Journal of Hand Surgery (European Volume)

A single stage homodigital reverse pedicle island flap is described for the repair of volar or dorsal tissue loss on the finger or thumb. Donor site morbidity is minimal, and the length of the digit is preserved. Satisfactory function results in 25 patients are presented.

Indications for the use of the reverse digital artery flap described by Zancolli are considered, with a modification to the technique which leaves a more acceptable donor defect in the palm of the hand.

Compartment syndrome in the upper arm is uncommon, but early recognition and treatment is as essential as it is in other sites. A case of compartment syndrome in the upper arm is reported.

The effect of post-operative haemorrhage on intra-compartmental pressure has been studied in a primate model. The common practice of closing a wound and applying a compression bandage before deflating the tourniquet is shown to raise intra-compartmental pressure. Subsequent tourniquet release causes a further rise in pressure. Post-operative intra-compartmental pressure remains significantly higher during the first 3 hours of reperfusion in limbs bandaged prior to tourniquet release than in limbs in which the tourniquet is released and haemostasis gained before compression bandaging is applied.

More than 2 million upper limb injuries occur each year in Britain. Information about the precise sequence of events leading up to an accident may help prevention of similar injuries by alteration of the work environment or through safety education. The first impression of the cause of an accident may not identify the key event triggering it. The Merseyside Accident Information Model (MAIM; Manning, 1987) provides a structured questionnaire, based on a menu-led computer programme. This not only allows the first unforeseen event to be identified from the history, but is also the basis of a database. Pooled data can then be analyzed. We present an analysis of 100 consecutive cases presenting to one Plastic Surgery Unit.

Data are reported from a study of 1,003 patients attending with hand injuries at an Accident and Emergency Department. Among both left- and right-handers, injuries to the right hand were more common than to the left hand, except for accidents to right-handers at work. For this group there were more injuries to the left hand. Male and female patients differ in the frequency with which they present for medical attention but show similar types of injury.

The platypus (ornithorhynchus anatinus) is a furry duck-billed mammal that inhabits the waterways of eastern Australia. The male may reach 60 cm in length with a 20 cm beaver-like tail. We report the case of an American naturalist stung whilst trying to study the male in the wild. This resulted in an intense local reaction. Warning signs should therefore be erected at air and sea ports warning tourists of the dangers of these venomous Australians.

Spot weld burns of the hand result in damage to structures deep to the skin by dissipation of heat locally causing extensive necrosis. This must be appreciated to optimize treatment.

The incidence and aetiology of 6,857 phalangeal fractures of the hand have been reviewed in a series of 235,427 patients, looking for an age-specific vulnerability to fracture. We found sports to be the main cause of fracture in the 10–29 years age groups and accidental falls to be the leading cause in those aged 70 years or older. We made a new observation that the highest incidence occurs in the male 40–69 age group and machinery was the dominant cause of fracture in this group. Recognition of the frequency of industrial trauma is needed, and public expenditure should be invested in its prevention and treatment.

A rare case of isolated complex dorsal dislocation of the MP joint of the ring finger is described. Differences in the pathological findings between dislocations of the ring finger and other digits are discussed.

Idiopathic avascular necrosis of the scaphoid is a rare condition. A review of the literature shows a variety of conditions labelled as spontaneous avascular necrosis or Preiser’s disease. In this paper we report on a study of eight patients with idiopathic avascular necrosis affecting only the proximal pole of the scaphoid. Seven of these patients had positive ulnar variance. The possible aetiology is discussed and the natural history has been studied. A staging system is proposed, as this helps to determine the prognosis and appropriate management. Two of our patients were managed conservatively; the others were treated successfully by partial silastic replacement of the scaphoid

A review of the anatomical and clinical literature found that previous descriptions of the scaphoid were not detailed enough to match our present clinical knowledge or the requirements of modern imaging. With this in mind a revised and extended description has been produced following a study of 50 dry cadaver scaphoids. The incidence of the new features described were assessed in 90 pairs of Caucasian scaphoids

External fixation is a useful method of treating unstable fractures of the distal radius. There is a lack of information regarding the behaviour of mini-fixation systems, particularly under cyclical loading, which would be expected to occur at the wrist.

This laboratory study was designed to investigate the mechanical characteristics of nine current fixation systems. A programme of loading was devised to mimic forces acting on the distal radius. Wooden dowel was used to mount the fixator. Distraction and compression forces were applied in an Instron rig. Displacement was monitored throughout the load programme.

No fixator failed at the loads tested. The small Hoffman rectangular frame proved stiffest in compression and extension, but was heavier than other devices.

A trend of progressive, permanent deformation became apparent in those fixators which contain plastic or composite materials. This feature has implications for loss of fracture reduction in the clinical setting.

A case is reported of lunate subluxation in combination with a Salter-Harris type 2 fracture of the distal radius in a child.

Carpal subluxations or dislocations are rare in children. This combination has never been reported before. It significance lies in the combination of injuries, the more common of which led the lunate injury to be overlooked, emphasizing the importance of careful study of all available radiographs of an injury.

A case of volar dislocation of the lunate, associated with multiple rupture of the flexor tendons of the fingers, is described in a 76-year-old man with calcium pyrophosphate arthropathy.

We report a case of a closed rupture within the carpal tunnel of the flexor digitorum profundus tendon of the little finger. There was no underlying pathology.

Two cases of migration of silastic rods into the forearm after the first stage of flexor tendon grafting are reported. A CT scan shows the rods well if they are not visible on a plain X-ray. Possible factors involved in distal detachment of the rods are the composition of the tendon spacer, method of distal fixation, method of proximal fixation and the time between the stages of reconstruction.

We report a detailed comparative evaluation of flexor tenosynovectomy in 55 fingers in which the A1 pulley was divided and 45 fingers in which the A1 pulley was retained. The metacarpophalangeal joint subluxed volarly in 49% when the A1 pulley was divided, compared to 11% when the pulley was preserved. Bowstringing occurred in 7% and only when the A1 pulley was divided. Ulnar deviation was 7° worse when the pulley was divided. Active range of movement was limited in both groups. It was 11° less when the A1 pulley was divided.

The Harrison–Nicolle Intramedullary Peg is used for the arthrodesis of digital joints. We report our experience of complications found using this peg in a series of 16 arthrodeses. At review after an average of 2.9 years, three cases had been revised. Only five of the remaining 13 cases showed a bony fusion and in only two of these five was the fusion in an acceptable position. In nine cases the joint became straight or extended; the preset angle of the peg did not determine the final angle of the arthrodesis. In five cases the tips of the peg appeared to be eroding through bone.

A damaged interphalangeal (IP) joint may be treated by fusion. Arthrodesis should leave the joint at the most functional angle and give sound bony union in the shortest possible time, maintaining maximum proximal and distal joint motion. The lateral oblique placement of a single AO lag screw, proximal to distal, achieves these aims. This method gives sufficient proximal bone for screw purchase and better control of the desired angle of fusion. This technique has led to fusion in 22 of 23 joints (96%), taking an average of 8.2 weeks.

A 37-year-old sports teacher suffering from idiopathic haemochromatosis with arthropathy of the MP joints has been treated and followed-up by us for 4 years. Three out of four affected MP joints were treated with arthroscopic operations; one of these had been treated elsewhere previously by arthrotomy. This article presents a brief review of the condition and its treatment by arthroscopic surgery with detailed technique. We believe that MP joint arthroscopy in certain cases is an alternative to open surgery and gives excellent results. No specific instruments are needed apart from a standard small joint arthroscopy set.

A loose body flicking in and out of the pisotriquetral joint was found to be the cause of intermittent wrist pain and locking in two patients. Appropriate X-rays gave the diagnosis and surgical removal provided a satisfactory cure.

In a retrospective study, the results of 18 wrist fusions with a radial sliding graft and a dynamic compression plate are reviewed. All 18 fusions united, with an average position of 16° of extension and 7° of ulnar deviation. Wrist strength and stability and diminished pain allowed improved function. However, decreased manoeuvrability impaired function for some activities.

We present the results of the modified Liverpool total elbow joint replacement. The humeral component of the original prosthesis was modified because of a high incidence of loosening. 19 patients who had total elbow joint replacement for rheumatoid arthritis were reviewed 8 years after surgery. 14 patients had the modified prosthesis implanted. There was dramatic relief of pain and improvement in function following surgery. There was a reduced fixed flexion deformity and an increased range of movement with the modified prosthesis. None of the humeral components of the modified prosthesis have as yet required revision. In selected patients therefore, this operation is a predictably successful procedure. Our follow-up confirms the ability of the modified prosthesis to provide a pain-free, stable and mobile joint.

A total of 107 patients with thoracic outlet syndrome were reviewed an average of 4.1 years (range 2–11 years) after primary scalenotomy. The sample included 86 women and 21 men, and the mean age at surgery was 41.9 years (range 16–59 years). The three most disturbing pre-operative symptoms were pain at rest (87%), numbness (66%) and lack of power (55%). The post-operative success rate diminished from 71% 1 month after operation to 63% at follow-up. The retirement frequency increased from 6% up to 33% during the follow-up time. It was highest among factory workers at 60%. Of the patients older than 45 years at surgery, 68% were retired at follow-up. The importance of careful selection for operation is emphasized, and also the need to consider vocational rehabilitation before resorting to surgical treatment of thoracic outlet syndrome. We recommend surgical treatment for this disabling disorder, especially for younger patients with clear evidence of thoracic outlet syndrome who are engaged in occupations demanding little repetitive work. The best results have occurred in this group.

Three cases of tuberculosis of the hand are presented. There was a significant delay between the onset of symptoms and the correct diagnosis. Several observations are made to increase the awareness of this condition.

Congenital ulnar pseudarthrosis is a very rare condition. Two cases are reported in addition to 36 already reported in the English literature. One of the cases reported had a “one-hone forearm” procedure done, with a satisfactory result after 6 years. The second case had a free vascularized fibula graft procedure with restoration of the bony alignment and union after 8 months of follow-up.

We report three cases of ulnar ray deficiency in one family. The father had a left ring finger deficit, and a hypoplastic little finger was amputated at childhood. His first baby had a deep cleft between the ring and little finger in the right hand, and his second baby had complete absence of the left ulna, only one metacarpal, and two digits were present on the hand. All three cases were unilaterally involved and they had no other skeletal abnormalities.

Patients with Apert’s syndrome usually have severe complex syndactyly affecting both hands. Surgical separation of the distal digital bony fusion often exposes bone and cartilage which can cause problems with graft take.

A case is presented where the bare divided bone between two digits was kept apart with a silastic sheet. On its removal 4 weeks later, the previously bare bone was covered with a membrane. This was covered with a full thickness skin graft with a complete graft take.

A new fibrin seal has recently been evaluated in terms of axonal regeneration; however morphological examination of the fibre composition of regenerated nerves may not necessarily provide functionally relevant information. This study therefore aims to evaluate the functional regenerated sensation, following peripheral nerve transection treated with fibrin seal (Tisseel-Duo, Immuno; Austria). The sural nerve-innervated skin of the rat hindfoot served as the target organ. Previously published results from animals following transection and suture served as controls. Ten 3-month-old female Sprague-Dawley rats were used. The sciatic nerve was divided and rejoined with fibrin seal. The rats were allowed unrestricted movement directly after surgery and allowed to survive for 3 months. Our observations show that the functional results of regenerated polymodal nociceptors and low-threshold mecanoreceptors show no statistical difference when compared with microsuture. This strengthens the early positive morphological impression of this new product. Further prospective studies in man are anticipated.

We have carried out a retrospective study of 88 consecutive digital nerve repairs in 84 patients who presented to this department between September 1989 and September 1991. 94% of the patients were operated on within 24 hours of the injury, and the nerves were repaired using magnifying loupes (× 4.5)

71 patients were assessed clinically 8 to 32 months post-operatively. 17% of the patients had excellent results, 51.1% good results, 22.8% fair results and 9.1% had poor results.

Close correlation between age and recovery of sensation and between smoking and nerve recovery were found. Results were better in nerves that were cut cleanly (64.3% were excellent/good) than in crushed nerves (28.1%). Without the availability of an operating microscope, loupes give a satisfactory result in nerve repair, and this study compares well with reported series.

In order to determine if fibrous flexor sheath ganglia had any histological features that could distinguish them from other ganglia, we reviewed 50 consecutive ganglia treated by surgical excision. Of these, eight were fibrous flexor sheath ganglia. They did not have any specific features to distinguish them from the other ganglia. Furthermore, an absence of true synovial lining in them refutes the theory that they may result from synovial herniation around the A1 pulley.