Journal of Hand Surgery (European Volume)

Precise clinical and electroneurographic examinations were made of 51 patients before and after anterior transposition of the ulnar nerve. The mean follow-up period was 9.6 years. In 86%, hand function improved, while in 10% it remained unchanged. Subcutaneous transposition was better than submuscular transposition, especially with regard to sensation. This method is simple and involves low morbidity for patients.

Anterior transposition and/or medial epicondylectomy are often considered procedures of choice for ulnar neuropathy at the elbow. Much experience suggests simple decompression to be a comparably effective alternative which involves less trauma, morbidity, and rehabilitation time. The post-operative clinical and electrophysiological results of 52 cases of simple decompression (41 patients) are summarized. Excellent or good clinical results were found in 75% of the nerves. Mean ulnar motor conduction velocities were significantly improved post-operatively, although nerve conduction parameters did not consistently correlate with clinical outcome. The average return-to-work time was 5.1 weeks. The advantages of simple decompression make it the procedure of choice for most cases of ulnar neuropathy.

Prospective analysis of 27 medial epicondylectomies in 22 patients with McGowan grade I ulnar neuropathy demonstrated an improvement in clinical symptoms. In all patients a N.C.V. study, in which compression of the ulnar nerve at the cubital tunnel was evident, has been a prerequisite for operation. Conduction velocity across the cubital tunnel averaged 48% of normal (26.4 +/– 8.7 metres per second) preoperatively and increased to 85% of normal (46.7 +/– 9.7 metres per second) postoperatively.

A preoperative N.C.V. study allows the achievement of a high success rate, especially in the less well clinically defined group of patients with grade I neuropathy (subjective complaints without any objective signs of muscle atrophy). Medial epicondylectomy is safe and predictable in the treatment of cubital tunnel syndrome.

Specificity of muscle reinnervation and the recovery of muscle contractility were studied after repair of the transected rat sciatic nerve. Six different techniques were compared: epineurial suture, perineural suture, whole nerve graft, interfascicular grafts, skeletal muscle bridge and tubulization. Muscle tetanic force and specificity of reinnervation were evaluated 12 weeks after nerve repair. Recovery of tetanic force was superior after repair with epineurial sutures. There was no statistical significance between the other methods in respect of tetanic force. The specificity of muscle reinnervation was best after tubulization, repair with interfascicular grafts and perineurial suture.

The literature indicates that tourniquet-induced neurological injuries are relatively common and frequently occur at a subclinical level. In order to evaluate the pressure transmitted to the major peripheral nerves of the arm by an externally applied pneumatic tourniquet, a fully implantable biomedical pressure transducer was placed adjacent the radial, median and ulnar nerves in six cadaver upper extremities of average dimensions. This sensor allowed accurate, reproducible measurements of perineural pressures without requiring significant disruption of the normal anatomical structures of the test limb for its installation. At levels of tourniquet cuff inflation which are commonly used in clinical practice, there was little or no decrease in the pressure detected in the perineural regions over that applied to the surface of the limb. In addition, there was a steep gradient of perineural pressure between locations beneath the edge of the cuff and those under its midpoint. This was most marked at the highest levels of tourniquet inflation. At presently accepted levels of inflation, pneumatic tourniquet cuffs transmit high pressures to the peripheral nerves without any significant attenuation by the intervening soft tissues. The distribution of these forces is one which may subject the underlying nerves to deleterious shear forces, especially at higher levels of inflation.

52 hands have been dissected to check the anatomy and function of the extensor pollicis brevis. Various abnormalities were found: absence of the E.P.B. (two), insertion on the distal phalanx (four), absence of bony insertion on the base of the first phalanx and insertion on the extensor hood (36). In ten cases (in addition to the two with absence of E.P.B.), no function was elicited by pulling the tendon which inserted upon the extensor hood.

The hind paws of rats were subjected to vibration at a frequency of 80 Hz., an acceleration of 32 m./s.² _rms (i.e. a_hw~6.3m./s.² _rms) for five hours daily during five consecutive days. Morphological, histochemical and immunohistochemical analyses of the soleus, extensor digitorum longus and the plantar muscles in the vibrated limb and the contralateral control limb were performed. No changes were seen in the soleus or extensor digitorum longus muscles but different degrees of degeneration of the muscle fibres were seen in the plantar muscle sections as well as signs of regeneration. No changes were observed in the contralateral unexposed limb. It is concluded that it is not only nervous tissue but also muscle tissue that can be affected by vibration. The changes seem to be confined to muscles close to the vibration exciter.

Recent studies have demonstrated an intrinsic neovascular response in intrasynovial healing tendons, introducing the possibility of mitogenic and/or angiogenic capability of intrasynovial tendon. To explore this hypothesis, healing canine flexor tendons were treated with early passive mobilization and the repair sites analysed at three, ten and 17 days. Specimens were mechanically digested and subjected to a standard BALB/c 3T3 mitogenic assay, which measures the capacity of tissue extracts to induce DNA synthesis and cell division in fibroblasts. Results revealed that both control and repaired flexor tendons possessed mitogenic activity, with the greatest activity observed in control specimens. Decreasing activity was noted as the time between repair and analysis increased. These data provide increasing evidence for the flexor tendon’s active role in the healing process, and support the concept that mitogenic or growth-promoting factors are associated with flexor tendons and may be released following injury, during the early stages of healing.

This study examined the potential use of absorbable polytrimethylene carbonate (Maxon) sutures for tendon surgery. Flexor tendons of the third toe of 48 chickens were transected and sutured, then evaluated both mechanically and histologically at 0, five, 15 and 45 days after operation. Mechanical testing showed that the suture kept its strength long enough to unite tendon ends. However, high tissue reactivity of polytrimethylene carbonate during its dissolution caused adhesions.

We compared the strength of a new step-cut technique for flexor tendon repair with that of the widely used Kessler-Tajima technique, giving special attention to the relative contributions of the core and epitendinous sutures. 36 flexor digitorum profundus tendons from human cadavers were used. Corresponding digits from the same donor were paired, and the two tendons of each pair were placed in the Kessler-Tajima and step-cut groups, respectively. Each group had three subcategories of repair: (1) core repair alone; (2) epitendinous repair alone; and (3) full repair. In the Kessler-Tajima repair, the core stitch contributed more to ultimate tensile strength, while the epitendinous stitch contributed more to gap formation resistance. In the step-cut repair, however, the epitendinous stitch contributed more to both measures of strength. The full step-cut repair was 65% stronger in resisting gap formation and had 84% more ultimate tensile strength than the full Kessler-Tajima repair. We attribute the greater strength of the step-cut repair to the additional number of epitendinous loops, which lie perpendicular to the long axis of the tendon.

In the most widely accepted model of injuries to the carpus, scaphoid fracture and scapho-lunate dissociation are held to be mutually exclusive. Four cases in which they occurred together are reported, and the likely mechanism proposed.

Isolated trans-carpal injuries in children are rare. This paper presents three cases of trans-carpal injury associated with an ipsilateral distal radial fracture. Two cases involved simultaneous fractures of the scaphoid and the capitate. The third case involved the scaphoid and the triquetrum. The full extent of these injuries was not recognized on the initial X-rays. If a child presents with a displaced fracture of one carpal bone it may not be an isolated injury.

Palmar tilt measured on true lateral radiographs of 100 normal wrists revealed that dorsal palmar tilt is not found in the normal adult, and women generally have a larger palmar tilt (average 12.4°) than men (average 9.3°).

The long-term outcome of algodystrophy is unknown. Ten years after Colles’ fracture, 26% of 55 cases showed features of the syndrome. The finding of poor finger function three months following the fracture correlated significantly with the presence of components of algodystrophy after ten years.

The “S” Quattro has shown its value in the management of displaced comminuted intra-articular phalangeal fracture dislocations. Since then the system has been used as a dynamic flexible external fixator in the treatment of five maluniting phalangeal fractures, five comminuted condylar and four severe compound fractures.

These challenging fractures have been dealt with by easy operations, taking full advantage of the versatility of the “S” Quattro to achieve good results.

147 proximal phalangeal fractures of the hand were managed by Accident and Emergency doctors and hand surgeons. Most were treated conservatively with good results. Those treated in A. and E. were usually transverse or basal fractures of the shaft. Articular, oblique, comminuted and compound injuries were associated with greater morbidity and required specialist care.

Two cases are described in which reduction of distal phalangeal epiphyseal fractures was prevented by a bridge of nail fold.

A case of rupture of the flexor carpi radialis tendon in association with scapho-trapezial osteoarthritis is reported. The symptoms of pain and swelling contrast with the loss of function which characterizes rupture of other tendons in the hand and wrist.

Pisotriquetral arthrosis in young patients is considered rare and the diagnosis may be difficult to distinguish from other ulno-carpal problems. 12 patients under 40 years of age (15 cases) who underwent pisiformectomy were reviewed at a mean of 41 months. Patients with a good history of trauma and a positive response to intra-articular local anaesthetic injection did well. Others with an indefinite history and bilateral symptoms did not do so well. Trispiral tomography is the radiological investigation of choice.

The cytogenetics of cell cultures derived from Dupuytren’s tissue, adjacent palmar fascia and palmar skin from patients undergoing fasciectomy have been examined and the results compared to cell cultures established from palmar fascia, flexor retinaculum and palmar skin of patients undergoing carpal tunnel decompression. Chromosomal abnormalities were detected in cell cultures from Dupuytren’s tissue in eight of the nine patients studied. Clones of cells trisomic for chromosome 8 were found in five of the nine patients. Trisomy 8 was also present in two of five flexor retinaculum cultures from carpal tunnel syndrome cases. These findings in both Dupuytren’s contracture and carpal tunnel syndrome suggest the presence of chromosomal instability in the palmar fascia. The significance of the chromosomal abnormalities is however unclear, but they indicate a possible common pathway in the onset of pathological fibrosis.

We reviewed ten hands in nine patients who had enzymatic fasciotomy for Dupuytren’s contracture, with an average follow-up of 6.5 years. While all patients were initially satisfied with the results, the disease recurred quite rapidly to pre-operative levels in seven patients over the subsequent two to three years.

Localized digital ischaemia following tourniquet deflation is an event producing considerable concern after surgical procedures on the hand, and is more common when severe pre-operative deformity has been radically corrected. We describe three such cases of digital ischaemia, occurring immediately after the release of severe flexion contractures of the digits. Our cases were treated successfully by the application of a proximal cutaneous glyceryl trinitrate patch, which produced prompt recovery of the circulation in the affected digits. We suggest that this simple technique has an important role as theraputically, and possibly also as a diagnostic aid, in the evaluation and management of the post-operative ischaemic digit prior to re-exploration being undertaken.

The survival rate and elastic properties of the anterior abdominal skin flap in Sprague-Dawley rats were studied in three groups of animals. In group 1 where the flaps were supplied by a normal artery, arterial flaps (1A) had better survival rate and elastic properties than venous flaps (1B). In group 2, where the flaps were supplied by an artery with diminished perfusion pressure, the arterial flaps (2A) still had slightly better results than venous flaps (2B). However, in group 3 where the flaps were supplied by a vein, venous flaps (3B) had better results than arterial flaps (3A).

The clinical features of 58 patients with typical cleft hand were examined and compared with 86 patients with syndactyly between the long and ring fingers, 27 patients with syndactyly between the ring, little and other fingers, 53 patients with hypoplastic thumb and 100 patients with symbrachydactyly. The clinical findings of the typical cleft hand resembled those of syndactyly. There were two unusual cases of typical cleft hand associated with hypoplastic thumb, congenital heart anomalies and absence of the axial triradius. One of these also had cleft lip and palate. The critical embryonic period of the heart anomaly is early, while that of the cleft lip and palate is late. These findings suggest that an embryo with typical cleft hand and hypoplastic thumb results from impairments at two different times in the early embryonic period.

Two patients are described who have a congenital ectopic nail on the little finger associated with absent flexion in this finger. One patient was treated by surgical excision of the nail.

Isolated paralysis of flexor pollicis longus is an uncommon variation of the anterior inter-osseous nerve compression syndrome. Two cases occurring in twin sisters were treated by brachioradialis tendon transfer when no recovery was evident after six months, with good results. Brachioradialis transfer is technically easy to perform, but complete mobilization of the tendon and muscle is necessary to achieve the desired excursion of the muscle-tendon unit.

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.