adults (18 to 41 years old). Four patients with two or more finger amputations received two sequential second toes; four patients with two finger amputations received one toe; and each of three patients with single-digit amputation received a single toe. All but one amputation were performed less than 3 weeks after the accident. All toes survived. Range of motion at the native proximal interphalangeal joint was more than 90 percent in all patients but one; however, it was minimal at the transplanted joints. Patient satisfaction was high from a cosmetic and functional standpoint. Ten of 11 laborers resumed their previous activity. On the basis of this experience, a classification with aesthetic and functional implications is proposed to help in the decision-making process when dealing with multidigital injuries. It is concluded that second-toe transfer is an excellent choice for finger amputation distal to the proximal interphalangeal joint in laborers. Its prime indication is for amputations of two fingers where at least one toe should be transferred, as required, to achieve an "acceptable hand" (three-fingered hand). Early transfer allows salvage of critical structures from the damaged finger, such as joints, tendons, and bone, that otherwise would be lost. Early transplantation is highly recommended.