Nine children with congenital aplasia or hypoplasia of the thumb were treated by pollicisation of the index finger. Functional assessment was performed on average five years after surgery. It demonstrated normal sensation and a power grip, pinch grip and adductor grip of the thumb of 63%, 56% and 63% respectively of the unoperated hand. Efficient use of the hand increased after surgery and continued to improve for some years. The results indicate that pollicisation benefits hand function and should be performed early.
A prospective trial is reported which compares distal osteotomy of the first metatarsal with Keller's arthroplasty in the treatment of adult hallux valgus. A total of 33 patients attended for review at least three years after operation. Symptomatic improvement, as assessed by patient satisfaction, pain relief, cosmetic improvement and restoration of function, was similar in the two groups. Objective measurement showed that the range of movement of the metatarsophalangeal joint was better maintained after osteotomy, as was the relationship of the sesamoid bones to the head of the first metatarsal. Correction of the valgus deformity also was significantly better in the patients who underwent osteotomy and in these patients the first intermetatarsal angle was reduced to within normal limits. There was no evidence that initial degenerative changes or subluxation at the metatarsophalangeal joint compromised a successful result from osteotomy.
Proximal femoral varus and derotation osteotomy is a common procedure performed in the management of developmental dysplasia of the hip. This procedure imposes high shear stress on the femoral epiphysis, depending on the degree of varus obtained. We report two cases of proximal femoral epiphyseal slip after varus derotation osteotomy and discuss the management and outcome. Such epiphyseal slip may or may not be symptomatic, and a careful radiologic examination should be carried out in suspected cases. Management should be individualised. Surgical correction of varus may be required.
A 13-year-old girl presented to the accident and injury department following a hyperabduction injury in the gymnasium, when she fell off a vault. She presented with her arm locked overhead and a 'white' extremity without a brachial, radial or ulnar pulse. The humeral head was palpable in the axilla. She also complained of tingling in her fingertips in the ulnar and median nerve distributions, and had weakness of the thenar eminence muscles.A plain radiograph revealed an inferior dislocation ( Fig. 1) of the left shoulder.She was taken to the operating theatre immediately where a closed reduction of the dislocation was performed under a general anaesthetic and fluoroscopic control. The dislocated shoulder reduced with ease using DePalma's method of closed reduction--overhead upward traction of the arm followed by adduction of the arm toward the trunk. However, post-reduction, the brachial and radial pulse were still absent, both on digital palpation and Doppler examination.An angiography was performed. This revealed a complete occlusion of the third part of the axillary artery, without any significant collateral circulation (Fig. 2). There was no surrounding extravasation of the dye.She underwent an immediate exploration of the axillary artery, which revealed a 1.5 cm intimal tear. The adventitia was intact, but a haematoma was present around the vessel. An interposition reversed long saphenous vein graft was harvested from the right groin. A 2 cm segment of artery was resected, and the vein graft was sutured end to end in its place with a continuous prolene suture along an oblique anastomosis. The branches of the brachial plexus were identified and found intact but bruised. The radial pulse was palpable at the end of the procedure. Postoperatively, she was monitored by frequent clinical examination for compartment syndrome and reperfusion injury, but developed neither.She remained in a poly-sling for a period of 3 weeks. At 3 weeks, we began gentle pendulum exercises. Abduction beyond 908 was restricted until week 6 to protect the vascular repair. She regained a full pain-free range of movement with physical therapy by 14 weeks. She remained recurrence-free and asymptomatic at her 2-year follow-up.
DiscussionLuxatio erecta or inferior shoulder dislocation is a rare injury, with a reported incidence of 0.5% of all shoulder dislocations. 6 There are only two cases of
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