Journal of Hand Surgery (European Volume)

Psychological factors related to the treatment and rehabilitation of hand-injured patients were identified by interviewing of thirty patients under treatment. Findings were compared with those reported in the literature.

Concern for inactivity, desire to return to work, and effort toward recovery were identified as significantly common factors; pain and fear of disfigurement were not. Patients perceived themselves as making the greatest effort toward recovery but not that this was the most important factor in the recovery process. Responsibility varied significantly among the early, middle, and final phases of treatment. The results of the investigation were discussed in relation to hand-rehabilitation and implications for counselling and occupational therapy.

Studies were carried out in Edinburgh to determine the nature, causes and economic consequences of hand injuries requiring more than one visit to hospital. Information on 236 out-patients was collected during a period of six weeks and on 122 in-patients during a period of six months. In both studies, follow-up was by postal questionnaire six weeks after injury. More serious injuries requiring admission to hospital occurred at home (39%) than at work (27%), and of injuries treated on an out-patient basis, the highest proportion (30%) happened at sport. As a result, demands on hospital services were highest in the later part of the day and evening. The main causes of injury were falls at home, at work, in the street or through violence, and only a few were caused by industrial machinery. Two-thirds of the patients were employed, and the mean time off work was three weeks for out-patients and seven weeks for in-patients. Although Edinburgh may not be typical of other cities in the United Kingdom, the studies suggest that even so-called ‘trivial’ hand injuries make considerable demands on hospital services, with related costs to the individual, the employer and the nation.

This paper is a review of the hand injuries occurring in the Yorkshire Wool Industry and referred to the Regional Plastic Surgery Unit for skin replacement, or other treatment, during the years 1965–1984.

A total of forty-one cases has been seen, and although the number employed in the industry has fallen about fivefold, the injuries referred yearly have remained approximately constant. An analysis of the types of injury has been made and the improvement in the results is shown with changes in the method of acute treatment.

The case for early referral, active initial treatment and early mobilisation is very obvious from the results.

We present a prospective study of 1,074 consecutive hand problems which were presented to our Accident and Emergency Department over an eight week period. This number accounted for 1 in 5 of all accident attendances. Over 40% of these patients were males aged 12–29 years. Nearly half of the hand patients presented within two hours of injury. Over half the patients needed only reassurance or a simple dressing but 55 patients (5%) had to be admitted for surgery.

In a survey of 383 moderate and severe hand injuries in adults, 246 (64.4%) occurred outwith work. Falling (sixty-four patients) and punching (forty-eight patients) were the commonest mechanisms of blunt injury. Glass (eight), knives (seven) and “do-it-yourself” materials (eight) were most frequently implicated in sharp trauma. No outstandingly dangerous hobbies or social activities were identified.

The incidence of slipping accidents is unknown, but accident and emergency departments in the United Kingdom probably treat over one million injuries per annum caused by slipping of the feet. Many injuries to farm livestock are caused by slipping. Previous research led to speculation that some animal species may have developed slip-resistant feet and the polar bear was chosen for a study of adaption to a slippery environment. Feet were photographed and a footpad was sectioned and examined by light and electron microscopy. Hardness of the footpads of two tranquillized bears was measured. The footpads were found to have a rough papillary surface overlying a soft dermis containing a dense network of collagen and elastic fibres. These findings support a hypothesis that shoe solings for use on an icy substrate should be soft with a hardness value in the region of 24 on the Shore A scale. The surface should be covered in conical projections having a mean diameter of 1mm. Further work on the feet of animal species could lead to a better understanding of slip-resistance and reduce injuries to humans and livestock.

A system is described which allows an accident department doctor, who has no specific knowledge of computer operation, to record standardised demographic and clinical details of patients with hand injuries. An educational element is present which suggests possible diagnoses following specific injuries and most of the recording is carried out using a light pen, thus obviating the need for any keyboard skills. The information obtained is stored on ‘floppy’ discs (each disc can hold details of up to five hundred patients) allowing straightforward storage, retrieval and analysis of information by either micro or main frame computer.

We have developed a computerised system for the storage, retrieval and analysis of the workload of a hand clinic. In a study of 800 patients we have found it superior to a punched card system collecting similar information.

The computer system functioned reliably and achieved its user specification. It should prove a useful tool in helping a surgeon in matters of audit, research and disease or accident prevention but its long term performance in this regard requires evaluation.

A microcomputer based system has been designed for precise, objective quantification of hand strength. Pinch, grasp and shear strengths are measured using force transducers. The system, which is quick and easy to operate, not only measures these strengths accurately, but also collects, stores and displays this data numerically or in graphical form, at the touch of a button. The data can be manipulated to answer any type of statistical question related to any group of patients.

The assessment of hand strength in ninety-six people, representing normal hand function, by means of this system, is reported.

A simple device has been developed to measure skin resistance. Normal values have been established and the effect of changing measurement parameters has been investigated. Peripheral nerve blocks have also been applied and their effect upon the skin resistance reported.

A quick and simple method of measuring the electrical resistance of the skin is presented as an objective test of peripheral nerve injury. Patterns of altered skin resistance in patients with nerve injuries were found to coincide with operative findings. The method can be used in the preoperative assessment of hand injuries and to monitor the recovery of nerve function.

The continuation of an unacceptable failure rate with tendon repair or grafting procedures, largely due to adhesions, suggested that an artificial flexor tendon could be an attractive alternative. A literature search found no published data of the mechanical properties of fresh human finger flexor tendons, so a study of the strength and extensibility of 153 tendons was carried out. The bone insertion strength of twenty middle finger tendons was also examined. The results showed that an artificial tendon should have a strength of approximately 1500N, and that it should extend 13% at that load, an elongation of 26mm for a tendon 200mm long. The insertion strength was less than a half of the tendon strength. This data will allow an artificial flexor tendon to be designed with sufficient strength and the correct elastic properties to allow its function to integrate reliably with natural tendons in adjacent fingers.

A system has been devised to monitor the movements of the finger made by patients after a tendon repair. A small transducer was used attached to the nail. The results were analysed by computer. The fingers moved much less than expected in spite of instruction.

The common peroneal nerve was transected and repaired by epineurial suture in nine cats. In a further nine the nerve was transected twice and similarly repaired so as to produce a short autograft. Recovery of stretch receptors in peroneus brevis was monitored histologically and physiologically from six to fifty weeks. In recovery after single neurotomy functionally identifiable muscle-spindle and tendon-organ afferents were reduced to 25% and 45% of normal, respectively; after double neurotomy (autograft) both were reduced to about 10% of normal. Muscle spindles were reinnervated with annulospiral terminals, or wholly abnormal fine axon terminals, or both. Recovery evidently entails not only a reduction in number of stretch afferents, but also the making of some incorrect reconnections that presumably result in abnormal proprioceptive feedback and reflex action. When a graft is used the sensory impairment is compounded.

The case of a fifteen-year-old child where the delay between division and successful repair of the ulnar nerve was nine years is presented. This case and a review of the literature emphasise the importance of repairing nerves in children irrespective of the time interval between division and repair.

Revascularisation of a thumb pulp by restoring volar venous drainage is described, stressing the need to search for volar veins in distal replants or revascularisations. The literature describing digital volar venous drainage is reviewed and the author’s own findings during the course of dissecting twenty thumbs are presented.

A case of Dupuytren’s Disease is presented in which a combination of dermofasciectomy and proximal interphalangeal joint replacement using a Swanson’s prosthesis improved hand function and avoided further digit amputation.

Fifteen dermofasciectomies, the excision extending from the distal palmar crease to the distal interphalangeal crease and carried out to the midaxial line on either side are reviewed, stressing the good take of skin graft in well vascularised fingers. The technique is strongly recommended as the first line of treatment in recurrent digital Dupuytren’s contracture.

In one hundred patients with Dupuytren’s disease, one hundred and fifty-four operations were performed. The average pre-operative proximal interphalangeal joint contracture was 42° and the average percentage improvement in proximal interphalangeal joint extension at post­operative review was 41%. Fourteen amputations were performed (9.1%). The primary deformity is caused by disease involvement of the palmar fascial structures. Secondary changes may prevent correction of the deformity despite excision of the contracted fascia. The anatomy of the joint is reviewed together with the primary and secondary mechanisms of joint contracture in Dupuytren's disease. Arthrodesis, osteotomy of the proximal phalanx and joint replacement are considered as alternatives to amputation when a systematic surgical approach fails to correct the flexion contracture.

The results of carpal tunnel release are generally good, but not all patients obtain complete and long lasting relief. Persistence of signs and symptoms after adequate decompression of the median nerve is uncommon. Forty-seven suboptimal results in thirty-four patients have been evaluated to determine the reasons for failure. Thirty-eight of the suboptimal results (81%) were associated with the persistent neck pain and/or abnormal cervical radiographs (typically narrowing of C5–6 and/or C6–7 disc spaces). This retrospective review supports a “double crush” phenomenon that influences both the manifestations of carpal tunnel syndrome and the outcome of its treatment.

A series of 418 patients with lacerations of the hands were allocated randomly to a control group or to a group where the injury was treated with povidone iodine before suture. The incidence of infected and imperfectly healed wounds was determined seven days later. As well as the effect of povidone iodine on infection, thirteen other factors were also analysed. The overall infection rate of 5.0% and the 38.5% imperfect healing rate were not significantly affected by povidone iodine treatment, although both were reduced. The figures of four other trials were combined with this trial and this showed a significant effect of povidone iodine treatment. There were no adverse reactions to povidone iodine. It is therefore recommended that hand lacerations should be treated with povidone iodine prior to suture.

Other factors found to be significantly important in wound infection or imperfect healing were the condition of the dressing, the part of the hand injured and pain. Patients should be strongly advised to keep their dressing clean and dry.

The management of patients with clinical evidence of a fracture of the carpal scaphoid bone but without radiological evidence of a fracture is based on dogma emphasizing the need to immobilize the wrist in all cases. Because of the apparently high proportion of patients who spend up to six weeks in a plaster cast and in whom no fracture is ever demonstrated radiologically, a study was undertaken to determine the fate of those wrist injuries diagnosed as clinical fractures of the scaphoid.

All patients who presented with clinical or radiological evidence of fractures of the scaphoid over a one year period were reviewed. Of the 108 patients in whom the diagnosis of clinical fracture of the scaphoid was made at the time of presentation none was proved radiologically to have a fracture of the scaphoid subsequently after a period of mobilization. These patients spent an average time of 21.9 days in a plaster cast which represents a significant loss of productivity to the community and inconvenience to the patient.

A soccer injury resulted in dislocation of the index metacarpal and trapezoid bones.

We report a case of fracture of the ulnar sesamoid of the metacarpophalangeal joint of the thumb. The role of arthrography and stress X-rays in delineating the pathological anatomy of this injury is discussed.

A case translunate, transmetacarpal, scapho-radial fracture with perilunate dislocation occurred as a young man drove his motorcycle into the side of a car. Closed reduction was performed initially. Open reduction was performed with a screw in the lunate. Eighteen months later the screw was removed and after two and a half years x-rays revealed no signs of avascular necrosis or arthrosis. The patient fully recovered. This case stresses the necessity of open reduction in cases of complicated carpal fracture dislocations.

The functional role of the scaphoid in stabilising the wrist joint is discussed and the literature on scaphoid dislocations reviewed.

A case of isolated dislocation of the scaphoid has been presented with the salient diagnostic features and preferred line of management which includes percutaneous Kirschner-wire fixation to ensure maintenance of the reduction.

Overlapping of fingers on flexion of the hand caused by malunion of a phalanx was corrected in two patients by a rotational osteotomy of the base of the corresponding metacarpal, avoiding a more delicate operation on the phalanx, with good results.

Reduction deficits of metacarpals requiring treatment are an uncommon problem. A patient with bilateral short ring fingers is reported and a technique of Z lengthening is described.

A case of simultaneous fracture of the carpal scaphoid and trapezium is reported and the mechanism of injury is considered.

Linscheid and Dobyns (1972), in a classical article on post-traumatic instability of the wrist described two major types of instability, dorsal and volar. The dorsal intercalated segment instability (D.I.S.I.) was the more common and occurred with scapholunate dissociation and displaced scaphoid fractures. The instability occurred in these conditions as a result of the scaphoid losing its ability to support the carpus. They presented five cases of volar intercalated segment instability (V.I.S.I.) of which four were related to congenital ligament laxity and not to traumatic ligament disruption. In the one case of traumatic origin they felt that the capitolunate ligament was ruptured. However, more recent publications by Taleisnik, Prietto (1982) and Reagan, (1984) have proposed that for V.I.S.I. to occur the lunate triquetral interosseous ligament must be disrupted.

We report this case as it demonstrates which ligamentous structures are torn for V.I.S.I. to occur. In addition, these ligament disruptions were pathological and occurred spontaneously as a result of longterm systemic steroid medication.

A patient with hysterical, “artificial” or factitious oedema of the hand caused by the application of a tourniquet is reported. A high index of suspicion is needed in diagnosing this condition in which surgery should be avoided. Psychotherapy is the ultimate treatment but a pneumatic compression bag was found to be of use and helped confirm the diagnosis.

One hundred and ninety six cases of Volkmann’s ischaemic contracture in the upper limb were studied for their pattern of contracture and recovery (Sundararaj and Mani 1985). Mild, moderate and severe forms of contracture have been described (Tsuge 1975; Sundararaj and Mani 1985). The management of 102 of these cases has been studied and discussed here.

A case of monostotic fibrous dysplasia of a long bone of the hand is reported. There has been only one similar case recorded, though it is not uncommon in other long bones. The diagnosis was proved by histology, and the tumour treated by subperiosteal excision. There has been no recurrence after 31 months, though in similar cases excision including the periosteum has been advised to reduce the likelihood of recurrence.

A thirty-seven-year-old male with Osteoid Osteoma of the proximal ulna is described. He had suffered from pain in his elbow for two and a half years prior to diagnosis. Computer Tomography demonstrated and localised the nidus which was surgically removed.

A case of tenosynovial chondroma of the left middle finger is presented. The treatment of this benign lesion is local excision.

Osteoid osteoma of the pisiform seems not to have been previously reported. In both the cases reported in this paper there was diagnostic difficulty and delay. Complete surgical removal of the nidus was curative.

A case of chondrosarcoma of the thumb treated by excision and reconstruction with a free bone graft is reported. The patient regained excellent function. The indication for this method of conservative resection is discussed.

Juvenile digital fibromatosis is a rare condition in which distinctive benign soft tumours occur in the hands and feet of children and adolescents.

If bony involvement is found at presentation a malignant soft tissue tumour must be excluded and extensive investigation is required using plain x-rays, scintigraphy and angiography. Histological examination, however, is the only definitive diagnostic measure.

In this paper a case of juvenile digital fibromatosis is presented with a discussion of the differential diagnosis.

A case is presented in which a .177 air rifle pellet became lodged in a metacarpophalangeal joint of a thirteen year old boy causing lead synovitis and a raised serum lead level. The local and general effects of lead in a joint merit immediate exploration and removal of the material.

Avulsion injuries of the thumb resulting in volar defects and loss of neurovascular bundles are presented.

Treatment should aim at restoration of the skin and pulp with as near normal sensation as possible.

A new technique is described using a cross-finger flap or flaps with transfer of the superficial terminal branch of the radial nerve. It is claimed that this gives near normal restoration of sensation to the tactile surface of the thumb.

The fingers may be treated in the same way for similar injuries.