Journal of Hand Surgery (European Volume)

An interposed segment of nerve was used to enhance the distance over which freeze-thawed muscle autografts will support effective peripheral nerve regeneration. Gaps were created in the sciatic nerves of adult Lewis rats. Regeneration through 1 and 1.5 cm freeze-thawed muscle grafts was compared to regeneration through nerve-muscle sandwich grafts in which muscle grafts of equivalent length were divided and a 2 mm segment of the distal nerve sutured between the two halves of the muscle, providing an intermediate depot of Schwann cells. Electrophysiological and morphological evaluation was carried out 40 weeks after operation. Despite lengthening the graft, and having four anastomoses instead of two, this manoeuvre enhanced nerve regeneration over each gap studied and for the 1.5 cm gaps compared favourably with perfect match nerve autografts. In addition, a number of grafts were examined at 7 and 14 days by Sl00 immunohistochemistry. Schwann cell migration was seen to proceed both proximally and distally from the intermediate segment at a rate similar to that from the distal stump. It is concluded that sandwich grafts may prove to be effective alternatives to cutaneous nerve grafts for peripheral nerve reconstruction.

This study introduces a new nerve conduit material consisting of orientated strands of the cell adhesive fibronectin. Axonal regeneration, Schwann cell behaviour and the degree of inflammation were quantified using immunohistochemical techniques and computerized image analysis. The results when fibronectin was used to bridge a 1 cm defect in rat sciatic nerve were compared to those with autologous nerve grafts and freeze-thawed muscle grafts used as controls. The nerve grafts supported the highest rate and amount of axonal regeneration in the first 10 days; however, the fibronectin supported a significantly faster rate of growth (P=0.0008) and amount (P=0.0001) of axons than the freeze-thawed muscle grafts. From day 15 onwards, the fibronectin and nerve grafts had comparable amounts of regenerating axons and Schwann cells. We conclude that the orientated form of fibronectin is a suitable material for successful nerve repair and has potential clinical use.

We report a comparative study of stimulation thresholds of cutaneous fibres of the rat in vitro skin and saphenous nerve preparation with psychophysical measurements of sensibility to cutaneous electrical stimulation in human volunteers. The same clinical diagnostic stimulator and modified skin electrodes were used in both animal and human experiments. Axons were recruited by increasing the stimulus strength, and correlation was made between the stimulus intensity required for unit activation and their conduction velocities. The findings suggest that an initial “tingling” sensation is due to recruitment of Aβ fibres and that later sharp “pricking” occurs with recruitment of Aδ fibres.

The subjective, objective and functional outcome following repair of isolated ulnar nerve injuries was assessed in 50 patients, 1 to 7 years after repair. We tried to identify those patients who may benefit from early tendon transfer. This study confirmed a satisfactory functional result in sedentary workers, but not in manual labourers.

Intrinsic muscle power, grip strength, key pinch and sensation continued to improve following repair of high injuries for at least 2 years, and of low injuries for at least 3 years. Early tendon transfers are only recommended in manual workers who complain of poor grip or key pinch.

48 patients with 50 involved limbs were retrospectively analyzed to determine factors influencing the outcome of surgical treatment for cubital tunnel syndrome. All patients were treated by anterior submuscular transposition of the ulnar nerve with Z-lengthening of the flexor-pronator origin. There were 24 men and 24 women with an average age of 42 years± 16.4 years (range, 5–75 years). The average follow-up time was 58 months (range, 12–156 months). A grading system was used pre- and post-operatively based on the severity of subjective complaints and objective findings. 92% of the patients were satisfied, or satisfied with some reservations, and only 8% were dissatisfied. All patients had either fair or poor pre-operative grades. 84% had excellent or good post-operative grades and only 16% had fair grades. There were no recurrences or poor post-operative grades in our series. Workers’ compensation status had no statistically significant adverse effect on postoperative patient satisfaction or post-operative grade. Anterior submuscular transposition of the ulnar nerve in this series provided satisfactory subjective outcome, relief of symptoms and adequate decompression of the ulnar nerve at the elbow.

Radial tunnel syndrome results from compression of the radial nerve by the free edge of the supinator muscle or closely related structures in the vicinity of the elbow joint. Despite numerous reports on the surgical management of this disorder, it remains largely unrecognized and often neglected. The symptoms of radial tunnel syndrome can resemble those of tennis elbow, chronic wrist pain or tenosynovitis. Reliable objective criteria are not available to differentiate between these pathologies. These difficulties are discussed in relation to 29 patients who underwent 30 primary explorations and proximal decompressions of the radial nerve. Excellent or good results were obtained in 70%, fair results in 13% and poor results in 17% of patients. The results can be satisfactory despite the prolonged duration of symptoms. We believe that a diagnosis of radial tunnel syndrome should always be born in mind when dealing with patients with forearm and wrist pain that has not responded to more conventional treatment. Patients with occupations requiring repetitive manual tasks seem to be particularly at risk of developing radial tunnel syndrome and it is also interesting to note that 66% of patients with on-going medico-legal claims had successful outcomes following surgery.

Motion of the median nerve was compared on an axial ultrasonographic image in the mid-carpal tunnel in 30 wrists of 15 women with bilateral idiopathic carpal tunnel syndrome and 30 wrists of 15 healthy women. During passive flexion and extension of the index finger, the control wrists had transverse sliding of the nerve beneath the flexor retinaculum (1.75±0.49 mm), which was regarded as a physiological phenomenon. In contrast, the wrists of patients with carpal tunnel syndrome had significantly less sliding (0.37±0.34 mm; P=0.0001), which indicates that physiological motion of the nerve is restricted. This decrease in nerve mobility may be of significance in the pathophysiology of carpal tunnel syndrome.

A new one-portal technique for endoscopic carpal tunnel release (ECTR) is introduced with its clinical results. The incision is made at the palmar aspect of file hand. A custom-made glass tube with a groove is inserted, and under endoscope observation, a meniscus knife is pushed forward along the groove to release the flexor retinaculum. This new technique has been studied in ten fresh cadaver hands and used in 123 patients' hands. Results of the cadaver study showed that the flexor retinaculum was released completely in all ten hands. No injuries to tendons, nerves, or arteries were noted. In one case the cotton tip was lost from the stick. All clinical releases were performed uneventfully except for three cases of neuropraxia of the digital nerve of the radial side of the ring finger, one laceration of the motor branch of the median nerve, one mild infection, one loss of cotton tip from the cotton swab stick, and one case of chipping of the glass tube. The case with the laceration of the motor branch of the median nerve occurred early in the series and required the conventional open incision to repair the nerve. The cases with loss of cotton from the stick and chipping of the tube also required a conventional incision to remove the cotton and glass chip. Advantages of this one-portal technique with the glass tube include less scar tenderness than with two-portal techniques, decreased risk of injury to the superficial palmar arch and ulnar nerve because of the distal approach, a view of pathology in the carpal tunnel through the glass tube, and confirmation of release of the flexor retinaculum.

To determine the long-term results of carpal tunnel release, we retrospectively reviewed 60 cases, an average of 5.5 years after surgery. 87% reported a good or excellent overall outcome; the average time to maximum improvement of symptoms was 9.8 months. However, 30% reported poor to fair strength and long-term scar discomfort, and 57% noted a return of some pre-operative symptoms, most commonly pain, beginning an average of 2 years after surgery. We found no correlation between pre-operative symptoms or extent of surgical dissection (internal neurolysis) and outcome. Carpal tunnel syndrome was job related in 42%; of these, 26% changed from heavy to lighter work following surgery. Although occupational cases were slower to improve and remained off work longer, the long-term subjective results were the same for both groups. We found significant morbidity from the surgical scar and decreased strength, and often considerable delay until ultimate improvement, especially in patients with job-related carpal tunnel syndrome.

We describe an unusual case of digital neuropathy of the thumb due to compression of the median nerve in the distal forearm by an extruded ganglion cyst originating from the radio-scaphoid joint of the wrist. Electrophysiologically, both conduction slowing and block of median motor and sensory axons were present across the cyst. These changes improved after surgery.

We have reviewed a series of 14 angioleiomyomas of the hand. Unlike angioleiomyomas elsewhere, those occurring on the hand are less commonly painful, have an equal sex distribution and are not predominantly of the solid type as seen in the lower limb. We were unable to find a strong association between histological appearance and clinical presentation. We were able to demonstrate nerve fibres within angioleiomyomas, which have not been reported previously.

We report a case of vascular leiomyoma of the pulp of the index finger that recurred twice and underwent malignant change. Ray resection proved to be curative. An extensive literature review is given

The vascular networks of the periphery of the fingernail have been studied on fingers of adults, foetuses and neonates, by injecting the vascular system with gelatinous Indian ink. The nail is an avascular structure, partially covered by the nail wall. It is lying on the nail bed which is prolonged forwards with the hyponychium. Each part of the nail apparatus presents a characteristic vascular network derived from dorsal collaterals arising from the palmar digital vessels and from their arcades. These networks are papillary, pseudopapillary, reticular and subdermal. Their morphology and density vary according to their localization and correspond with histological variations of the different parts of the nail apparatus. Thus, the germinal part of the nail bed shows poor vascularization. It is responsible for the colour of the lunula. The sterile part and the hyponychium have dense vascular networks with glomus bodies.

Digital ischaemia following radial arterial cannulation is uncommon. It is usually the result of thrombotic occlusion of a dominant radial artery. However, factors other than arterial thrombosis per se may operate in the critically ill patient to produce digital ischaemia. The following case presentation includes a review of possible mechanisms of digital ischaemia following radial artery cannulation and discusses the therapeutic options available.

This paper reviews the literature on the techniques for removing a ring from a swollen finger. A new technique using a serf-adherent compression bandage is described.

Equipment used in the mass vaccination of farm stock is a source of high pressure injection injury. We present four cases due to chicken vaccine, and one due to pig vaccine. Unlike injuries caused by paint or oil guns the vaccination delivers a fixed volume. Although the vaccine is in a mineral oil carrier it appears to elicit little inflammatory reaction in a small dose. The outcome is related to the volume injected. In chicken vaccine the dose is small enough to allow conservative or minimally invasive management. The large volume in pig vaccine requires treatment as for conventional high pressure injection injuries.

Tenography has been performed on eight detached lingers and two intact hands of cadavers. Bulging and overlapping of synovial pockets between the ligamentous structures during flexion, their flattening during extension and the continuous change in expansion of the proximal cul de sac suggests a possible mixing mechanism for the synovial fluid. During flexion and extension a physiological joint-type bowstringing of the flexor tendons was observed at the PIP and DIP joints. This finding supports the theory that the flexor tendon moment arm is increased at these joints.

The risks of foreign implantation may be avoided in tendon repair by the use of absorbable sutures, for example polydioxanone. In this study, the in vivo tensile strength half-life of 4/0 polydioxanone was found to be approximately 4 weeks. Using a rabbit model, we compared polydioxanone tendon repairs with polypropylene tendon repairs. Unilateral flexor digitorum longus repairs were performed on 46 rabbits using either polydioxanone or polypropylene. Tendons were harvested at 3 days, 2 weeks and 4 weeks and the tensile breaking strengths were obtained. 30 intact rabbit flexor digitorum longus tendons and 20 freshly repaired tendons were also tested. By 4 weeks, the repair strength had increased eight-fold from approximately 20 N to 166 N. The sutures made little contribution to the overall strength of a 4-week-old repair. There was no significant difference between polydioxanone and polypropylene repairs at any stage. These results show that polydioxanone repairs were as strong as polypropylene during the first critical weeks of tendon healing.

We report an unusual case of tenosynovitis in the hand. A female farm worker aged 66 developed swelling of the middle and little fingers. Extensive synovectomy of the flexor tendon sheaths was performed, and the synovitis was found to be due to Listeria monocytogenes, which is unusual in this area. Treatment with amoxycillin and gentamicin for 10 days was replaced by trimethoprimsulfamethoxazole for 3 weeks. There was no recurrence of infection 3 months after surgery, and flexion and extension were complete at that time.

Even though Charcot–Marie–Tooth (CMT) disease is seen frequently, relatively little has been written about the successful treatment of upper limb involvement using tendon transfers. It appears that there are several types of CMT disease and there is extreme variability in the clinical symptoms. The results of treatment were assessed by looking at four specific areas of hand function: decreased conduction velocity of the nerves, lack of opposition, weak pinch, and clawing of the fingers. A plan has been developed for tendon transfers that has worked well in clinical practice.

Although the histology of Dupuytren’s tissue is well-documented, conventional stains do not distinguish between the different types of collagen which biochemistry and immunochemistry suggest are present. Dupuytren’s specimens [nodules (n = 26), cords (n = 15) and dermofasciectomies (n = 6)] were stained with haematoxylin and eosin, Van Gieson’s, Mallory’s, Masson’s, and Herovici’s picropolychrome stain, and examined for both cellularity and collagen staining characteristics. All stains illustrated the marked cellularity of the nodules, contrasting with a paucity of cells within the cords. The first four stains demonstrated uniformity of the collagen staining within the tissues. Herovici’s picropolychrome, however, showed distinct staining patterns for the dermis, nodules and cords, with both purple/red and blue areas. Other studies suggest that those fibres stained purple/red and blue are types I and III collagens respectively. These findings may shed further light on the tissue of origin of Dupuytren’s disease.

Two new indications for the use of the first dorsal metacarpal artery (1st DMA) in reconstruction following severe hand injury are reported. In the first case, a primary pollicization of the index finger was based solely on the dorsal arterial network. The second case involves a microvascular arterial revascularisation of a 1st dorsal metacarpal artery island flap. Neither procedure has previously been described.

A case of severe traumatic injury to the thumb treated by an extended variation of the first dorsal metacarpal artery neurovascular pedicled island flap is reported.

The use of a V-Y advancement flap for reconstruction of a volar/lateral soft tissue defect in a digit involving segmental loss of the neurovascular bundle of up to 10 mm at middle phalangeal level is described. This flap allows immediate reconstruction with primary repair of the nerve and gives good functional results. Two cases are presented.

To evaluate the safety of inserting Kirschner wires into bones or across joints in a setting other than a completely sterile operating theatre, a prospective study of all hand fractures treated by closed reduction and internal fixation was conducted in a mid-city Emergency Department. Indications for percutaneous fixation were displaced, unstable long bone fractures of the hand.

71 fractures in 68 patients were treated, and in 91% the fixation crossed a joint. No patient developed osteomyelitis or pyarthrosis, and there was no deep pin track sepsis. Seven patients with open fractures healed without infection or delayed union. Patients in whom data were available obtained 90% to 95% of the motion of the contralateral digit. The taboo against percutaneous fixation of fractures in a non-operating theatre setting is not warranted. The procedure can be performed with minimal complications in an out-patient setting.

18 consecutive patients suspected of and treated for an acute scaphoid fracture were examined by lowfield MRI. This showed 11 fractures while seven scaphoids were considered normal. T1 weighted images showed a fracture as an area of decreased signal intensity. Two radiologically obvious fractures produced normal MR images. These fractures proved to be the result of old trauma. A wide spectrum of additional traumatic lesions in the wrists, not detected by routine X-ray analysis, were also demonstrated. These included seven fragmented triangular fibrocartilages (TFC), torn scapho-lunate ligaments in four cases and one torn triquetro-lunate ligament. Bone bruises of other carpal bones and seven other carpal fractures were also detected.

Low field MRI can be used to show scaphoid fractures and allows diagnosis of additional or simulating lesions.

The consequences of non-union of the scaphoid with or without deformity were evaluated before and after surgery with non-parametric tests, MANOVA and discriminant analysis, and Spearman correlation and contingency tables. 18 consecutive cases of scaphoid non-union, operated upon through a dorsal approach preserving the carpal ligaments since 1987, were used for measurements. Carpal height, radio-lunate and radio-scaphoid angles, lunate covering ratio, and apparent translation of the capitate and lunate were analyzed on standard views of the wrist before and after scaphoid repair. We found that the lunate covering ratio combined with the radio-lunate angle was the main indicator of deformity before the repair as suggested by the strong correlation between the radio-lunate angle and lunate covering ratio (P= 0.0001). After repair, the only indicator of mal-union was the apparent translation of the lunate on frontal views (P= 0.0033) as suggested by the strong correlation between real-union and lunate translation (P= 0.0001). Translation of both the lunate and capitate correlated well before and after repair. Radio-scaphoid angle and carpal height showed no significant changes and are not informative in the presence of subtle carpal alteration. Repair of the scaphoid produced an improvement in the radio-lunate angle in all cases, even in the presence of mal-union. However, full restoration was never achieved even in the absence of mal-union. More precise techniques of measurement might contribute to a better understanding of the carpal mechanics in relation to wefi-defined diagnoses such as scaphoid non-union.

We report four cases of late avascular necrosis (AVN) of the proximal part of the scaphoid following apparent healing of acute scaphoid fractures. One patient had been treated conservatively, by plaster immobilization, and the other three had undergone internal fixation of their acute fractures. The onset of symptoms associated with AVN varied, being as late as 2 years in one patient. Late AVN following healing of a scaphoid fracture does not appear to have been previously recognized, perhaps due to the fact that patients are seldom followed up for long enough. We feel that this condition is in many ways analogous to late AVN following femoral neck fractures and as such is a special complication related to the fact that both bones are intracapsular and have a precarious blood supply.

A rare case of total palmar trans-scaphoid-lunate dislocation is reported. Open reduction, bone grafting and internal fixation were followed by uneventful healing. At follow-up 70 months after injury there is no osteonecrosis and the wrist function is almost normal.

Most cases of zig-zag deformity following treatment of pre-axial polydactyly have resulted from inadequate reconstruction of bifid bony elements. We report its development after simple suture ligature of the radial component of a bifid thumb in the form of a soft tissue tag at the level of the MP joint. Successful reconstruction has been achieved with the use of similar principles proposed for the more characteristic zig-zag deformity. Parents, paediatricians, and obstetricians should be warned that simple suture ligature of the soft tissue tag may allow the development of a zig-zag deformity and require further reconstruction.