- Email: [email protected]
Congenital bilateral isolated fifth metacarpal agenesis
Correspondence and communications
409
2. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678e83. 3. Verpaele AM, Blondeel PN, Van Landuyt K, et al. The superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure sores. Br J Plast Surg 1999;52:385e91. 4. Leow M, Lim J, Lim TC. The superior gluteal artery perforator flap for the closure of sacral sores. Singapore Med J 2004;Vol 45(1):37e9. 5. Verhaegen P, Stekelenburg C, van Trier A, et al. Perforatorbased interposition flaps for sustainable scar contracture release: a versatile, practical, and safe technique. Plast Reconstr Surg April 2011;127(4):1524e32.
C. Harris Northern Ireland Plastic and Maxillofacial Surgery Service, Royal Victoria Hospital, Belfast, UK Plastic Surgery Department, Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast, BT16 1RH, UK E-mail address: [email protected] L. Damkat-Thomas Northern Ireland Plastic and Maxillofacial Surgery Service, Royal Victoria Hospital, Belfast, UK C.E. Black Northern Ireland Plastic and Maxillofacial Surgery Service, Royal Victoria Hospital, Belfast, UK
ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.032
Figure 1
Congenital bilateral isolated fifth metacarpal agenesis Sir, We present a 22-year-old man who was admitted to our clinic with a complaint of unusual appearance of both of his little fingers. Neither familial history nor previous treatment was noted. There were no other systemic or phenotypic disorders. He did not state any functional complaints but was not satisfied with the unusual appearance of his fifth fingers. (Figure 1) Because there was an abducted posture of the little fingers, the fourth webs were wider compared to the other webs. The palm width of the left hand was 71 mm and that of the right hand was 73 mm. Mal-positioning of the joints restricted oppositioning of the fifth fingers; other movements were normal. X-ray examination, revealed complete bilateral absence of the fifth metacarpal bones, with bilateral pseudo-joint formations and enlargement of the fourth metacarpal bones. The fourth metacarpal bones formed bilateral inverted Y- shaped views. Radiography also showed a pseudo metacarpophalangeal joint formation between the fourth metacarpal diaphysis and proximal phalanx of the little finger. (Figure 2) Peker et al.,1 reported a case of unilateral absence of the fifth metacarpal bone that was managed by deepening the web space and correcting the alignment of the little finger with a reverse wedge osteotomy of the proximal phalanx. Buckwalter et al.,2 reported seven adult patients with an absence of the fifth metacarpal bone by reviewing 1700 patients with congenital abnormalities of the hand and
Bilateral absence of fifth metacarpal bones.
410
Correspondence and communications
Figure 2
Bilateral fifth metacarpal agenesis and pseudo-joint formations
upper extremity. In three of the seven patients, the fifth metacarpal bone was completely absent. To date, no reports of patients with congenital bilateral isolated metacarpal agenesis exist in the literature. Congenital absence of metacarpal bones is a rare anomaly; it can occur unilaterally or bilaterally and is, sometimes accompanied by enlargement of the fourth metacarpal bones. We conclude that management should be individualised for each patient. In patients with no functional problems, a conservative approach should be the first choice of treatment.
Dumlupinar M. Etimesgut Asker Hastanesi Bastabipligi Plastik Cerrahi Klinigi, Etimesgut, Ankara 06990, Turkey E-mail address: [email protected]
ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.038
None.
Initial management of open tibial fractures in peripheral hospitals does not necessarily correlate with an increase in flap failure rates
Funding
Dear Sir,
Conflict of interest
None.
References 1. Peker F, Ac ¸ikel C, Ulku ¨r E. Congenital isolated absence of fifth metacarpal bone. Plast Reconstr Surg 2002 Apr 15;109(5): 1752e4. PMID: 11932642 [PubMed - indexed for MEDLINE]. 2. Buckwalter JA, Flatt AE, Shurr DG, Dryer RF, Blair WF. The absent fifth metacarpal. J Hand Surg Am 1981 Jul;6(4):364e7. PMID: 7252111 [PubMed - indexed for MEDLINE].
Fikret Eren Cenk Melikoglu Sevket Gokhan Beyhan
The landmark paper of Naique et al. has formed the basis for the new guidelines on combined management of open tibial fractures, yet there are no other studies that have confirmed their findings, specifically with respect to an increase in flap failure rate in cases managed initially in peripheral hospitals.1,2 Our unit previously reviewed the management of open tibial fractures with respect to the 1997 guidelines which emphasized timing of debridement and flap cover, rather than combined care in Specialist Centres.3 This demonstrated, as have others, that fracture fixation revision and need for further debridement was unacceptably high in cases managed in non-specialist units. 35% cases required further operative intervention prior to flap cover, including a fracture fixation revision rate of 22% and re-debridement of 13%. However, re-analysis of our original data with respect to flap failures gives us differing
409
2. Koshima I, Moriguchi T, Soeda S, et al. The gluteal perforator based flap for repair of sacral pressure sores. Plast Reconstr Surg 1993;91:678e83. 3. Verpaele AM, Blondeel PN, Van Landuyt K, et al. The superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure sores. Br J Plast Surg 1999;52:385e91. 4. Leow M, Lim J, Lim TC. The superior gluteal artery perforator flap for the closure of sacral sores. Singapore Med J 2004;Vol 45(1):37e9. 5. Verhaegen P, Stekelenburg C, van Trier A, et al. Perforatorbased interposition flaps for sustainable scar contracture release: a versatile, practical, and safe technique. Plast Reconstr Surg April 2011;127(4):1524e32.
C. Harris Northern Ireland Plastic and Maxillofacial Surgery Service, Royal Victoria Hospital, Belfast, UK Plastic Surgery Department, Ulster Hospital, Upper Newtownards Road, Dundonald, Belfast, BT16 1RH, UK E-mail address: [email protected] L. Damkat-Thomas Northern Ireland Plastic and Maxillofacial Surgery Service, Royal Victoria Hospital, Belfast, UK C.E. Black Northern Ireland Plastic and Maxillofacial Surgery Service, Royal Victoria Hospital, Belfast, UK
ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.032
Figure 1
Congenital bilateral isolated fifth metacarpal agenesis Sir, We present a 22-year-old man who was admitted to our clinic with a complaint of unusual appearance of both of his little fingers. Neither familial history nor previous treatment was noted. There were no other systemic or phenotypic disorders. He did not state any functional complaints but was not satisfied with the unusual appearance of his fifth fingers. (Figure 1) Because there was an abducted posture of the little fingers, the fourth webs were wider compared to the other webs. The palm width of the left hand was 71 mm and that of the right hand was 73 mm. Mal-positioning of the joints restricted oppositioning of the fifth fingers; other movements were normal. X-ray examination, revealed complete bilateral absence of the fifth metacarpal bones, with bilateral pseudo-joint formations and enlargement of the fourth metacarpal bones. The fourth metacarpal bones formed bilateral inverted Y- shaped views. Radiography also showed a pseudo metacarpophalangeal joint formation between the fourth metacarpal diaphysis and proximal phalanx of the little finger. (Figure 2) Peker et al.,1 reported a case of unilateral absence of the fifth metacarpal bone that was managed by deepening the web space and correcting the alignment of the little finger with a reverse wedge osteotomy of the proximal phalanx. Buckwalter et al.,2 reported seven adult patients with an absence of the fifth metacarpal bone by reviewing 1700 patients with congenital abnormalities of the hand and
Bilateral absence of fifth metacarpal bones.
410
Correspondence and communications
Figure 2
Bilateral fifth metacarpal agenesis and pseudo-joint formations
upper extremity. In three of the seven patients, the fifth metacarpal bone was completely absent. To date, no reports of patients with congenital bilateral isolated metacarpal agenesis exist in the literature. Congenital absence of metacarpal bones is a rare anomaly; it can occur unilaterally or bilaterally and is, sometimes accompanied by enlargement of the fourth metacarpal bones. We conclude that management should be individualised for each patient. In patients with no functional problems, a conservative approach should be the first choice of treatment.
Dumlupinar M. Etimesgut Asker Hastanesi Bastabipligi Plastik Cerrahi Klinigi, Etimesgut, Ankara 06990, Turkey E-mail address: [email protected]
ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.038
None.
Initial management of open tibial fractures in peripheral hospitals does not necessarily correlate with an increase in flap failure rates
Funding
Dear Sir,
Conflict of interest
None.
References 1. Peker F, Ac ¸ikel C, Ulku ¨r E. Congenital isolated absence of fifth metacarpal bone. Plast Reconstr Surg 2002 Apr 15;109(5): 1752e4. PMID: 11932642 [PubMed - indexed for MEDLINE]. 2. Buckwalter JA, Flatt AE, Shurr DG, Dryer RF, Blair WF. The absent fifth metacarpal. J Hand Surg Am 1981 Jul;6(4):364e7. PMID: 7252111 [PubMed - indexed for MEDLINE].
Fikret Eren Cenk Melikoglu Sevket Gokhan Beyhan
The landmark paper of Naique et al. has formed the basis for the new guidelines on combined management of open tibial fractures, yet there are no other studies that have confirmed their findings, specifically with respect to an increase in flap failure rate in cases managed initially in peripheral hospitals.1,2 Our unit previously reviewed the management of open tibial fractures with respect to the 1997 guidelines which emphasized timing of debridement and flap cover, rather than combined care in Specialist Centres.3 This demonstrated, as have others, that fracture fixation revision and need for further debridement was unacceptably high in cases managed in non-specialist units. 35% cases required further operative intervention prior to flap cover, including a fracture fixation revision rate of 22% and re-debridement of 13%. However, re-analysis of our original data with respect to flap failures gives us differing