Journal of Hand Surgery (European Volume)

Primary bone tumours are rare in the hand and wrist. This 34-year survey of the Leeds Regional Bone Tumour Registry reveals 80 such tumours, representing 3.9% of the total number of bone turnouts in the registry.

The large majority of these tumours were benign (86%), and were found predominantly in younger patients. Malignant lesions were found more frequently in older patients. 61% of tumours were found in the metacarpals and proximal phalanges. Two-thirds of patients (67.5%) presented with features of swelling, either with or without pain.

We conclude that the information gathered from Bone Tumour Registries is of value in describing tumour characteristics, where such information could not be gathered by personal experience alone.

Aneurysmal bone cysts are uncommon in the hand. An aneurysmal bone cyst in the capitate of a 16-year-old girl is presented, and 32 previously recorded cases are discussed.

Aneurysmal bone cysts are rare lesions which even more rarely involve the bones of the hand. We report a case of a cyst involving the lunate which was initially mistaken for interosseous ganglion. Due to delay in diagnosis, marked destruction of the lunate occurred, necessitating excision and scapho-capitate arthrodesis. Although rare, aneurysmal bone cysts should be included in the differential diagnosis and ruled out prior to embarking on a course of treatment.

Fibrolipomatous hamartoma of nerve is a rare benign infiltrating condition of peripheral nerves leading to progressive functional loss. Previous descriptions have virtually all been confined to the distal part of the upper limb, with the median nerve being the commonest reported site. Most cases occur in the first 3 decades of life and a third are associated with macrodactyly. A case is described in a 63-year-old woman, involving the whole of the brachial plexus, a previously unreported site for this particular lesion.

Erb’s palsy is the most common obstetric brachial plexus injury followed by total plexus palsy. The distribution of Klumpke’s birth palsy with modern obstetric practice is unknown. In this paper, we studied the distribution of Klumpke’s birth palsy in our series of 235 consecutive cases of obstetrical brachial plexus injury and determined the incidence of this type of palsy to be 0.6% as cited in the English literature over the last decade.

The association of fractures and neurological injuries is well recognized, especially with certain upper limb fractures. Typically, the nerve injury occurs at the time of initial fracture displacement. A case is reported of an unusual combination of fracture and nerve injury in a child, with the extremely rare occurrence of a slowly evolving nerve injury. The potential for delayed nerve injury following a fracture needs to be appreciated to prevent delays in diagnosis and treatment.

We reviewed 49 cases of flexor to extensor tendon transfer following injury to the radial nerve (22) or brachial plexus (27). Post-operative follow-up averaged 5.6 years (0.5–12.5). Function was improved in 84% (41) of patients. 16% (8) reported no improvement; of these, four (50%) had associated vascular injuries. In those with improvement, impaired coordination and dexterity were reported by 79% (15 of 19) of the plexus injuries and in 64% (14 of 22) of the radial nerve palsies. Premature fatigue was noted by 89% (17 of 19) of plexus injuries and in 82% (18 of 22) of radial nerve palsies. The power of wrist extension averaged 22% of the contralateral side (8% to 80%), power of digital extension was 31% (5% to 130%), and power grip was reduced to 40% (5% to 86%).

Cardiovascular functional stability of 11 women with thoracic outlet syndrome (TOS; mean age 34.5) and nine female controls (mean age 35.1) was studied using an orthostatic test, a deep breathing test, Valsalva manoeuvre and hand-grip test. The heart rate at rest was significantly higher in TOS patients. The TOS group showed significant accentuation in T wave vacillation in the orthostatic test. The rise in diastolic blood pressure of the TOS group during a hand-grip test was significantly less than that of the control group. TOS patients experienced significantly more distress according to the modified somatic perception questionnaire (MSPQ) than the control group. Pain was correlated with the score of MSPQ, the resting heart rate and increase in diastolic blood pressure in a hand-grip test. The results suggest that TOS patients’ symptoms often reflect a wider disturbance than merely anatomical compression in the thoracic outlet. It seems possible that sympathetic tone is higher in TOS patients than in controls. In addition to possible operative treatment, it may be necessary to provide psychological help, relaxation and endurance training.

We describe a strapping device for elevation of the shoulder in patients with thoracic outlet syndrome (TOS). The device was used by 86 patients with TOS whose symptoms had been alleviated by passively raising the shoulder. Symptoms of TOS were classified as proximal, including pain in the shoulder girdle, and distal, in which there were neurological deficits related to the brachial plexus. The device was more effective in patients with distal symptoms: pain disappeared or improved in 67% of patients; numbness in 85%; sensory disturbance in 84%; and motor disturbance in 80%. However, proximal symptoms were relieved in only 65% of the patients. The ability to perform activities of daily living was rated as excellent in 33% of patients, good in 44%, fair in 12%, and poor in 9%. The shoulder orthosis described in this report can counterbalance downward traction on the brachial plexus and reduce the tension on it, thereby relieving symptoms of TOS.

Correspondence is presented recording an operation for release of the carpal tunnel performed in 1924, together with a biographical note on the surgeon, Herbert Galloway.

Superficial sensory communication between the ulnar and median nerves is well recognized. In the vast majority of cases this communication is from the ulnar nerve to the median nerve.

We report a case in which a communicating branch passed from the median nerve to the ulnar nerve immediately proximal to the wrist to supply sensation to the little finger. The presence of this branch correlated with the presence of symptoms which had persisted in spite of conventional open carpal release 7 years earlier. Surgical decompression of this branch led to complete resolution of those symptoms.

With the recent introduction of computer-assisted sensibility testing devices, it is possible to investigate the hypothesis that the neurological mechanisms responsible for perception of pressure and two-point discrimination are influenced by skin hardness. This study examined the relationships between the skin hardness of the human index and little finger pulp and the perception of pressure in 25 adults. Skin hardness was measured using the Derma-Durometer. Pressure perception was measured with the Pressure-Specified Sensory Device®* for both static and moving touch stimuli and for two-point discrimination. The mean hardness of the fingertip pulp was 12.5 ± 0.6 gm/mm². There was no statistically significant difference in hardness between the dominant and non-dominant, right and left, index and little, or male and female fingertips. Skin hardness was independent of age for this population. The highest correlation, which was r = 0.46, was found between the cutaneous pressure threshold for one-point static touch and skin hardness. While this degree of correlation is significant at the P < 0.02 level, the r² = 21%, demonstrating that this degree of correlation leaves 79% of the variability unexplained. These results suggest a physical interaction between mechanoreceptors and dermis that is only partially explained by the hardness of the skin.

A method of surgical correction is described for Wartenberg’s sign, or persistent abduction of the little finger, using a slip of the extensor digitorum communis of the ring finger. The transferred component can be either the central slip, or the ulnar slip extended by the connexus intertendineus to the little finger.

This technique maintains the integrity of the extensor mechanism of the little finger, avoiding loss of active extension, which is frequently observed when extensor digiti minimi is used. The donor site is dependable since the extensor digitorum communis tendon of the ring finger is always composed of several slips.

This technique should be considered only in cases of isolated persistent abduction of the little finger, when there is no claw deformity.

29 patients with severe upper extremity injury were treated with 27 emergency free flap and three emergency toe-to-hand transfers, after radical débridement and primary reconstruction of all injured structures. There was no flap failure, and no infections or wound-healing complication were seen.

Follow-up ranged from 3 months to 6.6 years with a mean of 3.2 years. 19 patients returned to work (14 to their original jobs), three were retired and another seven had no employment before injury. Operation time ranged from 2 hours 45 minutes to 18 hours 20 minutes with an average of 7 hours 45 minutes, depending upon the size of the defect and mechanism of injury.

Long-term follow-up revealed successful functional and aesthetic results, decreased morbidity and invalidity, and reduced rates of free flap failure, post-operative infection, secondary operative procedures, hospital stay and medical expense.

A case is reported of the difficulties associated with late free toe transfer for thumb reconstruction after an initial reverse radial forearm flap.

We have developed a simple, cheap and efficient method of management of fingertip injuries using an occlusive dressing – the fingertip cap (Hyphecan). The results of 156 fingertip injuries treated with this method demonstrate recovery to a near normal fingertip.

59 dog cadaver flexor digitorum profundus tendons were repaired with one or two knots inside or outside the tendon, using two, four and six suture strands. The ultimate tensile strength and gap strengths were compared. Locating the knots outside rather than within the tendon repair site showed significantly higher ultimate tensile strength for two, four, and six strand sutures. The strength was greater in one knot than in two knot sutures; the value of the six-strand suture using the one knot outside technique was the greatest. Similarly, increased gap strength was also obtained from the one-knot-outside technique. We concluded that the knots should be located away from the tendon repair site and there should be as few as possible.

A new simple cut and fold technique is described, which allows precise shortening of extensor tendons in the hand by a few millimeters.

Closed avulsion of both flexor digitorum profundus and superficialis from the same finger is rare. Only ten cases have been described in the literature. The majority were treated with a two stage reconstruction of the flexor digitorum profundus. We describe a case in which primary repair of both tendons was performed.

Two cases of loss of function of the flexor pollicis longus tendon are presented. Initial assumptions that these were cases of primary tendon rupture proved to be wrong when unexpected intraoperative findings suggestive of previous long standing tendon rupture were later matched with a history of previous trauma. Spontaneous subcutaneous rupture is rare in otherwise healthy tendons.

Between 1989 and 1993, 20 patients with distal radial fractures were treated with a buttressing technique felt to be safe, effective and simple. Out of the initial 20 patients, 16 have been followed-up and are reported. The technique uses an intramedullary styloid pin and a combined extramedullary–intramedullary dorsal buttress pin. The insertion technique and the use of a medial corner pin are illustrated. Results are evaluated from both final X-ray appearance as well as return of function using the five X-ray parameters of Abbasazadegan et al (1989) and the Mayo modification of the Green and O’Brien wrist score (Cooney et al, 1987). The average score on return of function was 78 (two excellent, eight good, six fair). Final axial shortening averaged –1.4mm (+5 mm– –4 mm), radial displacement averaged 0.68 mm (0 mm–5 mm), radial angle averaged 24.75° (18°–34°), dorsal angle averaged +8.25° (–5°–25°) and dorsal displacement averaged +1.31 (0 mm–+12 mm). From this study we recognize the need for a posterior medial pin, and that routine stress views after pinning can yield information concerning carpal instability, palmar instability and the need for bone grafting.

Assessment of the grade of deformity after fracture of the distal end of the radius demands an accurate method of determination of radial shortening. Radiographs of 50 patients with malunited Colles’ fractures were analyzed in order to find the method which is least affected by changes in ulnar and palmar flit. Two new landmarks, the centre-point in the distal articular surface of the radius and the capitate vertex, are introduced as possible new landmarks for radial shortening determination. Results derived from commonly used methods and the new method are compared and analyzed. These show that radial shortening measured according to the commonly used landmarks is greatly affected by changes in ulnar and palmar tlit, leading to errors. Shortening measured by the two new landmarks gives results that are less influenced by rotation of the distal fragment in the frontal and sagittal planes.

Human cadaver thumbs were tested to evaluate stability of the radial side of the MP joint. The contributions of the dorsal capsule, radial collateral ligament, accessory collateral ligament, and volar plate were examined with the joint in 0° and 30° of flexion. At 0° flexion, the average joint angulation increased 4° following isolated radial collateral ligament transection and 6° following isolated accessory collateral ligament transection. Release of both the accessory and radial collateral ligaments produced marked instability with joint angulation of at least 46° The accessory collateral ligament helped to stabilize the extended MP joint. There were no significant contributions to stability from the dorsal capsule and volar plate when the collateral ligaments were intact. In the laboratory setting, radial-side instability of the MP joint of the thumb requires transection of both the proper and accessory radial collateral ligaments.

Between March 1977 and December 1991, 98 surgical procedures on 85 patients were performed at SOS Main Strasbourg for osteoarthrosis of the carpometacarpal joint of the thumb. The mean age was 56 and 90% were female; 13 were operated on bilaterally. 40% had Swanson arthroplasties (group 1), 15% Ashworth-Blatt hemiarthroplasties (group 2), and 45% had soft tissue arthroplasties (group 3). 62 cases were reviewed at an average follow-up of 5 years. Normal thumb range of motion was obtained in all cases, regardless of the technique used. Complete pain relief was achieved in 77% of the cases in group 1, 37.5% in group 2 and 71% in group 3. 15% of group 1 and 50% of group 2 required surgical revision, either for displacement or fracture of the implants. No revision was necessary in group 3. One case of silicone synovitis requiring secondary surgery was noted 6 years after surgery, accounting for 2.9% of the total number of silicone implants reviewed, but radiological signs of silicone synovitis were much more common (56%). Proximal metacarpal migration in group 3 averaged 38% of the initial arthroplasty space, and was not related to the type of ligamentoplasty used, or presence or absence of an “anchovy”. The migration increased to 68% of the space if an associated MP joint arthrodesis was carried out at the same time. Complications included reflex sympathetic dystrophy (4% in group 1 and 14% in group 3). The Ashworth-Blatt hemiarthroplasty failed to gain satisfactory results, but both silicone arthroplasty and soft tissue arthroplasty proved to be useful procedures. However, due to the risk of synovitis the present treatment of choice is soft tissue arthroplasty.

Surgery for recurrence of Dupuytren’s disease often results in a volar skin defect. The use of the distally-based dorsal hand flap for resurfacing is reported. 17 flaps were used to cover 16 fingers after radical digital fasciectomy. All flaps survived with minor areas of partial necrosis in four of them. The raising of the flap was a simple procedure and good quality skin cover was achieved. There were no complaints about the donor site or the flap pedicle passing between the digits. The short post-operative immobilization time might result in less stiffness and a better functional result. It is concluded that the flap is a useful technique in treating skin defects in this condition resulting from surgical excision of the disease and involved skin.

Two patients with a rare form of congenital varicella involving the upper limb are described. The spectrum of disease, pathophysiology, principles of management and prevention are discussed.