Journal of Hand Surgery (European Volume)

The spinal cord, dorsal rootlets, and ventral rootlets at the cervical level were visualized by endoscopy in ten goats. It is currently possible to visualize and document avulsed rootlets. With refinement in techniques and instruments, it will be possible to perform repairs, transfers or implantation of avulsed rootlets in the brachial plexus.

A case of an accidental burn caused by the operating microscope light during brachial plexus reconstruction is reported along with the various factors which could lead to such an injury.

41 heterodigital neurovascular island flaps were used to cover defects of the tactile pad of the thumb in 17 years. With an average follow-up of 75.5 months, 30 patients were reviewed. 17 were treated by the original Littler technique and 13 were treated with the same flap reconstruction but with division of the digital nerve innervating the flap and re-anastomosis of this nerve to the proximal nerve end of the ulnar digital nerve of the thumb.

Good aesthetic and functional results were achieved in both groups. Sensory acuity did not appear to decrease with time. The nerve reconnection technique solves the “double sensibility” phenomenon (present in 41.1% of our cases treated by the original technique), but two-point discrimination is less than that achieved by the Littler technique. Most complaints were related to the donor site such as hypertrophic scarring or scar contracture and cold intolerance, but these did not cause any real functional impairment.

Different internal spring-splint configurations were examined to determine the most effective in preventing adduction contracture after severe injuries disrupting the first web space.

A case of acute scapho-lunate dissociation is described in which the operative treatment was facilitated by the use of the “TAG” suture anchor.

Is lunate collapse in Kienböck’s disease a consequence of spontaneous revascularization, leading to focal osteolysis? A literature review of osteonecrosis in other locations such as the femoral head and bone allografts showed clearly that the loss of mechanical integrity is due to cellular processes which follow the spontaneous restoration of blood supply. We found no evidence in the literature that the lunate has been shown to be avascular at the time of collapse. On the contrary, increased osteoclastic activity has been reported. We excised and reimplanted the lunate in two monkeys, and found spontaneous revascularization, leading to increased osteoblastic activity. Other parts of the bone were destroyed by osteoclasts, leading to collapse. This histological example suggests that it may be possible to make an analogy with osteonecrosis in other locations. Thus, changes on plain radiography may indicate that the bone is revascularized spontaneously. Before performing operative revascularization of the lunate, one should consider that revascularization is a probable cause for collapse.

In patients with chronic wrist pain of more than 6 months duration, arthroscopy may reveal fraying of the ulno-triquetral and ulno-lunate ligaments. This can be a sign of longstanding triquetro-lunate dissociation.

We present a prospective study in which frayed ulno-triquetral (UT) and ulno-lunate (UL) ligaments were sought on wrist arthroscopy and correlated with longstanding triquetro-lunate (TL) rupture.

51 wrists of 30 embalmed cadavers have been used to perform an anatomical and radiological study relating cartilaginous and ligamentous lesions of the wrist with sex, age, ulnar variance (UV) and the state of the triangular fibrocartilage complex (TFCC) in an elderly population (mean 76.6 years). Two-thirds of all wrists (66%) showed cartilaginous lesions, mainly on the lunate (22, or 44%). The TFCC was perforated in 23 wrists (46%), and most were central degenerative perforations. Correlations were found between ulnar variance and TFCC thickness (P<0.05) and ulnar variance and TFCC perforations (P<0.05). A significant relation was observed between age and proximal row intercarpal ligamentous ruptures (P<0.05) and between age and ulnar variance (P<0.05). No statistical correlation was seen between ulnar variance and cartilaginous lesions on the lunate (P<0.05) in this slightly ulnar negative population (mean–0.37 mm).

13 patients who sustained high-energy crush or blast injury of the carpal bones were reviewed after a mean follow-up period of 30 months. These complex injuries resulted in unusual disruptions of the distal carpal row and adjacent metacarpals. Frequent involvement of the carpometacarpal (CM) joints and violation of the proximal carpal row were also demonstrated. Nine were open injuries, with the majority accompanied by significant soft tissue damage. Treatment included either closed reduction or open reduction and Kirschner wire fixation, and soft tissue procedures as indicated. In this series, the majority of the open injuries gave unfavourable functional results despite adequate carpal, alignment. Several cases had disastrous outcomes related to associated vascular injuries. Closed injuries, on the contrary, followed a relatively benign course. Nevertheless, decreased grip strength persisted in both groups for a long time. Patients with such a complex carpal injury should expect a less favourable prognosis due to the severe nature of the trauma.

Of 231 patients with fractures of the triquetrum, 65 were followed up after a mean period of 46.8 months. The fractures were classified and radiological and clinical follow-up was carried out. Pathomechanical aspects of the origin of the fracture were also considered. It appears that the chisel action of the dorso-proximal edge of the hamate striking against the fully extended and ulnar-deviated wrist is the major cause of the dorsal chip fracture of the triquetrum. Conservative therapy involving immobilization of the injured wrist for 3 weeks proved to be successful. If the bone fragment healed, it took 6 to 8 weeks. There was no indication for surgical intervention. We found no signs of post-traumatic instability of the joint. There was good vascularization of the bone, which excluded the possibility of avascular necrosis. All fractures involving the main body of the triquetrum united.

Malunion after a fracture of the distal radius in a young patient causes a significant disturbance of wrist function. We have performed distal radial osteotomies in 11 patients to correct radial malunion. Surgery was indicated in young patients with functional disability in the wrist due to limited wrist motion and pain. Many had an unacceptable cosmetic appearance of the wrist. In all patients surgery consisted of opening wedge osteotomies to correct radial tilt and radial angle. In some instances it was not possible completely to restore radial length without a reduction in ulnar length. Post-operatively combined dorsal and volar flexion improved from a mean of 34° to 72°. Combined pronation and supination improved from a mean of 68° to 106°. Pain assessed on a simple four-point functional score was decreased from a mean of 3.3 to 1.3.

Phalangeal neck fractures are uncommon in children. When these injuries to the proximal and middle phalanges are displaced and not treated operatively the fracture may heal in a malunited position with loss of motion at the IP joint. Remodelling in the area of the phalangeal neck is thought to be reduced because of its distance from the physis. In cases of malunion osteotomy of the phalangeal neck may be required to restore anatomy and motion. A case is described which demonstrates complete remodelling of a displaced middle phalangeal neck fracture in a child and recovery of a normal range of motion without operative intervention.

A prospective clinical trial compared two forms of initial management for closed stable fractures of the shaft of the finger metacarpals. Patients were randomized to treatment with a compression glove and early mobilization (21 patients) or to immobilization in a plaster splint (21 patients).

The mean loss of total active flexion (MP+PIP+DIP) in the second week after injury was 56° in the glove group and 84° in the splint group (P=0.0036). In the third week, the mean loss of flexion was 23° and 46° respectively (P=0.0010).

Hand volume and PIP joint circumference were significantly smaller in the glove group in the second week but not in the third and fourth weeks. Within each group, however, there was no correlation between range of motion and swelling, suggesting that these were independent variables in this study.

The support of the glove helped to relieve pain. Use of a compression glove avoided the loss of function imposed by splintage and was associated with a greater range of movement during the second and third weeks.

The rolling belts on argicultural machinery attract children who unconsciously grab them. The injuries produced include friction burns, injuries to flexor tendons, digital nerves and arteries, skin in Zone 2 and fractures. Subtotal or total amputation may occur.

We present the results of such injuries to 44 fingers in 16 children aged 1 to 9. The functional results are not satisfactory. In order to grade the results we have devised a classification to this injury. The survival rate for all fingers was 71%, but in the fingers with circulatory problems the survival rate was 50%. On functional assessment seven patients had a good result, seven moderate, and two fair.

A case is reported of significant ischaemic damage to a fingertip from the use of Sellotape. The elasticity of Sellotape has been tested and compared with that of Elastoplast, illustrating the stiffness of Sellotape and thus emphasizing its unsuitability. The general public needs to be aware of the dangers of using non-proprietary dressings and the medical profession must remain vigilant about the elasticity of dressings.

A series of 233 patients with complete divisions of flexor tendons in zones 1 and 2 underwent operation following emergency admission over a period of 3.5 years. These included 203 patients with 317 divided tendons in 224 fingers injuries in zones 1 and 2 and 30 patients with 30 complete divisions of the flexor pollicis longus tendon in zones 1 and 2. All of these patients were mobilized post-operatively in a controlled active motion regimen. 13 (5.8%) fingers and five (16.6%) thumbs suffered tendon rupture during the post-operative period. Patients treated during the last year of the study were followed prospectively for a minimum period of 3 months; ten of the 16 (62.5%) fingers with zone 1 repairs, 50 of the 63 (79.4%) fingers with zone 2 repairs, all three (100%) FPL divisions in zone 1 and three of four (75%) FPL divisions in zone 2 had good and excellent results on assessment by the original Strickland criteria (Strickland and Glogovac, 1980).

These results confirm the safety of this regimen as an alternative to other regimens of post-operative flexor tendon repair mobilization in zone 1 and 2 finger injuries. However, in the unmodified form used in this series, this regimen has too high a rupture rate for FPL mobilization.

A rare case of median nerve entrapment after posterior elbow dislocation is reported. Nerve entrapment was both in the healed medial epicondyle fracture and within the elbow joint and we recommend placing this type of entrapment separately in an extended classification of median nerve entrapment following elbow dislocation.

A case is presented of a bifid median nerve whose longest portion had a normal course while the other portion passed through a hole in the FDS tendon of the middle finger, at its musculotendinous junction. This caused nerve compression during muscle contraction, producing pain and dysaesthesia in the middle finger suggesting carpal tunnel syndrome.

Reported complications of endoscopic carpal tunnel release have increased as more surgeons use this technique to release the flexor retinaculum. We used a cadaver model to compare the results of endoscopic carpal tunnel release through a one-portal distal (Group A, 15 specimens) and a one-portal proximal (Group B, 15 specimens) entry site with a new endoscopic technique. Our custom-made glass tube of three different sizes (5, 7, and 9 mm in diameter) is designed to house an endoscope and accommodate a meniscus knife for releasing the flexor retinaculum. Complete release of the flexor retinaculum was obtained in all limbs in both groups. In Group A the one complication (7%) was loss of the cotton tip from the cotton swab stick within the carpal tunnel. In Group B, there was a single case of injury to the superficial palmar arch in one hand and breakage of a glass tube in another hand, for a total complication rate of 13%. No other damage to anatomical structures was noted.

A retrospective study was performed of 112 non-diabetic patients (133 bands) who bad open surgical treatment for carpal tunnel syndrome, to determine the factors associated with poor outcome. None of the patients had a previous carpal tunnel release and all had a positive nerve conduction study to confirm the clinical diagnosis of carpal tunnel syndrome.

Outcome was assessed at least 18 months after surgery and classified as excellent, good or poor. Outcome was deemed poor when symptoms were minimally improved, unchanged or worse after surgery. This occurred in 13.5% of treated hands. There was a higher chance of poor outcome in patients with physically strenuous work activities. All these heavy or repetitive manual workers were also involved in compensation and their poor outcome correlated with their inability to return to their original work. Other predisposing factors, associated hand conditions, duration of symptoms prior to surgery, the presence of bilateral or nocturnal symptoms, and the severity of the preoperative nerve conduction deficit did not affect the final outcome after surgery.

A retrospective study of 15 diabetic patients (20 hands), who underwent carpal tunnel release, was performed to determine the outcome. All patients had a minimum of 18 months of follow-up. Outcome was considered excellent if there was complete resolution of symptoms and this occurred in 35% of the treated hands. Eight hands (40%) had a good outcome with significant improvement of pre-operative symptoms. Outcome was considered poor when symptoms were minimally improved, unchanged, or worse after surgery and this occurred in 25% of treated hands. All hands with a poor final result had either no electrodiagnostic evidence of localized compression or only mild compression in pre-operative nerve conduction studies. It was postulated that the contribution of localized compression to pre-operative hand symptoms was less than the contribution of peripheral neuropathy in these hands.

The onset mechanism of cubital tunnel syndrome and carpal tunnel syndrome may be similar in haemodialysis patients. Carpal tunnel syndrome is well recognized as a consequence of dialysis-associated amyloidosis. This case report documents the development of cubital tunnel syndrome in a patient on haemodialysis treatment for 10 years. Proliferating granulation tissue at the elbow had entrapped and displaced the ulnar nerve. This was corrected surgically, and the patient experienced immediate relief of the numbness and the “tingling”, but the muscular atrophy had not improved after 8 months.

Patients receiving haemodialysis for more than 10 years were selected for this study in order to clarify an apparent sequential association of cystic lesions of carpal bones and carpal tunnel syndrome. X-rays and computed tomographs of 138 hands of 69 patients revealed cystic radio-lucency of carpal hones in 35% of the hands. Radiographs were classified into three groups: Group A—cyst growing, Group B—cyst not growing, and Group C—cyst absent. The prevalence of carpal tunnel syndrome was 100% (27/27) in Group A, 5.6% (1/18) in Group B, and 6.5% (6/93) in Group C. Growth of the cyst precedes the development of carpal tunnel syndrome by about 2 or 3 years. Growth of the bone cyst indicates that inflammation had already extended to the tenosynovium and median nerve. Cystic radio-lucency of the carpal bones appears to be a useful indicator of the onset of carpal tunnel syndrome.

We report two cases with long-standing systemic lupus erythematosus (SLE) who developed widespread calcification in subcutaneous tissue and peri-articular structures. To our knowledge only 26 case reports have appeared concerning this abnormality in SLE. However, there has been no report of calcification in an SLE patient in the literature of orthopaedic surgery. The calcifications of the forearm were marginally removed because of pain surrounding them. X-ray analysis revealed that the calcification was made of pure calcium phosphate.

We report five children with tranverse defects of the upper limb who developed calcified deposits at the distal end of the limb. The lesions were excised from two children and had the typical histological appearance of tumoral calcinosis but on clinical grounds it is unlikely that this is the same condition as that previously described as tumoral calcinosis.

Two cases of tumoral calcinosis are reported in children with congenital hand malformations. After excision of large calcific masses, reconstruction was performed using a free phalangeal graft in one case and a free toe transfer in the other.

Abductor digiti minimi transfer was used to restore opposition in 20 patients, the majority suffering from congenital anomalies of the hand. The transfer was shown to be effective in restoring abduction, but less effective in restoring the rotational component of opposition in these cases. The donor site was critically reviewed and found to be acceptable. The surgical techniques and benefits of this transfer are reviewed.

Two cases of Poland’s syndrome are reported in whom myoelectric prostheses have been used. The rare congenital sporadic disorder of Poland’s syndrome characterized by absence of pectoralis major and varying degrees of ipsilateral upper limb deficiency has been reported by various authors (Rasjad and Sutiaksa, 1991, Gausewitz et al, 1984; David, 1982; Ireland et al, 1976). Management of the upper limb deficiency depends on the degree of functional and cosmetic disability. We report two cases of Poland’s syndrome where myoelectric prostheses have been successfully used. We have been unable to find any published report of the use of a myoelectric prosthesis in Poland’s syndrome.

An isolated constriction of the tendon sheath of extensor digiti minimi caused triggering of the little finger. Incision of the tendon sheath resulted in recovery of frictionless gliding of the tendon.

A prospective study of hands with Dupuytren’s contracture was designed to test the association of three variables, the presence of an interdigital soft tissue mass, the presence of flexion contractures at each digital joint, and the duration of contracture, with the formation of spiral nerves. 66 digits in 37 hands affected by Dupuytren’s disease were examined intra-operatively. Of the 34 digits (52%) with spiral nerves, 28 had soft tissue masses (42%). The sensitivity of a soft tissue mass alone as a predictor of a spiral nerve was 59% and the specificity 75%. The presence of a flexion contracture at the PIP joint had a sensitivity of 88% and a specificity of 62% for the presence of a spiral nerve. The combination of a soft tissue mass and a PIP joint contracture was a very specific (94%) but not a particularly sensitive (50%) test for spiral nerve formation. The formation of a spiral nerve is progressive, occurring most often in hands with significant PIP joint contractures with or without soft tissue interdigital masses.

The Sagas of Icelandic bishops composed in and around the 13th century reveal something of the incidence and treatment of various hand conditions in the medieval period. A selection from the relevant material is translated and discussed.