Israel Medical Association Journal

Background: Delays in diagnosis and inadequate treatment of acute scaphoid fractures can lead to non-unions, presenting surgeons with unique challenges regarding optimal management.

Objectives: To evaluate the clinical and radiographic outcome of scaphoid non-unions treated with percutaneous screw fixation.

Methods: The study group comprised12 patients with scaphoid non-unions of an average duration of 8.7 months. There were 11 males and 1 female with an average age of 24 years (range 14–47 years). All patients were initially treated with percutaneous screw fixation without bone grafting. A volar percutaneous approach was used in eight patients and a dorsal percutaneous approach in four. Wrist range of motion (ROM) and disabilities of the arm, shoulder, and hand (DASH) questionnaires were used to assess clinical outcomes. Postoperative radiographs were reviewed to assess the fracture union, carpal alignment and screw position.

Results: Eleven of the 12 (92%) fractures united successfully with no additional procedures. These fractures achieved radiographic union at an average of 4 months. One patient with sickle cell anemia required revision fixation, which consisted of repeat percutaneous fixation and bone grafting. In this patient his non-union healed 3 months after the revision procedure. The average DASH score at final follow-up was 6 (range 0–16). Average wrist ROM was extension of 66 degrees (range 50–80) and flexion 71 degrees (range 55–90). None of the patients showed radiographic signs of osteoarthritis, osteonecrosis of the scaphoid, or hardware-related complications.

Conclusions: For scaphoid waist nonunions without collapse, percutaneous fixation without supplementary bone grafting provides satisfactory results with a high union rate, early return of function and minimal complications.
 

Background: Coverage of part of a soft tissue defect in the thumb, without bone shortening and without long-lasting immobilization in an inappropriate position leading to stiffness, is difficult to achieve.

Objectives: To report our experience using Foucher’s modification of the first dorsal metacarpal artery flap for thumb reconstruction in 21 cases.

Methods: Foucher’s flap is based on the neurovascular structures of the first dorsal metacarpal artery flap and radial nerve-sensitive branches on the dorsum of the second metacarpal and proximal phalanx. The cause of injury was work-related in all 21 cases. The patients' mean age was 37 (range 17–68 years), and mean follow-up was 19 months (range 12–31). Emergency surgery was performed in 13 patients, with a time delay after injury of 4–12 hours. The minimum defect was 12–18 mm and the maximum 20–40 mm. Pedicular length was 55–95 mm. A skin bridge was left intact in 16 cases. In two cases of early postoperative venous congestion and flap loss, a cross-finger flap was performed as a salvage procedure.

Results: Subjective satisfaction score was 8.37/10 (range 4–10); cold intolerance was experienced in 60% and dysesthesia in 33%. All except one patient are able to use their thumb in daily activity. Loss of mobility in the proximal interphalangeal joint of the index finger was less than 20 degrees. Semmes-Weinstein sensitivity evaluation score was 3.61–4.31 on the flap and 0–6.65 on the donor site. Two-point discrimination was 10.8 mm (range 8–20). Grip strength was reduced by 15% compared to the unaffected hand (hand dominance was not taken into consideration). Rehabilitation was not consistent as almost all the patients were living in another location.

Conclusions: First DMCA[1] pedicle flap is a successful thumb reconstruction method, especially in patients not disturbed by its cosmetic appearance.

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[1] DMCA = dorsal metacarpal artery