Journal of Hand Surgery (European Volume)

Twenty cases of total wrist fusion, performed for post-traumatic conditions, were reviewed objectively, subjectively and radiologically. All patients were satisfied with the position of the fused wrist and had good pain relief. All patients would have had the procedure sooner, having had an average of three operations on the wrist before the fusion. There was a high complication rate (45%), although only four patients required further procedures for those complications. Hand function, as assessed by the Jebsen and Purdue tests, was found to be poor; this may be due to a reduced range of finger movements. There was no correlation between position of fusion, carpal height or number of joints radiologically fused, and the pain score, grip strength or Buck-Gramcko score.

Fourteen cadaveric wrists were dissected to investigate a modified dorsal approach that involved osteotomy of the small and dorsal tubercles without opening the third compartment. This approach could be safely made with good exposure of the dorsum of the wrist. The mean normal angle formed by the extensor pollicis longus tendon at the level of the dorsal tubercle was 144°. An approach that involves division of the third compartment may lead to effective lengthening of the extensor pollicis longus musculotendinous unit by 8 to 17 mm with corresponding decrease in the tension generated by its contraction. The modified approach permits restoration of the normal alignment of the extensor pollicis longus tendon, and may be useful for performing arthrodesis of the non-rheumatoid wrist in young manual workers.

In order to determine the effectiveness of wrist arthrodesis using dynamic compression plating and bone grafting, we reviewed 18 consecutive procedures in 17 patients performed using a standardized technique over a 6-year period. Fourteen patients had previously undergone an average of 2.1 operations prior to arthrodesis. Mean follow-up was 48 months. All but one patient reported considerable pain relief and were satisfied with their results. Grip strength remained limited compared to the contralateral wrist. Complications were limited to one case of reflex sympathetic dystrophy and metacarpophalangeal joint contracture, and minor problems related to the bone graft donor site.

The findings at arthroscopy of the wrist in 48 consecutive cases carried out over a 4.5 year period have been retrospectively reviewed.

In correlating the clinical and arthroscopic findings in the 36 patients with wrist instability and triangular fibrocartilage injuries we found concurrence in 28 of the cases. In the six patients in whom we were unable to make any provisional clinical diagnosis we did not find arthroscopy helpful.

Arthroscopy usefully influenced the management in two of the six patients in whom the articular surface was assessed.

We feel that a careful clinical examination of the wrist is the mainstay of diagnosis in wrist disorders. Arthroscopy remains useful in selected cases but has a limited specialized role which should continue to be provided from specialist centres.

A case of fracture of the hook of the hamate associated with a palmar dislocation of the fifth carpometacarpal joint is described. Surgical exploration revealed that the different elements of the flexor carpi ulnaris musculotendinous unit, which includes the pisiform, the pisohamate and pisometacarpal ligaments, were displaced proximally together with the avulsed fragment of the hook of the hamate and the fifth metacarpal. These findings suggest that such an injury results from a sudden, violent contraction of the flexor carpi ulnaris against the fixed wrist. It was successfully treated by open reduction and fixation of the hook of the hamate fracture and stabilization of the carpometacarpal joint.

The physical attributes of the three capitohamate interosseous ligaments were tested in a computer-controlled multi-axis testing machine using 12 human cadaver specimens. After an intact test run, selected ligaments were cut in random sequence and the test repeated. The remaining ligaments were tested to failure with servohydrolic stress at 5 mm/second.

In the intact joint complex, the average dorsopalmar rotational displacement was approximately 9° in each direction. Under the load limit, the dorsopalmar translational displacement averaged 0.9 mm and 0.5 mm respectively, proximal–distal translational displacement averaged 0.8 mm and 0.4 mm respectively, and distractional displacement averaged 0.3 mm.

Based on the sequential sectioning it was found that the dorsal ligament provided 76% (SD 14) of the rotational resistance with palmar rotation of the capitate and 44% (SD 19) of translational constraint with palmar translation of the capitate. The deep ligament provided 51% (SD 15) of the rotational resistance with dorsal rotation of the capitate and 63% (SD 24) of translational resistance with dorsal translation of the capitate. With proximal—distal translation, the dorsal ligament was the most important constraint in each direction. In resisting distraction, each of the three ligaments was equally effective. Failure testing showed the deep ligament was strongest at 289 N, followed by the palmar at 171 N and the dorsal at 133 N.

A fracture at the medial end of the distal third of the radius with an epiphyseal separation of the distal ulna in a 16-year-old boy is described. This injury, known as the Galeazzi-equivalent lesion in children, is characterized by complete distal ulnar epiphyseal separation without rupture of the distal ligamentous stabilizing system between the radius and ulna, which includes the triangular fibrocartilage complex, interosseous ligaments and periosteal tube of the ulnar. The Galeazzi fracture-dislocation and the Galeazzi-equivalent lesion appear to be completely dissimilar in their pathological anatomy. We suggest calling the latter a “pseudo-Galeazzi injury”.

We assessed the results of 86 trapeziectomies in 83 patients. Simple excision of the trapezium was performed in 54 thumbs. This was combined with shortening of the abductor pollicis longus tendon in 14 thumbs and with soft-tissue interposition and/or ligamentous reconstruction in 17 thumbs.

88% of the patients were satisfied with the result, 76% had relief of pain and 74% had no functional disability. The subjective results achieved with the three different techniques were similar.

Clinical assessment of 57 thumbs revealed no statistical difference in web span, thumb adductionflexion, key pinch and grip strength between the three operative procedures, nor in comparison with the non-operated contralateral hand.

The direct midlateral approach and the lateral enlarging procedure of the pulley system have been utilized in our service since 1972. The incision runs directly behind the neurovascular pedicle, which is left in the palmar skin flap of the anterior compartment of the finger, in order to ensure its blood supply and sensibility. The transverse digital lamina of Landsmeer’s skin anchoring system and Cleland’s ligament are preserved and are used to perform a lateral enlargement of the pulleys after tendon repair. The technique allows wide surgical exposure of the digital fibro-osseous tunnel, enlargement and reconstruction of the pulley system and tendon sheath, flexor tendon repair (using the technique of choice) and reduces postoperative impingement in zone 2.

Apart from real-time sonography, in most of the imaging techniques used to examine the musculoskeletal system, such as X-ray, computerized tomography scan and magnetic resonance imaging produce mainly static images. Although colour Doppler imaging (CDI) is generally used in the examination of blood flow, it may offer the opportunity to study the dynamic characteristics of tendons and muscles. The purpose of this study was to examine the unilateral flexor and extensor tendon pathologies of the hand and compare these images with the healthy side. A Philips Quantum Doppler was used to study patients with tendon adhesions and trigger finger. The normal and pathological tendons were scanned at three anatomical levels: wrist, metacarpal and proximal phalanx. The results obtained from the comparison of pathological images with normal ones indicate that CDI offers a promising approach to image dynamically and, in the future, to quantify the function of the tendons and muscles in the musculoskeletal system and to define their pathologies.

We evaluated the mechanical properties of six different circumferential tendon sutures with a variable number of suture strands. Seventy-two human cadaver flexor profundus tendons were cut and repaired using only a 6/0 polypropylene circumferential suture. The six running suture techniques were: Simple; Simple-locking; Lembert; Halsted; Cross-stitch; Lin-locking; using 10, 14 and 18 suture passes. The increased suture passes increased both tensile and gap strengths. The tensile strength of the Lin-locking technique (29 to 63 N) was significantly stronger than the others, followed by Cross-stitch (27 to 38 N), Halsted (21 to 27 N), Lembert (20 to 27 N), Simple (11 to 22 N) and Simple-locking (10 to 17 N). The gap strength values were between 3 to 14 N, with no significant differences between the techniques. The resistance to gliding, as measured by work of flexion, was not affected by the number of strands. However, the Lin-locking significantly increased the resistance to gliding (33-36%) compared to the other techniques (6-21%); there were no significant differences between these five techniques.

We report three clinical cases in which Dupuytren’s disease was triggered by surgical trauma. All patients developed the contracture between 3 weeks and 3 months after operation for unrelated / pathology of the hand. They had significant swelling of the hand postoperatively, preventing full mobilization. They did not have a strong diathesis for the disease. Since the appearance of the contracture, they have not developed the disease in the contralateral hand or anywhere else in the body. In one case, a similar operation on the contralateral hand has not provoked onset of the disease.

The results of long-term follow-up (range 9–19 years) are presented in a continuous series of patients treated for Dupuytren's contracture by one surgeon using the open palm technique. Mean preoperative total range of movement was 48% rising to 96% postoperatively. Mean total range of movement was 92% at follow-up. Survivorship analysis revealed 86% survival at 10 years and 77% survival at 19 years. There was one digital nerve injury and one case of algodystrophy. This technique gives good long-term results without the use of night splintage or physiotherapy.

Simultaneous tendon transfer and dermofat graft augmentation of the first web space of the hand with intrinsic paralysis is described. Fifty per cent over-correction of the web space volume is recommended in anticipation of postoperative graft resorption. Other techniques of fat auto-transplantation are discussed.

The magnetic resonance imaging appearance of the proximal interphalangeal joints of cadavers was correlated with histology of the same specimen allowing many small-scale features to be identified that might otherwise have been misinterpreted. It enabled the magnetic resonance signal to be understood at a tissue and cellular level, allowing identification of synovial folds extending from the extensor tendon and volar plate, the entheses of the proper collateral ligament, the epitenon of the flexor tendons and the presence of osteophytes and sites of cartilage erosion. The main difficulties in matching two-dimensional magnetic resonance images with histology were the differing section thicknesses of the two methods and shrinkage of histological specimens. There are many advantages in producing high resolution three-dimensional datasets—the magnetic resonance section thickness is reduced and the individual components of the joint can be viewed simultaneously in two or more planes. A unique magnetic resonance atlas of three dimensional joint structure is presented.

Ten patients with radiological non-union of the scaphoid and four patients with suspected nonunion were explored surgically. At operation, ten scaphoids looked united; five of these went on to definite union but the other five to non-union (in one case, despite a Herbert screw). In another four patients, there appeared at operation to be partial union; all proceeded to complete union. Even with the scaphoid in front of you, it can be difficult to decide whether it has united or not.

A retrospective study of 12 young women (14 cases) complaining of chronic wrist pain, obscure numbness and reduction of grip strength is presented. The average duration of the complaints was 7.3 years. All wrists were in VISI alignment, with normal motion series and normal intrinsic interosseous ligaments demonstrated arthrographically. The dorsal-displacement stress test showed subluxation of the capitolunate (in nine cases) or both the capitolunate and the radiolunate joints accompanied by a marked feeling of apprehension. Surgical management consisted of ligamentous reefing of the whole palmar aspect of the midcarpal joint and the radiolunate joint when needed. Additionally, a neurectomy of the terminal branch of the anterior interosseous nerve was done in four cases. The result was excellent in eight cases, good in five cases and fair in 1 case. Young women with “delicate” wrists and obscure wrist pain may have isolated instabilities of the capitolunate and radiolunate joints. In cases that do not respond to conservative measures ligamentous reefing should be considered.

We compared biodegradable pins with standard Kirschner wires in the fixation of fractures, arthrodeses and osteotomies in the hand in a prospective, randomized study.

Eleven patients were allocated to the biodegradable pin group and 12 to the Kirschner wire group. Age, gender, operative procedure and postoperative treatment did not differ in the two groups.

All patients were evaluated after 6 months. No differences in time to union or complication rates were found, but the number of additional operative procedures in the Kirschner wire group significantly exceeded the number needed in the biodegradable pin group.

We report a rare case of fracture of the neck of the fifth metacarpal which required open reduction. The radial and ulnar collateral ligaments entrapped the displaced metacarpal head. This patho-anatomy resembles that of rotational supracondylar fractures of the proximal phalanx.

Soluble fibronectin and nerve growth factor (NGF) promote axonal regeneration when placed in silicone tubes. We investigated the ability of orientated fibronectin mats to bind and release bioactive NGF and the possibility of augmenting axonal regeneration following axotomy by using fibronectin conduits impregnated with NGF. The release of NGF was quantified using a fluorometric ELISA and bioactivity confirmed with a neuronal culture bioassay. Immunohistochemical techniques and computerized image analysis were used to assess the rate and volume of axonal and Schwann cell regeneration. The delivery of NGF to the site of injury produced an increase in the rate (P≤0.007) and volume (P≤0.004) of both axonal and Schwann cell regeneration when compared to conduits of plain fibronectin. We conclude that the local delivery of NGF by impregnated fibronectin conduits enhances axonal regeneration.

Anatomical and clinical research has shown that the entire lateral epicondylar region is innervated only by radial nerve branches. Based on these investigations we have developed a surgical procedure for complete denervation which is indicated only in resistant cases of tennis elbow. Only one nerve pathway calls for careful exposure, otherwise denervation is accomplished blindly by disinsertion of certain muscles. The result of this procedure also depends on simultaneous indirect decompression of the posterior interosseous nerve. Excellent or good results were obtained in 90% on average. Results of denervation did not improve by additional direct radial nerve release.

A skin stretching device (SSD) harnessing the viscoelastic properties of skin using incremental traction has been used in 20 patients with skin deficits in the upper extremity. Complications were few considering the extensive damage to the skin and included slight partial dehiscence, necrosis of skin edges, local infection and hypertrophic scars. All wounds healed without the need for further surgical procedures. Application of the SSD is simple and it can even be used at the bedside under local anaesthesia. It reduces the need for more complicated surgical procedures like grafts or flaps.

A total of 43 patients (49 hands; 424 flexor tendons), who had rheumatoid arthritis of more than 15 years duration at the time of surgery, were clinically assessed at a mean follow-up of 5.7 years (range, 1.2–12 years). Pain and inability to flex actively despite a good passive range of motion were the main surgical indications. The results suggest that the patients had excellent sustained pain relief (mean score=0.9) and were highly satisfied with the outcome of the procedure (mean score = 2.2). 81% had adequate pulp-to-pulp and key pinch. Range of finger motion (total active motion, TAM) was excellent to good in 45% and fair in 22%. Thirty-three per cent were graded as poor and these were found to be multifactorial in origin, with associated significant joint disease, preoperative tendon ruptures, extensive digital surgery, readhesions and combinations of operative procedures which adversely affect the rehabilitation programme. Flexor tenosynovectomy with tenolysis is a useful procedure with a low rate of recurrence.

A case of carcinoma of the lower alveolus metastasizing to the phalanges of the hand is reported. The possible mechanism of such metastases, the clinical and radiological features and the role of fine needle aspiration cytology are discussed.

Six metastatic tumours of the hand are reported. Five were located in long bones of the hand and one in the soft tissues without bone involvement. The primary tumours arose in the lung, kidney, hard palate, larynx and pharynx. Treatment was palliative and consisted of amputation for distal lesions and local excision and/or radiation for proximal lesions when symptomatic. Short-term prognosis was poor with a median survival of 7 months. In two patients, hand metastases were the first sign of malignant disease.

A rare case of eccrine spiradenoma of the hand is described. The tumour mimicked a lipoma on clinical examination and in macroscopic appearance. The classification and treatment of eccrine tumours are discussed.

We report on clinical and electrophysiological findings and management in nine patients who developed carpal tunnel syndrome during the course of amyotrophic lateral sclerosis and late onset cerebellar ataxia, two neurodegenerative diseases. The patients were treated with surgical decompression (five cases) and local steroid injections (four cases). Only one showed lasting relief of symptoms and significantly improved distal conduction in the median nerve at follow-up after 2 to 3 months. The symptoms and conduction data remained unchanged in three patients who could be followed for more than 1 year. We think that axonal neuropathy plays an important role in the development of carpal tunnel syndrome in these patients and accounts for the failure of the standard treatments.

We report a case of cubital tunnel syndrome caused by tophaceous gout. The ulnar nerve was compressed by a tophus at the distal cubital tunnel. Surgical decompression relieved the symptoms.