Journal of Hand Surgery (European Volume)

Cold induced arterial vasospasm was studied in ten patients with single digit replantation, by measuring finger systolic pressure at different finger temperatures. Each patient was examined three times; within 2 weeks of surgery, after 1 year and after 3 years. The replantations were performed using long arterial and venous grafts. Cold-related vasospasm is established during the first year after trauma, and thereafter seems to be persistent. It is concluded that the subjective cold intolerance, which affects all patients after digital amputation regardless of whether replantation is performed or not, is partly due to vasospasm. It is less pronounced in patients without pathological vasospasm in the replanted digit. Cold intolerance is likely to decrease during the first 2 years after replantation, but not to disappear completely.

Eight hands amputated at wrist or distal forearm level were replanted between 1983 and 1990. Steinman pins were used to obtain skeletal fixation at the wrist level in three patients. Secondary surgery was performed in seven patients. Six of the patients were available for review between 1.5 and 7.5 years (mean 3.6) after the injury. The functional results were assessed using the Tamai scoring system. Recovery of useful hand function has been achieved in most patients, although long-term recovery of sensibility was found to be disappointing. Despite this finding, five out of the six patients were highly satisfied with the result and four have returned to work.

Free vascularized fibular transfers were used in six patients with extensive bony defects after excision of a giant cell tumour of the distal end of the radius. The results have been satisfactory.

This study reports results in nine patients with extensive loss of soft tissue, extensor tendon, and bone, treated with an emergency free flap for skin cover, primary bone grafts, and tendon grafts passed through individual tunnels in the free flap. Four had a good result, four were fair and one poor. Six patients returned to work, two were not working and one was retired. In select patients, emergency reconstruction of severe extensor tendon injuries appears to produce better function, with fewer operations, a shorter hospital stay, minimal complications, and a shorter period of disability.

Cutaneous flaps are not entirely satisfactory when used for soft tissue defects of the palm, because the skin cover is too mobile. Use of muscle flaps can therefore be advocated for this recipient site. A case is reported where the pronator quadratus muscle has been used as a free muscle flap for coverage of a small defect of the palm.

A supernumerary extensor muscle to the middle finger was found to be present bilaterally in a male cadaver. It originated from the distal end of the ulna and its tendon inserted into the proximal phalanx of the middle finger. The bilateral presence and manner of insertion appear to be unique from a review of the literature. Morphological variability and clinical significance are reviewed. Such variations may be clinically significant during hand surgery, especially tendon transfer procedures.

We present a modification of Bunnell’s technique for harvest of the palmaris longus tendon. Using a 0.5 cm distal incision and a proximal stab incision the tendon is harvested with minimal scarring and, in our experience of over 30 cases, no morbidity.

Post-traumatic rupture of flexor tendons is a very rare event. We report such an event following an epiphyseal fracture of the distal radius. This has not previously been reported in the English literature.

We reviewed 83 consecutive patients with unilateral Colles’ fracture in order to identify factors that predict poor functional outcome. All fractures were treated by closed reduction and cast immobilization, and followed-up for at least 2 years. Our results showed that only final dorsal angulation was correlated to loss of flexion. In contrast to other reports, we could not find any relationship between radial shortening and loss of grip strength or loss of range of motion. In addition, the severity of initial displacement, involvement of radio-carpal or distal radio-ulnar joints, and the presence of ulnar styloid fractures or their non-union did not affect the functional outcome.

Post-traumatic radio-ulnar synostosis is an unusual but serious complication of adult forearm fractures. This is the first report of radio-ulnar synostosis following external fixation to be described in the English literature. A 52-year-old man sustained a fracture of the distal radius and ulna which was managed by external fixation. Following this, he developed a radio-ulnar synostosis at the pin-track site. The synostosis was successfully removed and he regained significant rotatory movement of his forearm.

34 patients treated by the iliac crest bone graft technique for wrist arthrodesis were reviewed. The average age was 45.6 years and the mean follow-up was 45 months. The procedure is performed through a straight ulnar approach and the head of the ulna is removed. A longitudinal trench is created in both distal radius and carpus preserving the anterior, posterior and lateral cortices. A curved trapezoidal monocortical iliac crest bone graft is embedded inside the trench. The position of the arthrodesis automatically follows the curvature of the graft. No fixation device is used. A short-arm cast is applied for 2 to 3 months. All arthrodeses except two fused within 3 months. Pain was completely relieved in 85% of the cases. Pronation and supination returned to normal 5 months post-operatively. Grip strength was increased in 80% of the cases. The carpometacarpal joints remained pain-free even when not fused. Complications were rare: two lesions of the dorsal branch of the ulnar nerve; two cases of delayed union due to errors in technique, and displacement of the graft in one case. Although it is technically demanding, the embedded iliac crest graft wrist arthrodesis improves pronation and supination as a result of resection of the distal radio-ulnar joint, preserves or improves grip strength, and relieves pain.

15 wrists with Madelung’s deformity were operated on between 1972 and 1990, constituting the largest series of radial osteotomies reported for this deformity to date. The technique that evolved is described in detail, as are the preliminary follow-up results. All patients reported symptomatic relief and return to normal activity levels.

A right-handed man with an enlarging bony swelling of his dominant hand developed symptoms of median and ulnar nerve compression. He underwent simple excision of the hamate and histology showed the lesion to be a benign chondroblastoma. At 2-year follow-up he was found to be doing a heavy manual job with no functional problems and there were no signs of recurrence of the tumour. To our knowledge this is the first reported case of a benign hand tumour treated by simple excision of the hamate.

The motions of the scaphoid and triquetrum relative to the lunate have been studied on cadaver specimens. The helical axis concept was applied. The wrist motions performed were flexion-extension and radial-ulnar deviation. The results showed increased relative motion of the scaphoid towards terminal extension, and to a lesser amount in the case of the triquetrum, towards terminal flexion. The lunate might be considered as a keystone in the proximal carpal row when wrist stability is considered. It is doubly intercalated: longitudinally and transversely. Wrist ligaments co-ordinate the positioning of the bones in the mid-range of carpal motions, and restrict further motion in extreme positions of the wrist joint.

Palmar plate resection arthroplasty of the PIP joint, a new technique for operative treatment of destroyed PIP joints, is presented. By combining palmar plate arthroplasty with a flexor tenodesis a stable arthroplasty with adequate active motion can be performed. It can be used even in severely destroyed joints and still provide adequate post-operative stability and motion. Exercise can be started early.

100 thumbs with primary osteoarthrosis of the joints of the trapezium were treated by trapeziectomy and a FCR sling arthroplasty to reconstruct a first intermetacarpal ligament by the method described by Burton and Pellegrini (1986). Pain at rest remained in five. Some pain at or after exertion persisted in 46, and 49 became completely pain-free. 88 were satisfied with the procedure and there was a significant increase in pinch strength and in the ability to perform activities of daily life. It has become our preferred procedure for treating osteoarthrosis of the basal joint of the thumb.

This study evaluated dynamically the morphology of the carpal tunnel during the wrist motion. The object was to determine the transverse dimension (TD), anteroposterior(AP) dimension and cross-sectional area (CA) of the carpal tunnel in the neutral, flexed and extended positions. The wrists of eight male and eight female volunteers aged 20 to 38 years were studied.

With wrist extension, AP and CA decreased while the TD increased at the pisiform level, and CA increased at the hamate level. With flexion, TD and CA decreased at the pisiform level and CA decreased at the hamate level. The results showed that the median nerve may be subjected to significant pressure at the pisiform level when the wrist is extended. During wrist flexion, the cross-sectional area decreased at both the level of the pisiform and the hook of the hamate.

Assessing the functional outcome of peripheral nerve suture in the hand requires a battery of tests which are valid, reliable and comprehensively evaluate cutaneous sensibility. This study explores the relationship between a battery of sensory tests and the patient’s capacity to perform everyday functional activities. An analysis of the interrelationship between all outcome variables reveals that the tests of sensibility do not predict the patients’ ability to use their hands in everyday activities, thus indicating that patients are able to compensate for sensory deficit through the use of vision and bilateral use of the hands. An assessment of outcome should therefore include an additional measure of performance on daily living tasks.

72 fingers with divided digital nerves on one side alone had their nerves repaired and the sensory recovery assessed at different intervals of up to 2 years. Another 36 fingers with similar digital nerve injuries had their divided nerves left unrepaired and sensory recovery similarly assessed for comparison. In the “repaired” group, the result continued to improve and by 2 years, 90% reached S3⁺ or above. In the “unrepaired” group, improvement plateaued after 6 months, and at 2 years only 6% reached S3⁺ or above, although all had regained some protective sensibility.

The movements of the MP and PIP joints occur together and enable the fingers to acquire different postures. A graphic record of these movements gives an idea of the working space of the fingers. Normally, the tracing forms the shape of a quadrangle with almost parallel sides. If muscle paralysis occurs or joints are diseased, the shape of the quadrangle—the “working space”—becomes distorted. Different patterns of distortion are seen with different finger problems.

“Finger dynamography” is a simple bedside procedure requiring only a goniometer. If supplemented with additional data on pinch and grip strengths and sensibility, it gives a pictorial record which is easy to interpret and can be used for documentation.

Finger dynamography is a bedside technique for evaluation of the moving abilities and working space of the hand. Various operative procedures used for correcting the claw finger deformity restore the functional abilities to a varying extent. The palmaris longus transfer with insertion into A1–A2 pulley appears to be a better procedure than lateral band insertion, extensor diversion or extensor many-tail procedures. The use of palmaris longus as a motor seems to have advantages over flexor digitorum superficialis transfer where removal of FDS as a motor produces local deficits.

This study examined the use of upper arm and forearm tourniquets for hand surgery. 40 subjects (20 males, 20 females) were randomly assigned to one of four groups: left upper arm, left forearm, right upper arm and right forearm. Tourniquets were applied to these areas. Subjects were asked to rate their discomfort at 10-minute intervals and the total time of tourniquet tolerance was recorded. The results of a three-factor ANOVA revealed no statistically significant differences in either pain rating or tourniquet tolerance between any of the groups. In addition, forearm tourniquets were used in 18 clinical cases. None of the individuals with tourniquet times less than 30 minutes required any medication in order to tolerate this procedure. Of the 13 patients with tourniquet times greater than 30 minutes, ten required medication in order to tolerate the procedure. We conclude that patients tolerate upper arm and forearm tourniquets equally.

This study reports the causes, characteristics and treatment of injuries to the hand and wrist presented to five accident and emergency departments in a 2-year survey of 13% of the Danish population. The rate of injury to the hand or wrist was 28.6% of all injuries, or 3.7 per 100,000 inhabitants per year. 34% of the accidents were domestic, 35% were leisure accidents, 26% were occupational and 5% were traffic accidents. Only 2% of the patients were admitted to hospital for further treatment or observation and 13% were referred to a hospital as outpatients. The most frequent causes for admission were fractures (42%), tendon lesions (29%) and wounds (12%).

A case is reported of a locked MP joint due to ulceration of the metacarpal head. This was clearly visible on MRI scan.

Two cases are described of anterior dislocation of the proximal interphalangeal joint which could not be reduced because of interposition of the central slip of the extensor mechanism. In common with previously reported cases the injuries were sustained in a spin drier. The literature on anterior dislocation of the proximal interphalangeal joint is reviewed. Three distinct patterns of dislocation are recognised and their management is discussed.

In nail gun injuries of the fingers, removal of the nail in the antegrade fashion (in the same direction as its introduction) prevents soft tissue entrapment by the hooked barbs of the nail. This concept is illustrated in a case report.

We report two cases in which white spirit has been injected accidentally into the hand by golfers, while attempting to remove the grip of the golf-club handle in order to replace it. One of our patients has anecdotal evidence of this happening in at least two other cases, one of which resulted in amputation of the index finger, and the other in severe damage to the thumb.

Samples of skin and underlying cord obtained at dermofasciectomy for Dupuytren’s contracture have been examined for the presence of smooth muscle α-actin (SM α-actin), a marker for myofibroblasts. 15 of the 20 samples stained positively for SM α-actin corresponding with areas of hypercellular Dupuytren’s tissue. In 12 of these 15 samples SM α-actin-positive hypercellular Dupuytren’s tissue extended into the dermis, in three cases reaching the epidermis. In eight samples, diffusely distributed cells positive for SM α-actin and resembling fibroblasts were seen in the dermis. These cells appeared to be separate from the Dupuytren’s foci. The presence of hypercellular foci and isolated fibroblasts positive for SM α-actin within the dermis may explain the high recurrence rate of Dupuytren’s disease after fasciectomy.

The skin has previously been implicated in the process of Dupuytren’s disease. The dermal dendrocyte is a factor XIIIa positive cell, which has been found in normal skin and some pathological conditions associated with fibrosis. In this study we examined the distribution of factor XIIIa positive cells in and around tissue from Dupuytren’s disease. Immunohistochemistry was performed using a panel of antibodies for factor XIIIa, macrophages (CD68 and MAC387) and MHC II. Many factor XIIIa positive dendritic cells were present in and around Dupuytren’s tissue; fewer CD68 and MHC II positive cells and very few MAC387 cells were seen. We propose that the factor XIIIa positive cells are dermal dendrocytes. This study may indicate an important link between the skin and pathogenesis of Dupuytren’s disease.

A 25-year-old lady presented with painful periungual tumours which were associated with lytic changes of underlying terminal phalanges. She had been previously treated as a case of chronic paronychia but the problem recurred. She was subsequently diagnosed as a case of Incontinentia pigmenti which is a rare genodermatosis with mixed ectodermal and mesodermal polydysplasias, onchychodystrophy being a very rare manifestation.

She was treated by excision of painful finger lesions, but there is no specific treatment for the underlying condition.