A new treatment of mallet fractures of the distal phalanx is presented. Open reduction and internal fixation was performed using a "hook" plate fabricated from a 1.3 mm AO hand modular system straight plate. This technique avoids the need to place implants or wires through the small avulsion fragment while still being able to achieve a stable "tension-plate" type of fixation construct strong enough to allow protected early active motion of the distal interphalangeal joint. In minimising the need for prolonged splinting, patient comfort is also improved. In a consecutive series of nine fractures, union was achieved in all cases. At an average follow-up period of 17 months, four had excellent and five had good results using the Crawford rating scale. Using the Warren and Norris scale, all patients had a successful result. The final average active range of flexion of the distal interphalangeal joint was 64 degrees and there was no extensor lag.

We propose a three-tier clinical classification system that can aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis of the upper extremity.

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the hand and wrist at presentation is extremely rare, and the diagnosis is often missed. Operative findings of "rice bodies, millet seeds, or melon seeds" are highly suggestive of tuberculous tenosynovitis. Six patients with TB of the hand and wrist at various stages of disease with characteristic operative findings are reviewed. Four patients had underlying immunosuppression. One patient had previous pulmonary TB, whereas 3 patients had radiographic evidence of previously undiagnosed pulmonary TB. The interval to presentation ranged from 1 week to 2 years. Two patients had median nerve irritation, 3 patients had osteomyelitis, and 1 patient had flexor tendon rupture. Mycobacterial cultures were positive in 4 patients; acid-fast bacilli stain, and polymerase chain reaction were positive in remaining 1 patient; and both stain and culture were negative in the last patient who had history of pulmonary TB. All 6 patients were managed with combination therapy comprising antituberculous chemotherapy and at least 1 debulking tenosynovectomy. Two patients had 2 debridements. Of these 2 patients, 1 underwent wrist arthrodesis during the second procedure. Mean follow-up was 4 years. There were no recurrences after the most recent debridement. The diagnosis of TB of the hand and wrist is often missed. The surgeon has to be aware of the significance of loose bodies when performing routine excision of innocuous looking wrist ganglia. Combination therapy comprising thorough excisional debridement and antituberculous chemotherapy will minimize recurrence of this difficult-to-treat disease.

Many operative and non-operative treatments of dorsal fracture dislocations of the proximal interphalageal (PIP) joint have been described. Return of good joint function requires anatomical reduction of the articular fragments and restoration of joint congruity and a stable functional arc of motion, with the fixation construct stable enough for early mobilization. To prevent recurrent dorsal subluxation, the attachments of the ligamentous palmar restraints and the bony buttress provided by the palmar lip of the middle phalanx base must be restored. Open reduction and internal interfragmentary screw fixation using 1.5 or 1.3mm screws was employed in 12 fingers in 10 patients with unstable dorsal fracture dislocations of the PIP joints of Schenck grades III and IV. At an average follow-up of 8.7 months, all patients in this series achieved good to excellent results and an average total active interphalangeal motion of 132 degrees (range 105 degrees -165 degrees). Additional benefits over non-operative techniques included improved patient comfort and simplified nursing care and therapy supervision.

Chronic post-traumatic dynamic distal radioulnar joint instability following rupture of the distal radioulnar ligaments may cause disabling and progressive ulnar-sided wrist symptoms. We use a free tendon graft to anatomically reconstruct both dorsal and palmar distal radioulnar ligaments simultaneously. Nine patients who underwent this procedure between 1990 and 1997 were assessed using a modified Mayo Wrist Score. Following surgery, average wrist scores improved from 66 (95% CI, +/-3.0) to 92 (95% CI, 92+/-6.9) and were maintained in the long term (average score, 87 at 9 years). Joint stability was restored and maintained in seven of the nine patients, but two developed recurrent instability. Pain, grip strength and function were better following surgery in the short and long term. Range of supination and pronation decreased slightly from an average of 169 degrees pre-operatively to 155 degrees (90% of normal) in the long term. Long-term radiographs show no distal radioulnar or ulnocarpal joint osteoarthritis.