Journal of Hand Surgery (European Volume)

Total scaphoid excision and radial advancement osteotomy has been investigated in a eadaverie and clinical study. In three below-elbow fresh amputation specimens, the technique was utilized and stability was checked by radiographs. Instability on ulnar deviation was prevented by extensor carpi radialis longus tenodesis.

Four patients were treated in this way. The wrist was immobilized in a below-elbow splint for 45 days, then active motion was encouraged. After 10 months, three patients had excellent results and one patient had good result using the criteria of Cooney et al (1987).

We report seven patients (eight wrists) with osteoarthrosis of the wrist associated with an exostosis arising from the dorsal aspect of the scaphoid. We believe that the exostosis is secondary to impingement of the scaphoid on the radial styloid process and is a consequence rather than a cause of osteoarthrosis. Conservative management is advised.

We report a case of bilateral symptomatic scaphoid exostoses associated with osteoarthritis of the wrist. These were treated by surgical excision with good short-term results.

We present an unusual case of carpal dislocation which to our knowledge has not previously been described in any of the current classifications of such injuries. Despite the extensive damage sustained, the case was managed without difficulty and outcome has been very satisfactory.

20 fresh frozen human wrist specimens were dissected. Gross and histological examination and biochemical evaluation were performed on the intrinsic ligaments (scapho-lunate and luno-triquetral) and extrinsic ligaments (radio-scapho-capitate and radio-lunate). All ligaments were observed to have longitudinal collagen bundles. The intrinsic ligaments had large amounts of fibrocartilage near insertions and no elastin, while the extrinsic ligaments had little fibrocartilage and sparse amounts of elastin. The intrinsic ligaments were noted to have significantly more collagen Type 3 (41%) than the extrinsic ligaments (19%). These findings suggest that structural differences between the intrinsic and extrinsic ligaments of the wrist may in part account for the biomechanical observations that the intrinsic ligaments are stronger and elongate further prior to failure than the extrinsic ligaments.

12 male (mean age 28) and 11 female (mean age 32) patients treated with lunotriquetral (LT) arthrodesis were reviewed with a median follow-up of 28 months (range 18–40 months) for this retrospective study. At first presentation 12 patients were unable to work, and at follow-up only three men remained out of work. The relief of pain was significant (P < 0.001) and the median Culp (1993) wrist score obtained 74 (min. 45, max. 96); however, only one patient was totally free of pain and seven men had to change their occupations. Men lost 455 working days, women 191, a highly significant difference (P = 0.006). This loss correlated (P = 0.007) with the LT angle measured in the frontal plane: all patients but one with a LT angle of less than 31° returned to work within 1 year, but only four with a greater angle (P=0.007). This emphasizes the importance of correct positioning of the triquetrum, which seems hard to achieve with two AO lag screws. Furthermore, even two screws seem unable to ensure solid fusion as shown by the high rate of pseudarthrosis (57%). LT fusion cannot be considered as a routine procedure and results are not yet predictable. According to these results, we feel that a bone graft placed in a slot from lunate to triquetrum is the procedure of choice. In the presence of a chondromalacia in the ulnar midcarpal joint, a four bone fusion is primarily recommended.

In 1966, Wilhelm published a technique of denervation of the wrist joint based on his own anatomical studies of 1958. Other authors have published their experience in wrist denervations with similar results, but there are some discrepancies in descriptions of the innervation of the wrist.

We have studied the innervation of the wrist by dissection under magnification on 20 cadaver limbs and by histological examination of five human foetal wrists. Based in our anatomical findings, we have demonstrated that Wilhelm's technique does not achieve total denervation of the wrist.

We have analyzed the results of 22 total wrist denervations following Wilhelm’s technique and a series of 30 patients treated with denervation of the posterior interosseous nerve alone. Results of denervation have been classified depending on the pain (visual analogue scale) as other parameters (mobility and strength) have not been found to have any statistical significance. Results after partial denervation are worse than results achieved by total denervation.

The use of intravenous guanethidine blocks is an accepted treatment for established reflex sympathetic dystrophy (RSD). Some units administer intravenous guanethidine peri-operatively with the intention of protecting their patients from post-operative dystrophy. There have been no studies confirming this protective effect of peri-operative guanethidine. Between 1992 and 1994 we performed a prospective randomized double blind study in 71 patients undergoing fasciectomy for Duputyren’s disease. Peri-operative guanethidine did not prevent post-operative RSD in our series.

Upper limb surgeons have little in the way of training in the identification or management of the psychological aspects of limb injury. Surgeons in training tend to see their speciality in technical terms, only slowly appreciating that the psychological state of the patient profoundly affects outcome in many cases.

The case report that follows charts the psychological progress of a patient following severe upper limb injury. Surgeons usually view rehabilitation in physical terms. This report emphasizes the psychological aspects of a major limb injury to a policeman (MP) who subsequently studied psychology at PhD level.

The prevalence of forearm and hand disorders was examined by questionnaire and clinical examination in 199 automobile assembly line workers and in 186 controls. The pressure-pain threshold, hand grip force and hand anthropometry were also studied. There was an increased prevalence of de Quervain’s disease for male automobile assembly line workers, and of carpal tunnel syndrome in female workers. The prevalence of symptoms in the forearm and hand during the last 7 days were twice as high among automobile assembly line workers than controls for both men and women. The occurrence of symptoms in the last 7 days was associated with de Quervain’s disease, carpal tunnel syndrome and sick-leave due to forearm or hand problems, and it also influenced activities of daily living. Hand grip strength and anthropometries were not associated with findings in the clinical examination or the occurrence of symptoms in the last 7 days. Low pressure-pain threshold was not associated with findings in the clinical examination, except for reported occurrence of symptoms in the last 7 days for women. Pressure-pain threshold as an indicator of tissue damage is discussed.

Rupture of an anomalous tendon slip between the FDS aponeurosis and FDP tendon to the ring finger was found in a young woman’s forearm upon surgical exploration after months of forearm pain and disability. Excision of the anomalous slip resulted in quick and complete recovery.

We report one case of ulnar nerve compression in Guyon’s canal due to calcium deposits in a 50-year-old woman with long standing systemic scleroderma. To our knowledge, this is the second known case. The symptoms consisted of a motor and partial sensory disturbance. Calcification of the piso-triquetral joint was prolonging into Guyon’s canal, lifting its contents, and into the subcutaneous tissue of the ulnar border of the wrist. Excision of calcium deposits and of the pisiform in combination with external neurolysis of the ulnar nerve resulted in complete relief of symptoms.

Despite surgical advances and new antibiotics, upper extremity infections continue to present a serious problem. Soft tissue infections of the upper extremities were prospectively examined to elucidate incidence, cause, bacterial pathogens involved, and treatment. Special attention was paid to infections associated with parenteral drug abuse. During an 18-month period all patients over 16 years of age presenting for treatment of an established infection were included in the study. Conservative treatment consisted of immobilization and antibiotics. Radical débridement with removal of all necrotic tissue was the guideline for operative care. In addition, for both regimens a penicillinase-resistant antibiotic was administered. A total of 415 patients (271 men and 144 women; mean age 36.7 ± 14.5 years) were enrolled into the study, 55 of whom were parenteral drug abusers; 45 of these were HIV-reactive. Infections of fingers (excluding paronychia), paronychia, and abscesses at injection sites were the most common diagnoses. Operative and conservative treatment were performed in 285 and 130 patients respectively. Staphylococcus and streptococcus species were the predominant organisms recovered from 212 specimens of pus. Anaerobic bacteria and yeasts were of minor importance. Therefore, a penicillinase-resistant antibiotic is a good initial choice.

A case ofMycobacterium marinum infection of a finger is described. This is a rare condition in the UK. The relevant literature is reviewed.

Delayed rupture of a flexor tendon in the hand due to the presence of a retained foreign body is rare. We present the case of a late flexor pollicis longus rupture 30 years after traumatic implantation of a glass fragment. The foreign body had migrated distally a distance of 4.5 cm from the site of the original injury and eroded into the flexor tendon sheath. Thumb function was restored with a flexor digitorum superficialis tendon transfer from the ring finger with excellent results.

A case of closed rupture of the extensor mechanism associated with a fracture of the proximal phalanx of the little finger is presented. Diagnosis was made only after surgical exposure for internal bone fixation.

We report the effects of early and late ultrasound treatment protocols on healing of surgically lacerated zone 2 flexor tendons in a chicken model. Ultrasound was administered directly using a coupling gel. Treatment was shown to increase range of movement, to advance scar maturation and to decrease the amount of inflammatory infiltrate around the repair site. No adverse effects on tensile strength were noted in either group. Early (starting 7 days post-operatively) administration was more effective than late (starting 42 days post-operatively) administration in achieving these effects. These results suggest that ultrasound therapy may be of benefit in the early healing process of flexor tendon lacerations.

A modification of the flap first described in 1935 by Tranquilli-Leali and described again by Atasoy et al (1970) is presented. The relative indications for use of the original and the modified flap are examined in the light of our experience of 116 flaps over a period of 4 years.

This paper reports 25 cases of a versatile homodigital triangular neurovascular island flap for fingertip reconstruction. This flap was used to reconstruct traumatic oblique palmar amputations, with loss of fingertip pulp requiring advancement of not more than 2 cm. Good results were obtained in terms of fingertip contour and padding, sensibility, and functional recovery. The tendency for flexion contracture at the PIP joint was prevented by using a dynamic extension splint at night. Cold intolerance must be expected, especially in cold countries.

Sixteen patients presenting 18 hook-nail deformities have been treated by the advancement of a homodigital island flap. With an average follow-up of 31 months; Results were considered good or excellent in seven cases, fair in seven and poor in four. Six cases, although improved, had a marked recurrence of the deformity, six had a partial recurrence and six had almost no recurrence. Patient satisfaction was limited as the finger still had a short nail and a square shape.

Dynamic digital flexion was examined by video recording healthy subjects making a fist. The are of the fingertip sweep from full extension to full flexion was replayed frame by frame and plotted. A similar technique was employed to measure the MP, PIP and DIP joint angles throughout digital flexion. Graphs were plotted of MP against PIP, and PIP against DIP flexion. These results were related to a theoretical 45° line.

The fingertip appears to sweep through an elliptical pathway when flexing, rather than an equiangular curve. Graphs of joint flexion showed that male and female fingers flex in a similar fashion, as do the index and little finger. Graphs of PIP against DIP flexion suggest some limiting mechanism of either the extensor or flexor system.

These graphs give useful insights into the complex mechanisms of dynamic digital flexion, and may be of diagnostic and prognostic importance.

The findings are presented of a conference on Outcomes of Hand Surgery organized by the audit committee of British Society for Surgery of the Hand in 1993. Measures of outcome in terms of movement, power, sensibility, pain, activities of daily living, complications and patient satisfaction are considered, and an example of a patient evaluation measure given as an appendix.