Journal of Hand Surgery (European Volume)

A series of 36 digital replants is reported in which microvascular anastomoses were each performed with four to six stitches and topically applied fibrin glue. Thirty-two digits survived, comparable to survival with conventional microvascular anastomosis. The average operative time per replanted digit was 3.2 hours, considerably less than documented with standard replantation technique (4.5 hours per digit). These clinical findings indicate that fibrin glue-assisted microvascular anastomosis does not compromise replant outcome and can reduce the operative time by reducing the number of microsutures that need to be placed in each anastomosis.

Thirty consecutive patients with amputation or devascularizing injuries of the thumb or two or more fingers proximal to the PIP joint were reviewed. Replantation or revascularization had been done in 27 patients, in 24 successfully. Three patients had primary amputation. The distribution of calculable costs was dominated by those for sick leave (49%), operation (26%) and ward costs (20%). Out-patient care, physiotherapy and travel together constituted only 6%. The cost of a successful replantation was equal to 1.6 times the mean annual salary of these patients and that of primary amputation about half as much. Mobility, power and performance of a standardized grip test were better for the successfully replanted or revascularized patients. Subjective evaluation of 23 parameters of function, cosmesis and quality of life did not disclose any differences. All patients except three had returned to their original work within 2 years.

The functional anatomy of the triangular fibrocartilage complex (TFCC) was investigated in 20 fresh cadavers. Dynamic changes in the TFCC during rotation were also examined from both the proximal and distal aspects. In our analysis, the TFCC was separated into three components. The distal component was stable, functioning like a hammock to suspend the ulnar carpus. The proximal component was the fan-shaped triangular ligament, the true radioulnar ligament. This was found to originate from the fovea of the ulna in a vertical fashion and was easily twisted during rotation. The third component, the ulnar collateral ligament, also twisted during rotation. When analysed by coronal section, the internal portion of the TFCC was found to be loose, and probably serves as a cushion to absorb local deformities in the TFCC during rotation.

Fifty preserved cadaver wrist specimens were studied. The anatomy of the distal radioulnar joint is complex, with varying configurations in the transverse and midcoronal planes. There is disparity in the radii of curvature of the sigmoid notch and the ulna-articular surface in the transverse plane, with resultant articular incongruity. Motion at the distal radioulnar joint is, hence, likely to be a combination of sliding and rotation with a small area of true appositional contact. The palmar osteocartilaginous lip of the sigmoid notch, along with the interosseous membrane, may be of importance in distal radioulnar stability. Palmar and dorsal radioulnar ligaments may act as “check-rein” ligaments, especially when seen with the “flat face” (type A) sigmoid notch.

Oedema remains one of the most common causes of hand stiffness. Local venous return is intimately associated with oedema formation and management. To elucidate, the underlying mechanisms of venous return, the venous pumping systems in the hand were objectively and quantitatively investigated using Doppler ultrasound, cadaveric dissection and venography.

It was demonstrated that functionally there are three independent venous systems: the superficial palmar, deep palmar and dorsal veins, which are activated by palm compression, isometric intrinsic muscle contraction, and dorsum compression, respectively. Each system was investigated independently and found to increase venous blood velocity in both the cephalic and ulnar veins. These systems were also shown to act in synergy, producing the greatest velocity increase when concurrently activated during fist-clenching. The volume of blood pumped during fist-clenching could also be potentiated by preloading by digit abduction. The clinical applications of these findings are discussed.

A new electrogoniometer technique is described for the measurement of wrist movements, including circumduction, with the results being displayed as figures.

Clinical validation has been performed and the system found to be highly accurate and reliable. Applications of the technique are illustrated. It is suggested this technique should in the future be used to assess wrist movement in clinical and research applications.

We have used the motion analysis system to evaluate the maximal area of fingertip motion. Some modification in setting the cameras and use of a smaller marker is required. In this series, 58 examinations have been accomplished on 28 fingers with various traumatic injuries. The closed curve derived from the motion analysis system and the area calculated from it were easier to interpret and could be compared in serial examinations. A high linear correlation between the fingertip motion area and total active motion was found. The computer-aided motion analysis system complements the traditional methods of assessing an injured finger.

A case of trigger index finger is reported. The diagnosis was made in the neonatal intensive care unit. The proximal interphalangeal joint (PIP) was locked in a flexed position. A nodular thickening of the flexor tendon was felt at the A2 pulley level. Surgery revealed thickening of both the A2 pulley and the radial slip of the flexor superficialis tendon. Division of the A2 pulley released the PIP joint locking.

We report triggering of the thumb in a 2-year-old female child caused by intratendinous granulation tissue after trauma to the thumb.

Four non-invasive tests for central slip integrity were analysed using 20 fresh frozen cadaver fingers. A pre-boutonnière deformity was simulated by dividing the central slip. A passively correctable boutonnière was simulated by dividing the central slip, triangular ligament and oblique fibres of the extensor expansion. The test described by Boyes, which evaluates distal interphalangeal joint flexion, was found not to be reliable for the diagnosis of either injury. The test described by Elson, which evaluates distal interphalangeal joint rigidity while actively extending the flexed proximal interphalangeal joint, was the only manoeuvre which was able to discern central slip integrity in both simulated injuries. The central slip tenodesis test and testing resistance of active proximal interphalangeal joint extension should be performed with the proximal interphalangeal joint in flexion to weaken the effectiveness of the lateral bands.

Twenty seven opponensplasties for ulnar and median paralysis in 25 leprosy patients were performed using extensor indicis proprius. An additional transfer of the radial half of flexor pollicis longus to extensor pollicis longus was done to stabilize the metacarpophalangeal joint of the thumb. The biomechanical aspects of extensor indicis proprius tendon transfer were studied and results evaluated using various anatomical and functional parameters. Extensor indicis proprius provides adequate strength to position the thumb. However, sometimes it does not reach its new insertion. There is no significant deficit at the donor site but in a few cases the index finger may lose its capability for independent extension and sometimes a proximal interphalangeal joint contracture may develop.

A comprehensive evaluation system for opponensplasties has been described taking into consideration several variables. Each variable has been assigned a score depending upon its significance in the normal hand. The total score of the hand is used for grading the results as good, fair and poor.

The results following primary and delayed primary repair in zone 2 flexor tendon injuries were evaluated prospectively in 88 fingers of 71 patients using two different early postoperative mobilization programmes. In 33 patients, the Kleinert rubber band passive flexion method was used. In the remaining 38 patients, the early active mobilization programme was used. All patients were reviewed 1 year after operation and the results assessed by the Strickland criteria. During this evaluation maximum grip strength was also measured.

The results were excellent or good in 78% of digits and mean grip strength was 84% of the uninjured hand in the Kleinert rubber band passive flexion group. In the early active mobilization group, excellent or good results were achieved in 85% of the digits and the mean grip strength was 90% of the uninjured hand. There were two early ruptures in each group.

A new technique of attachment of the flexor digitorum profundus tendon and flexor tendon grafts to the distal phalanx, without using a button on the nail, is described and its use reported in 14 cases.

Nine patients (11 cases) with inflammatory arthritis who had an early boutonnière deformity of the thumb treated by rerouting of the extensor pollicis longus tendon were reviewed.

Preoperatively, all patients complained of pain, disability in activities of daily living and extensor lag of the MP joint ranging from 10 to 60°. At a mean follow-up of 38 months, nine thumbs had equal active and passive MP joint extension. Two thumbs had a moderate extensor lag. Functional strength assessment demonstrated no deleterious effect of the procedure in the operated compared to the non-operated thumb. Subjectively, all patients but one were satisfied.

This procedure appeared to correct or to limit the progression of the deformity. A deficit of interphalangeal extension in five patients may require a modification of the procedure to tighten the extensor pollicis longus distal to the MP joint.

Avulsion fractures of the index metacarpal at the insertion of extensor carpi radialis longus are rare. We report such a fracture and the resulting complication of division of the extensor pollicus longus tendon, by the avulsed bony fragment.

Careful clinical assessment and appropriate radiological examination is needed to diagnose this rare fracture and internal fixation is recommended.

Expanded polytetrafluoroethylene (e-PTFE) may be used as a barrier to reduce formation of restrictive adhesions following tendon surgery within the flexor tendon sheath region. In order to assess its effects on the cellular activity of healing tendons, synthesis and contents of matrix components and synthesis of DNA were compared in divided and sutured flexor tendons that either had been covered with e-PTFE membranes or with sham-operated tendon sheaths in 30 rabbits. At intervals of up to 12 weeks segments of the tendon repair sites were harvested, placed in wells and labelled with 35S-sulphate, 3H-proline and 3H-thymidine during short-term culture in vitro. Adverse tissue reactions and tendon disruptions were not observed at harvest. At each time interval synthesis of matrix components and DNA and contents of protein and collagen in the repaired tendon segments were similar in the two groups. Measured over all intervals, synthesis of non-collagen protein and contents of protein and collagen were lower in the e-PTFE groups. These results show that reconstruction of flexor tendon sheaths with e-PTFE membranes may not significantly impair cell proliferation but to some extent may reduce protein synthesis of healing tendons.

Arthrogryposis multiplex congenita is a specific, well-defined congenital deformity which primarily affects muscles of limbs resulting in secondary joint deformities. The aetiology is still uncertain.

One of monozygotic twin brothers with classical arthrogryposis multiplex congenita is presented, proving that this specific condition is not genetically transmitted.

Three cases of unilateral duplication of the little finger in children with Apert's syndrome are presented. They provide additional evidence that the hands in Apert's syndrome are not always symmetrically affected.

A neonate with extremity gangrene resulting from intrauterine embolization of infarcted placental substances is discussed. This rare clinical entity is thought to be most commonly a manifestation of embolic phenomenon during maturation of the neonatal circulatory system. Management of neonatal gangrene is conservative, delaying amputation as long as possible since the line of demarcation tends to migrate distally. Evidence of multiple emboli should be carefully sought prior to definitive treatment.

The case of a 64-year-old man with idiopathic symmetrical osteolysis affecting both hands and feet is presented. The phalanges were principally affected, with relative sparing of the carpus and tarsus. The relevant literature has been reviewed and this reveals that the distribution of osteolysis in this case is unique. We suggest that this case represents a different disease entity, which has not been described previously.

This study investigated specific regeneration of a mixed motor and sensory nerve by the method of spinal dorsal root ganglions resection. A 10 mm segment of tibial nerve was resected and the nerve ends inserted in a silicone tube. Fourteen weeks later, dorsal root ganglia from L6 to S1 were resected on the experiment side. Twenty weeks later, the regenerating motor nerve fibres of mixed nerves selectively grew into motor branches. The rate of misdirected growth in mixed nerves was less than 6%. These results suggest that regenerating motor and sensory axons of mixed nerves are able to select their distal target organs accurately. Better results may be obtained using the entubulation repair method.

We measured pressure changes in Guyon's canal and the carpal tunnel before and after endoscopic (11 cases) and open (10) carpal tunnel release. We found that release of the flexor retinaculum by endoscopic and open techniques measurably decreased pressure in both the carpal tunnel and Guyon's canal. This study provides an explanation for relief of ulnar tunnel syndrome symptoms following carpal tunnel release and may indicate that carpal tunnel release alone may be sufficient to provide symptomatic relief for most patients with carpal and ulnar tunnel syndromes.

An isolated compression neuropathy of the palmar cutaneous branch of the median nerve is described in a woman who presented with a small tender mass over the anterior aspect of her distal forearm and complete numbness over the thenar eminence. Surgical exploration revealed thickening of the palmar cutaneous nerve as it passed upwards through the antebrachial fascia on the ulnar aspect of the flexor carpi radialis tendon. Neurolysis of two separate fascicles of the palmar cutaneous branch of the median nerve and excision of a window of antebrachial fascia resulted in complete return of sensation over the thenar eminence.

The roof of the carpal tunnel (or canal) consists of the distal portion of the flexor retinaculum, the flexor retinaculum (or the transverse carpal ligament) and the proximal portion of the flexor retinaculum. We tried to determine which anatomical structures were relevant to complete endoscopic carpal tunnel decompression in long-term haemodialysis patients with carpal tunnel syndrome. Carpal tunnel pressure was measured using the continuous infusion technique before and after endoscopic release of the flexor retinaculum, distal portion of the flexor retinaculum and the proximal portion of the flexor retinaculum respectively in 257 hands.

We concluded that release of the distal portion of the flexor retinaculum, in addition to the flexor retinaculum, is essential for complete carpal tunnel decompression in long-term haemodialysis patients.

A 59-year-old patient underwent endoscopic carpal tunnel release by Chow's two-portal technique. He developed a pyogenic tenosynovitis and an infection within the ulnar and radial bursae, an abscess in the middle palmar, thenar and Parona's space, and a pyogenic wrist arthritis. Surgical treatment included a wide exposure of the infected region, débridement, irrigation, application of a resorbable collagen sponge containing gentamicin, insertion of two drains and primary wound closure. The infection was brought under control and hand function restored.

Eight patients underwent middle ray amputation with excision of the whole of the middle metacarpal and careful soft tissue repair. Excision of the base of the middle metacarpal allowed easier approximation of the index and ring rays without the tendency of these fingers to either scissor on finger flexion or to remain slightly apart. Complete removal of the middle metacarpal appears to allow the bases of the index and ring metacarpals to migrate together. The removal of the metacarpal base caused no functional problems and the technique created a good three-finger hand from both a functional and cosmetic point of view.

A herpes simplex type 2 infection of the hand after injury is described in a 26-year-old man. The management and implications of such an unusual hand infection are discussed.

A study of seven cases of giant cell tumours of the hand is reported. All tumours were treated by an en bloc excision of the tumour or by whole ray resection. En bloc resection of the tumour and reconstruction with a fibular graft where necessary should be considered as the treatment of choice in giant cell tumour of the hand.

We report a case of osteoid osteoma of the radial diaphysis. Excision of the nidus relieved pain.

A rare case of myxoma of the dorsal aspect of the little finger is described. Classification of myxomas of the upper limb is discussed.

A case of a subcutaneous haemangioma of the hand clinically mimicking a glomus tumour is described. Other discrete small hand tumours that may present with the triad of pain, tenderness and cold intolerance are discussed.

We report a case of stroke due to carotid artery dissection in a young man following a traumatic brachial plexus palsy associated with a pseudoaneurysm of the axillary artery.

Thirty-three patients with single and multiple digital amputations were fitted with a total of 50 prosthetic silicone fingers over a mean period of 4 years. The prosthetic fingers were custom made using a special method which has been modified at our institution. This study provides a detailed analysis of patients’ occupational and cosmetic usage of and satisfaction with their prostheses, as well as describing the fabrication technique.