Journal of Hand Surgery (European Volume)

A descriptive severity scoring system for injuries to the hand, distal to the carpus, has been designed. Each ray of the hand is assessed separately. Each ray’s score is then multiplied by a weighting factor for that ray and added to the scores of the other rays to obtain a total score for the injury. This system has been tested on a series of specimen injuries and compared with the opinion of experienced hand surgeons. A retrospective study of hand injuries has also been conducted, and the Hand Injury Severity Score (HISS) has been found to closely correlate with return to work. Four grades of increasing severity of hand injury have been described. Although this system has been designed as a research tool, it is envisaged that it would be a useful immediate measure of severity and a guide to likely outcome.

In order to investigate the cellular effects of exposure to air during surgery and to compare the effects of simultaneous irrigation with physiological saline, the deep flexor tendons of both forepaws of 12 rabbits were surgically exposed. In one experiment, the extent of surgical exposure and, in a second experiment, the time of exposure was evaluated. Treated segments of the flexor tendons were collected and labelled in vitro for determination of the ability to synthesize DNA, proteoglycan, collagen and non-collagen protein.

With increasing surgical exposure in vivo, an increasing rate of cellular proliferation was observed in segments of the exposed deep flexor tendons examined in vitro. Synthesis of matrix components and the rate of cellular proliferation were reduced by 50% after 40 to 100 minutes of exposure to air and by nearly 100% after 120 minutes of exposure. In contrast, irrigated tendons retained their cellular capacity to proliferate.

Twenty-three preserved cadaver upper limbs were dissected to show the level of entry of the nerve supply to flexor carpi radialis and the extent of exposure of a new approach to the flexor surface of the distal radius. We describe a new approach to the flexor surface of the distal radius in which both the radial artery and the median nerve are protected by muscles or tendons.

Intraarticular fractures of the base of the middle phalanx are difficult to treat, especially if the fragments are comminuted. A spring dynamic traction device is described and the results in the first 14 patients presented. Patient acceptance has been high and the results comparable to other methods of treatment.

A prospective study of 32 patients was carried out to investigate the significance of dynamic magnetic resonance imaging (MRI) in diagnosis of triangular fibrocartilage (TFC) lesions. Tears of the TFC can be diagnosed well by means of static MRI and arthroscopy. Dynamic MRI examination has an advantage in evaluating the stability of the TFC and ulnocarpal impingement. By means of dynamic MRI it was possible to make a preoperative diagnosis of an ulnocarpal impingement in five patients, a diagnosis which was confirmed through arthroscopy in all cases. In three further patients, dynamic MRI showed ulnocarpal impingement caused by instability of the ulnar attachment of the TFC. This kind of impingement could not be ascertained arthroscopically.

Dynamic MRI extends the possibilities of evaluating obscure ulnar wrist pain. Its significance lies in the non-invasive examination of ulnocarpal impingement as well as the evaluation of TFC stability.

Long-term use of hand-held vibrating tools may induce various types of hand problems. One hundred symptomatic men exposed to vibration from such tools were interviewed and examined with special reference to neurosensory and vasospastic problems. Three distinct symptomatic groups were identified: isolated neurosensory symptoms (48%), isolated vasospastic problems (20%), and combined neurosensory and vasospastic problems (32%). Abnormal cold intolerance (pain and coldness without blanching of the fingers on exposure to cold) occurred in 27% of the patients. Neurosensory problems were more predominant than vasospastic ones, especially during the first 20 years of vibration exposure. Of 80 patients with neurosensory symptoms, only 22 had signs of a carpal tunnel syndrome (CTS). It is concluded that vibration-induced neurosensory and vasospastic symptoms can occur separately or together, and that the neurosensory symptoms are often not due to a CTS.

The long-term results of a technique for correction of syndactyly are reported. The technique consists of a dorsal omega flap and a palmar anchor forming two palmar and lateral flaps. A long-term review was made of 50 patients with a minimum of 8 years follow-up operated over a period of 10 years. A total of 122 web spaces in simple, complex and syndromic syndactyly were operated on. Most patients achieved satisfactory reconstruction of the web spaces, resulting in a web of good shape. At long-term review, web creep was recorded in eight webs, and skin contractures in three fingers. This study shows the technique to be effective in reconstructing web spaces and in minimizing the prevalence of complications.

Two cases of rhabdomyosarcoma (RMS) of the hand are reported.

Syndactyly correction results in skin deficiency. Skin grafting is avoided by the use of an extended dorsal interdigital flap for the web and approximation of the side flaps to cover the length of the digits. The technique has been used in 17 cases with all varieties of syndactyly. There were no early complications. The follow-up averaged 2 years. There were two cases of web creep but no contractures. The method combines the advantage of direct suture with an acceptable frequency of web creep.

Fifty-six cases of radial palsy due to injections have been seen during the last 13 years. Thirteen patients recovered spontaneously. Seven patients were treated by neurolysis, of which five had full recovery in 1 year. The remaining patients were treated by modified Robert Jones transfers. In ten cases flexor carpi ulnaris was spared as a strong flexor of the wrist, which improved the results in heavy manual workers. Radial nerve palsy caused by injection is an avoidable injury. There is a need for proper training of paramedical workers.

Difficulty in interpreting X-rays following carpal injury emphasizes the importance of clinical assessment in diagnosing scaphoid fractures. The classical sign of tenderness in the anatomical snuffbox is not specific and leads to many unnecessary out-patient reviews. A prospective comparison was made between anatomical snuffbox, scaphoid tubercle and scaphoid compression tenderness as indicators of scaphoid fracture in 221 patients with suspected scaphoid injury. Swelling was determined by measuring the difference in circumference at the wrist joint to compare between fracture and soft tissue injury.

Scaphoid compression tenderness was found to be the most accurate test with a sensitivity of 100% and a specificity of 80%. Swelling of the wrist joint was significantly greater when there was a fracture, compared to soft tissue injury alone, even when the initial X-ray was normal. This was independent of any physiological variation in circumference between dominant and non-dominant sides.

Scaphoid compression tenderness is therefore suggested as the most accurate indicator of scaphoid fracture and marked swelling should raise suspicion even if the X-ray is normal.

In a prospective study of 80 operations in 61 patients for carpal tunnel syndrome, special attention was given to the course of the thenar motor branch and its variations. An anomalous origin of the branch was found in 21%. Multiple motor branches occurred in 12.5%. Seventeen patients had operations on both hands, but anomalies were often found in one side only. Special attention is drawn to an additional anomaly where the motor branch lies superficially to the retinaculum buried in a hypertrophic preligamentous muscle. If this anomaly is not borne in mind, the nerve can easily be injured during splitting of the flexor retinaculum. We found this variation in 9% of our patients, but it is rarely mentioned in the literature and in many large series it is not described at all.

A case of ulnar neuropathy associated with an anatomical anomaly of the ulnar nerve is reported.

Sinus histiocytosis with massive lymphadenopathy (Rosai-Dorfman disease) is a disease of bone marrow stem cell origin which primarily affects lymph nodes. Solitary bone lesions are rare and can cause diagnostic difficulties. A primary lesion in the right index finger of a 10-month-old child is reported.

We present five cases of mycobacterial tenosynovitis of the flexor tendons of the fingers. These cases were observed during the last 12 years and treated by the same surgeon. This pathology is uncommon now, but it is becoming more frequent, especially in patients with diminished immunity. The diagnosis was most commonly made after synovectomy in patients presenting with carpal tunnel syndrome associated with slightly painful swelling at the wrist.

Histological and bacteriological examinations are very important and revealed tuberculosis in four of our patients and mycobacterium in one, and the treatment consists of synovectomy and appropriate antibiotics.

The functional result is usually good, but recurrence is not uncommon. Long-term follow-up is necessary. Local corticosteroid therapy could have a part in the causation of this condition.

We studied the medium- to long-term results of steroid injection into the carpal tunnel of women with the carpal tunnel syndrome (CTS).

Of 45 hands, only 11 had lasting relief of symptoms and 22 had no relief whatsoever. There was no correlation of the typical signs and symptoms of CTS with outcome.

Other series have offered various predictive factors for the outcome of injection but we found little or no correlation between these factors and outcome.

The conjugation of horseradish peroxidase with wheat germ agglutinin was used to identify the effect on retrograde axonal transport of stretching the rat sciatic nerve indirectly by 10% and 20% femoral lengthening with a unilateral external fixator. To investigate the relationship between retrograde axonal transport and blood flow in the stretched nerve, nerve blood flow in the sciatic nerve was measured by a hydrogen washout technique. At 11% strain (20% femoral lengthening), the numbers of horseradish peroxidase-labelled motor neuron cells and nerve blood flow had decreased by 43% and 50%, respectively. Histological examination demonstrated ischaemic changes, but not mechanical damage. However, at 6% strain (10% femoral lengthening) there were no significant abnormalities. These findings suggest that the inhibition of retrograde axonal transport can be induced by acute stretching of the peripheral nerve and that circulatory disturbance is the main cause of the inhibition of retrograde axonal transport at the low strain.

Plantar fibromatosis is a recognised form of Dupuytren's disease. Two cases are presented in which there were flexion contractures of the toes in the involved feet. This is an extremely rare form of this plantar affliction.

A unusual example of Dupuytren's disease occured in a black patient with a strong diathesis. The disease affected the insertion of flexor carpi ulnaris at the wrist as well as the palm.

Palmar prolapse of the flexor tendons as a result of attenuation of the A1 and A2 pulleys occurs in rheumatoid arthritis and other conditions in which the joints of the fingers are chronically flexed. The flexor tendons may be palpable and sometimes visible as longitudinal bands crossing the palm. This can lead to confusion with the palmar bands of Dupuytren's disease. These bands are illustrated in a small series of patients and a serious complication of a misdiagnosis of Dupuytren's disease is presented. The pathogenesis of these palmar bands in rheumatoid arthritis is discussed.

A case of rupture of flexor digitorum profundus tendon of the little finger caused by calcification of the triangular fibrocartilage (TFC) is reported. At operation, a round defect of the TFC and rupture of the flexor digitorum profundus tendon (FDP) of the little finger were observed. The defect of TFC was repaired using the palmaris tendon and FDP of the little finger was woven into FDP of the ring finger. Eleven months after operation, the patient had almost full flexion and extension of the distal and proximal interphalangeal joints.

Scaphotrapeziotrapezoid (STT) joint fusion was carried out for pain relief in eight patients with isolated arthritis. Seven patients had satisfactory relief of symptoms. The subjective results were excellent in five, good in two and bad in one patient, who had non-union of the arthrodesis and was also the only patient to develop trapeziometacarpal arthritis.

Average grip strength was 0.8 and lateral pinch strength was 0.7 of that in the other hand. There was a very small relative difference in dexterity. There was an average difference of 9° of flexion–extension and 13° of radio-ulnar deviation.

It is concluded that for isolated idiopathic STT arthritis, fusion gives very satisfactory results with minimal complications.

A case of post-traumatic radiocarpal ankylosis is described.

We report a case of complete palmar dislocation of the lunate in a rheumatoid patient. X-rays showed a normal bone structure of the lunate without sclerosis or collapse and on MRI an almost normal signal intensity was found. The lunate was removed. Histological examination showed complete necrosis of both marrow and bone cells, and tetracycline labelling showed no fluorescence. This case illustrates that neither X-ray nor magnetic resonance imaging (MRI) can detect complete bone necrosis. When X-ray or MRI changes do occur, these are indications of cellular events following some degree of spontaneous revascularization.

A 23-year-old man presented with spontaneous carpal collapse of his dominant wrist, with radiographic destruction of the lunate, scaphoid and distal radius, for which no cause could be found.

A simple modification of the catheter technique for retrieving flexor tendons is presented. The technique is based on the Seldinger principle. A flexible metal guide-wire is used to route a polythene catheter through the flexor tendon sheath, enabling tendon retrieval.

A 21-year-old man had proximal radioulnar synostosis 10 months after fracture of the proximal radius and the ulna. The bony bridge was excised and a direct posterior interosseous island flap was interposed as a biological barrier. One year after surgery, the range of forearm rotation was 65°. There was no radiographic evidence of recurrence.

The injured and operated hand is routinely immobilized for a variable period of time in a palmar plaster splint. To minimize subsequent joint stiffness, the preferred position of immobilization of the hand is the “safe position”.

The true position of the hand in a splint was assessed on a lateral X-ray directly after application and just before removal 3 weeks later. It appears that in time the hand in a conventional palmar plaster splint loses its initial position because the bandage stretches. The “double-T” plaster splint maintains the safe position of the hand significantly better than the conventional palmar splint.

A case of recurring digital fibroma of childhood is presented. The natural history of this condition over several years is documented. The literature is reviewed, with particular reference to the management of the condition.

Surgeons should be aware of the clinical features and the principles of management of this condition, as patients may be referred because of associated finger or toe deformities.

A child with absence of all nails associated with missing terminal phalanges is reported.

Hyperphalangism is a rare congenital anomaly, with an extra phalanx between the phalanges in a finger. About 100 cases have been recorded in the literature. We report 42 cases in six generations of a family with various manifestations.

We report a rare case of subungual dermatofibroma in a 38-year-old man who was noted to have bulging and thinning of the thumb nail plate. Growth of the nail plate to normal thickness and shape was achieved after surgical removal of the tumour and careful repair of the nail matrix.

Five cases of spontaneous thrombosis of a palmar digital vein are presented. The patients, all female, complained of a tender and unsightly lump over the digital palmar surface at the proximal interphalangeal joint level. Two fingers were affected in one patient. None could recall any history of trauma. In four cases a surgical excision was carried out. Histology confirmed the intraoperative findings of thrombosis of a superficial digital vein in every case. All patients are free from recurrence at a mean follow-up of 2.5 years.

We report a case of melorheostosis of the hand which showed a sclerotomal pattern of involvement, with swelling and pain. Surgical debulking resulted in correction of the deformity and relief of pain.

Forty-three trigger thumbs and fingers in 33 children (15 boys and 18 girls, average age 2 years and 4 months) were treated using a polyethylene splint. Affected digits included 40 thumbs, one index finger, and two middle fingers. The IP joint was stabilized in maximum extension via a strap on the dorsal side. The splint was applied only at night and during day-time naps. Twenty-four digits recovered completely in an average of 10 months, seven digits improved, and two digits required surgery. Eight patients (10 digits) dropped out of treatment. Splint therapy is effective in treating trigger thumbs and fingers in children.

The biological adaption and integration of flexor tendon pulleys reconstructed with expanded polytetrafluorethylene (e-PTFE) were investigated 3 months after operation. E-PTFE pulleys showed no signs of failure, adverse tissue reactions or detrimental effects on the surface of underlying tendons. Cells in pulleys reconstructed with e-PTFE synthesized proteoglycan, collagen and non-collagen protein at a higher rate, and DNA at a lower rate, than cells in sham operated pulleys. Cells in pulleys reconstructed with e-PTFE synthesized proteoglycan at a lower rate, and protein at a higher rate, than cells in e-PTFE strips placed subcutaneously. Flexor tendon segments underlying reconstructed or sham operated pulleys synthesized matrix components and DNA at comparable rates.