The Journal of hand surgery
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Comparative Study
Comparison of nail bed repair versus nail trephination for subungual hematomas in children.
Fifty-three fingers in 52 children were divided into 2 groups, operative and nonoperative, after fingernail crush injury. Criteria for inclusion into the study were an intact nail and nail margin with subungual hematoma and no previous nail abnormality. The length of the follow-up period averaged longer than 2 years for each group. ⋯ Although formal nail bed reconstruction has been advocated for hematomas larger than 25%, we found no notable difference in outcome between the 2 groups regardless of hematoma size, presence of fracture, injury mechanism, or age. Charges, however, were 4 times greater for the operative group. Based on the results of this study, we do not feel that nail removal and nail bed exploration is indicated or justified for children with subungual hematoma and an intact nail and nail margin.
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Pressure reduction for standard open fasciotomy and a novel endoscopic fascial release were compared in experimental conditions of elevated forearm compartment pressures by continuously monitoring intracompartmental pressures in 22 cadaver forearms. Both methods were effective in diminishing tissue pressures. Intracompartmental pressures were reduced to significantly lower levels following open versus endoscopic assisted fasciotomy (2.9 mm Hg vs. 13.2 mm Hg). ⋯ The results of this study suggest that endoscopic assisted fasciotomy can reduce elevated tissue pressures, confirming previous findings that fascial release is of primary importance in decreasing intracompartmental tissue pressures. Open fasciotomy, however, gave significantly greater decompression than the endoscopic technique, a difference that may be even more substantial in the clinical setting due to several limiting factors of this in vitro model. Our results also suggest that immediate skin closure following fasciotomy increased tissue pressure and therefore should be avoided.
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Anatomic dissections under microscopic magnification were performed on 30 fresh cadaveric hands to depict the course and interconnections of the sensory nerves to the digits. The dissections included the median nerve, the ulnar nerve, the superficial branch of the radial nerve, the dorsal branch of the ulnar nerve, and the dorsal branch of the proper digital nerve. The communicating branches between the median and ulnar nerves in the palm were found in 20 of the 30 (67%) specimens. ⋯ Four types of palmar-dorsal interconnections, located in the middle of the proximal phalanx, were found in the digits but not in the thumb. The presence of these branches indicates dual innervation of the dorsal and palmar side of the distal areas of the digits. These anatomic findings may help hand surgeons interpret discrepancies in sensory loss after either dorsal or palmar injuries.
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Flexor carpi ulnaris (FCU) transfer to the extensor carpi radialis brevis (ECRB) and/or the extensor carpi radialis longus (ECRL) has been commonly used to provide wrist extension. The ability of this wrist extension transfer to also provide forearm supination has been inferred but not formally investigated. This laboratory study investigated the forearm supination effect of FCU transfer to the ECRB and to the ECRL in a cadaveric model. ⋯ Releasing the distal two thirds of the FCU ulnar origin resulted in a mean supination that was significantly greater than the mean supination achieved with releasing the distal one third of the FCU ulnar origin. We concluded that in the cadaveric model, transfer of the FCU into either the ECRB or ECRL provided similar resultant supination and that freeing the distal two thirds of the FCU ulnar origin provided significantly more supination than freeing only the distal one third. For the hand surgeon treating wrist flexion in combination with forearm pronation deformity, transfer of the FCU into the ECRB and/or the ECRL can be used to concomitantly provide wrist extension and forearm supination.
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Case Reports
Subcutaneous tissue emphysema of the hand secondary to noninfectious etiology: a report of two cases.
Subcutaneous emphysema of the hand can be benign and noninfectious in origin. Emphysema from gas-forming organisms is associated with systemic symptoms, whereas benign subcutaneous emphysema is not. High-pressure pneumatic tool injuries are a well-known cause of subcutaneous emphysema. ⋯ The benign nature of the emphysema was revealed by a lack of local pain and inflammation in the presence of extensive crepitus and a lack of systemic symptoms. A noninfectious cause should always be considered. This may prevent unnecessary surgical intervention, which occurred in 1 of the 2 cases presented here.