Journal of Hand Surgery (European Volume)

This paper reports an epidemiological and clinical study of 813 patients with 1,111 peripheral nerve injuries who were treated for upper limb trauma, which included nerve injury, at two plastic surgery units in south-east England, predominantly between the years 1982 and 1991. The frequency distributions of the levels of nerve injury, and the causes of nerve injury in the sample, are presented, together with the surgical management and timing of nerve repair in these patients. 1,018 clinically suspected nerve injuries in 730 patients (91.6% of nerves, 89.8% of patients) were treated by primary nerve repair, elective delayed nerve repair or primary surgical exploration alone. Divisions of 93 nerves in 83 patients (8.3% of nerves, 10.2% of patients) were treated other than by primary repair or elective delayed repair, due to delayed referral from accident and emergency departments, resulting from missed or uncertain diagnosis at presentation or otherwise unaccounted delay in the initial referral.

Eleven cases of symptomatic distal radial intraarticular malunion were treated by radio-lunate arthrodesis from 1983 to 1991. The mean age was 35.3 years. There were 11 men, all manual workers. The mechanism was usually a high velocity injury. The time elapsed since injury was a mean 23 months (2–109 months).

The range of motion was, on average, flexion 39°, extension 27°, radial deviation 10° and ulnar deviation 20°. Pain was present on light work and grip strength was 45% of the opposite side. The average step-off was 4.4 mm. The scapho-lunate gap was greater than 3 mm in three cases and 5 mm in one case. An ulnar translation of the carpus greater than 4 mm was present in four cases. Posterior subluxation was significant in three cases. The distal radio-ulnar joint (DRUJ) was totally destroyed in three cases, and incongruent in five.

Radio-lunate arthrodesis is performed by a posterior approach. Other procedures were combined, mainly on the DRUJ.

The average follow-up was 28.5 months (8–79 months). Healing was achieved in ten out of 11 cases in 45 to 90 days. Pain was absent or moderate after 4 months. The range of motion was 33° in flexion, 39° in extension, 17° in radial deviation and 29° in ulnar deviation. The average post-operative strength was 57% of the opposite side (19 kg/33). Eight patients returned to their previous work and two to lighter work.

A new triaradiate skin incision is presented as an approach to the wrist. Centred over Lister’s tubercle, it consists of one longitudinal proximal and two oblique distal rays, making three 120° skin flaps. These provide an excellent triangular operating field to the distal radius, the radio-carpal joint and the carpus itself, allowing for most procedures in this region. There have been no complications in 32 patients, and the cosmetic appearance has been excellent in most of them.

This experimental work studies the role of ligamentous structures in suspending the carpal bones from the radius and ulna.

Thirteen human cadaver wrists underwent a distal radio-ulnar arthrodesis in a neutral position and an arthrodesis between the three bones of the first carpal row. Progressive postero-anterior forces in a palmar direction were applied to the fused carpal bones. Displacement was measured by two dial gauges before and after sequential section of the different fibrous structures.

The largest absolute average displacement (both, dorso-palmar and induced rotational displacement) was observed after section of the ulnar styloid process. No significant differences were observed after section of the extensor retinaculum, extensor carpi ulnaris sheath, posterior ulno-carpal and posterior radio-carpal ligaments.

This work suggests that the carpus is suspended not only from the radius, but also from the distal ulna and particularly at the ulnar styloid and the structures which insert onto it.

Synovial osteochondromatosis is an uncommon lesion characterized by cartilagenous and osseous metaplasia of joint synovium. It is typically monarticular, affecting large joints such as the knee and hip, although it has also been described in the ankle, elbow and shoulder. It is exceptionally rare in the hand, but has been reported involving the tenosynovium of the digits and the wrist. We report a rare case of synovial osteochondromatosis involving the distal radio-ulnar joint in a 16-year-old man.

Rotation, angulation, deviation, shortening or a combination of deformities can occur due to phalangeal malunion and can lead to impairment of hand function.

A historical cohort study of 57 patients who had phalangeal corrective osteotomies for post-traumatic malunion between 1978 and 1990 was undertaken. 59 rotational, radial/ulnar deviation, flexion/extension, length adjustment procedures, and combinations thereof were performed, using rigid internal fixation. Concurrent tenocapsulolysis was done in 50% of the cases.

Satisfactory correction was obtained in 76% of the patients. Bony union was obtained in all cases. A net gain in active range of motion was achieved in 89% of the patients. Excellent and good results were obtained in 96% of the patients who had corrective osteotomies for malunion involving only the bone and in 64% of the patients who had corrections for malunion with involvement of multiple structures (P < 0.01).

The use of a single osteotomy combining both rotation and angulation is described, with a means of achieving the correct angle and direction of the osteotomy. Patients who have been treated by this method are presented.

Fibrin glue has been applied in the anastomosis of vein grafts placed in rat femoral arteries using the telescoping technique at both ends of the graft. 34 out of 35 grafts which were patent 1 to 3 weeks post-operatively were kept for 3 months to assess the long-term patency, and the effect of the glue on the diameters of the graft and femoral artery. All 34 grafts were patent 3 months post-operatively. Excessive enlargement of the graft diameter was alleviated by the fibrin glue without affecting the diameter of the femoral artery. The diameter at the proximal anastomosis was 66% and that at the distal anastomosis was 87% of the diameter of the femoral artery.

In an experimental study, somatosensory evoked potentials were used to evaluate sciatic nerve regeneration in the rat after 12 mm-long conventional nerve grafting, vascularized nerve grafting and frozen muscle grafting. This experimental method was found to be technically easy and highly reproducible. No statistical difference was found between the three groups concerning amplitude of the negative electrical wave recorded at the cortex level after distal stimulation. Conduction velocities were found to be significantly higher in both the vascularized nerve group and the frozen muscle group, compared with the conventional nerve grafting group. The frozen muscle grafting technique is valuable as it gives good experimental results, is easy to carry out and causes minimal damage to the donor site.

It has long been recognized that the first and second lumbricals are normally innervated by the median nerve, whereas the third and fourth lumbricals are innervated by the ulnar nerve (Sunderland and Ray, 1946). However, the courses of the motor nerves, particularly to the first two lumbricals and their loci of insertion, have not been clearly described. Because this information may be useful to a surgeon operating in the palm, we undertook a cadaver study to define more precisely the pathways of innervation of the lumbrical muscles.

The incisions used for fasciotomy of the upper arm are re-appraised in the light of recent advances in the understanding of the vascular anatomy of the integument of the upper arm, and a new approach is described.

The surgical treatment of the divided FDP tendon, more than 6 weeks old, in zone 2 is reviewed in 50 patients. The method used was the excision of the divided FDP tendon and the insertion of a thin tendon graft. There were 50 patients in this study; 36 were male and 14 female, aged from 18 to 60 years. All patients were markedly disabled because of loss of strength of the involved finger. Follow-up ranged from 1 to 25 years following tendon grafting. In 35 patients plantaris tendon was used and in 15 patients palmaris longus. Definite advantages were found in using the tendon grafting procedure; strength, dexterity, pinch and grasp were markedly improved. Functional results were evaluated by the Boyes method, with the Pulvertaft method as a secondary assessment. Among the 50 patients, 80% had excellent and good results (excellent 32%, good 48%) and 20% fair.

The effects of a shortened post-operative mobilization programme following flexor tendon repair in zone 2 in the hand were examined in a prospective, randomized study. 91 digits in 82 patients were included in the study. All injured tendons were repaired within 24 hours and all patients were subjected to the same mobilization programme during the first 6 weeks using a passive flexionactive extension régime. After 6 weeks the patients were randomized into two groups; in group A full activity was allowed after 8 weeks while in group B unrestricted use of the injured hand was not allowed until 10 weeks after the tendon repair. Functional results were compared using the Louisville, Tsuge and Buck-Gramcko assessment systems. Grip-strength was measured 16 weeks after repair, subjective assessment of hand function was recorded on a visual analogue scale, and absence from work was registered. No significant differences were observed between the groups regarding functional results, rupture rates, grip strength or subjective assessment, but absence from work was reduced by 2.1 weeks with the shorter mobilization programme.

Using the described régime, full activity can be encouraged 8 weeks after flexor tendon repair in zone 2 of the hand without adverse effects on functional results or increased risk of rupture of the repair.

The role of the tendon sheath in flexor tendon healing was investigated in rabbits. Tendon sheath was reconstructed with syngeneic parietal peritoneum or a non-tanned processed porcine collagen membrane.

Resection of the tendon sheath led to adhesions. Reconstruction of the sheath with either graft resulted in a synovial–like lining, resembling a neo-tendon sheath. Even when combined with tendon repair a neo-tendon sheath was seen after reconstruction with both grafts, without adhesions. Subcutaneously implanted processed porcine collagen membrane was completely resorbed in less than 3 months.

We report two cases in whom human composite flexor tendon allografts were used, and followed-up for more than 5 years. The results show a real improvement in function, without any complications.

Histopathological studies of extracted whole lunate bones obtained from 10 patients with Stage 3 Kienböck’s disease at surgery for tendon-ball replacement were correlated with magnetic resonance imaging (MRI), computed tomography (CT) and tomography images made prior to surgery. A reforming zone, or a reactive interface between the reactive new bone and granulation tissue formation, and new vascularization were observed surrounding the bone necrosis area showing empty lacunae, fatty necrosis, and disappearance of osteoid. Findings of CT, tomography and microradiography of slices of extracted lunate bone confirmed that fractures of the articular cartilage and the subchondral bone occurred secondarily by overloading, and showed the extent of the collapsed area of the lunate. MRI showed complete loss of signal intensity in T1 images of the lesion of the lunate in advanced Stage 3 Kienböck’s disease. MRI is at present unable to distinguish bone necrosis, the histological reactive interface or surrounding hyperaemia in detail. However, the low-intensity arc, or the reactive interface present on MRI in early Stage 3, sometimes correlates with the histological findings of osteoid and granulation zones.

A neurovascular island flap has been developed to reconstruct volar-oblique fingertip amputations. This study analyzes the data collected on 16 patients who were treated with this flap and had at least 2 years follow-up. The average active/passive range of motion was 54/55° at the DIP joint, 96/98° at the PIP joint, and 83/83° at the MP joint. Twelve out of 16 flaps (75%) had two-point discrimination better than 10 ram. Moderate and severe problems included cold intolerance (six patients), hypersensitivity (three patients), stiffness (three patients), and numbness (two patients). Out of the 16 patients treated with this technique, 14 were satisfied with their surgical outcome. In experienced hands, this technique is a safe and reliable method with which to reconstruct volar-oblique fingertip amputations.

We have investigated five devices suitable for scaphoid fixation (ASIF 2.7 mm and 3.5 mm cannulated screws, Herbert, Herbert-Whipple, and Howmedica Universal Compression Screw). The biomechanical properties tested were compression and resistance to cantilever bending. There was no statistically significant difference in compression between devices. There were significant differences in resistance to cantilever bending, with the Howmedica screw being strongest in both failure mode and in ultimate failure strength.

Patients treated for total radial aplasia have been reviewed. It was possible to re-align the carpus by radialization in five out of six limbs treated with pre-operative distraction, but in only one out of six treated without distraction.

The average improvement in radial angulation in the non-distraction group was 19° and in the distraction group 38°. The average improvement in radial translation was 16 mm and 17 mm in the two groups respectively.

Pre-operative distraction with the Kessler device permits re-alignment of the hand without skeletal resection or excessive tension on the radial neurovascular structures.

Four cases of carpal tunnel syndrome in children and adolescents with no history of trauma are discussed. The pertinent literature and a classification of the different causes of carpal tunnel syndrome in this age group is presented.

Although Dupuytren’s disease of the hand has been reported in teenagers, it is generally considered to be a disease of adults. A series of nine children who developed Dupuytren’s disease of the hand before the age of 13 years is presented. Eight had surgical removal of the diseased tissue and histological confirmation of the diagnosis before the age of 13 years and one at 14 years of age. The presence of the condition in young children and teenagers is discussed and the literature summarized.

We describe a congenital peripheral neuroepithelioma of the hand in an infant aged 6 weeks. This primitive malignant tumour of neuroepithelial origin is extremely rare in neonates. Peripheral neuroepitheliomas of the hand have not been described in the literature previously. Specific diagnosis and the current therapeutic approaches are discussed.

Infantile haemangiopericytomas (IHP) are rare subcutaneous tumours arising from pericytes. Clinically they are difficult to diagnose and pathologically they appear to be locally invasive, but they have a better prognosis than adult haemangiopericytomas. We report a case of IHP affecting the hand of a 7-week-old child that required urgent treatment.

A case of giant cell tumour of the left fifth metacarpal with pulmonary and skeletal metastases is reported with follow-up of 14 years. The pulmonary metastases were treated by chemotherapy, but the size of the metastatic nodules continued to increase, and no further treatment was given. The pulmonary metastatic nodules started to regress 8 years after the diagnosis without any treatment, and had disappeared after 14 years. The skeletal metastases were unchanged at the latest follow-up. Both pulmonary and skeletal metastases have been asymptomatic for the 14 years after they were diagnosed.

It is suggested that pulmonary metastases of benign giant cell tumour has a good long-term prognosis and these patients should be kept under observation only, avoiding extensive lobectomy, chemotherapy or radiotherapy.

A number of musculo-tendinous variations around the medial epicondyle have been alleged to cause ulnar nerve compression. Subluxation of the ulnar nerve, a “snapping” separate medial head of triceps, a prominent medial head of triceps covering the ulnar nerve, anconeus epitrochlearis, Osborne’s band, and the ligament of Struthers have been implicated. We present a case of clear-cut compression of the ulnar nerve at two levels just at and posterior to the epicondyle by a tightly applied prominent head of the triceps, and at a more distal level beneath an anconeus epitroch-learis muscle.

A dorsally displaced epiphyseal fracture of the middle phalanx (Salter–Harris Type I) is described. The epiphyseal fragments were attached to the central slip of the extensor tendon and collateral ligaments. The articular surface of the PIP joint was intact and smooth. The epiphysis was reduced and fixed without cutting the central slip or the collateral ligaments 8 months after injury. This kind of fracture can occur in the PIP and DIP joints, and presents special diagnostic difficulties. Open reduction is evidently necessary to correct the displacement.