Journal of Hand Surgery (European Volume)

Two cases of irreducible dorsal dislocation of the metacarpopbalangeal joint of the thumb are reported. In both cases, there was interposition of the tendon of flexor pollicis longus. Open reduction was required to achieve successful reduction.

A prospective study of the possibilty of confirming clinically suspected scaphoid fractures was carried out over one year.

Analysis of the results suggest that ultrasound scanning of suspect scaphoid fractures is a reliable method of assessing this condition. It has one weakness in that the diagnosis is based on subjective sensation and this may at times be faulty. Our results, however, suggest that once practice in the technique has been achieved, then mistakes are rarely made.

Primary osteoarthritis of the trapezial joints has been treated by an interposition tendoplasty according to Weilby in eighty-nine cases. After excision of the trapezium, a strip from the flexor carpi radialis was wound around the main portion of the flexor carpi radialis tendon and the abductor pollicis longus. The abductor tendon was then duplicated over the tendoplasty and reinserted to the first metacarpal base. In 40% of cases, osteoarthritis was present in more than one trapezial joint. 57% had an adduction contracture of the first metacarpal, half of which were relieved postoperatively. 73% of patients were satisfied at follow-up. Complications included four cases with loss of active metacarpal abduction which was regained after reinsertion of the abductor pollicis longus. It is concluded that the Weilby tendoplasty is a useful alternative to Silastic implants, especially in cases of adduction contracture. The risks of implant dislocation and silicone synovitis are eliminated.

Twenty-two patients with 26 fractured metacarpals were treated by internal fixation using A. O. mini-fragment screws and plates. This form of internal fixation was reserved for metacarpal fractures which were multiple, unstable, displaced or rotated. Nine patients bad open fractures, two had divided extensor tendons and four had multiple fractures.

Fractures consistently united without infection or deformity. The mean duration of postoperative immobilization was seven days and mean time off work was six weeks. All but one patient did manual work. No patients had persistent symptoms which caused difficulty with work or sport. Fourteen patients regained full movement. Four had total active movement of 220 degrees or more in the involved ray and 6 patients had total active movement of between 180 and 220 degrees. Restricted movement was present in patients with open fractures and divided extensor tendons or intra-articular fractures of the metacarpal head.

Uniformly satisfactory results were found after mini-screw and plate fixation of metacarpal fractures.

Fracture-dislocation of the trapezio-scaphoid joint is an extremely rare injury. We report a case treated using Herbert’s compression screw technique.

The results of our first fourteen patients with fractured scaphoids treated with the Herbert bone screw have been disappointing. Six have failed to unite. The operation is technically demanding and there is a high incidence of malpositioning of the screw which correlates with failure to achieve union. This is predictable from initial radiographs and peroperative radiology is advised. The osteosynthesis should be protected until union has occurred radiologically, especially in manual workers.

The commonest carpal fractures are those of the carpal scaphoid. Triquetral fractures are relatively uncommon, but when present, often go undiagnosed or are misdiagnosed as lunate fractures. Clinical suspicion and careful evaluation of the appropriate radiographs, especially an oblique view, should ensure the diagnosis.

There is no documentation of the incidence of osteoporosis in patients with Colles’ fractures. We have prospectively studied 127 patients over the age of fifty with unilateral Colles’ fractures to determine the incidence of osteoporosis and to investigate its influence on the bony deformity. The cortical width of the second metacarpal was used as the indicator of osteoporosis. 74.8% of patients in this group were osteoporotic. The final deformity was significantly greater in patients with osteoporosis.

A case is reported of the avulsion of the insertion of Extensor Carpi Radialis Longus, an injury that has been reported only once before. The anatomy of the region and mechanism of injury are discussed, as is the importance of open reduction with internal fixation.

Computed tomography of the carpal tunnel was performed in the hands of both patients and controls in a neutral position, in flexion and in extension.

The median nerve was not compressed between the long flexors and the flexor retinaculum in either flexion or extension of the wrist. In flexion, the nerve usually moved dorsally, away from the flexor retinaculum. No difference could be found between the cross-sectional area of the carpal tunnel between patients and controls.

Two cases of dorsal trans-scaphoid perilunar dislocation are reported, in which the fracture was found, at operation, to contain interposed ligament.

It is recommended that such fractures be explored unless perfectly reduced, and that percutaneous pinning of the reduced fracture may be inadequate treatment.

Many causes for metacarpophalangeal joint locking have been documented. However nearly all are from volar entrapment of periarticular structures. The following case, unlike those previously reported in the literature, was one with locking caused by dorsal entrapment. The differences in presentation and its importance to subsequent treatment are highlighted.

The phenomenon of ‘endoneurial bulging’ from the cut end of the divided nerve fasciculus in the rat sciatic nerve has been examined with light and scanning electron microscopy and the morphological changes compared when dividing the fasciculus with either micro-scissors or a sharp razor blade.

It has been recognised for a long time that damage to the median or ulnar nerves is usually followed by slowing of growth of the fingernails. In the past, this has always been ascribed to immobilization of the appropriate digits, rather than to a neurotrophic factor. No other nail changes appear to have been described in association with nerve damage. We present two patients with marked nail changes following median nerve injury, in which immobilization does not appear to be responsible.

Stereognosis and sensory localisation were studied in hands of patients with partial anaesthesia due to peripheral nerve injury both before and after tendon transfer to impart movement to the anaesthetic part. One patient showed a marked improvement in stereognosis and localisation, but in general little was gained in terms of improved sensation. Function was improved more in the dominant than in the non-dominant hand. Earlier tendon transfer in cases of peripheral nerve injury might decrease cortical exclusion.

0.5% Bupivacaine was administered around the sciatic nerve of rabbits by means of a catheter, over a period of ten days. Twenty nerves showed no histological changes, but in three there were areas of demyelination and axonal degeneration, especially near the surface of the nerve. However, similar changes occurred in two out of six nerves to which normal saline was administered instead, and it is suggested that the damage may have been caused by mechanical trauma from movement of the catheter.

A case of posterior interosseous nerve syndrome presented with difficulty in extending the metacarpophalangeal joint of the little finger. Compression was caused by a bicipital bursa. Surgical decompression led to a complete recovery.

We report two cases of synovial chondromatosis presenting with peripheral nerve compression syndromes involving respectively the median nerve at the wrist and the posterior interosseous nerve at the elbow. Only one previous instance of nerve compression due to this condition has been described, involving the ulnar nerve at the elbow.

In one of our cases the disease process was at an early stage in its natural history and in the other at an advanced stage. The occurrence of nerve compression was related to the site rather than the stage of the disease.

Full recovery followed local excision with decompression of the peripheral nerve involved.

Thirty-six patients were treated for 38 phalangeal fractures using 1.5 mm and 2 mm A. O. screws. Plates were not used in the fingers. Oblique fractures of the condyles, shafts or bases of the proximal or middle phalanges were treated by internal fixation because of instability, displacement or rotation. 40% of fractures had associated skin wounds, were comminuted or had damage to the extensor mechanism. The mean duration of post-operative immobilization was 9 days and the mean time off work was 6 weeks. Total active movement in the involved ray was 220 degrees or greater in 24 cases, 180 degrees to 215 degrees in eight cases, and less than 180 degrees in two patients at follow up. The patients were reviewed between three and 54 months after treatment and the mean duration of follow up was 24 months. The most frequent complication was 10 degrees to 30 degrees of flexion deformity of the proximal interphalangeal joint after internal fixation of condylar fractures. Results were satisfactory in 90% of cases.

A case of volar of intercalary carpal instability following a radial fracture is described and the mechanics of injury examined.

Such an injury is rare and the type of radial fracture which produced it unusual. Continued instability of the carpus produces late degenerative changes. In contrast to the many reports of early and persistent pain and functional limitation this patient’s wrist settled rapidly.

Eight cases in which soft tissue expanders have been used as an adjunct to reconstruction in the hand are reported. Cases involved reconstruction after skin grafting for burns and crush injuries as well as skin resurfacing in the management of the painful hand. Patient tolerance was excellent and the final result was significantly aided by the use of this technique. The technical details of expansion as well as complications are discussed.

Cold intolerance is a common problem after injuries to the band. To elucidate the mechanism of this cold sensitivity, eight patients with successful replantations of amputations of the thumb or index finger were studied one and half years later.

In six patients the Doppler signal from the anastomosed arteries was normal and in two patients signs of mild stenosis were found. All patients had normal or slightly reduced basal finger systolic pressure in the replanted finger. Six had signs of marked vasospasm.

Alpha-receptor blockade had no effect on the cold-induced decrease in finger systolic pressure in the replanted finger.

It is concluded that cold intolerance after hand injuries results from a defect in vasoregulation and is not caused by organic insufficiency of the circulation.

Six consecutive patients whose clinical Allen test suggested a non-patent radial artery have been investigated by intra-arterial fluorescein angiography.

Cannulation of the radial artery and injection of fluorescein typically perfused only the thumb and thenar eminence. Occlusion of the ulnar artery, leaving the radial artery as the dominant supply, resulted in fluorescein perfusion of the entire hand. It is concluded that the Allen test is of no clinical value.

A radial forearm flap including a segment of the cortex of the radius, based on the distal pedicle of the radial vessels and the cephalic vein, was used to reconstruct an intercalated defect of the thumb in two cases. In one case it was used as an ipsilateral pedicle flap while in the other case it was used as a free microvascular flap. In both cases, the skin flap as well as the segment of bone survived in toto without any evidence of creeping substitution. The functional result was good in both cases. This flap provides thin skin of good texture together with bone for a one-stage reconstruction.

The Chinese forearm flap is a versatile flap in hand reconstruction. Five cases are reported. The mechanism and reliability of retrograde venous return is discussed.

Electromyographic investigation of subjects wearing dynamic flexor tendon repair (Kleinert) splints shows a wide variability in the amount of contraction in the flexor digitorum profundus muscle during extension of the finger. We suggest there is no advantage in giving extra resistance to the extensor muscles, and that the strength of the rubber bands needs to be only just sufficient to flex the finger passively back to its resting position.

Several modifications of the Kleinert splint are described including a modified pulley bar, taping of the pulps to prevent skin ulceration and the use of constant-tension springs to simulate more closely the normal flexor muscle function.

Two cases are described with full flexion of the proximal interphalangeal joint produced by an intact short vinculum after complete laceration of both superficialis and profundus tendons. To establish the clinical diagnosis of complete flexor digitorum superficialis division, the necessity of examining the flexion strength of an injured finger is emphasized.

A reliable method of atraumatic retrieval of the retracted proximal end of a flexor tendon of finger or thumb is described. The technique is to pass a catheter through the sheath from proximal to distal alongside the tendons, without removing them from the sheath. The catheter and tendon are stitched side-to-side. The tendon can be advanced by traction on the catheter.

Flexor tendon ruptures are a very rare complication of Colles’ fracture. Only ten cases have been previously reported in the literature. We describe a case of multiple sequential flexor tendon rupture as a delayed consequence of a malunited Colles’ fracture.

Attrition ruptures of flexor tendons to the fingers following Colles’ fractures are very rare. In the case reported here, a protruding bony fragment caused a delayed rupture of the flexor digitorum profundus tendon to the index finger one year after a fracture of the distal end of the radius. Suture of the distal end of the tendon to the adjacent profundus tendon two years after the fracture produced a successful result.

Malignant melanoma in childhood is rare. An unusual case of amelanotic melanoma of the volar thumb in a fourteen-year-old boy which posed problems of recognition and management is presented.

Two cases of eccrine tumour of sweat gland origin found in the hand are presented. They were on-tender rounded masses of eight months to two years duration, beneath and adherent to the pidermis but movable on underlying tissue. The pre-operative diagnosis in each case was that of sebaceous cyst. Histology revealed one to be an eccrine spiradenoma and the other a chondroid syringoma. The lesions were considered unusual in that such tumours usually occur on the trunk, head and back and are rarely found in the hand.

A prospective trial was undertaken on 85 adult patients with open fractures of the distal phalanges of less than 6 hours duration, treated by conventional surgery. They either received no antibiotic therapy, or cephradine in short or long courses. The infection rate was 30% in the group without antibiotics and less than 3% in the treated groups. Three different antibiotics regimes were compared, with no difference in the infection rate: therefore the simplest and surest method, a single pre-operative dose and a single post-operative dose, is recommended.

A randomised prospective trial was carried out to compare the use of semipermeable and petroleum gauze dressings in fingertip injuries. The results demonstrate advantages in the use of semipermeable dressings.

This is a report of an unusual surgical curiosity involving the median nerve at the wrist. A sewing needle, which penetrated the region of the wrist joint anteriorly, unknown to the patient, also penetrated the median nerve without causing any initial discomfort or neurological deficit. There was no damage to the nerve hut locating the “disappearing” needle at operation was difficult.

Diaphyseal aclasis (multiple hereditary exostoses) occurs in the bones developed in cartilage and gives rise to cartilage-capped exostoses. It usually affects the ends of the diaphyses of long bones of extremities (McKusick, 1972). Although the phalanges of the fingers may be shorter than normal, no record could be found of significant deformity. A case of digital deformity is described below.

A case of dislocation of the extensor tendons of the hand caused by focal myoclonic epilepsy is presented. This particular aetiology, which has not previously been reported, is discussed. The tendons were repositioned and there was no sign of recurrence one year later.

A case of previously undiagnosed maturity onset diabetes in a fifty-eight-year-old man with a “septic index finger” is reported. Intial X-rays showed gross destruction of the distal phalanx, suggestive of acute osteomyelitis. Control of the diabetes combined with minimal debridement of the finger resulted in healing of the lesion. X-rays taken four weeks later showed complete reconstitution of the distal phalanx, confirming the need to be conservative in the management of lesions associated with diabetes. In spite of a careful and extensive search into the literature covering unusual presentations of diabetes mellitus, the author is unable to trace a similar recorded case involving the digit of upper limb.

A forty-seven-year-old man was bitten by a dog on his left index finger. Despite initial antibiotic treatment, he developed acute osteomyelitis of the middle phalanx over the next three weeks. Pasteurella multocida and Bacteroides were isolated from the necrotic bone. Subsequently the infection was successfully treated by debridement and Tetracycline.