Journal of Hand Surgery (European Volume)

Referral letters and histories of patients seen for sarcomas involving their hands repeatedly describe a serious tumour found during or after shelling out a “lump”. Many times these apparently unexpected encounters are followed by an incomplete excision which is, in turn, followed by one or more local recurrences. Repeat operations are often amputations of increasing magnitude, and are not infrequently followed by the death of the patient. The hand is a site in which a patient usually presents for evaluation of a swelling when it is quite small. For the patient with a sarcoma, initial adequate surgery offers the best hope of cure.

Why are these relatively uncommon tumours of such interest and importance? They frequently afflict young, productive patients. When treated late or inadequately, they can result in tremendous suffering.

In recent years there has been considerable progress made in the treatment of sarcomas. Early and effective treatment often allows local control of the tumour without amputation. In order to accomplish this, the approach to these patients must be cautious and precise.

A rare case of an isolated granular cell tumour of the thumb pulp clinically mimicking a glomus tumour is described. The rationale behind performing oestrogen receptor staining for granular cell tumours is discussed.

We report an uncommon case of intermittent axillary nerve palsy caused by a humeral exostosis in an 11-year-old boy. After excision of the cartilagenous exostosis of the proximal end of the left humerus, the pre-operative symptoms of axillary nerve compression were alleviated.

181 patients treated for thoracic outlet syndrome by first rib resection were reviewed. 88 (49%) indicated a single traumatic event which precipitated the thoracic outlet syndrome. 79% of patients with a history of a single traumatic episode had good to excellent results after first rib resection. A separate group of 18 patients developed work-related thoracic outlet syndrome due to repetitive activities. Ratings of good to excellent results were lower (66%) among workmen’s compensation cases.

17 patients with haemophilia have been treated for a neurological deficit of the upper limb. Four of the five entrapment neuropathies have been operated upon, and only two patients recovered completely. Only two of the 12 patients with a compartment syndrome have been operated upon, and only two had sequelae. Clotting factor replacement is always indicated as primary treatment. Surgical release is indicated if the condition fails to improve. Late treatment was responsible for incomplete recovery, whatever the cause of the nerve compression.

A 60-year-old man with wasting and weakness of the right hand following ulnar nerve entrapment at the elbow was referred for electrotherapy. An ulnar nerve transposition had been performed 2 years previously. This had produced some improvement in nerve conduction without significantly improving hand muscle function.

The right first dorsal interosseous muscle (FDI) was stimulated for 4 hours per day over a 6-week period with a stimulus pattern replicating the discharge of a single motor unit from a healthy, fatigued FDI (patterned neuromuscular stimulation or PNMS). The response was assessed using a single case design. Significant improvements in the strength and fatigue resistance of the FDI were observed, associated with improvements in general hand function.

PNMS may be useful in restoring hand function in patients with muscle atrophy following entrapment neuropathy.

Carpal tunnel syndrome is one of the many so-called cumulative trauma disorders thought by some to be related to the performance of repetitive tasks in the work-place. The cause of this disorder is unknown. We have observed lumbrical muscle incursion into the carpal tunnel during finger flexion. This study was conducted to determine the amount of this incursion in normal wrists. Five cadaver upper limbs were analyzed radiographically with radiopaque markers on the flexor retinaculum and the lumbrical muscle origins in four finger positions: full extension, 50% flexion, 75% flexion, and 100% finger flexion. The lumbrical muscle origins were an average of 7.8 mm distal to the carpal tunnel in full finger extension. They moved an average of 14 mm into the carpal tunnel with 50% finger flexion, 25.5 mm with 75% flexion, and 30 mm with 100% flexion. Abnormal lumbrical muscles have been cited as a possible cause of carpal tunnel syndrome. These findings suggest that lumbrical muscle incursion during finger flexion is a normal occurrence and is a possible cause of work-related carpal tunnel syndrome.

The dynamic relationship of the lumbrical muscles to the carpal tunnel was studied in 35 hands in 32 patients and their movement into the tunnel on finger flexion was examined with a view to its use as a diagnostic provocation test in carpal tunnel syndrome.

We have compared the regeneration of axons through frozen-thawed or heated muscle autografts in the sciatic nerve of adult rats. Our results have shown that axons regenerate through muscle grafts which had been either frozen-thawed or heated to 60°C prior to transplantation. However, axons failed to regenerate through muscle grafts which had been pre-heated to 80°C. We speculate that this difference may be related to the thermal lability of components of muscle basal lamina, such as laminin and fibronectin, which are known to play an important role in axonal outgrowth.

To test the hypothesis that cognitive capacity is correlated with the outcome of functional sensibility after nerve repair, 19 patients were evaluated 2 to 5 years after median or ulnar nerve repair at the distal forearm level. The sensory evaluation included tests for functional sensibility as well as assessments addressing perception thresholds for touch/pressure and vibration. Psychometric tests for cognitive capacity were also carried out.

Multiple regression analysis, correcting for the effect of age and the ability to perceive touch/vibration, was used to investigate the relationship between functional sensibility and cognitive capacity, and to determine which of the tested central nervous factors had the greatest influence on the outcome of recovery of functional sensibility. On a ranking list of such factors verbal learning and visuo-spatial logic capacity were the most important ones, indicating significant correlations with functional sensibility. It is concluded that cognitive capacity factors may play an important role for the functional outcome following nerve repair and that variations in such factors may help to explain the variability in the outcome of nerve repair.

The soccer goalkeeper is particularly prone to injuries of the hands. We report three cases in which soccer goal-posts were the cause of a hitherto unrecorded type of accident, which resulted in severe ring avulsion injuries requiring surgical amputation or replantation. In each case the injury occurred when a ring worn by the goalkeeper caught on one of the hooks by which the netting is attached to the goal-posts. Proposals made for the prevention of such injuries include increased awareness through education, discouragement of the wearing of rings during sporting activities and the redesign of the attachment systems of goal nets.

An arterial graft was taken from the left femoral artery of the rat and grafted into the right femoral artery using the telescoping anastomotic technique at both the proximal and distal anastomoses to compare the patency rate with that of the vein grafts interposed into the arterial defect with the same telescoping technique. The time required for each anastomosis was about 10 minutes and all of the 31 grafts remained patent without application of xylocaine, yielding a higher patency rate than the vein grafts interposed in an arterial defect. The telescoping technique proved to be so dependable that it could be used at least twice in an artery. Inserting one vessel stump into another using the telescoping technique may not itself be responsible for the failure of vein grafts interposed in an arterial defect, but distortion of the slack venous wall of the graft by high arterial blood pressure is.

Early stage 3 Kienböck’s disease has been treated by inner débridement, recontouring, height reconstruction, bone grafting and core revascularization of the lunate; additional procedures included temporary external fixation of the wrist and/or shortening osteotomy of the radius in selected cases.

26 patients, representing an uninterrupted series of 28 procedures, were followed-up for an average of 6.7 years (range 2.5–9.3 years) with periodic clinical and radiographic evaluations until they reached the final comprehensive assessment that included trispiral tomography and MRI.

Every patient was subjectively improved, pleased with the result and able to resume his previous job. Pain intensity, rated on a zero to five scale, improved from 2.5 points pre-operatively to a final score of 0.8 points. Wrist motion gained slightly. Grip strength improved significantly. Lunate reconstruction proved successful in 37% of the cases; in an additional 23%, the disease process was stabilized. Carpal height decreased 4.7%; ulnar translation was not substantially altered. Arthrosis increased postoperatively in 55%, remained unchanged in 36% and progressed in 9%.

Overall, 43% good and excellent, 43% fair and 14% poor results were observed.

Silicone implant arthroplasty is, arguably, the most effective treatment for the majority of patients with symptomatic arthritis in the hand and wrist. In 1985 the problem of silicone synovitis was first brought to our attention. Since that time there have been numerous reports on this condition leading to a worldwide trend against the use of silicone implants. However, the true incidence and effects of silicone synovitis have not been clearly defined. For this reason, we have undertaken a survey of all patients who have undergone silicone implant arthroplasty in the wrist and hand in our Unit between 1975 and 1990.

Patients with rheumatoid arthritis and those undergoing MP or IP joint arthroplasty were excluded. Of the 289 implant arthroplasties remaining, we have been able to review personally 229 implants with a mean follow-up of 3.8 years (range 1–15). Although 40% of cases showed significant radiological changes, only 11 patients (4.8%) developed symptoms requiring treatment. Of these, two were managed conservatively whilst the rest underwent revision surgery, all with entirely satisfactory results.

We conclude that silicone implant arthroplasty remains the treatment of choice for patients with painful joint disease in the hand and wrist.

We have reviewed the results in 34 patients (39 operations) following simple excision of the trapezium for osteoarthritis of the basal joint of the thumb. The average age at operation was 57 years and the average follow-up was 6 years. All the patients were graded clinically and radiologically and were asked their opinion of the procedure.

There was dramatic relief of pain following this procedure. Stability of the thumb was not compromised. When compared to the unoperated side, thumb length, thumb abduction and first web span were similar. There was a reduction in pinch strength (operated 8.1 k.p.a., non-operated 9.6 k.p.a.) and grip strength (operated 15.5 k.p.a., non-operated 19.5 k.p.a.) and an increase in MP extension (operated 5.4°, non-operated 2.9°) following this procedure but the differences were not statistically significant. 11 patients (32%) had scar hyperaesthesia on testing but this was a clinical problem in two patients only (5%).

Simple excision of the trapezium is a satisfactory procedure for the majority of patients with this disorder, but has a long post-operative rehabilitation period.

Over a 10-year period, 32 trapeziometacarpal (TM) joint fusions were performed in 29 patients, and reviewed. Pin fixation with tension band wiring was used in 14 cases, screws in eight cases, a plate in six cases, K-wires in three cases and staple fixation in one case. None was bone grafted. Splinting was applied for 4 to 5 weeks. There were four cases of delayed union (more than 2 months) and four cases of non-union requiring re-operation (12.5%). The average follow-up was 6 years and 7 months. Grip (26.5 kg) and pinch (4.9 kg) strength were respectively 7% and 18% less than the normal contralateral side. In bilateral osteoarthritis, grip and pinch were stronger than the contralateral side.

Joint angulations measured on X-ray films showed for the peritrapezial joint an 18° arc in flexion-extension (a reduction of 64% compared to the contralateral side) and 11° of arc in abduction-adduction (a reduction of 72%). MP joint mobility increased in extension (160%), in flexion (23%), in abduction (120%), in adduction (157%). Despite the marked decrease in motion, subjective functional complaints were minimal. 78.1% of the patients were fully satisfied, 15.6% partly satisfied, and 6.3% dissatisfied. Pain was absent in 50% of the cases and very mild in 40.7%. Three patients complained of discomfort. Eight patients were noted to have osteoarthritic changes in the scaphotrapezial joint.

We investigated the use of real time linear ultrasonography in determining movement at a scaphoid fracture site in 27 patients with non-united scaphoid fractures. 24 of these patients had surgical treatment. Fracture movement was observed at the time of surgery and this was compared with the ultrasonographic findings. The technique proved to be 100% specific for visualization of movement at the fracture site and it was non-invasive. However, it was of no benefit in assessing proximal pole non-union.

144 patients with post-traumatic wrist pain hut normal standard radiographs were examined by wrist arthroscopy. Ligamentous lesions were observed in 75 patients. TFCC lesions, classified according to the Palmer classification and including lunato-triquetral interosseous ligament lesions, were seen in 61, and scapho-lunate interosseous ligament lesions in 14 patients. Degenerative TFCC changes were equally common in patients younger than 40 years of age but significantly more common with more than 2 years duration of symptoms.

Varying degrees of instability were noted in patients with scapho-lunate interosseous ligament lesions but no associated ligament lesions were observed. Because of the variety of pathological changes arthroscopy is recommended in the management of patients with post-traumatic wrist pain.

This paper describes a new and simple approach to the flexor tendon via strategically placed transverse incisions in the flexor tendon sheath.

We report a comparative study of the outcome of flexor tendon repairs mobilized by either a “passive flexion-active extension” or a “controlled active motion” regimen. We show that the controlled active motion regimen conferred significant benefits on the final range of motion and extensor lag. The rupture rate was raised with “controlled active motion” but this was not greater than levels reported by other authors using “passive flexion-active extension” regimens.

Continuous extension of Dupuytren’s contracture prior to fasciectomy results in a softening of the tissue, allowing straightening of the fingers. The observed change in cross-link profile indicates an increase in newly synthesised collagen due to increased turnover. This was confirmed by demonstration of the increases in levels of the degradative enzymes, the neutral metalloproteinases, collagenase and gelatinase and the acidic cathepsins B and L. Both types of enzyme effectively depolymerize the collagen fibres, albeit by different mechanisms, leading initially to loss of tensile strength and ultimately to solubilization. We suggest that the increase in enzyme activity is generated by tension on the fibroblasts of this metabolically active tissue produced during the continuous extension of the retracted fingers. The weakening of the fibres by degradation and the increase in newly synthezised collagen provide an explanation for the extension of the tissue without trauma.

After complete elongation using the continuous extension technique the palmar fascia of four patients with Dupuytren’s contracture was examined by light and electron microscopy and compared with non-elongated samples from 20 patients at the same clinical stage of the disease. Nodules and cords were no longer clinically recognizable after extension. The tissue contained collagen fibrils of uniform diameter (about 50 nm), densely packed in fibres parallel to the stretching force. Fine filaments (presumably proteoglycans) formed a network which was intermingled with and periodically bound to the collagen fibrils. Fibroblasts and myofibroblasts with an high biosynthetic activity and oxytalan-like microfibrils were aligned along the collagen fibres.

The results show that in Dupuytren’s disease the contracted palmar fascia reacts to external forces with neoformation and reorientation of all tissue components by myofibroblasts.

The flexed PIP joint presents a particular problem in the treatment of advanced Dupuytren’s disease. Following reports of the use of skeletal traction in the treatment of this condition, a simple device, the “Pipster” was developed to extend the PIP joint by skeletal traction before surgery. In seven fingers in five patients with severe contractures, there was a pre-operative improvement of at least 45° in the flexion angle (measured as maximum achievable passive extension). The technique was effective in primary and recurrent disease. Subsequent surgery was facilitated and amputation avoided in five tigers. The optimum distraction technique was identified. The study continues with more patients.