Journal of Hand Surgery (European Volume)

Skin biopsies from patients with reflex sympathetic dystrophy were immunostained using a variety of antisera. An incidental finding with S100 staining was the presence of numerous Langerhans cells in the epidermis. All patients had significant pain at the time of biopsy, and all had symptoms refractory to treatment. The potential implications of this finding are discussed.

The performance of a variety of common office-based clinical tests for detection of carpal tunnel syndrome (CTS) was assessed in 119 subjects with and without electrophysiological evidence of CTS. Symptoms compatible with CTS and electrophysiological tests positive for median mononeuropathy at the wrist were observed in 57 hands, symptoms compatible with CTS and normal electrophysiological test results were observed in 58 hands, and no symptoms compatible with CTS and normal electrophysiological test results were observed in 123 hands. For all the diagnostic tests studied, the proportion of subjects who had a false positive clinical test result was much higher in the electrophysiologically normal subjects who had CTS compatible hand symptoms than in the electrophysiologically normal subjects who were asymptomatic. These results suggest that many studies that have evaluated diagnostic tests for CTS have produced falsely optimistic estimates of the test’s performance because of their use of asymptomatic comparison subjects.

The purpose of this study was to review retrospectively and evaluate a uniform group of C6-spared quadriplegics who had similar surgical procedures. Eight patients undergoing 12 procedures were reviewed at an average of 3.8 years follow-up. There were three bilateral procedures. All patients had extensor carpi radialis longus to flexor digitorum profundus and brachioradialis to flexor pollicis longus transfers to improve grip strength and key pinch. All patients reported subjective improvements in quality of life, activities of daily living and patient-centred goals. There were six excellent and two good results. Objective improvements included mild improvements in key pinch and grip strength.

A computerized digital dynamometer was used to assess the contribution of individual fingers to total grip strength in 100 hands from 50 randomly selected healthy subjects. The dynamometer simultaneously recorded force data from each digit (index, long, ring, and small) and cumulative grip directly to a laptop computer. The percentage contribution of each finger force to total grip force was calculated at three successive handle sizes for dominant and non-dominant hands.

Individual digital contributions to total grip strength were approximately 25%, 35%, 26% and 15% for the index, long, ring, and small fingers respectively. This pattern was consistent irrespective of handle size, hand dominance, and grip strength.

Sixty paired cadaver forearms were dissected to examine the distribution of the radial nerve branches to the muscles at the elbow and forearm. Emphasis was placed on the innervation of the extensor carpi radialis brevis and the supinator muscles because of discrepancies in the literature concerning these muscles. The most common branching pattern (from proximal to distal) was to brachioradialis, extensor carpi radialis longus, superficial sensory, extensor carpi radialis brevis, supinator, extensor digitorum/extensor carpi ulnaris, extensor digiti minimi, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus and extensor indicis. The branch to extensor digitorum and extensor carpi ulnaris came off as a common stem often with the branch to extensor digiti minimi. The branch to the ECRB muscle was noted to arise from the posterior interosseous nerve in 45%, superficial sensory nerve in 25% and at the bifurcation of the posterior interosseous and superficial sensory nerves in 30% of specimens. The supinator had an average of 2.3 branches from the posterior interosseous nerve (range 1–6). The branches to the supinator showed a wide variability proximal to and within the supinator.

Sixty paired cadaver upper extremities were dissected to study the anatomy of the flexor pollicis longus in the forearm and its relation to the median and anterior interosseous nerves. An accessory head was noted in 33 (55%) of 60 specimens. The accessory head was noted to pass anterior to the anterior interosseous nerve in all specimens. The accessory head was noted to pass posterior to the median nerve in 57 specimens, and anterior to the nerve in three. Tendon or muscle anomalies were noted in eight specimens (13%), seven of which involved an anomalous attachment between the FPL and the flexor digitorum profundus of the index.

Four patients with dorsal dislocation of the distal radioulnar joint and ulnar styloid malunion had corrective osteotomy of the ulnar styloid. Dislocation of the distal radioulnar joint was reduced in three of four patients. Subluxation persisted in the remaining patient. Wrist function improved in all patients. These results support the contention that a displaced ulnar styloid fracture with distal radioulnar joint dislocation should be reduced and internally fixed. Corrective osteotomy is recommended for malunion of the ulnar styloid associated with dislocation of the distal radioulnar joint.

We report two cases of avulsion fractures at the fovea of the ulna. This injury is caused by a strong distraction force which avulses the insertion of the triangular ligament at the fovea of the ulna. This injury can be classed as an injury to the triangular fibrocartilage complex.

From the interosseous membrane of the forearm a tract extends to the dorsal capsule of the distal radioulnar joint. The structure and function of this tract have been investigated. The tract originates from the radius 22 mm proximal to the distal dorsal corner of the sigmoid notch. Central fibres are attached there with fibrous cartilage and superficial bundles mix with the periosteum. The tract is 8 mm wide, 31 mm long and 1 mm thick. Distally it inserts at the capsule of the distal radioulnar joint between the tendon sheaths of extensor digiti minimi and extensor carpi ulnaris. Deep fibres insert directly at the triangular fibrocartilage. The tract of the interosseous membrane is taut in pronation and loose in supination. It strengthens the dorsal capsule of the distal radioulnar joint. During pronation the tract protects the ulnar head in a sling. Its attachment at the triangular fibrocartilage influences the distal radioulnar joint. Its insertion at the triangular fibrocartilage and the support of the weakest part of the dorsal capsule are of interest.

The complications of the five different incisions used for centralization from 1970 to 1996 were evaluated. In five cases access was by an S- shaped incision, in one with a transposition flap. Sixteen centralizations were done using a radial Z-plasty in combination with an ulnar excision and four by using two opposite Z-plasties, preserving wrist mobility as much as possible. In 1995 and 1996 a bilobed flap was used in seven cases. No complications occurred with the primary procedures prior to 1995. In all seven cases where the bilobed flap was used venous congestion was seen. In four out of these seven superficial necrosis of parts of the flaps occurred. In all cases though wound healing occurred spontaneously by delayed primary healing after the standard 8 weeks of cast immobilization.

Six children with radial club hand had distraction lengthening of the ulna using the Ilizarov technique at the mean age of 10 years. The mean lengthening achieved was 4.7 cm (46% of original ulna length). Complications included nocturnal pain, pin track infection and callus fracture or delayed union. Distraction lengthening of the ulna can enhance the ability to perform normal activities of daily living, such as reaching the perineum or driving a car, but complications are extremely common. The high rate of callus fracture in this series reinforces the need for regular radiographic review during distraction and suggests that after distraction it may take more than 4 weeks for satisfactory callus consolidation before removal of the fixator.

Nine patients underwent Ilizarov distraction-lengthening for congenital anomalies. All were late cases and had undergone other procedures. In five radial club hand patients with very short forearms, we achieved an average 5.8 cm increase in length with each distraction cycle. In two patients with symbrachydactyly of the cleft hand type, we achieved pinch grip between a radial and an ulnar digit by lengthening the short ray. Another case of the monodactyly type in which we tried to lengthen three transplanted proximal toe phalanges ended in failure. A soft tissue distraction was attempted in a case of camptodactyly but failed. We report the problems we encountered and suggest some solutions.

This study reports the characteristics, causes and disposal of isolated injuries to the hand and wrist presenting to six accident and emergency departments over a period of 4 months. The rate of isolated injury to the hand or wrist was 6.6%. The male: female ratio was 2.2: 1, with the mean age for injury being 26.4 years in men and 29.2 years in women. The modal age group for injury was 21–25 years in men and 11–15 years in women. The right and left hand were injured almost equally. The dominant hand was more commonly injured although this was influenced by the cause of injury: 16.3% were caused by a fall; 15% by sport; and 7% were work/machinery related. 13.3% were referred to specialities for further treatment.

Deficiency of the proximal pole of the scaphoid due to fracture or necrosis was treated by costo-osteochondral replacement arthroplasty using rib bone/cartilage autografts in 22 patients who were followed prospectively and assessed at a median 24 month follow-up (range, 12–72 months). Improvement of wrist function occurred in all patients with increased motion, improved grip strength and less pain. The average modified Green and O’Brien Wrist Function Score improved from 53 out of 100 preoperatively to 80 at the most recent review. All patients were graded fair or poor at initial review and all but three improved to good or excellent at the most recent assessment. Despite the absence of the scapholunate ligament, carpal alignment did not deteriorate in any patient and there were no graft non-unions or significant complications. In the short and medium term a costo-osteochondral autograft can satisfactorily restore mechanical integrity of the scaphoid proximal pole and maintain wrist motion while avoiding the potential complications of alternative replacement arthroplasty techniques.

The purpose of this study was to evaluate the compressive capabilities of the Herbert scaphoid screw system. A transverse osteotomy was performed at the waist of eight scaphoids removing a 3 mm wafer of bone. A custom-designed load washer was inserted within this defect to measure intrascaphoid compression during Huene guide application, during screw insertion, after screw insertion and after guide release. The intrascaphoid compression was noted to peak during screw insertion; however it dramatically decreased without any clinical subjective evidence of decreased insertional torque by the surgeon. The average final compression as a percentage of maximal compression was 38 (SD 26) %.

Thirteen painful end-neuromas of nerves of the palm and the dorsum of the hand were treated by resection of the neuroma and relocation of the nerve ends into the pronator quadratus muscle proximal to the wrist in ten patients. The effectiveness of this treatment was assessed by measurement of changes in level of spontaneous pain, pain on pressure, pain on movement and hyperaesthesia at the original site and at the site to which the nerve was relocated. Subjective comments on changes of hand function and ability to return to work were also recorded. All ten patients reported total relief or marked improvement in each of the four modalities of pain assessed. In the five patients in whom the neuromas were the only significant cause of hand dysf.unction, there was sufficient improvement in hand function to allow the patients to return to work. In this series, the pronator quardratus muscle has proved a suitable site for relocation of sensory nerve ends after resection of painful neuromas in the proximal part of the hand and wrist.

Based on the theory that recurrent neuroma formation can be prevented if the cut nerve end is implanted into the lumen of a vein, 14 patients have been treated by neuroma excision followed by proximal vein implantation over the last 5 years. Thirteen patients reported dramatic pain relief following surgery, and this was sustained in all but one case. Both failures were re-explored, when it was found that the nerve had pulled out of the vein, leading to recurrent neuroma formation. Both cases were revised successfully using the same technique. With a mean follow-up of 15 months, 11 patients remain symptom-free, whilst three have minor residual symptoms which are not severe enough to require further surgery.

The prognostic value of concurrent phrenic nerve palsy in newborn babies with Erb’s palsy was investigated. The records of 191 babies with Erb’s palsy were reviewed retrospectively at two institutions. Poor spontaneous return of the motor function of the limb was found for infants both with and without concurrent phrenic nerve palsy. Concurrent phrenic nerve palsy in newborn babies with Erb’s palsy has no prognostic value in predicting spontaneous motor recovery of the limb.

We describe the use of a sternomastoid flap to seal a dural tear after a brachial plexus injury.

A comparative study of six tendon suturing techniques (1. Modified Kessler + simple epitendinous running suture; 2. Modified Kessler + Halsted epitendinous suture; 3. “Six strand” suture; 4. “Interlocking” suture; 5. “Cross stitch” suture; 6. simple epitendinous running suture) was carried out by evaluating strength in relation to the beginning of separation between the tendon stumps, a 3 mm separation and rupture in porcine flexor tendons. The technique most resistant to initial separation was the modified Kessler + Halsted epitendinous suture followed by the “Six strand” suture. The “Six strand” suture was the most resistant to the 3 mm separation and rupture followed by the modified Kessler + Halsted epitendinous suture. Despite the greater resistance to rupture of the “Six strand” technique, we conclude that modified Kessler + Halsted epitendinous suture showed the best overall performance and was easier to use.

Forty cadaver hands (160 fingers) were dissected to study the morphology and variations of the chiasma of the flexor digitorum superficialis tendon. Ten types of chiasma were noted. One chiasma did not fit into any of the patterns. The long and ring fingers had a very similar distribution of types of chiasma but the index and small both had different patterns. The length of chiasma showed a marked variability which appeared to be independent of phalangeal length.

We have examined and successfully visualized active and passive movement of tendons and muscles using colour Doppler ultrasound. This preliminary study suggests that colour Doppler may be very useful to examine the movements of tendons and muscles.

We report a diagnostic sign of ulnar neuropathy. Function of the interossei is tested by asking the patient to hold a sheet of paper between the middle and ring fingers, by adducting the fingers while the examiner pulls it firmly away. The metacarpophalangeal joints will flex more on the affected side as the flexor tendons are recruited. This test can easily detect muscle weakness in the early stage of ulnar neuropathy, and is produced by a similar mechanism to that of Froment’s sign.

A case of ulnar nerve compression in Guyon’s canal due to a haemangioma of the ulnar artery is reported.

A total of 105 patients with fracture of the neck of the ring or little metacarpal bone were randomized to receive three different types of treatment: dorso-ulnar plaster-of-Paris from the proximal interphalangeal joint to elbow; functional brace around the wrist; or elastic bandage. Twenty patients (19%) had to be excluded for different reasons leaving 85 patients in the study. The remaining patients were examined after 4 weeks and 3 months. There was no difference in patient satisfaction between the three different types of treatment. The functional brace was in our opinion superior to the two other types of treatment: the patients had as little pain as the patients treated with plaster-of-Paris and less pain than patients treated with elastic bandage. Patients treated with a functional brace mobilized as fast as patients treated with elastic bandage and faster than patients treated with plaster-of-Paris. Based on these findings, we recommend the functional brace for treatment of fractures of the neck of the ring and little metacarpals.

We have used the “S” Quattro Turbo to treat four neglected dorsal interphalangeal joint dislocations. At an average follow up period of 45 months, there was a mean increase in the range of movement of the PIP joints by 74° and of the IP joint of the thumb or DIP joints by 45°. We recommend this technique for treating dorsal dislocations of the interphalangeal joints of more than 3 weeks duration.

We report a patient with an irreducible dislocation of the proximal interphalangeal joint which was due to entrapment of the head of the proximal phalanx in the opening of the flexor digitorum superficialis tendon just proximal to its chiasma.

A 30-year-old man presented with bilateral, simultaneous, transient triggering of the middle digits which developed acutely after prolonged and sustained use of a garden rotavator. He was asymptomatic in the period before presentation and has remained so 7 years since.

Forty-two children with trigger thumb were reviewed to determine the possibility of spontaneous recovery and the outcome of treatment. There were 22 boys and 20 girls. All of them had a normal physical examination at birth. Ten patients had spontaneous recovery within 3 months of their initial visit. Thirty-two patients underwent surgical release. All of them had satisfactory results. Our findings suggest that spontaneous recovery of trigger thumb in children is possible and may be related to a traumatic cause for the condition. Delaying operation until after the age of 3 years will not affect the outcome.

Twenty-two patients with a diagnosis of scapholunate instability underwent a modified Brunelli procedure. The overall results of this short follow-up study showed that a majority of patients (17 out of 22) had relief of pain. Grip strength recovered well. Postoperative range of motion was reduced in extension and flexion, remained unchanged for radial deviation and improved for ulnar deviation. The radiological appearance of dynamic or static scapholunate instability did not change after the procedure. Most patients (17 out of 22) felt subjective improvement and would have the operation again. A significantly poorer result was seen in those patients with an unresolved medicolegal claim. Although short-term results are encouraging for some patients, the authors feel that more long-term follow-up is needed before recommending the procedure.

A case of acute perilunate dislocation associated with acute scapholunate dissociation and acute carpal tunnel syndrome is described in which the treatment was facilitated by the use of the TAG suture anchor.

We report an uncommon palmar translunate, transhamate carpal fracture dislocation. CT-scans with three-dimensional reconstruction were most helpful for the assessment of the injury, which was treated operatively through a palmar approach. The lunate and hamate fractures were fixed using mini-screws and the radial styloid fracture and the scaphoid were reduced and stabilized with K-wires.

Various patterns of transscaphoid, transcapitate fracture-dislocations have been described in the literature. There is little information on the method of management and the long-term results of such severe and rare injuries. The case described here involved a transscaphoid, transcapitate, palmar perilunate fracture-dislocation with ejection of the proximal pole of the scaphoid and lunate into the palmar aspect of the forearm. The functional result 32 months after delayed open reduction and internal fixation is reported.

A dislocated pisiform associated with type II Salter-Harris fractures of the distal radius and ulna in a 9-year-old child is described. Closed reduction followed by immobilization achieved good radiological and clinical results. The current literature on dislocation of the pisiform is reviewed.

Five cases of chronic instability of the radial collateral ligament of the thumb metacarpophalangeal joint are presented. All patients were treated using the Mitek suture anchor to reattach the avulsed ligament to bone in its anatomical position. Tendon advancement or graft reinforcement was not used in conjunction with the repair. A stable thumb metacarpophalangeal joint was achieved in each case with no recurrent instability or pain found within 9 months of follow-up. Postoperatively, each patient exhibited a full return to activities of daily living within 2 to 3.5 months. Grip and pinch strength and range of motion were nearly the same as in the uninjured hand. We recommend the Mitek suture anchor as a simple and effective method of repairing the chronic radial collateral ligament injury. The importance of correct anatomical placement of the anchor is stressed, and guidelines for this are discussed.

Recurrent giant-cell tumours of bone have a higher risk of malignancy than primary giant-cell tumours of bone, and giant-cell tumours of bone in the hand are more likely to recur than those that arise elsewhere. Therefore, en bloc resection and reconstruction, or amputation, have been the accepted treatments for recurrent giant-cell tumours of bone in the hand. We describe two cases of successful transplantion of a metatarsal to a metacarpal, which was the site of a recurrent giant-cell tumour. The patients had satisfactory results 3 years later without problems in the foot. En bloc resection of the tumour and reconstruction with an autograft should be considered in the treatment of recurrent giant cell tumour of the hand.

We treated a 72-year-old woman by excision of the right thumb sesamoid which contained a giant-cell lesion. Nine years later she had normal function and no evidence of other lesions, recurrence or metastasis. We recommend that the diagnosis of giant-cell reparative granuloma and giant-cell tumour be considered when a bony mass in a sesamoid bone is discovered. Surgical excision at least in our one case was definitive treatment.

An apocrine hidrocystoma occurring on the finger of a 55-year-old man is reported. The lesion presented as a solitary, painless cystic nodule on the dorsal aspect of the middle phalanx of the index finger. Apocrine hidrocystoma is a benign tumour developed from apocrine sweat glands, but the location of the lesion was, however, not consistent with reported locations of apocrine glands in the adult.

An unusual Salter type 2 fracture of the distal phalanx is described. The metaphyseal fragment of the fracture consisted of a long and thin plate of bone corresponding to the insertion site of the flexor digitorum profundus tendon. Differences between this combined fracture and the isolated mallet deformity or flexor profundus tendon avulsion fracture are discussed.