Journal of Hand Surgery (European Volume)

32 patients with cerebral palsy underwent operations for pronation deformity. The deformity is classified into four groups. Patients in group 1 are capable of supination beyond neutral. No surgery is necessary. Those in group 2 are able to supinate to the neutral position. A pronator quadratus release is advised and may be combined with a flexor aponeurotic release. In group 3, patients have no active supination. However a full range of passive supination is readily achieved. A pronator teres transfer is advised. Patients in group 4 have no active supination. Full passive supination may be present, but is tight. A flexor aponeurotic release and a pronator quadratus release may unmask active supinator activity. An active transfer for supination is possible as a secondary procedure.

34 children with cerebral palsy had operations to correct flexion deformities of the wrist and fingers. 30 out of 34 patients were improved functionally and cosmetically. Zancolli’s classification provides sound guidelines on which to base surgical decisions.

The majority of cases of Madelung deformity are caused by hereditary dyschondrosteosis at the wrist. The principal lesion in the ulnar zone of the distal radial physis retards growth asymmetrically, especially in late childhood. Resection of this zone and its replacement with autologous fat (Langenskiöld procedure, or physiolysis) restores growth and minimizes deformity. The resection of an abnormal ligament tethering the lunate proximally may assist carpal advancement. A series of 17 patients (24 wrists) treated over a 12-year period is presented, with sufficient follow-up for evaluation of 11 patients (15 wrists). The results of this prophylactic procedure are encouraging, and, if it is performed early, the authors believe that Madelung deformity may be preventable, or at least controllable.

15 patients with pain and disability on the ulnar side of the wrist were treated by distal ulnar hemiresection arthroplasty. The patients’ diagnoses fell into three groups, namely ulnocarpal impingement, primary osteoarthritis of the distal radio-ulnar joint and traumatic disruption of the distal radioulnar joint. Patients were assessed pre- and post-operatively on the basis of pain and forearm rotation. Grip strength was assessed and compared with the unaffected side. Their subjective view of the operation was also sought. The best results were seen in those patients with osteoarthritis or traumatic disruption, although all patients were improved and none made worse. No patient complained of weakness although three were assessed to have a weak grip. Subjectively, 14 of the 15 were pleased or very pleased. The procedure was well tolerated and had low morbidity.

For distal radio-ulnar joint disorders, the Sauvé-Kapandji procedure, previously attributed to Lauenstein, of arthrodesis of the joint and distal ulnar pseudarthrosis is a very useful procedure, yet is not often practised. This paper describes the technique and presents the results of 81 procedures in 71 patients. There was excellent patient satisfaction. The procedure is a reliable and effective method of dealing with distal radio-ulnar joint disorders, especially in rheumatoid arthritis and following distal radial fractures. Some changes to previous techniques are emphasized.

It is now over ten years since the Herbert bone screw was first released in Australia. In 1984, Herbert and Fisher first published their experience with the use of this new bone screw in the management of scaphoid fractures. Since that time, there has been a growing interest in the technique and over 60 articles have appeared in the English literature. The purpose of this paper is to review and comment on the relevant publications as they relate to the biomechanical properties of the screw, to its use in the management of scaphoid fractures and to other applications in surgery of the hand.

We report a case of a fracture occurring in the proximal phalanx of a child following pulley reconstruction. The operative technique and the difficulties of pulley reconstruction in the immature skeleton are discussed.

The anatomy and histology of the volar plate at the proximal interphalangeal joint and the mechanism of fracture/subluxation of the base of the middle phalanx in closed proximal interphalangeal joint injuries is reviewed. Our current technique of repair for these injuries and its evolution from Eaton’s original procedure is described. The results of 71 cases of volar plate arthroplasty performed over a five-year period for fracture/subluxations of the proximal interphalangeal joints are presented with follow-up ranging from six months to four years. 62 (87%) patients achieved a stable pain-free joint with a range of motion from 5° to 95° within two months. Complications were uncommon and correctable with an overall eventual patient satisfaction rate of 94%.

Intraosseous ganglion cyst of the lunate is an uncommon lesion and cause of wrist pain. Histopathologically it is identical to the common dorsal wrist ganglion and treatment by arthrotomy, curettage of the ganglion and bone graft resulted in clinical improvement in nine patients, six of whom became symptom-free.

The non-subungual area of the hand is a rare anatomical site for malignant melanoma, lesions in this site comprising only 0.37% of 8,584 cutaneous melanomas in the Sydney Melanoma Unit database. This is approximately the same frequency of melanoma as is found on the subungual region of the hand, which represents a much smaller surface area. Not only is the sub-site distribution on the hand unusual but in addition the histogenetic types of melanoma found on the dorsum of the hand are not those commonly encountered on sun exposed skin. In this study, comparison is made between melanomas occurring on the non-subungual areas of the hand and those on the foot, an anatomically similar surface area. Comparison is also made between melanomas arising on the dorsal non-subungual surface of the hand and those on the face, a region with an equivalent surface area and similar sun exposure. The results of surgical treatment of 31 melanomas of the non-subungual region of the hand are reviewed.

Complex physical therapy was used in 78 patients with post-mastectomy lympboedema (17 with grade 1 and 61 with grade 2). This involves: skin hygiene, a special lymphatic massage, compression bandaging and garments, and special exercises which supplement the massage. Two courses of treatment were given, lasting four weeks each, with a year between them. There was a highly significant decrease in the oedema in both grades, with more than 50% removed in the first course of treatment and 50% of the remainder in the second. There was even a small, but very significant decrease during the interval between the two courses.

30 cases of iatrogenic injection injuries to the hand and upper limb are reported. 16 followed therapeutic injections (steroids—11 cases, infusions—five cases) and 14 occurred during anaesthetics procedures (local blocks—ten cases, general anaesthetics—four cases).

Guidelines for minimizing the risk of injection injury are outlined.

Arterial spasm due to exaggerated sympathetic response is an important mechanism for Raynaud’s phenomenon in scleroderma associated often with periadventitial scarring. The results of cervical sympathectomy have been unsatisfactory in the upper limb because of additional sympathetic pathways. Flatt therefore devised a distal sympathectomy by stripping the vessels of their adventitia over a short length of artery. The results of this operation were found by Wilgis in a large series to be poor in patients with scleroderma. A radical distal microarteriolysis including adventitia and surrounding scar is described and the results in 13 patients, 11 with scleroderma, are reported. Minimum follow-up is one year. All patients had relief from pain at rest and healing of painful ulceration. Mild recurrence of small ulcers was seen in only four patients.

The phenomenon of clinical regression of Dupuytren’s contracture is described and discussed. It is already recognized and used in fasciotomy where it follows the release of longitudinal tension. The quite extraordinary resolution produced by continuous passive skeletal traction in extension is presented. Regression beneath grafted skin is described and discussed with its clinical implications.

The generally accepted view of Dupuytren’s contracture being “irreversible” now presents a challenge for further clinical and pharmacological studies.

The possibility of non-surgical control does exist.

A retrospective study has been made of the long-term results of silastic replacement of the trapezium, including functional, clinical and radiological assessment of 43 hands, one to 13 years postoperatively. The results showed good function and relief of pain in 88% of hands. Radiolucent bone lesions, presumably due to silastic particle reaction, occurred in 53% of hands, but their presence did not correlate well with symptoms. Four patients (9%) developed significant synovitis which was improved by removal of the prosthesis. In this series, clinical silastic synovitis occurred in the first four years, and its incidence did not increase with further follow-up to 13 years.

Successful intercarpal arthrodesis requires a stable fusion with maintenance of correct alignment and spatial relationship of the carpus. The technique described utilizes a series of tube saws to fashion the arthrodesis bed and then insert a sized iliac crest dowel bone graft with a tight interference fit. This technique has been used in 24 patients over a two-year period in both medial and lateral column intercarpal fusions. All wrists had fused by the tenth post-operative month. The technique is precise, reproducible and technically simple with a high fusion rate and minimal donor site morbidity.

Comparative studies have shown that bone-bone union develops faster than a junction between grafted tendon and bone, and would thus allow earlier post-operative movement, limiting adhesion formation. In this context the nature of the insertion of the plantaris tendon into the calcaneus is reviewed as a possible source of composite bone-tendon grafts. It is proposed that the composite plantaris tendon with its bony block attachment is inserted through a hole in the distal phalanx of the finger creating an immediate firm distal fixation. From cadaver dissections it was found that in at least 80% of cases the insertion of the plantaris tendon was directly into the calcaneus, independent of the tendo Achilles, and was therefore suitable for use as the proposed tendon graft.

To minimize adhesions following tendon repair, early post-operative movement is recommended. This has proved difficult with tendon grafting because of weakness of the repair sites, particularly distally, and because of slow revascularization.

A potential solution is the use of a composite tendon-bone graft in which a bone block is attached to the end of the tendon. The tendon is threaded through a hole in the distal phalanx from the dorsal to the palmar side and impacted like a cork to create an immediate strong fixation. The tendon itself is then tunnelled through the pulley system and the proximal repair is carried out with a multiple weave technique which can withstand immediate active movement.

The ideal tendon-bone complex is the plantaris attached to a segment of calcaneus.

A preliminary report with two case studies is presented.

Abductor pollicis longus, long regarded as a motor for the thumb, is anatomically and functionally a radial deviator of the wrist and should be so named. The abductor carpi is proposed. If the other radial deviators of the wrist are acting this tendon can be selectively utilized as a transfer without loss of function. Reflex spasm of this muscle probably plays an important role in the radial deviation deformity seen in the rheumatoid hand.

Closed ruptures of both normal flexor tendons in the same finger are extremely rare, only nine cases having been reported in the literature. We describe the case of a patient who sustained a closed rupture of both flexor digitorum profundus and flexor digitorum superficialis of the ring finger, following a forced hyperextension injury. The patient was treated by a two stage reconstruction of the flexor digitorum profundus. He regained full flexion and extension of the finger.

Over the last three decades an error in performing Finkelstein’s test has crept into the English literature in both text books and journals. This error can produce a false-positive, and if relied upon, a wrong diagnosis can be made, leading to inappropriate surgery.