We assessed the value of three‐compartment magnetic resonance (MR) wrist arthrography in comparison with non‐enhanced magnetic resonance imaging (MRI) for the evaluation of 13 individual wrist ligaments in 35 patients with refractory wrist pain. In 20 of these patients MR findings were correlated with the findings from multiportal wrist arthroscopy. For MR imaging (1.5‐T magnet) a three‐dimensional volume acquisition with a gradient‐recalled echo sequence and 0.6–1.0 mm effective slice thickness was used. The delineation of individual wrist ligaments was rated as “good” in 10% of non‐enhanced MR and 90% of MR arthrography images. Ligament evaluation was possible with high diagnostic confidence in 11% by non‐enhanced MR imaging and 90% by MR arthrography. With wrist arthroscopy as the standard of reference, average sensitivities/specificities/accuracies for the diagnosis of full‐thickness ligamentous defects were 0.81/0.75/0.77 for non‐enhanced MR imaging and 0.97/0.96/0.96 for MR arthrography. Our findings suggest that MR arthrography is more accurate than standard MRI in delineating and evaluating the ligaments of the wrist.J. Magn. Reson. Imaging 1999;9:468–474. © 1999 Wiley‐Liss, Inc.

MR arthrography, using three-dimensional volume acquisition with thin slices (0.6-1.0 mm), combines the advantages of three-compartment arthrography and non-enhanced MRI. It shows the precise location and magnitude of ligamentous defects of all parts of the SLIL, correlates well with wrist arthroscopy and has potential implications for diagnosis and treatment planning.

The real extent of damage in high-pressure injection injuries (grease gun injuries, paint gun injuries, pressure gun in juries) is hidden behind a small and frequently painless punctiform skin lesion on the finger or the hand. These kinds of injuries require prompt surgical intervention with surgical debridement of all ischemic tissue. Possibility of a general intoxication by the fluid must always be ruled out. Postoperative intensive physiotherapy is essential for the final hand function. The initial benign aspect is frequently causing a delay for an adequate treatment while in the mean time the possibility for subcutaneous damage continuously increases. Because of this delay the chance of permanent reduced functionality in the hand or finger amputation raises. Not only the latency time to adequate treatment but also the injected fluid's nature, the pressure, the volume and the location of injection, has influence on the seriousness and extensiveness of subcutaneous damage. All these factors influence the functional outcome of the patient.

The authors studied botulinum toxin type A therapy of severe biceps-triceps cocontractions after nerve regeneration following birth-related brachial plexus lesions. Six children (age, 2 to 4 years) were treated two to three times over a period of 8 to 12 months with 40 mouse units of botulinum toxin at two sites of the triceps muscle. Elbow range of motion improved from 0 to 25 to 50 deg to 0 to 25 to 100 deg (p < 0.05), and muscle force of elbow flexion increased from a mean of Medical Research Council classification 1.7 to 3.7 (p < 0.05). After a 1-year follow-up, there was no clinical recurrence.

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Besides the free omentum flap, the free latissimus dorsi transfer is the only option for coverage of subtotal or total scalp defects. Compared to the omentum flap, the latissimus dorsi offers more tissue, has less donor site morbidity, and secondary surgery such as cranial bone reconstruction is possible. Contrary to most authors, our preferred donor vessels are maxillary artery and the external jugular vein. To avoid any vascular compression we are using a myo-cutaneous flap. The skin island must be removed secondarily. In patients were no bone reconstruction is possible or planned, the deepithelialized skin paddle can be used for correction of a contour defect.

Extensive pulp (zone 4) defects of the thumb, with the exposure of tendon or bone, are challenging reconstructive problems. Surgical treatment includes the use of local, regional, and free flaps. The first dorsal metacarpal artery flap has been used successfully for defects of the thumb. The innerved first dorsal metacarpal artery flap from the dorsum of the index finger was first described by Hilgenfeldt and refined by Holevich. An island flap carried on a neurovascular pedicle consisting of the first dorsal metacarpal artery was first demonstrated by Foucher and Braun. Seven innervated FDMCA island flaps were performed from May 2005 until July 2007 for thumb reconstruction. There were three women and four men with an average age of 54.9 years (range 28–89 years). The mean follow-up period was 15.4 months (range 4–29 months). The dominant hand was involved in six (85.7%) patients. In a retrospective clinical study, the following criteria were evaluated: (1) etiology of the defect, (2) time of reconstruction (primary vs. delayed), (3) survival rate of flap, (4) sensory function (Semmes–Weinstein monofilaments, static 2-PD, pain, cortical reorientation), (5) TAM measured with the Kapandji index, and (6) subjective patient satisfaction (SF 36). Four patients presented with trauma, two patients with defects after tumor resection and one with infection of the thumb. The flap was used for immediate reconstruction in three (42.9%) patients and for delayed reconstruction in four (57.1%) patients. Delayed reconstruction was performed 4.75 (1–12) months after initial trauma or first surgery. The donor area was grafted with full-thickness skin grafts in all cases. All flaps survived. The mean SWMF was 3.31 g and average statis 2-PD over the flap was 10.57 mm. Pain at the flap scored 3.71 over 10 and at the donor site 2.17 over 10. Paresthesia at the flap scored 0.57 over 4 and at the donor site 0.33 over 4. Complete cortical reorientation was only seen in one patient. The mean Kapandji score of the reconstructed thumb was 7.43 over 10. Using the SF-36, mean physical health of the patients scored 66.88% and mean mental health scored 70.55%. Disturbing pain and paresthesia of the flap are exceptional. The static 2-PD is more than 10 mm, and is clinically over the limit. Cortical reorientation was incomplete in all but one patient. Touch on thumb is felt on the dorsum of the index finger; however, sensation is not disturbing or interfering with the patient’s activities. Foucher described the technique débranchement–rébranchement in order to improve this problem. The postoperative total amount of motion of the reconstructed thumb was very good. The results demonstrated that the FDMCA flap has a constant anatomy and easy dissection. It has a low donor site morbidity if FTSG is used. It also shows good functional and aesthetic results. Therefore, the FDMCA flap is a first treatment of choice for defects of the proximal phalanx and proximal part of the distal phalanx of the thumb.

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