Journal of Hand Surgery (European Volume)

Seven uninjured and three injured patients were studied using midsagittal computed tomographic (CT) images at 10° increments from full extension to full flexion. Each injured patient had a confirmed scapholunate ligament tear and normal radiographs. CT bony contours were digitized, and incremental motion determined using a specifically designed automated contour-matching algorithm. We expressed wrist motion as a ratio of lunocapitate (midcarpal) motion, and radiolunate (radiocarpal) motion. In normal wrists, motion occurred equally at the midcarpal and radiocarpal joints. In wrists with scapholunate ligament disruption, lunocapitate motion increased significantly throughout the arc of motion.

Over a period of 24 years, the author has used five different methods of bone-grafting for ununited scaphoid fractures. The clinical and radiological results have been reviewed, with a minimum follow-up of 1 year. Radiologically the best results (78% definite union) were obtained with a “wedge” graft and Herbert screw, while the worst results followed the original Russe operation. The clinical result often did not coincide with the radiological outcome. All methods led to a decrease in pain in most cases, but little or no pain was achieved most often by the modified Russe graft. With proximal pole fractures, bony union was only achieved in 54% but the symptoms were always lessened.

We assessed the value of bone scintigraphy combined with X-ray registration for the diagnosis and management of wrist pain in 65 patients. Studies were reported independently by two observers before and after registration. Registration improved localization of scan abnormalities in 53% (observer 1) and 61% (observer 2). In these patients, the bone scan contributed to the diagnosis independently of the X-ray in 37% and the management was altered in 31%. The value of the bone scan in the early diagnosis and management of wrist pain is increased when it is registered with X-rays.

We describe an unusual case of carpal coalition in an otherwise asymptomatic 28-year-old man. The combination of scaphoid, trapezium, trapezoid and capitate fusion detailed in this article has not, to the best of our knowledge, been previously recorded.

Bilateral transscapholunate dislocations were treated with immediate open reduction and internal fixation. Eighteen months after injury the patient was asymptomatic.

Scapholunate dissociation is well documented as a condition occurring in adult patients. We report it in a 14-year-old female patient. Persistent wrist pain 9 months after a well healed fracture of the distal radius triggered further investigation. Dynamic clinical and radiological studies demonstrated the instability.

Nonunion of distal radial fractures in children are rare. We report a case of a closed distal radial fracture in a healthy child, which developed a nonunion following closed reduction and plaster immobilization.

One hundred patients who had sustained a Colles’ fracture were observed for features of algodystrophy at 1, 5, 9 and 12 weeks following injury. The diagnosis of algodystrophy was possible as soon as 1 week after fracture. Early diagnosis has important clinical implications: the aetiological factors may become apparent and different treatment modalities be identified; furthermore, early treatment can be started, limiting the morbidity of the condition. It is proposed that patients with features of algodystrophy require physiotherapy after a Colles’ fracture. Those without features may not.

An anatomical and biomechanical study of the stabilizing ligaments of the thumb trapeziometacarpal joint was conducted on 32 hand specimens. Five main ligamentous structures could be identified. The mechanical properties (in particular, strength) of the five ligaments using a strain-rate failure test were determined and evaluated quantitatively. The maximum tensile strength of each ligament was correlated with the condition of the trapeziometacarpal articular cartilage. In studying the anterior oblique ligament, maximum strength decreased from Grade 0 to Grade 1 by 51%. With the first intermetacarpal ligament, the drop from Grade 1 to Grade 2 was 53%. With the posterior oblique ligament, the decrease was closely related to the grade of the deterioration of the trapeziometacarpal articular surface. These three ligaments also significantly decreased in strength with age. Our results may suggest that the anterior oblique ligament, intermetacarpal ligament and posterior oblique ligament play a large role in stabilizing the trapeziometacarpal joint and that the decrease in their strength is related to the pathogenesis of trapeziometacarpal osteoarthritis.

We report a case of osteoarthritis of the scaphotrapeziotrapezoid (STT) joint secondary to a scaphotrapezial ligament injury.

Seventy-six consecutive patients suffering from advanced Dupuytren’s contracture were analysed in order to evaluate the safety of day care surgery. The complication rates for haematoma, necrosis, infection and reflex sympathetic dystrophy were acceptable, but we found an unacceptably high percentage of nerve lesions. Day care treatment was achieved in all but seven cases. We concluded that advanced Dupuytren’s contracture can be treated by day care surgery but the operations should be performed by surgeons who are skilled in hand surgery, and individual selection of patients with recurrence seems advisable.

We have reviewed 90 rays in 67 patients who had undergone radical digital dermofasciectomy. Follow-up was from 24 to 100 months. Problems with skin grafts, moving two-point discrimination and active range of joint movement were noted. The recurrence rate in this series was 8%, a very much better figure for disease control than has been reported for standard approaches for Dupuytren’s disease. Radical digital dermofasciectomy is strongly recommended for all cases of recurrent Dupuytren’s disease requiring reoperation and as a primary procedure when there is significant skin involvement.

Traumatic rupture of Dupuytren’s contracture is rare. It has been reported only twice in recent times and only on four previous occasions over the last millenium. These cases are reported and the forces involved in rupturing Dupuytren’s contracture are discussed.

We carried out a retrospective and prospective study of 67 patients who had sustained hand injuries from punching glass over a period of 33 months. All had consumed alcohol and had argued with a partner. The mean age was 25 years, 90% were male and 56% were unemployed. Seventy per cent of injuries occurred between 23.00 and 04.00 hours. Total damage included division of 149 tendons, 33 nerves and nine arteries. Fifty-two per cent of patients required admission for more than 1 day. The mean number of follow-up visits was 3.6 and the majority needed hand therapy and occupational therapy services. Cost per injury was estimated as £1,120. Such injuries cause major disability in an already disadvantaged section of society. The challenge is to educate the susceptible patient group.

The distally based ulnar artery island flap is a highly versatile flap for hand reconstruction. It fulfils all the necessary criteria required for a flap to the hand providing thin pliable hairless skin. It can be used as a composite flap including tendon and bone and provides an ideal tunnel for tendons to glide in. It can be used as a fasciocutaneous flap or as a fascial flap and can easily be rotated to the dorsum of the hand by opening Guyon’s canal. The palm or dorsum of the hand and even the fingertips can be reached easily. A superficial venous anastomosis should be made if marked venous congestion is noted intraoperatively. Six cases utilizing a distally based ulnar island flap in hand reconstruction are presented.

Recently we have extended the use of the V-Y advancement flap for the purposes of releasing flexion contractures of finger joints, improving the appearance of congenitally anomalous fingers and repairing segmental skin defects in fingers, with gratifying results.

We present the results of a prospective randomized trial comparing the treatment of ganglia by aspiration under local anaesthetic and either instillation of steroid alone or with the prior use of hyaluronidase. Thirty-five patients were treated in each group and followed up for 2 years. The cure rate with the combined use of hyaluronidase and methylprednisolone was 89%, compared to 57% when treated by aspiration and instillation of methylprednisolone alone.

Eighty-six mucous cysts in 79 patients were surgically excised. Follow-up was carried out at an average of 2.6 years. Fifteen digits (17%) had a residual loss of extension of 5 to 20° at the IP or DIP joints. One patient developed a superficial infection and two developed a DIP pyarthrosis, which eventually required DIP arthrodesis. Nail deformities were present in 25 of 86 digits preoperatively (29%), 15 of which resolved after surgery (60%). Four of 61 digits developed a nail deformity which was not present preoperatively (7%). Three of 86 digits (3%) developed recurrence. Other complications included persistent swelling, pain, numbness, stiffness, and radial or ulnar deviation at the DIP joint. We recommend that patients be informed preoperatively of the potential risks of decreased range of motion, persistent swelling and pain, infection, recurrence, and persistent or postoperatively acquired nail deformity.

The distribution of fibrous flexor sheath ganglions was studied in 57 patients. They were found to be more common in the third decade and in the middle finger. Both hands were equally affected. There was no clear relationship to occupation or repeated trauma. The striking finding in our study was the male predominance.

Nine cases of subungual glomus tumour in which a transillumination test was used for diagnosis and a different operative technique was used to prevent postoperative nail deformity are described. The transillumination test is a new method for identifying a glomus tumour. With our surgical technique it is simple to approach a glomus tumour under the proximal nail bed and it produces a minimal defect.

Nine patients with enchondromas in the hand were treated by endoscopic curettage of the tumour without bone grafting. The procedure was performed on an out-patient basis using axillary block anaesthesia. New bone formation and remodelling of the lesions were observed in all patients. There were no postoperative fractures, infections, recurrences or other complications. Functional recovery was rapid. We conclude that endoscopic curettage without bone grafting is an effective treatment of enchondroma in the hand.

Enchondroma is a common benign cartilaginous tumour which arises from the medullary cavity, most commonly in the phalanges of the hands and feet. Enchondroma involving the carpal bones, however, is rare; only three cases of scaphoid enchondromata and one patient with multiple carpal enchondromata have been reported in the English literature. We report the diagnosis and treatment of a case of scaphoid enchondroma presenting as chronic wrist pain after relatively trivial injury.

An unusually large chondrosarcoma arising in the hand of a young patient with multiple hereditary exostoses is presented.

Amniotic sac puncture carried out on day 13 mouse embryos induces a high incidence of craniofacial and limb abnormalities that resemble the anomalies seen in the oromandibulofacial limb hypogenesis syndrome occasionally encountered following chorionic villus sampling carried out during early human pregnancy. It has been hypothesized that this syndrome probably has a vascular basis, possibly due to hypotension and hypoperfusion of tissues secondary to placental trauma, though no detailed aetiology has so far been described. We have determined embryonic heart rates in control embryos, in embryos at intervals following anaesthesia, and following amniotic sac puncture. An increased duration of bradycardia is seen following this procedure which is not observed in anaesthetic-only controls and in embryos in the contralateral (non-operated) uterine horns. We discuss why the incidence of oromandibulofacial limb hypogenesis syndrome is low following chorionic villus sampling, and propose a possible aetiology for the limb abnormalities seen in this condition.

A classification of limb anomalies in oral-facial-digital (OFD) syndromes is offered to help differentiate between the various types of OFD syndromes. A clinical case is presented with clinical features consistent with both OFD syndrome type I (Papillon Leage-Psaume syndrome) and type VI (Váradi syndrome). The final diagnosis as a new mutation of type I syndrome was established after reviewing the radiological findings in the hands.

We present a case of congenital unilateral hypertrophy of an upper extremity due to aberrant muscles. Reviewing the previous Japanese reports, we discuss the clinical features and the pathogenetic factors of this rare anomaly.

The electrophysiological properties of the normal brachial plexus and functional motor innervation were examined during the operation of transfer of contralateral C7 transfer from the healthy side. Different roots of the brachial plexus were stimulated and maximum amplitudes were recorded. The results showed that functional motor innervation of brachial plexus roots were: C5 mainly forms the axillary nerve to innervate the deltoid muscle; C6 mainly forms the musculocutaneous nerve to innervate biceps; C7 mainly forms the radial nerve to innervate triceps; C8 mainly forms the median nerve to innervate flexor digitorum superficial is and profundus; and T1 mainly forms the ulnar nerve to innervate the intrinsic muscles of the hand.

In nine patients with obstetric brachial plexus lesions (Klumpke type), an impingement of the bicipital tuberosity on the ulna was the main cause for the forearm and hand to be fixed in supination. A surgical technique using reinsertion of the biceps tendon on the bicipital tuberosity is described in detail. It has substantially improved all patients. After a mean follow-up of 29.4 months the hand was in a more functional position than preoperatively in all patients. In seven cases pronation could be increased by contraction of the biceps muscle. By relaxing the biceps muscle and by contraction of the supinator muscle a limited active supination was possible in six cases.

The closure of fasciotomy wounds creates problems for patient and surgeon alike. Split thickness skin grafting results in unsightly and insensate wounds and often requires general anaesthesia and prolonged inpatient care. We describe an improvement of a previously reported technique which is as effective as proprietary medical devices currently available. The technique may also be applied to the delayed primary closure of traumatic wounds.

We measured grip and pinch strengths in non-manual, light manual and heavy manual workers using a Jamar dynamometer and a pinch measuring device. Heavy manual workers had the strongest grips with the least difference between sides. Office workers had the weakest grips and the greatest difference between sides. Light manual workers were between these two groups.

Consequently, the occupation of the patient must be taken into account when using grip and pinch strength measurements to assess the need for rehabilitation and in medicolegal reports.

We measured passive axial rotation at the metacarpophalangeal (MCP) joints of the index, long, ring and small fingers of both hands in 100 healthy subjects using a magnetic position and orientation system called an Isotrak. Large degrees of passive rotation were found, with the ring and small finger MCP joints displaying significantly greater ranges of supination than the other two joints. Supination ranges were also found to be significantly greater than the pronation values in each joint. These results support present anatomical understanding that, during prehensile activities, axial rotation of the MCP joints occurs to allow the hand to adapt to an object being held.

A new method for reconstruction of the pulley system of the thumb using the extensor retinaculum is described.

Seventy cadaveric hands were dissected to study variations of the flexor digitorum superficialis tendon (FDS) to the little finger. Anatomical variations were present in 13% of hands and 10% of the hands showed an anatomical variation that would preclude independent FDS function in the little finger.

The distance of the decussation from the metacarpophalangeal joint was measured. A ratio of this distance to proximal phalangeal length was calculated. The ratio indicated that decussation position was independent of phalangeal size.

We report a case of simultaneous closed avulsions of the terminal extensor insertion and the central slip of the little finger which required operative treatment.

We report a prospective study of dynamic splintage following extensor tendon repair. Eighty-four patients with 101 extensor tendon injuries were studied. Using Dargan’s evaluation system, there were 97% excellent results for the thumb and 93% excellent and good results for the fingers. The average total active motions were 107° for thumbs and 245° for fingers. Over 80% of patients regained good power grip. Patients with associated digital fractures or with ragged lacerations had poorer results. Overall, we found that dynamic splintage was a satisfactory method after extensor repair.