Journal of Hand Surgery (European Volume)

The individual difference in ulnar variance measurements between diseased and unaffected wrists in 38 patients with unilateral Kienböck’s disease was determined and related to the degree of arthrosis in the affected wrists.

In patients without arthrosis there was no difference in measurements. With increasing arthrosis there was a progressive increase of patients with individual difference in ulnar variance measurements: up to 50% in those with severe arthrosis. Where a difference in ulnar variance was encountered, the wrist with Kienböck’s disease represented the more negative value in 90%. It is concluded that over-representation of the so-called “ulnar minus variant” in Kienböck’s disease is based on osteo-arthritic changes in the wrist, resulting in a pseudo-lengthening of the distal radius, and that this is therefore a consequence of the disease. The “ulnar minus variant” seems to have no bearing on the cause of Kienbüock’s disease.

We report the results of an experimental study to investigate the mechanical properties and histological structure of the tendon-bone junction following surgical implantation of tendon into bone in the rabbit.

The results following tendon transfer and tendon grafting were compared.

The normal four-zone tendon junction was not reproduced histologically, in either group, After 20 weeks, the mechanical strength of the tendon transfers had reached 60% of the controls and that of the tendon grafts 20% of the controls.

Microangiography demonstrated that these differences were not related to the vascularisation of the tendon bone juction. The mechanical properties of the tendon-bone junction may be dependent more on the functional state of the implanted tendon than on its structure.

A study was made of collagen fibril populations in healing tendon using a window lesion in rat extensor tendon. Two environments were thus created. One (the lesion area) where stress levels were reduced; the other (the non-lesion area) where stress levels were increased. In both areas a population of small diameter (<50nm) collagen fibrils were synthesized. Lesion area fibrils increased their diameter only slowly. Non-lesion area fibrils added to a population which increased its diameter distribution comparatively rapidly. It is suggested that in the lesion area fibrils were synthesized in response to tissue damage and low levels of stress. These may be of type III collagen. In the non-lesion area fibrils were synthesized in response to raised levels of stress. These may be of type I collagen. Implications of these events, especially as they might relate to gap formation in flexor tendon surgery are discussed.

67 patients with 176 repaired flexor tendons have been reviewed after a mean interval of 26.4 months. 160 tendons to 100 fingers, and 16 flexor pollicis longus tendons were repaired. When evaluated by Buck-Gramcko criteria, the functional results in 92% of the fingers and 69% of the thumbs were graded as excellent or good.

Patients with partially divided tendons fared no better than those whose tendons were completely divided. The results of repair in the little finger were less satisfactory than in other fingers.

A questionnaire on the use of splintage before and after operations for Dupuytren’s contracture has been completed by 45 hand surgeons and ten hand therapists. None considered that preoperative splintage was beneficial, but nearly all used some form of splintage after operation. The types of splint and programmes for using them varied widely, and these are discussed.

The trend towards conservativism in the management of Dupuytren’s contracture has resulted in less radical surgery than was previously advocated to release disabling contractures of the fingers.

38 cases of Dupuytren’s contracture in the palm have been treated by Z-plasty of skin and underlying contracted band without fasciectomy. Proximal interphalangeal joint contractures were treated by fasciectomy and skin closure with Z-plasties as required. Only one of 16 patients reviewed after two years had evidence of recurrence.

Skin compliance has been measured and a return to near-normal levels was found in all but the one patient with a recurrence.

The traditional approach to clinodactyly has been either to accept the deformity or to perform an osteotomy. As an alternative to osteotomy, a resection of the mid-zone of the continuous epiphysis along with the underlying physis and its replacement by a fat graft (physiolysis) is simpler and allows further growth in the phalanx. Twelve of these operations have been reviewed with a maximum follow-up of six years. Excellent functional and cosmetic results have been obtained. The renewed growth is manifest not only by an increase in length, but also by a decrease in the angular deformity and improvement of the articular surfaces. Osteotomy at maturity has only been necessary in one patient.

To distinguish the clinical features of amputation due to congenital constriction band syndrome from those of transverse deficiency, 42 cases of constriction band syndrome and 27 cases of transverse deficiency were analysed. All the transverse deficiencies were unilateral. Two cases of transverse deficiency were associated with pectoral muscle absence, whereas amputation from constriction band syndrome was often associated with similar anomalies in other parts of the body. The level of amputation of transverse deficiency was more proximal than that of constriction band syndrome. Rudimentary fingers and/or nails were common in transverse deficiency but there were few in constriction band syndrome. Various degrees of bone hypoplasia existed in adjacent fingers or in a proximal part of the affected limb in transverse deficiency, but there were no such findings in constriction band syndrome.

Three-dimensional computerized imaging is a new modality of radiological imaging. This new technique transforms the two-dimensional slices of bi-plane CT into a three-dimensional picture by a computer’s monitor adjusted to the system. This system enables the physician to rotate the angle of viewing of the desired region to any desired angle. Moreover, this system can delete certain features of different densities from the picture, such as silicone implants, thus improving visualization. Our preliminary results using this technique are presented. The advantages, pitfalls, and suggested future applications of this new technique in hand surgery are discussed.

102 patients with closed traction lesion of the brachial plexus resulting from motor cycle accidents have been studied. The majority were young men, with the dominant arm involved in 64%. 74% of the patients underwent early operative exploration and 54% of these were amenable to at least partial repair. 65% of the patients had sustained irreparable pre-ganglionic injury to at least three roots of the plexus. 74% of the patients had sustained additional injuries in the accident. Subsequent reconstructive procedures were performed in 26% of patients. 60% of the patients regained employment, but 76% complained of persistent pain in the limb.

A case of median nerve paralysis due to intra-articular entrapment occurring after closed reduction of a dislocation of the elbow joint is reported. In the present case, as in most other reported cases, diagnosis and treatment was delayed. If median nerve paralysis occurs following elbow dislocation and is accompanied by an unusual amount of pain, or if it occurs following reduction, entrapment should be suspected and the nerve explored without delay.

31 cadaver arms have been dissected to study the variations in the anatomy of the muscles and fibrous arches which might cause compression of the median nerve in the forearm. Pronator teres always had a superficial head and usually a deep head. Flexor digitorum superficialis varied greatly in its site of origin.

The median nerve might be crossed by two, one or no fibro-aponeurotic arches. Gantzer’s muscle, an accessory head of flexor pollicis longus, was present in 45% of cadavers. No ligament of Struthers was found. Possible sites and causes of nerve compression are discussed.

A positive Tinel’s sign was found in 63% of patients with electrophysiologically proved carpal tunnel syndrome. However, Tinel’s sign was also positive in 45% of control patients. It is therefore concluded that the sign is of no diagnostic value in individual patients with suspected carpal tunnel syndrome.

A prospective study was performed on 62 hands in 45 consecutive patients on chrome dialysis carpal tunnel syndrome developed within an average of 116 months after formation of the arterio-venous fistula. We measured the intra-carpal canal pressure by the wick catheter technique and performed neurography. At operation, a markedly thickened transverse carpal ligament was usually found. A pneumatic tourniquet was applied in all except three cases, whose functioning fistulae were made of implants, but no complications such as obturation of the fistulae occurred. Thirty-three (76.7%) of 43 cases had good results. Full recovery of sensibility was obtained in all hands in which symptoms had been present for less than two years. There was no benefit from operation in two patients (4.7%), both of whom had symptoms for more than two years.

In a randomised double-blind trial comparing 1% lignocaine with 0.5% bupivacaine in digital ring block, the mean time of onset of complete anaesthesia was 5.8 minutes (range 5 to 10 minutes) for lignocaine and 11.2 minutes (range 8 to 20 minutes) for bupivacaine. The duration of action was 59.6 minutes (S.D. ± 28.7 minutes) for lignocaine and 476 minutes (S.D. ± 277 minutes) for bupivacaine. We describe how these differences can be exploited in clinical practice.

A new prosthesis for the metcarpo-phalangeal joint is presented. Its advantageous design features and the early results following its use suggest that it is of value in treating the painful, stiff and ulnar deviated metacarpo-phalangeal joint in the rheumatoid hand.

Four cases of osteoid osteoma of the distal phalanx are described. The difficulty of diagnosis is stressed. Complete removal of the nidus is essential for surgical cure. Other modes of treatment are discussed and our series compared to other similar cases described in the literature.

Osteoid osteomata are rarely found in the distal phalanges of the hand. The 23 cases in the English language literature are discussed and two additional cases are described. The usual presenting features are chronic pain, nail enlargement and increase in size of the terminal part of the digit. Diagnosis is difficult but surgical excision is effective for treating the patients’ pain.

A sixteen-year-old male presented with pain and swelling of the distal phalanx of his right middle finger. X-ray examination demonstrated an osteolytic lesion which at operation was found to be an osteoid osteoma.

We report a woman patient with Ehlers-Danlos Syndrome who presented with trapeziometacarpal subluxation and whose hands exhibited several other skeletal features of Ehlers-Danlos Syndrome, including acro-osteolysis.

In developmental terms, the human hand is at the same time both specialised and primitive. Its manipulative ability, though somewhat better than that of the apes and monkeys, has lost strength compared with hands of recently extinct species of Man, and shows some evolutionary characteristics seen in reptiles of 250 million years ago. Its evolution, as presently understood, is described.