Journal of Hand Surgery (European Volume)

The pronator quadratus muscle has been neglected to a great extent in the anatomical and functional literature. This study confirms the consistent presence of two distinct heads to the muscle, and defines the gross and microscopic anatomy. The functional significance of these heads has been studied using in vitro and in vivo techniques to demonstrate that the superficial head is the prime mover in forearm pronation, and that the deep head is a dynamic stabilizer of the distal radioulnar joint.

Between 1988 and 1994 40 children (age range 9 months–14 years) with either congenital (85%) or acquired hand deformities underwent reconstruction by microvascular autotransplantation of one or more toes.

Fourteen underwent a single toe transfer whilst 26 had two second toes transferred to one hand. In 14 of these cases both second toes were transferred at one operation. Whether one or two toes were transferred, the children spent on average 9 days in hospital. None of the transfers failed but 75% of the children underwent staged additional surgery to improve appearance and function.

Thirty-seven of the 40 children attended with their parents for follow-up examination by an independent surgeon, a physiotherapist and a clinical psychologist in order to evaluate the results and consequences of surgery. This paper presents the technical considerations for this surgery and examines the influence of the transfer on growth.

Forty children with congenital (85%) or acquired hand disorders underwent transfer of one or two toes to one hand. The children were reviewed with their parents and assessed for functional and psychosocial performance. There was some evidence that the older the child at the time of transfer, the better the range of motion. The passive range of motion was on average 60° more than the active range of motion despite subsequent procedures such as tenolysis. All transfers recovered protective sensibility and the majority recovered good levels of two point discrimination and light touch perception. Almost all transfers were naturally incorporated into the use pattern of the limb for some or most of the time. Most parents and patients reported a very positive effect of this surgery on the child’s psychosocial functioning.

We have studied the effects of vibration on the regeneration capacity of the peripheral nerve. A rat model was used where one hind limb was subjected to vibration of defined magnitude and duration while the contralateral hind limb was not exposed to vibration. Seven days later, the sciatic nerves were transected bilaterally and cross-joined giving the following groups: group A, a proximal vibrated nerve end sutured to a non-vibrated distal nerve end; group B, a non-vibrated proximal nerve end sutured to a distal vibrated nerve end, and group C, non-vibrated proximal nerve end sutured to a non-vibrated distal nerve end. The regeneration distances were measured 3, 6 and 8 days after surgery. The control group showed a normal linear outgrowth. The outgrowth in the two experimental groups was initially not different to controls but later became significantly different, indicating a retardation of outgrowth in these groups. It is concluded that short-term exposure to vibration can impair nerve regeneration after transection and nerve repair.

The purpose of the study was to investigate if vibration-induced white finger may be a reversible symptom after cessation of vibration exposure. Fifty-nine welders, previously employed by a ship building company and who had shown various levels of vibration-induced vasospastic symptoms in the hand were interviewed 5 to 6 years after closure of the company. Out of the 43 patients exposed to no or insignificant vibration subsequently, 28 claimed improvement, 11 claimed unchanged problems and four complained of worse problems. Twelve of these patients had the cold provocation test repeated at follow up. One patient showed the same result as 5 years earlier, six showed improvement and five showed much improvement. Of 16 patients with continued vibration exposure none showed subjective improvement, nine claimed unchanged problems while seven patients were worse. It is concluded that vibration-induced white finger is not a progressive condition following cessation of exposure to vibration. On the contrary it may be static or even reversible to some extent.

The early skeletal muscle response to vibration stimulus at two different displacement levels was examined. Twelve rats were anaesthetized and the hind limb was exposed to vibration, 80 Hz, 63 μmrms (root mean square) (group 1) and 40 Hz; 130 μmrms (group 2) for 5 hours/day for 2 days. Cross-sectional areas of vibrated muscle fibres were significantly larger in group 2. Sizes of different fibre types were differently affected: the slow-twitch type 1 fibres were significantly enlarged in both groups, while the fast-twitch type 2 fibres demonstrated a mixed response pattern. Centrally positioned muscle fibre nuclei increased significantly after vibration in group 2. It is concluded that the level of tissue displacement is a crucial factor for development of vibration-induced muscle injury.

We report a case of avulsion of the insertion of the flexor digitorum profundus in which the whole palmar cortex of the distal phalanx was avulsed, giving an unusual radiological appearance.

The mechanical rigidity obtained by external fixation in a comminuted phalangeal fracture model was assessed and the results compared with two other types of internal fixation commonly used (lateral plate and crossed Kirschner wires) in a biomechanical cadaver study. Each fixation technique was tested in apex palmar bending, compression and torsion. The results showed that lateral plating provided the best rigidity in apex palmar bending and compression and that external fixation and Kirschner wires showed the same mechanical properties. For the torque test, external fixation provided the best rigidity.

The rigidities of five fixation methods have been studied with a comminuted phalangeal fracture model. Mechanical testing of compression, bending and torsion were performed for each fixation. Lateral plating with six screws seems to provide the most rigid fixation. If such lateral plating is not practicable, the four-Kirschner wire method would be a satisfactory alternative.

An injectable material which hardened in situ to form a carbonated hydroxyapatite, Norian SRS (Norian Corp., Cupertino, USA), was used as the only treatment of unstable distal radial fractures in six patients. Except for an external dorsal splint for 2 weeks, no other treatment was used. The material maintained reduction except in one case in which there were technical problems during hardening and the material fragmented postoperatively. By 1 year all patients had a satisfactory clinical outcome. There was an early return of motion. The possibility of mobilization 1 or 2 weeks after the operation may reduce postoperative stiffness and increase short-term functional outcome.

Simultaneous fractures of the distal radius and scaphoid is an uncommon wrist injury. During the period 1980 to 1993, 23 patients with a median age of 39 years were treated for this injury. The median follow-up period was 7 years. All scaphoid fractures were undisplaced and located in the waist or distal third. An extraarticular distal radial fracture was observed in 15 wrists. A below elbow cast including the thumb was applied in 18 wrists for a mean duration of 9 weeks, and operative treatment was used in only 5 patients.

All scaphoid fractures healed without complications. During conservative treatment there were three redisplacements of distal radial fractures. The final functional results were good in 18, fair in four, and poor in one patient. Because complications occurred at the distal radius we have changed our conservative treatment policy from a below elbow cast including the thumb to a dorsal splint for 6 weeks.

The method of insertion of the Herbert screw for scaphoid fractures and its long-term presence in the scaphotrapezial joint may predispose to degeneration in that joint. We examined a group of patients with long-term follow-up to assess this risk and found it to be insignificant.

A case is reported of an absent flexor carpi radialis in a patient undergoing tendon transfers for a posterior interosseous nerve palsy.

We present the case of a 10-year-old girl who presented with a block to wrist abduction. Plain radiographs of the wrist suggested a coalition between the carpal bones. ACT scan, however, revealed the presence of an osteocartilaginous lesion on the distal pole of the scaphoid. This was resected and histology showed it to be an osteochondroma.

We present a patient who developed irritation of the superficial radial nerve from an underlying scaphoid exostosis.

A case of pseudoaneurysm of the radial artery complicating excision of a wrist ganglion is reported. Tourniquet release prior to wound closure would have allowed detection and immediate treatment of the vascular injury.

Twenty-six hands in 25 male patients were treated for peace-time explosion injuries of the palmar aspect. All patients were examined after a mean interval of 7 (1–17) years. In order to establish a regional pattern for each injury the palmar surface of the hand was divided in 21 fields. For each field a score depending on the extent of injury was calculated. Comparing this regional score with the spatial relation between hand and exploding object resulted in six typical patterns depending on the grip during explosion. With knowledge of the three-dimensional relation between the hand and exploding object, the hand surgeon is prepared for potential problems during operation.

This prospective trial collected all cases where injuries had resulted from the hand passing through or striking glass and had been referred to a hand injury service during 1 year. Eighty-seven cases were referred and the factors relating to these injuries were examined. A record was made of the structures damaged, the surgery performed and prevailing socioeconomic factors. These injuries were very costly in terms of morbidity, surgical effort and time, with significant resource implications. The study appears to confirm other reports that current legislation on glazing safety was too long delayed and is inadequate now that it is in place.

We report a case of pyoderma gangrenosum affecting both hands simultaneously. Pyoderma gangrenosum affecting the hands is an extremely rare condition which may result in considerable tissue destruction. Management includes immunosuppressant therapy, treatment of associated medical conditions and minimal surgical intervention. Despite a high maintenance dose of corticosteroid and adequate control of coexisting ulcerative colitis and rheumatoid arthritis, tissue destruction in the hands spread rapidly in our patient. The key to the patient’s dramatic improvement was the tissue biopsy suggesting pyoderma gangrenosum and the subsequent treatment with the cytotoxic immunosuppressant, azathioprine.

Postoperative traction, using the “S” Quattro external fixation device, improved the initial correction in 17 of 18 fingers treated by limited fasciectomy for severe proximal interphalangeal joint contracture in Dupuytren’s disease. Unfortunately significant recurrence occurred in eight within 1 year and only five maintained improved function. Complications included infection, loosening, recurrence, stiffness and amputation.

Segmental aponeurectomy has been proposed as a less extensive procedure for the treatment of Dupuytren’s disease to limit the incidence of wound complications and stiffness associated with wide dissections.

Analysis of the late results showed that the operation brought a lasting correction of the contracture. In hands which did not show any sign of progression of the disease, the follow-up values were even slightly better than the immediate postoperative measurements. It also showed that the proportions of recurrences, extensions and hands free of the disease are similar to those after other procedures and that the type of operation does not appear to be related to the progression of Dupuytren’s disease.

The aim of this study was to see if nodular cells in Dupuytren’s disease differed from dermal cells in their contractile capacity and motility. Ten surgical specimens from patients with Dupuytren’s disease and contracture of the finger of more than 45° were harvested and the nodular cells were explanted and cultured. Dermal fibroblasts from the forearm were used as control cells. Both types of cell had the same growth pattern. The morphology on confocal laser scanning microscopy was also similar in both types of cell. Dermal control cells caused significantly more contraction of collagen lattices compared with fibroblasts from nodules of Dupuytren’s contracture. The F-actin content was equal in both groups. Platelet derived growth factor, PDGF-BB (but not PDGF-AA), increased the chemotactic activity of both cell types, but there were no differences between them. The results indicate that at a late state of the disease cells from Dupuytren’s nodules lose their contractile capacity and regain a phenotype resembling that of dermal fibroblasts.

We report the effects of rubber bands placed as decorative bands around the wrists of two infants by older children. These bands went unnoticed by their parents for several hours until swelling of the hand occurred. Early decompression of the carpal tunnel and fasciotomy of the dorsum of the hand are recommended. Education of the community is important in avoiding complications from placement of these rubber bands around an extremity.

A double-blind controlled trial of the effects of pulsed electromagnetic fields on flexor tendon healing in adult New Zealand White rabbits was performed. A pulse burst waveform, previously demonstrated to influence new vessel growth in the rabbit, was employed. No significant effect was observed on either the healed strength of the tendon repair or the adhesion formation between the repair and the surrounding tissues. The model used for examination of adhesion formation was reproducible and is recommended for further work on the adhesion formation of healing tendons.

Mechanisms which lead to disabling adhesions following flexor tendon surgery of the hand were investigated in a rabbit model which was used to assess the relative response of the cells of the synovial sheath, epitenon and the endotenon to injury. A transverse laceration, cutting through 50% of the tendon, was made just outside the synovial sheath on the flexor aspect of the flexor digitorum profundus tendon. The synovial sheath was preserved intact. Using monoclonal antibodies for localizing specific inflammatory markers, we were able to follow the response and activity of the synovial sheath, epitenon and endotenon with respect to these markers at various times after surgery. Our findings suggest that the synovial sheath and the epitenon are relatively more reactive in the early period after injury, as judged by a range of inflammatory indices with the notable exception of the expression of the potent neovascularizing agent, basic fibroblast growth factor (bFGF).

Using a computerized tensiometer, the mechanical properties of two types of repair in the canine flexor digitorum superficialis tendon were examined. The slope and ultimate tensile strength of a cross-stitch epitenon suture were compared to those of a simple over-and-over running epitenon suture. Both epitenon sutures were combined with a modified Kessler core suture. Suture material was 6/0 monofilament nylon for the epitenon suture, and 4/0 braided polyester for core suture. Average relative values of individual ultimate tensile strength for the cross-stitch group was 245% compared to that for the running suture group. There was no discrepancy in slope between the two groups.

The triangular fibrocartilage and its function in the kinematics of pronation and supination in the distal radioulnar joint was studied. Measurements of the constituent parts of this joint in 11 cadavers showed that the palmar radioulnar ligament is at least 2 mm longer than the dorsal radioulnar ligament. Based on these measurements the movements of the joint were modelled in a two-dimensional kinematic chain. Predictions based on this chain could be confirmed by direct observation and videotaping dissections of joints of unfixed specimens and three-dimensional reconstructions of a CT scan of a healthy volunteer. It could be concluded that (a) the dorsal part is tight during pronation and the palmar part during supination and (b) considerable asymmetrical translations, (dorsal translation being the largest) occur because of the length differences of the ligaments.

The percentage of axons from different types of neurons regenerating through the site of repair was assessed by retrograde horseradish peroxidase labelling in 30 male SD rats. These rats were randomly divided into groups and underwent epineurial, perineurial suturing and 4 mm nerve graft for transected peroneal nerves in lower limbs on one side. The contralateral nerves were not injured and served as controls. The number of labelled neurons in the experimental side divided by those in the control gave a percentage of regeneration. Four to 9 weeks after nerve repair, axonal regeneration through the repair site was assessed by number, location and diameter. Results revealed that the percentage of motor axons crossing the nerve repair site was the same as the sensory axons. The percentage of neurons with axons innervating muscle spindles was statistically lower that those innervating the other end organs. Perineurial repair produced a higher percentage of motor axons across the repair than epineurial repair or nerve graft.

This paper reported a long-term follow-up of seven cases (eight nerves) with peripheral nerve repair by non-nerve tissues. The injured nerves involved three median, two radial, one ulnar and one tibial nerves. These patients were treated 3 to 10 months after injuries. In five cases, pedicled muscles grafts were used to repair nerve gaps from 3 to 6 cm. Follow-up between 4 years and 10 months and 6 years and 8 months showed functional recovery ranged from MOS1 to M2 + S3. Two cases of nerve gaps 3 and 4 cm in length repaired by empty muscle membrane tubes recovered to M3S4 and M4S4. Liu concluded that pedicled muscle graft is not an ideal substitute for nerve graft. They peculated that inner structures in the muscle graft prevented growth of regenerating axons, which made the graft not function as effectively as an empty tube. One should be cautious in using non-nerve tissues to repair peripheral nerve gaps.

Ten cases with gaps in nerve trunks in the forearm were treated by interfascicular grafts of autogenous veins. These included three cases of median nerve injuries, five cases of ulnar nerve injuries and two cases of radial sensory nerve injuries. The nerve gaps ranged from 1.5 to 4.5 cm with an average of 3 cm. Completely divided nerve trunks were repaired by two or three vein conduits. For incomplete nerve injuries or replacement of a single fasciculus, a single vein conduit was used. For nerve defects over 3 cm, normal nerve tissues were sectioned from the proximal nerve fasciculus and inserted into the vein conduits. These cases were followed for 2 years and 2 months to 3 years. The results were M3 in two, M4 in six and S2 + in two, S3 + in seven and S4 in one nerves. This study suggests that interfascucular grafts of vein conduits can be applied in patients with nerve gaps shorter than 4.5 cm and with favourable wound conditions with fairly good clinical results. Interfascicular vein graft provides an alternative treatment option for gaps in distal peripheral nerve trunks.

A new method of using a distal ulnar bone block graft pedicled on the dorsal interosseous artery was developed to treat nonunion of the distal radius or ulna. Seventy cadaver upper extremities were injected by latex through humeral arteries and dissected under magnification to investigate the branches from the posterior interosseous artery of the forearm to the ulna. It was found that the dorsal interosseous artery gives off a perforating branch about 2.5 cm proximal to the ulnar styloid to participate in the dorsal carpal vascular network, and two to three constant branches to supply the distal ulna at a level 3 to 4 cm proximal to the ulnar styloid. These branches course along the interosseous membrane and supply the distal part of the ulna. Seven patients with distal forearm bony non-unions (five radius and two ulna) were treated by this procedure. The dorsal interosseous artery was separated with 1 cm of surrounding tissue beneath the radial edge of the extensor capri ulnaris until the periosteal branches to the ulna were observed. A bone block of the distal ulna 1.0 × 3.5 cm in size was harvested with the vascular pedicle and transferred to defects in the radius or ulna. Satisfactory bony healing was achieved about 3.5 months after operation, and a follow-up over 1 year showed good function of the hand. Removal of the bone block did not affect continuity of the ulna or function of the distal radioulnar joint.

A microsurgical anatomical study was performed in the hypothenar area in 34 hands of 17 fresh cadavers. The hands were injected by latex through the humeral arteries. The hypothenar area was dissected under a microscope. The length, diameter and location of the branches from the ulnar artery and cutaneous branches from the proper artery of the little fingers were examined. The sources of blood supply to the hypothenar flaps were: (1) one fairly constant hypothenar cutaneous branch of the ulnar artery together with two to six other cutaneous branches from the ulnar artery. The hypothenar cutaneous branch of the ulnar artery had a pedicle of 9.9mm in length, 0.13mm in diameter. This artery originated from the ulnar artery 1.6 cm proximal to the pisiform; (2) four to six cutaneous branches from the proper arteries of the little finger; (3) the cutaneous and muscular branches from the deep branch of the ulnar artery. The venous return was through (1) concomitant veins of the cutaneous branches of the ulnar artery; (2) a palmar subcutaneous venous network. The flap was innervated by one to two branches from the superficial branch of the ulnar nerve. This anatomical study indicates that a flap from the hypothenar area can be harvested with the pedicle of the hypothenar branch of the ulnar artery to repair soft tissue defects in hyopthenar area, palmar wrist region or fingers with the advantage of direct closure of the donor area.

This paper reported experience with application of the snuff-box cutaneous flap in 10 patients with skin contracture in the hands. The sites with skin contracture were the first web sight in six, dorsal wrist in two, and palmar wrist in two. The flap was harvested centred by the snuff-box region with a width of 3 to 5 cm and length of 10 to 14 cm. This flap was based on the perforating branches from the radial artery in the snuff-box area. The pedicle of the flap was 4.2 mm in length. Venous drainage was through two concomitant veins of the perforating branch and the cephalic vein. Clinical application of this flap produced good results in nine cases and partial necrosis in one due to venous congention. This local cutaneous flap of the hand is recommended as a rotational pedicle flap to cover skin defects in the first web or the wrist regions. However, the flap may have disadvantages, such as failure of adequate venous return due to flap rotation or the necessity for a skin graft in the donor area when the flap is large.

Free vascularized mini-flaps have been used in 18 patients with digital replantations since 1989. The mini-flaps were only 1 × 2 cm to 3 × 4 cm in size. These flaps were harvested from abandoned digits in 12 cases and from venous flaps of the forearm in six cases. The flaps taken from a useless finger included the extensor tendons in two, digital nerves in six and interphalangeal joints in one case. The primary surgical indication for the mini-flap was excessive soft tissue loss with vascular defects in the digits with intact phalanges. The mini-flap was also indicated in cases with severe injuries of several digits in which vascularized nerves, phalanges or interphalangeal joints were available from the relatively unimportant digits, and there was need to reconstruct these structures in functionally important digits. The methods of vascular anastomosis of the flaps included: (1) interposition graft of the vessels with the flaps between the proximal and distal parts of the amputation; (2) arterial–venous bypass anastomosis; and (3) arterial–venous network anastomosis. All the mini-flaps survived with fairly good functional return. This study provides new approaches for severe crush injuries in amputated digits, which had been considered previously as not suitable for replantation.