Journal of Hand Surgery (European Volume)

Ten normal ring fingers from ten donors were used to determine the effect of flexor tendon repair on the gliding resistance between the tendon and the A2 pulley. Gliding resistance was measured for the intact FDP tendon and for the same tendon after it was cut transversely and repaired with a 4/0 Ticron core suture and a 6/0 running epitendinous nylon suture. After repair, the gliding pattern of the tendon through the A2 pulley changed significantly. The resistance and the friction coefficient were approximately doubled (P<0.005).

Experiments were performed to evaluate biomechanical aspects of the performance of a “deep-biting peripheral suture” for flexor tendon repair, either when used alone or with a square or modified Kessler core stitch, and the technique was compared to the Kleinert repair. Tests included progressively increasing cyclic loads, force to pull the repair into the A2 pulley, and ultimate failure strength. 50% of the Kleinert repairs failed under 30 N cyclic loading, while 100% of the DBPS plus Kessler core stitch repairs survived. There was no discernable difference in gliding function or repair bulk between these sutures, but ultimate strength increased significantly with the DBPS repairs. We concluded that the DBPS plus Kessler-type core stitch will survive active mobilization better than the Kleinert method.

The results of replantation at the wrist and distal forearm are reported to be better than at the metacarpal level, in part because the latter involve direct injury to the intrinsic muscles. This study evaluates a new post-operative protocol for replantation at the metacarpal, wrist and distal forearm levels. 3 days after replantation, the patient was placed in a dynamic crane outrigger splint with MP joint control, compensating for intrinsic muscle function loss. From 4 to 12 weeks, an anticlaw splint alternated with the outrigger splint. After 12 weeks, a dynamic wrist extension orthosis was added to the anti-claw splint. 11 patients (four replantations at the transmetacarpal level, three at the wrist and four in the distal forearm) had this protocol between 1988 and 1993. For distal forearm replantation, TAM of fingers averaged 216°, grip strength 42 lb, and pinch strength 7.2 lb with 75% good or excellent results. For wrist replantations, TAM of fingers averaged 243°, grip strength 37 lb and pinch strength 10.6 lb with 100% good or excellent results. For transmetacarpal replantations, TAM of fingers averaged 189°, grip strength 37 lb and pinch strength 5.6 lb, with 75% good and excellent results. Early protected mobilization, as described here, preserves tendon gliding, muscle strength and excursion. Our results support this protocol for wrist and distal forearm replantation and especially for transmetacarpal replantation, the results of which tend to be poor according to the medical literature.

A 37-year-old right-handed male truck driver was admitted with a severe injury of the dorsum of his right hand following a traffic accident. He had a large combined defect involving skin, tendons and bone. A complex reconstruction was performed using a large iliac crest allograft, a tendon graft and a free serratus anterior flap in one stage, 8 hours after the injury. A skin graft was performed later. 2 years later the functional and aesthetic result are good.

Models of scaphoid non-union with static dorsi-flexed intercalated segment instability were produced in five frozen arms from cadavers or subjects following accidents by repetitive mechanical loading of the wrist joints longitudinally after a bone defect has been made at the mid-portion of the scaphoid. We designed four models of reduction: anatomical reduction; reduction with a shortened scaphoid; anatomical reduction but with the radio-lunate ligament sectioned, and a shortened scaphoid with the radio-lunate ligament sectioned. Results suggested that anatomical reduction with rigid fixation with a Herbert screw was most effective for correction of malalignment with DISI. Preservation of the radio-lunate ligament during the palmar approach to the scaphoid seemed to be important to prevent ligamentous carpal instability.

Three cases of 6- to 8-week-old transcapho-peri-lunate dislocation of the carpus were treated with pre-operative progressive distraction, using an external fixation apparatus for 1 week. Surgical reduction and osteosynthesis of the scaphoid was then easily performed.

Fracture-dislocation of all five carpometacarpal joints is extremely rare, only ten cases having been reported since 1873. A case of isolated dislocation of all five carpometacarpal joints is presented. A good result was obtained 1 year after open reduction and internal fixation. This case is the only isolated dislocation of all five carpometacarpal joints in the English literature.

Two experiments were performed on the second and fifth metacarpals of five normal cadaver hands. The forces obtained on full extension and flexion of the digits were measured. An oblique osteotomy was performed on the shaft of the metacarpal and fixed with dorsal angulation. The forces obtained on extension and flexion of the digits were measured. The relationships between the changes in force and the angle were analyzed. Flexion force decreased and extension force increased as the dorsal angulation increased, and these were significant beyond 30° of dorsal angulation. The differences between index and little fingers were not significant.

In the second experiment, the metacarpal bone was shortened at the osteotomy site, and the same measurements made. Flexion and extension forces both decreased, and were significant beyond 3 mm of shortening. The differences between index and little fingers were not significant.

The radiological diagnosis of distal radial fractures is usually easy, but some fractures without displacement cannot be detected at the first examination. In this retrospective study of 626 wrist injuries diagnosed as “wrist sprain” we found 39 distal radial fractures which were discovered only after repeated examinations. The incidence of distal radial fractures was much higher than other wrist fractures that were diagnosed after repeated examinations. Repeat standard four-view X-ray examination, as well as other imaging methods, are necessary to diagnose these fractures.

Five cases of painful diaphyseal pseudarthrosis of the distal phalanx were treated with a longitudinal compression AO mini screw, without bone graft, and all healed uneventfully in 3 to 4 months.

We report four cases with six episodes of concurrent carpal and elbow fractures or dislocations. Few such combinations of injuries have been reported in the literature. We discuss the mechanism and management of such injuries and conclude that elbow injuries should be suspected in severe carpal injuries. Surgical treatment may be required in their management.

The relative elongation with elbow flexion of the ulnar nerve, proximal and distal to the cubital tunnel, and of the cubital tunnel retinaculum, was measured in cadaver specimens by stereophotogrammetry. The proximal part of the ulnar nerve elongated significantly with full elbow flexion. No significant change of length was measured in the distal part of the nerve. The length of the cubital tunnel retinaculum increased by an average of 45% from full elbow extension to full flexion.

Cubital tunnel syndrome is the second most common entrapment neuropathy of the upper limb. This paper presents the experience of treating cubital tunnel syndrome with simple decompression in 131 patients (164 ulnar nerves) over the past 12 years. 85% of these patients had mild or moderate ulnar nerve disease. In 146/164 ulnar nerves (89%), simple decompression resulted in good or excellent immediate post-operative relief of symptoms. After an average follow-up of 4.3 years (range, 0.8–12.0 years), 130/164 (79%) still reported good or excellent relief. The independent predictors of a better long-term outcome were absence of post-operative subluxation, greater body weight, normal pre-operative two-point discrimination (2-PD), and a more recent date of operation. A physical therapy rehabilitation program generally began on the day after surgery. Active participation in this predicted a rapid return to work or activities of daily living. The average time to return to work with simple decompression was 20 workdays.

Surgical findings show important alterations of the extrinsic and intrinsic vascularity of the ulnar nerve in the epitroclear groove. Current procedures are only able to solve the mechanical aspect of nerve compression. Transposition may cause additional iatrogenic ischaemic damage of endoneural vascularity if the nerve is separated from the ulnar collateral artery to achieve anterior mobilization.

Our technique of transposition of the ulnar nerve with its vascular bundle maintains the advantages of anterior transposition currently in use, but is able to preserve the whole vascularity of the nerve, thus solving the biological aspect of nerve compression. This allows quicker recovery of axonal activity that was chronically compromised by the entrapment neuropathy.

The technique and the results in 30 patients (90% excellent and good, 10% fair) treated since 1987 are presented.

We report an intraneural ganglion of the posterior interosseous nerve causing lateral elbow pain. The cystic lesion was identified by magnetic resonance imaging, and surgical exploration using the microscope permitted complete extirpation of the cyst without damage to nerve tissue. The patient experienced complete relief from pain, with full preservation of function.

A case is described of spontaneous posterior interosseous nerve palsy of acute onset. The initial symptoms made it difficult to distinguish the condition from tendon rupture.

The diagnosis was established using ultrasound, nerve conduction studies and MRI. The patient underwent surgery to decompress the posterior interosseous nerve and the histological examination identified the tumour as a synovial haemangioma. 12 months after the operation, the patient had made a complete recovery, confirmed by EMG.

A rare case of delayed posterior interosseous nerve palsy that developed 39 years after an unreduced anterior dislocation of the radial head is reported. The posterior interosseous nerve was compressed and narrowed at the arcade of Frohse. Radial head resection and release of the arcade was done. The paralysis continued to recover 6 weeks after operation. The nerve, at the arcade of Frohse, was susceptible to compression by the dislocated radial head, especially in the supinated position. Repeated supination and pronation movement over time may have led to developmental changes that caused the delayed nerve palsy.

The authors compare in a prospective, randomized study the early outcome of carpal tunnel release using either a conventional palmar open release (n=40) or a two-portal endoscopic release (n=56). Both groups were similar. No statistically significant differences were found regarding pain, disappearing of paraesthesiae or time to return to work. However, better recovery of grip strength was observed in the endoscopic group at 1 and 3 months. No surgical complications were observed in either group.

Freeze-thawed muscle grafts (FTMG) have been suggested as an alternative to nerve grafts in reconstruction of peripheral nerve defects. This study compares the results of immediate and delayed nerve repair with freeze-thawed muscle graft in a large animal model.

Under general anaesthesia, ten adult sheep underwent excision of 3 cm of the right median nerve. Five had immediate nerve reconstruction with FTMGs (Group A) and five were repaired after 4 weeks (Group B). At 6 months, both the right (repaired) and left (“control”) median nerves of each sheep were assessed.

Nerve blood flow distal to the graft in both groups of repaired nerves was approximately 60% of that in their respective control nerves. Peak nerve conduction velocities were significantly slower in the repaired nerves. The mean fibre diameters of the immediate and delayed repairs were 5.06 and 3.90 μ respectively compared to a control mean of 8.58 μ. G-ratios confirmed that the repaired nerves in both groups were well myelinated.

The authors conclude that the FTMG can be used in delayed as well as immediate nerve reconstruction with minimal impairment of final results.

Restoration of motor function in the hand is difficult in brachial plexus injuries in which the C5, 6, 7 and 8 roots are involved, because there are insufficient motors available for transfer to restore the extensors of the fingers and wrist. We have used extensor digitorum tenodesis in 11 cases and found it effective and simple.

Intercostal nerve transfer is a well-established technique in the treatment of some severe brachial plexus lesions in adults. There is, however, concern that in the presence of an ipsilateral phrenic nerve palsy it may lead to a significant compromise of respiratory function. 20 patients having intercostal nerve transfers had their lung function assessed pre-operatively and 6 weeks postoperatively. The patients were subsequently questioned about symptoms of respiratory dysfunction. There was no evidence that intercostal nerve transfer leads to a significant reduction in respiratory function in adults. It therefore appears safe to perform intercostal nerve transfers in adults following brachial plexus injuries even in the presence of an ipsilateral phrenic nerve palsy.

A retrospective study of 178 patients undergoing axillary brachial plexus block (ABPB) for hand surgery used information gathered by a computer-aided anaesthetic record keeping system. The practical use of local techniques to augment the block meant that only two of the 178 patients required a general anaesthetic, giving a success rate of' 98.8%. There were no significant complications.

With the increasing popularity of day case surgery it is important to ensure that safe and appropriate techniques are being used.

We retrospectively reviewed a large series of 732 patients who underwent planned day case hand surgery under intravenous regional anaesthesia (modified Bier's block) over a 5-year period.

We found a modified Bier's block to be ideally suited to day case surgery with no deaths, minimal morbidity and a success rate in excess of 98%.

The development of codes for hand surgery as part of the Read Code System is described. A lexicon of clinical terms and surgery has been developed, and will shortly be available from the National Health Service Centre for Coding and Classification in Loughborough, UK.

An audit was designed to analyse the risk factors for developing post-operative wound infection following hand surgery. 249 consecutive patients were prospectively entered into the study. 236 (95%) patients were available for follow-up. Infection was diagnosed by clinical criteria. There was an infection rate of 10.7% in elective operations and 9.7% in emergency operations.

There was no significant reduction in infection rate in the elective group with the use of antibiotics (P=0.5). In the emergency group of patients peri-operative antibiotic administration was associated with an 8.5-fold reduction in infection rate (P=0.014). The presence of a dirty wound was associated with a 13.4-fold increase in post-operative wound infection rate (P=0.002).

A postal questionnaire of members of the British Society for Surgery of the Hand revealed a wide variation in antibiotic usage. Guidelines for antibiotic use in patients undergoing hand surgery are presented.

A new method has been designed for direct measurement of the two-dimensional range of motion (ROM) of the finger. The two-dimensional method encompasses the postures imposed by various combinations of contraction and relaxation of the finger motors, so that an individual muscle injury or adhesion might be more easily detected. The figures and values obtained from the two-dimensional method are easier to interpret than those from conventional measurements, making the progress of the rehabilitated finger more apparent. Since the passive ROM cannot be evaluated by this method, it is a supplement rather than a substitution for the conventional range of motion evaluation for each joint. The drawback of the two-dimensional method is that it is more difficult to use than the conventional method.

We have established a simple method of measuring joint motion under physiological conditions. For this purpose we use an ultrasound measuring system employing marker points consisting of miniaturized ultrasound transmitters. This device was tested on a simple biomeehanical model, the linkage of the proximal and distal interphalangeal joints. The angles of these joints were recorded during opening and closing of the fist in 34 index fingers of 17 healthy persons. The results of the measurements were plotted on a rectangular coordinate system. Analysis showed an approximately linear linkage between the IP joints of the index linger. The curve for extension was the same as that for flexion. The linkage varies greatly. On average 1° of PIP joint flexion is equivalent to 0.76° of DIP joint flexion. Our study showed no significant difference between the dominant and non-dominant hand. The results showed that there is a linear linkage between the proximal and distal interphalangeal joints, which is equal for flexion and extension.

Partial excision including the articular surface of the trapezium and interpositional arthroplasty using one half of the flexor carpi radialis tendon was done in 36 hands. The joint capsule was reattached to the trapezium and the thumb immobilized for 4 weeks post-operatively. No ligament reconstruction was done. 30 hands (83.6%) had complete relief of pain. The average post-operative pinch strength was 11 lb. Three patients who complained of weakness of pinch had hyperextension of the MP joint. Correction of MP hyperextension is recommended to improve pinch strength. The outcome of this operation is comparable to any of the techniques described in the literature. The technique is simple and easy to perform. Since the capsule is closed the operation is truly an interpositional arthroplasty.

In a retrospective study of resection arthroplasty of the MP joints in rheumatoid arthritis, 23 patients (32 hands, 128 joints) have been followed for 15 to 22 years. Patient satisfaction was high, and all patients had significant pain relief. Active motion of the joints averaged 35°, ranging from full extension to 35° of flexion. Ankyloses developed in five hands (13 joints, 10%). Ulnar deviation of more than 15° occurred in six patients (ten hands, 30%). Over the course of several years a significant remodelling of the joints was to be observed. In six hands (19%) the metacarpal heads became spontaneously restored to ball-shaped geometry. Gross metacarpal resorption was observed in nine hands (30%), causing significant shortening of the metacarpals. In one-third of patients the final result was rated as good, fair and poor, respectively. Careful patient selection is mandatory. Patients with mutilating arthritis should be excluded from the procedure; rheumatoid destruction of the wrist joint definitely influences the final result.

Two cases of pigmented villonodular synovitis (PVNS) affecting MP joints are reported with unusual radiological changes.