Journal of Hand Surgery (European Volume)

39 implant replacement arthroplasties were reviewed with a mean follow-up of 13 years. The study includes nine cases of partial replacement of the proximal pole of the scaphoid, 16 cases of total replacement of the scaphoid and 14 cases of replacement of the lunate. In 33 cases the conventional silicone elastomer (CSE) was used and in six the high performance elastomer (HP). Subjective, clinical and radiological evaluations gave different results. Respectively the results were excellent in 41, 23 and 5%, satisfactory in 41, 49 and 39% and poor in 18, 28 and 56% of the cases. Lytic lesions in carpal and/or pericarpal bones were present in all except two cases. Study of the X-rays chronologically revealed that they increased in number and size. Six cases had their implant removed. All had histologically proven silicone synovitis. A major secondary operation has been performed or is foreseen in all cases except one. We do not recommend implant replacement arthroplasty for the scaphoid or the lunate bone.

The osseointegration concept has been used for fixation of 68 MP joint endoprostheses in 31 patients operated on at the Department of Hand Surgery, Malmö General Hospital during the period 1988–1992. The indications were rheumatoid arthritis (50 joints), primary osteoarthrosis (three joints), post-traumatic osteoarthrosis (three joints), post-traumatic osteoarthrosis (five joints), post-infectious osteoarthrosis (seven joints) and joint deformities secondary to spastic conditions (three joints). The average follow-up time was 2.5 years (6–54 months). The surgical procedure included resection of the joint followed by introduction of screw-shaped titanium fixtures into the bone marrow cavities of the metacarpal and the phalangeal base. Rheumatoid cases usually required grafting of cancellous bone and marrow from the iliac crest. At the same time a flexible constrained silicone spacer was connected to the titanium fixtures in such a way as to allow later replacement of the spacer if accessory. The average active range of motion (ROM) was 57° in the rheumatoid cases and 50° in all cases. Radiological and clinical osseointegration occurred in every case, and there were no clinical signs of loosening. In four cases (6%) there was a fracture of the joint mechanism. Patient satisfaction was high, with pain relief, increased range of motion, improved hand function and good cosmetic appearance.

Two cases of traumatic ankylosis of the MP joint were treated by tendon ball interposition arthroplasty. Enough mobility for pinch and grasp was obtained at follow-up.

A case of irreducible dorsal dislocation of the first MP joint is presented. The tendon of FPL was trapped dorsal to the metacarpal head, and open reduction was necessary.

The range of motion of the MP joint of the thumb following repair of the ulnar collateral ligament has been compared with the range of motion of the uninjured thumb. By making this comparison we conclude that there is no good evidence that joint stiffness is a common post-operative complication.

50 consecutive patients with injuries due to skiing on an artificial ski slope were seen in our emergency department over a 16-month period; 76% of these involved the hand or wrist. 52.5% of hand lesions were fractures and only one-third of the first ray injuries were sprains of the ulnar aspect of the MP joint. These data significantly differ from those known for skiing on snow.

The unstable fracture dislocation of the proximal interphalangeal joint remains a difficult injury to manage despite the availability of a wide variety of treatment options. We describe a simple alternative method of treatment called the doorstop procedure.

In an audit of 68 scaphoid fractures with delayed and non-union that had been internally fixed using the Herbert bone screw, it was found that 39 had a significant fault in screw position. Poor intra-operatrve imaging was a major contributing factor. An anatomical and radiological study was therefore performed to evaluate which views were necessary in order to be confident about screw position. We recommend a minimum of four views. To display the proximal pole, an ulnar deviated postero-anterior (PA) view and true lateral; and to display the distal pole, a semi-pronated and semi-supinated view.

The concurrence of scapho-lunate diastasis and distal radial fractures is now well established. External fixation is considered to be one of the best methods of treating distal radial fractures, but in the presence of ligament injury, distraction fixation may lead to carpal instability and chronic wrist pain. We have reviewed existing English literature and analyzed possible mechanisms of injury, and offer some suggestions towards treatment of this combination of injuries.

Isolated injuries of the scapho-trapezial ligament complex are not well recognized. The ligament complex comprises the stout scapho-trapezial ligament, the floor of the flexor carpi radialis (FCR) tendon sheath and the scapho-capitate ligament.

Between August 1991 and May 1992, we diagnosed and treated four cases of partial chronic post-traumatic lesions of this ligament complex. There was chronic pain at the base of the thenar eminence and instability of the thumb-index-middle finger pinch. Standard X-rays were normal. The diagnosis of ligament rupture was confirmed by mid-carpal arthrography showing filling of the sheath of FCR tendon. Surgical exploration showed complete rupture of the tendon sheath of FCR in two cases, associated in the other two cases with complete rupture of the scapho-trapezial ligament. Direct repair of the ligamentous elements was performed in all cases. The tendon of FCR was sutured to the tubercle of scaphoid to protect and to reinforce the ligament repair.

The patients have been followed-up for between 6 and 12 months. All four patients recovered normal pinch strength to the middle finger. One patient suffered from chronic pain at work.

Two cases of aneurysmal bone cyst in the hand are reported. In one case the entire first metacarpal was resected and grafted using the fourth metatarsal. In the second case diaphysectomy of the middle phalanx of the index digit was performed, and the proximal phalanx of the second toe was used as graft. Satisfactory length and function were maintained, the grafts remained viable and there was no donor site morbidity. Transplant of a metatarsal or toe phalanx to the hand, as a free non-vascularized graft, is a relatively straight forward operation, requires minimal refashioning of the graft, provides articular surfaces for joint reconstruction and leaves little donor site morbidity.

The first reported case of eosinophilic granuloma of the hand is presented. A slowly expanding lesion of the right third metacarpal shaft was treated by biopsy and curettage. Histological examination confirmed the presence of eosinophilic granuloma. A bone scan showed that it was a solitary lesion. There has been no evidence of recurrence of the lesion during follow-up. Eosinophilic granuloma is a rare disease of the mononuclear phagocyte system, representing one of the clinical manifestations of Langerhans-cell histiocytosis. The lesions are usually associated with the skull, femur, mandible and ribs; this condition has not been previously reported in the hand.

Glomus tumour is sometimes difficult to diagnose accurately before surgery. We report a case where ultrasonography confirmed the presence and precise location of a lesion before surgery.

To assess the association between unilateral carpal tunnel syndrome and space-occupying lesions, 128 patients have been reviewed. They were divided into bilateral, subclinical (unilateral signs and symptoms, and bilateral slowing in the median nerve conduction) and unilateral carpal tunnel syndrome. Space-occupying lesions were investigated on the basis of physical examination and wrist imaging using plain radiographs and ultrasonograms. Of 20 patients with unilateral carpal tunnel syndrome, space-occupying lesions were found in seven (occult ganglion in five and occult calcified mass in two). In contrast, none of 89 patients with bilateral carpal tunnel syndrome and 19 with subclinical carpal tunnel syndrome had space-occupying lesions. We conclude that careful examination and wrist imaging on suspicion of local pathology, especially a space-occupying lesion, are needed when the condition is unilateral and the aetiology is not clear from the history and on physical examination.

To monitor the effect of open carpal tunnel decompression on grip strength in the hand, a prospective study was made of 25 patients undergoing a total of 31 operations. Hand grip, key pinch and pulp-to-pulp pinch strengths were measured pre-operatively and at regular intervals until 1 year following operation. At that time there was no significant difference in the hand grip and pulp-to-pulp pinch strengths compared to their pre-operative values, but the key pinch in females showed a marginally significant reduction (P=0.04) compared to the pre-operative value.

Posterior interosseous nerve compression is a well-described clinical entity with many aetiologies. Fewer than 12 documented cases of the condition due to an enlarged bicipital bursa exist in the literature. We describe a case in which magnetic resonance imaging (MRI) was used in the pre-operative assessment of a mass in the proximal forearm with a clinical diagnosis of partial posterior interosseous nerve compression.

A case of posterior interosseous nerve paralysis is reported with discussion of some characteristics that appear to distinguish it from entrapment neuropathy and neuralgic amyotrophy. The surgical implications are also discussed. More than ten similar cases have been reported, but the pathogenesis of this condition is still controversial. The patient presented with posterior interosseous nerve paralysis related to focal radial nerve constriction secondary to vasculitis in the perineurium. The constriction site was resected and the radial nerve was sutured. The patient recovered completely after 8 months.

Among 330 vibration-exposed workers, 24 cases of hypothenar hammer syndrome in 29 hands were diagnosed by arteriography. The right hand was involved in 13, the left hand in six, and both hands in five cases. The mean age was 55 years, mean duration of vibration exposure 19.4 years, and mean duration of episodic Raynaud’s phenomenon 6.4 years.

The vascular lesions of the ulnar arteries were classified into three major types with subtypes. Type 1: stenosis of the superficial palmar arch around the hook of the hamate. Type 2a: occlusion of the superficial palmar arch around the hook of the hamate. Type 2b: occlusion of both superficial and deep palmar arches around the hook of the hamate. Type 3a: occlusion of the ulnar artery at the proximal part of the wrist. Type 3b: occlusion of the ulnar artery near the wrist with the occlusion of the dorsal carpal branch of the ulnar artery.

Arteriography of an adult manual labourer presenting with numbness and cold intolerance in the middle and ring fingers of the right hand demonstrated filling defects in the digital arteries of these two fingers associated with a corkscrew-like configuration of the ulnar artery in Guyon’s canal. This arterial segment was subsequently excised revealing intramural necrosis and fibrosis and non-occlusive intraluminal thrombosis. An arteriogram performed 2 years previously for an unrelated condition revealed a similar but less pronounced corkscrew configuration of the artery, suggesting that this finding could be a marker for arterial injury which may eventually lead to embolization or thrombosis with accompanying ischaemic symptoms.

A laser Doppler flowmeter was used to assess the fingertip circulation serially in 41 patients with various hand injuries. The “flux value” measures the flow of red cells across the site of assessment and the “fluctuation” represents the pulsatile peak-trough difference in flux value with each cardiac contraction. Local temperature at the fingertip was raised stepwise by a special heater-thermostat from 36 to 44°C. Compared to the normal hand both the flux value and fluctuation in the injured hand are smaller at lower temperatures. The differences narrow down at higher temperatures and the trend reverses above 42°C and remains so on cooling. This may represent abnormal sympathetic tone in the injured hand.

The telescoping anastomotic technique was used at both ends of autogenous vein grafts bridging a defect in slow-running, vulnerable veins. This was done on left epigastric veins of the rat, the central part of which was used as a graft. In the right epigastric veins, both the proximal and distal anastomoses were repaired using the conventional anastomotic technique. The overall patency rate of the grafts repaired with the telescoping anastomotic technique was 27/29 (93.3%) compared to 17/28 (60.7%) in the conventional group. The telescoping technique was also easier to perform than the conventional method.

Thumb reconstruction following amputation was accomplished by microvascular transfer of the thumb from the contralateral paralyzed hand in two cases. The appearance and function of the transferred thumbs were excellent and no problem was seen in the donor hand.

23 finger amputations in 19 patients operated on for Dupuytren’s disease were reviewed 6 months to 8.5 years after operation (mean 4 years). The distribution of amputations were 17 little fingers and six ring fingers.

We found a recurrent lack of extension in nine out of 16 finger amputations distal to the MP joint and painful neuroma or phantom limb pain in five out of seven little finger amputations through or proximal to the MP joint.

When amputation in the little finger is necessary, disarticulation of the MP joint may be preferable to amputation at a more distal level.

Alternatives to finger amputation should be sought in difficult cases of Dupuytren’s disease.

A method of closed irrigation has been devised to treat infections in the hand. After adequate débridement, two tubes are placed in the infected area, an inlet tube and an outlet tube. For a small infection, one tube serves both purposes. The wound is closed completely. Irrigation with saline and antibiotic solution is continued for 1 week, extended up to 3 weeks in cases of severe infection. This method has been applied in 31 cases including pyogenic tenosynovitis, tuberculous tenosynovitis, pyogenic arthritis, osteomyelitis, bite injury, crush injury and amputation stump infection. Infection healed primarily in 29 cases. Further surgery was needed in two cases which healed finally.

Transection of both median and ulnar nerves provides an objective model to compare sensory and functional recovery. 22 patients were evaluated after nerve repair. The mean age was 30 years and the mean time since surgery 80 months. Primary direct suture was performed in 15 patients and six grafts were necessary. Median nerve suture and ulnar nerve graft were combined in one case. Both sensory and functional evaluation were completed. Statistical evaluation analyzed the relationship between age, injury location, mechanism, type of rehabilitation and the result, and the relationship between two-point discrimination distance (2-PD) and the functional score. According to the S0 to S4 grading, only 26.5% (ulnar) and 31% (median) of direct suture cases achieved S3+ or more. All nerve grafts in adults were poor. A strong relationship was found between two-point discrimination distance (moving and static) and the functional result, even after multivariate analysis. A modification of the Medical Research Council’s classification is suggested.

We report the results of examination of patients before primary and secondary unilateral digital nerve repair. Two-point discrimination was uniformly recorded. The results show that significant overlap of adjacent digital nerves is common and this has important implications for interpretation of results after repair. Recommendations are made regarding the evaluation of outcome following surgery.

The aim of this article is to show that the well-known Tinel sign is realiy a Hoffmann-Tinel sign. The translation of the two papers of Hoffmann, published in the same year that Tinel wrote his article (1915), is completed by a short biography of Paul Hoffmann.