Nine patients underwent Ilizarov distraction-lengthening for congenital anomalies. All were late cases and had undergone other procedures. In five radial club hand patients with very short forearms, we achieved an average 5.8 cm increase in length with each distraction cycle. In two patients with symbrachydactyly of the cleft hand type, we achieved pinch grip between a radial and an ulnar digit by lengthening the short ray. Another case of the monodactyly type in which we tried to lengthen three transplanted proximal toe phalanges ended in failure. A soft tissue distraction was attempted in a case of camptodactyly but failed. We report the problems we encountered and suggest some solutions.

Between 1993 and 1998, 12 distally based dorsal metacarpal artery flaps were used to cover defects of the fingers and palm. All flaps were raised from the dorsum of the hand. Eleven flaps allowed direct closure of the donor site area; one case required a full-thickness skin graft. Nine flaps healed uneventfully. Distal marginal flap necrosis occurred in three cases. All of these were used to cover defects at the distal part of the middle phalanx.

From 1989 to 2001 eleven children with the peromelic type of symbrachydactyly underwent a staged double second toes transplantation for restoration of two finger rays. The second toe of the feet were transplanted first to the small finger position and in the second step to the thumb position. One failure occurred in the first toe transplantation and another developed a venous thrombosis with partial necrosis and eventually a useless ray. Eight children were reviewed retrospectively in a mean follow-up of 5.3 years. The ability to pinch was restored in four children. In all patients without complications the function of the hand improved and the sensitivity was good.

Diagnosis of spontaneous fascicular nerve torsions is difficult and often delayed until surgical exploration is performed. This case series raises awareness of peripheral nerve torsions and will facilitate an earlier diagnosis by using nerve ultrasound (NUS) and magnetic resonance neurography (MRN). Four patients with previously ambiguous upper-extremity mononeuropathies underwent NUS and 3T MRN. Neuroimaging detected proximal torsions of the anterior and posterior interosseous nerve fascicles within median or radial nerve trunks in all patients. In NUS, most cases presented with a thickening of affected nerve fascicles, followed by an abrupt caliber decrease, leading to the pathognomonic sausage-like configuration. MRN showed T2-weighted hyperintense signal alterations of fascicles at and distal to the torsion site, and directly visualized the distorted nerves. Three patients had favorable outcomes after being transferred to emergency surgical intervention, while 1 patient with existing chronic muscle atrophy was no longer eligible for surgery. NUS and MRN are complementary diagnostic methods, and both can detect nerve torsions on a fascicular level. Neuroimaging is indispensable for diagnosing fascicular nerve torsions, and should be applied in all unclear cases of mononeuropathy to determine the diagnosis and if necessary, to guide surgical therapies, as only timely interventions enable favorable outcomes.

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