Subungual Malignant Melanoma of Hand (Case Report)

Of all cutaneous melanoma, approximately 2% occur on the hand and subungual melanoma is a rare form. The pathologic type of tumor and depth of invasion are determinants of overall prognosis. The subungual malignant melanoma has gained for itself a certain notoriety of being misdiagnosis and, therefore, treated later than other melanomas with a resulting poorer prognosis. The most common clinicopathologic type of subungual melanoma is acral lentiginous melanoma : however, other variants may occur. The amputation at the neck of the proximal phalanx of the thumb and at the level of the proximal interphalangeal joint in a finger is recommended for management of subungual melanoma. The most common site for recurrence of subungual melanoma is in the regional lymph node field, as with other cutaneous melanomas. But the role of prophylactic lymph node dissection for melanomas remains controversial. There is marked variation in reported overall 5-year survival rates ranging from 16% to 72%. But the survival rate for patients with subungual melanoma, stage for stage and thickness for thickness, is well below that for other cutaneous melanomas. The authors report one case of subungual malignant melanoma of hand which had been misdiagnosed for ten years and treated later.ope

Operative Treatment of Metacarpophalangeal Joint Avulsion Fracture

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Operative Treatment for Fracture of the Proximal Phalanx Base of the Little Finger

Fractures in metacarpophalangeal joint are mainly divided into metacarpal neck fracture and proximal phalangeal base fracture. The proximal phalangeal base fracture occurs easily in little finger because it is a peripheral finger with no outside protection. Fractures of proximal phalangeal base of little finger cause angular deformity and limitation of motion of little finger frequently. We have studied thirteen patients with the proximal phalangeal base fractures of the little finger. The average age was 25.7 years (range 8-63 years) and most of patients were included in 2nd and 3rd decades. Closed reduction and percutaneous pinning was performed in 9 cases and open reduction and internal fixation with Kirschner's wires in 4 cases. Dorsal angulation was present in all cases (average 25¡Æ) and ulnar angulation in 10 cases (average 10¡Æ) preoperatively. Angular deformities were corrected to average dorsal angulation 8.5¡Æand average ulnar angulation 0¡Æ. Dorsal angulation was not corrected enough in two cases and resulted in limitation in full grip and range of motion. Ulnar rotation deformity of 30¡Æwith limitation of motion of the little finger developed during the follow-up period in one case. Weakness and instability in grip were noted in three cases. In conclusion, the proximal phalangeal base fracture of the little finger causes angulation and rotation deformity frequently. As a result, the limitation of full grip and range of motion of the little finger developed. And so, the operative treatment should be considered for the anatomical reduction and firm fixation of the proximal phalangeal base fracture of the little finger if closed reduction fail.ope

Comparison between Kirschner's wire and Herbert's screw fixation in Scaphoid nonunion

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Treatment in Septic Arthritis with severe articular destruction of Metacarpophalangeal joint after Traumatic Suppurative Tenosynovitis of Finger Extensor

Septic arthritis of metacarpophalangeal joint which were occurred after fight injury or penetration wound around the metacarpophalangeal joints is a disabling disease unless it is managed properly. And, sometimes the sacrifice of the affected finger may be required in severe cases to salvage the hand. The hand may retain little useful function if it is involved the thumb and index fingers. In cases of established ankylosis of finger joints and the surrounding soft tissues such as extensor and flexor tendons were necrotized, reconstruction of the joint could be attempted. From 1985 to 1998, we experienced four posttraumatic septic arthritis of metacarpophalangeal joint and reconstructed the joints using free joint transfer in two cases. The results were good and functional hands without residual infection were achieved. But, to prevent these tragedies of secondary joint transfer procedures, careful management of laceration wound around the metacarpophalangeal joints is mandatory. The optimal management should include not only antibiotic therapy but also early aggressive surgical management of the wound.ope

inger Reconstruction with a Free Neurovascular Wrap-around Flap from the Big Toe

From 1983 to 1998, 16 cases of finger reconstruction with a free neurovascular wrap-around flap from big toe were performed. Fourteen cases were successful and excellent functional and cosmetic results were achieved. Pinch power was 51% of unaffected normal hand and two-point discrimination was 9.2mm. The bone resorption was 13% of the initial bone graft width and 9% of that in length. There were no complications such as fracture of grafted bone, nonunion, pulp dislodgement. This procedure provided length, stability and adequate sensibility for a functional pinch and grasp. The sensory return to wrap-around flap on the thumb is often greater than for the same area on the opposite foot. The donor site of the wrap-around flap is acceptable esthetically and functionally in open-toed shoe styles worn by young woman. Finger reconstruction with a wrap-around flap from the big toe gives excellent cosmetic and functional results in cases of amputation at the level of the metacarpo-phalangeal joints or distal to it. In addition, in cases of the avulsion injuries of fingers and reconstruction of soft tissue defect after tumor excision, this procedure could be an excellent choice of treatment.ope

Surgical treatment of the Kienbck's disease

The natural progression of lunate osteonecrosis is one of loss of vascularity, fragmentation, and later collapse with subsequent loss of carpal integrity. In the treatment of the Kienb ck's disease, reported that surgical treatment has been more effective than the conservative treatment, such as cast immobilization which cannot prevent the progress of the disease even if its initial stage. The ultimate goal of treatment is mechanical decompression and revascularization of the lunate. Many therapeutic guidelines were researched by several authors to the different stages, but not established absolute guideline yet. We have treated a total of 13 cases of Kienb ck's disease, their symptom duration was 40 months in average. All cases were followed for 39months in average. According to the Lichtman's classification, stage II in 3 cases, stage IIIa in 6 cases, stage IIIb in 4 cases were defined radiologically. The ulnar variance were negative in 8 cases, neutral in 4 cases, positive in a case. Operative treatments were performed with scaphoido-capitate fusion in 2 cases, triscaphe fusion in 8 cases, radial shortening in 3 cases, from Mar. 1991 to Dec. 1998. Their end results were analyzed with subjective pain, objective wrist motions clinically which based on Lichtman's criteria and with carpal height radiologically. Ten cases were satisfied and another 3 cases were unsatisfied according to the Lichtman's criteria. The pain was relieved in all cases but the range of motion was decreased mederately after scaphoidocapitate fusion. The carpal index was not changed from 0.50 preoperatively to 0.50 postoperatively in average in all cases. There were were a superficial wound infection and a paresthesia of the operative sites as postoperative complications.ope

Treatment of Bony Mallet Finger with Extension Block Technique

Purpose: To evaluate results of extension block technique for bony mallet finger. Materials and Methods: Between March 2002 and March 2005, twenty one patients who received extension block surgery for bony mallet finger were included in this study. Time from injury to operation, extent of joint involvement, subluxation of distal interphalangeal (DIP) joint, time from surgery to K-wire removal, range of motion, complications and patient subjective satisfaction at final follow up were surveyed. Results: The objective results were evaluated with Crawford's method which assess extension, flexion and pain. Out of 21 patients, 7 were excellent, 11 good, 2 fair and 1 poor. Regarding to subjective satisfaction, 17 patients showed excellent or good, 2 fair and 2 poor results. K-wire was removed at an average of 40 days after surgery. Average DIP motion was 66 degrees, and average loss of extension was 7 degrees. Bone union was achieved in all cases. The fair and poor results were related to improper position of K-wire. Conclusion: Extension block technique for the treatment of bony mallet finger is a less invasive and useful treatment modality in patients who have greater than one-third involvement of the joint surface, failure of reduction, and distal joint subluxation.ope

Operative Treatment of the Hamate Body Fracture with Subluxation of the Fourth and Fifth Carpometacarpal Joints

Purpose: Fracture of the hamate body with associated dorsal dislocation of the 4th and 5th carpometacarpal joints is rare and the diagnosis is frequently missed. Displaced carpal fractures requires anatomical reduction to restore normal carpal kinematics and obtain good outcome. We present the clinical and radiological results of the open reduction and internal fixation for hamate body fractures with concomittant 4th and 5th carpometacarpal joint dislocation. Materials and Methods: From Jan. 2003 to Dec. 2007, we experienced 10 cases of carpal bone fractures with ulnar carpometacarpal joint dislocation that underwent open reduction. Two cases had dorsal capitate and hamate fractures, and the other eight cases had dorsal hamate fractures with dislocation of the bases of the 4th and 5th metacarpals in all 10 cases. Treatment consisted of open reduction through dorsal approach and internal fixation with mini bone screw followed by splint application and immediate range of motion exercise. Bone union was evaluated with follow up x-ray and clinical evaluation was performed with grip strength, wrist and finger range of motion, and the degree of pain. Results: The mean follow up period was 12.3 months. All cases showed bony union at the average of seven weeks postoperatively. All cases achieved excellent range of motion. Grip strength were normal compared to the other side. Two cases had internittent pain as a complication. Conclusion: The diagnosis should be suspected on initial review of plain radiographs in any patient presenting with pain after blunt trauma to the hand. The operative treatment was required in cases with difficulty in maintaining closed reduction, open displaced fractures, and delayed diagnosis. Open reduction and internal fixation resulted in good clinical and radiological outcomes.ope

Anatomy and Biomechanics of the Elbow and Wrist

The elbow and the wrist are anatomic linkages bridging the hand to the shoulder, and act to enhance flexibility in hand function and placement. Many muscles, tendons and neurovascular bundles are located around the elbow and the wrist. In addition to the complex bony architecture of the joints, the elbow and the wrist are stabilized by many ligamentous complexes. It is very important to understand the anatomy and biomechanics of these joints for accurate diagnosis and proper treatment of the disease or trauma of the elbow and wrist.ope