Journal of Hand Surgery (European Volume)

In all types of peripheral nerve injury, it is important to realize that the lesion affects one extended cell, the neurone, which extends from the central nervous system down to the target tissue in the extremity. Compression of a peripheral nerve can disturb the intraneural transport (axonal transport) of a large variety of substances. This may be followed by morphological and biochemical changes in the nerve cell body. These central changes may effect the axon as a whole and confer on the nerve an increased susceptibility to trauma. Studies concerning the reaction of neurones to compression, relevant when discussing the double crush syndrome, are reviewed.

In a retrospective study of 229 patients with healed fractures of the waist of the scaphoid, the incidence and development of post-traumatic radiocarpal arthrosis was studied. With a minimum follow-up period of seven years, 5.2% of patients showed radiological evidence of radiocarpal arthrosis. It is concluded that an alteration of the carpal dynamics, due to deformation and shortening of the scaphoid, is the most likely cause of post-traumatic arthrosis after primary healing of scaphoid fractures.

Erik Moberg is the father of functional sensory testing. During the past three decades, his research into quantitative testing of hand sensibility has provided the insight to bring us from classic academic tests (permitting localisation of lesions within the central nervous system) to clinical capability of restoring sensation to the hand. He introduced the Ninhydrin test to document objectively innervation. He defined hand function as precision-sensory and gross-sensory grips. He correlated Weber two-point discrimination with hand function. He introduced the pick-up test to document hand function. He coined the term “tactile gnosis”. He hypothesised that proprioception is principally due to skin, not joint, afferents. He classified the tetraplegic hand according to its combined sensory and motor capacity. He set the standard for sensory recovery after primary nerve repair, relating recovered two-point discrimination to age (Önne’s line) and he inspired the present generation of researchers to quantify their own studies of sensation.

Erik Moberg pioneered the idea of validating measures of sensory function following peripheral nerve suture by correlating their results with those of functional tests. However it is important that powerful prior variables (age at suture, time elapsed since suture and delay between injury and suture) be controlled. Failure to do this may result in spurious correlations, as illustrated by analysis of two sets of data, one collected by the author and the other given in the classic paper of Önne (1962).

Eleven patients with lunatomalacia were treated by excision of the lunate and instillation of liquid silicone. The silicone vulcanised and formed an in-situ molded prosthesis. The patients were re-examined after a mean of 7.1 years. Four patients were pain-free and two had pain only at work; three had not been improved by the operation and two had undergone arthrodesis. The patients with good results all belonged to group IV pre-operatively. Surprisingly, no patient showed any sign of silicone synovitis, although all the prostheses except one had either fractured or deformed. The reasons for this are discussed and the indications for the operation established.

The operative results of radial shortening in 23 patients with Kienböck’s disease were analysed on the basis of age, stage of disease, ulnar variance and the amount of radial shortening. The patient’s age was found to be the factor which affected the operative result most and unsatisfactory results were obtained in patients over 30 years old. However, neither the clinical stage nor ulnar variance affected the results significantly and the results in patients with ulnar zero or plus were no worse than in patients with ulnar minus. The risk of ulnar wrist pain was increased when the radius was shortened more than 4 mm in patients with positive or zero ulnar variance. This was an important cause of unsatisfactory operative results.

Two patients with Kienböck’s disease who had been treated by radial shortening developed ulnar wrist pain post-operatively due to excessive radial shortening. In both cases, ulnar shortening was required to improve symptoms and function. Excessive radial shortening can cause ulnar wrist pain and compromise the improvement of grip strength and range of motion of the wrist.

During the period 1973–1986, 116 patients with rupture of the extensor pollicis longus tendon were operated upon. The lesions were categorised into three anatomical levels: proximal, intermediate and distal. Direct suture was performed for acute lesions; later reconstructive procedures were by means of tendon transfers or free tendon grafts.

The authors have treated 14 cases of spontaneous rupture of extensor pollicis longus tendon after fractures of the distal end of the radius, most of which were undisplaced or only slightly displaced. A microvascular study on five cadavers revealed that this tendon is subject to mechanical bending and attrition, has no mesotenon and has a poorly vascularised portion about 5 mm in length, which may be a cause of spontaneous rupture of the tendon.

The relationship between the quality of redaction and the occurrence of arthritic changes, symptoms and disability was studied in 41 Bennett’s fractures. Excellent position was obtained in five of nine fractures treated by closed reduction and plaster immobilisation, in four of six fractures treated by percutaneous K wire fixation and in 18 of 26 fractures treated by open reduction. After a median interval of 7.3 years, 15 of 18 reviewed patients with fractures healed in excellent position were free of symptoms, but this was so in only six of 13 fractures with residual displacement. The remainder had intermittent slight pain. Radiographic signs of arthritis was found in ten of 24 patients: three of 14 patients with excellent reduction and seven of ten patients with residual displacement.

The authors report nine cases of hetero-digital neurovascular island flaps raised by the “disconnecting-reconnecting” technique for defects of the tactile pad of the thumb. At an average follow-up of 25 months, all cases had good restoration of sensibility without any “double sensibility” phenomenon and patients regained good dexterity. No tender neuromata developed and donor site complications were not troublesome.

A prospective trial of dislocations of the interphalangeal joints of fingers treated by elastic double-finger bandage showed good final results with an almost normal range of motion. The method is found pleasant by the patient, being hygienic and causing no kind of skin reaction.

There exists on the articular surface of the central slip of the extensor tendon slip overlying the P.I.P. joint a constant structure which is morphologically similar to the patella of the knee joint and histologically similar to the fibro-cartilaginous palmar plate of the P.I.P. joint. It has been termed the dorsal plate. A study of 70 fingers, including 30 examined under magnification and 20 examined histologically, confirmed its constant presence and structure. Its functions appear to include stabilisation of the central extensor tendon and participation in stabilisation of the proximal interphalangeal joint.

In adult rabbits, an experimentally transected digital extensor tendon was repaired. The technique employed a tongue, created from the proximal tendon, folded over to bridge the transection and reattached distally. Animals were allowed immediate post-operative mobilisation. Tendon material, 14–120 days post-operatively, was examined ultrastructurally in control and experimental animals from four different zones within the repaired tendon. The operation was well tolerated and adhesion free. Associated with the repair, two types of collagen fibril populations were observed. Firstly, in areas where tendon tissue had been removed, there was a population of fibrils with a narrow range of diameters. Secondly, in areas where tendon tissue was subjected to an increased level of stress per unit cross-sectional area, a population of fibrils with a range of diameters similar to that of controls but with a marked increase in the percentage of small diameter fibrils. The relevance of these observations to human tendon repair is discussed.

Fifty-six patients with psoriatic arthropathy have been reviewed to assess the extent and severity of their hand involvement. The hand was affected in 84% of cases. Although the distal interphalangeal joints are said to be classically affected, we found the proximal interphalangeal and metacarpophalangeal to be more frequently involved. Many other findings often associated with rheumatoid arthritis (e.g. boutonniére and swan-neck deformities, or tenosynovitis) can be seen in psoriatic arthropathy.

A Chinese flap, based on the radial artery, has been used in 29 patients who presented with problems of reconstruction in the hand. The merits and complications of this procedure are discussed.

Sensory conduction of the median nerve at the carpal tunnel for eight consecutive 1 cm segments of the nerve was evaluated in 217 hands of 153 of our patients with carpal tunnel syndrome. Impairment was found to be highly focal and often confined to a single 1 cm segment of the nerve. The section of the nerve at or just distal to the distal margin of the carpal tunnel was affected most frequently, the section within the tunnel was affected less often, and the section proximal to the tunnel at the level of the mid-carpal and radio-carpal joints was affected least. The greatest contrast between frequencies of slowing at adjacent segments occurred at the proximal and distal margins of the carpal tunnel. The distribution of the nerve impairment was similar between the sexes; however, among the men the segment affected most frequently was located 1 cm distal to the segment affected most frequently among the women. The general pattern of slowing which we found does not substantiate some commonly-held opinions about the aetiology of carpal tunnel syndrome.

A retrospective study of 40 women with carpal tunnel syndrome developing in pregnancy and 18 women with carpal tunnel syndrome in the puerperium was undertaken. All the cases that developed in pregnancy occurred in the third trimester and resolved within two weeks of delivery. Those cases developing in the puerperium affected women who had breast-fed their infants and their symptoms lasted a mean of 5.8 months. These patients were older and more likely to be primiparous than if the condition occurred in pregnancy. All the pregnant women and none of the lactating women had symptoms of peripheral oedema. Spontaneous resolution with a good response to conservative measures occurred in both groups; only three cases were treated surgically. Residual clinical evidence of median nerve damage was present in 40% of all cases. Carpal tunnel syndrome which develops in pregnancy appears to be a separate clinical entity to that developing in the puerperium.

The incidence and the aetiology of chronic carpal tunnel syndrome in black South Africans was evaluated. This study showed that the incidence of idiopathic carpal tunnel syndrome was very low in this population group and that most patients who presented with symptoms and signs of chronic carpal tunnel syndrome had a specific pathology. A rare case of tumoral calcinosis causing carpal tunnel syndrome is presented. A case of perineural lipofibroma causing carpal tunnel syndrome is also described.

In a prospective study, eight patients with 15 hands affected by both vibration white finger and carpal tunnel syndrome were treated by surgical decompression of the carpal tunnel. On review six months later, the symptoms of carpal tunnel syndrome were improved in all cases and the symptoms of white finger were improved in half of the cases. Nerve conduction studies and palmar skin histology are discussed.

We describe the development of the carpal tunnel syndrome in a 58-year-old man, from perineural spread of a previously-excised cutaneous malignancy.

To identify which patients are likely to respond the medical management of carpal tunnel syndrome, 331 hands in 229 patients were evaluated. They were then treated with a wrist splint and anti-inflammatory medication. Follow-up averaged 15.4 months (minimum six months). Treatment was successful in 18.4%. Statistical evaluation identified five factors which were important in predicting response to treatment: age over 50 years, duration over ten months, constant paraesthesiae, stenosing flexor tenosynovitis, and a Phalen’s test positive in less than 30 seconds. When none of these factors was present, two-thirds of patients were cured by medical therapy. 59.6% of patients with one factor, 83.3% with two factors, and 93.2% with three factors failed. No patient with four or five factors present was cured by medical management.

We describe three instances of ruptured flexor pollicis longus tendons due to bony spurs within the carpal tunnel. In each case, the bony spur was excised and the remaining exposed bone was covered with a flap of flexor retinaculum.

Fracture of an acupuncture needle resulted in a foreign body within the carpal tunnel of a patient who then developed median neuropathy. The needle fragment was recovered from within the median nerve during carpal tunnel release, with rapid post-operative relief of symptoms. Development of peripheral neuropathy is a potential complication of acupuncture.

Thirty-five patients who had thirty-seven mucous cysts excised from the distal interphalangeal joints were reviewed not less than one year later. Seven out of 25 which had been treated by simple excision recurred, whereas only one out of twelve treated by excision and skin closure with a rotation flap recurred.

Intravenous regional anaesthesia using 0.5% lignocaine with a forearm tourniquet is a satisfactory technique for operations on the distal forearm, wrist and hand. Since recovery of pain sensation is rapid, haemostasis after release of tourniquet becomes difficult and sometimes impossible. Local wound infiltration or metacarpal block with 1% lignocaine just before release of the tourniquet can allow subsequent haemostasis and wound closure to be carried out without causing pain. 55 patients received this sequential forearm intravenous regional and infiltrative anaesthesia. Subsequent haemostasis and wound closure could be carried out without pain in 51 patients (92.7%); three patients (5.5%) noticed mild discomfort but the operations could be finished without any additional anaesthetic agent. No complications were encountered with this modified technique.

Acute ischaemia of the hand following the accidental intra-arterial injection of steroid has not, to our knowledge, been previously reported. We present such a case of the injection of Depo-Medrone with Lidocaine (Upjohn) into the right radial artery during attempted treatment of stenosing tenosynovitis of the right thumb. The resultant acute ischaemia was successfully managed after 20 hours by a combination of surgical thrombectomy, intra-arterial streptokinase and intravenous heparin and thymoxamine.

There are few reports in the literature concerning non-union of Colles’ fractures or its treatment. We describe two cases in which the fractures had been treated in the standard manner by reduction and plaster immobilisation for six weeks. The wrists of both patients were mobilised free of external support for several months before the complication of non-union was diagnosed. A simple radiographic technique for the diagnosis of non-union is described, using flexion and extension views of the wrist, and a method of treatment is outlined.

Ninety-one consecutive patients with 98 metacarpal fractures were looked at prospectively for rotational deformity. Whilst a quarter had minor rotation of the fracture of less than 10°, only five had more than this. In just two cases, was there rotational instability requiring operative intervention. Assessment of rotational deformity must include an end-on view of the finger-nail, as there is often restricted movement at the metacarpal phalangeal joint following fracture.

A case of fracture-separation of the distal phalanx epiphysis, with complete detachment from soft tissue, is reported and discussed.

A case is described in which a deep palmo-planar wart (myrmecia) caused erosion of the underlying phalanx.