Journal of Hand Surgery (European Volume)

The aim of this study was to characterize mechanical properties of tissues of Dupuytren’s disease and to attempt to identify changes due to cellular activity. Tensile tests confirmed the heterogeneity of Dupuytren’s disease tissue with distinct stress-strain curves for the three tissue types normally present, namely, cord, transition zone and nodule. The tensile strength for cord tissue was nearly twice that of nodule tissue, but the latter was nearly twice as stretchable as cord. In contrast, the transition tissue had the tensile strength of cord with the stretchability of nodule. It was found that tensile loading stimulated a cellular response as demonstrated by an increase in the creep strain rate of the tissue at 37°C compared with that at 4°C using Dupuytren’s tissue in an in vitro culture test. The creep strain rate for nodule at 37°C was more than seven times that for cord at a nominal creep stress of 0.75 MPa.

We have previously shown that the ability to mechanically extend Dupuytren’s contractures in vivo by the Continuous Elongation Technique before surgery resulted in increased metalloproteinase activity. However, under these conditions it was not possible to show whether the response was proportional to the mechanical stimulus or was inflammatory cell mediated. Using an in vitro system of controlled extensions in which inflammatory involvement is absent, we have now shown that there is a clear correlation between the load applied to the tissue and the release of matrix metalloproteinase-2. The subsequent degradation of the collagen results in a loss of mechanical strength reported in the preceding paper.

A clinical classification for Dupuytren’s contracture of the hand is described. The classification system has been used to sort patients with Dupuytren’s contracture into five broad surgical categories and takes into account predisposing factors, risk of recurrence and sympathetic tone in the individual patient. The system has many advantages in determining the approximate operation time and surgical experience required to treat patients. One hundred and four patients graded by this system have been analysed. There was a broad agreement between expected and actual operating times, with no significant difference between them.

Seventeen African-American patients were operated on for Dupuytren’s contracture over a 14-year period. Six-month minimum follow-up was available for 16 patients. The initial deformity, and results of surgical release of Dupuytren’s contracture in this population was similar to that described in North Europeans.

We present the results of fresh cadaver hand dissections and dye injection studies to help in raising a vascularized bone graft from the index or middle metacarpals based on the second dorsal metacarpal artery. This vascularized bone graft could be used for treating nonunion of the scaphoid and other carpal bones.

We report our experience in the use of a vascularized bone graft harvested from the head of the index metacarpal to treat scaphoid nonunion after failure of other techniques. Only 15 patients were treated between 1988 and 1994, showing the scarcity of indications for the operation. Union was obtained in 14 cases but the functional results were acceptable in ten cases only. This was due to previously unnoticed degenerative lesions.

We report the use of a bone graft harvested from the palmar and ulnar aspect of the distal radius and vascularized by the palmar carpal artery for the treatment of scaphoid nonunion in 17 patients, ten of whom had already had unsuccessful surgery. Union was obtained in all cases at an average of 60 days (range, 45–90 days).

The average follow-up was 16 months (range, 12–36 months). There were no failures.

This is a prospective study evaluating the efficacy of four clinical signs believed to be useful in the diagnosis of scaphoid fracture. Two hundred and fifteen consecutive patients with suspected scaphoid fracture were examined on two separate occasions to evaluate tenderness in the anatomical snuff box (ASB), tenderness over the scaphoid tuberele (ST), pain on longitudinal compression of the thumb (LC) and the range of thumb movement (TM). At the initial examination ASB, ST and LC were all 100% sensitive for detecting scaphoid fracture with specificities of 9%, 30% and 48% respectively. These clinical signs used in combination, within the first 24 hours following injury, produced 100% sensitivity and an improvement in the specificity to 74%. TM had 69% sensitivity and 66% specificity. Our results suggest that these clinical signs are inadequate indicators of scaphoid fracture when used alone and should be combined to achieve a more accurate clinical diagnosis.

This study describes the diagnostic potential of the panoramic X-ray technique in the evaluation of scaphoid fractures and nonunions. Fifty-eight symptomatic wrists were examined using both plain X-rays and the panoramic procedure. The panoramic images showed in detail the line of the scaphoid fracture and nonunion in detail; they revealed four scaphoid fractures and five nonunions that were not shown clearly with plain X-rays. The panoramic technique is a useful complement to plain X-rays for the investigation of scaphoid fractures and nonunions.

We describe a useful technique to remove a Herbert screw after union of a scaphoid nonunion, using a 3.5 mm AO drill guide to cut through the bony ingrowth that surrounded the narrow portion of the screw, which prevented removal using the screw driver.

Thirty-six patients with hemiplegic cerebral palsy had surgical treatment for the upper limb and were followed up for 18 months postoperatively. Various operations were done. A striking finding was a significant improvement of stereognosis (ability to describe and recognize objects without vision). Most patients had improvement in different functional grasps following surgical reconstruction. Range of movement in the forearm and wrist also increased in most patients. The thumb-in-palm deformity was completely corrected in 31 of the patients and improved in the other five. Most patients had some or all of their expectations of the procedure fulfilled.

Flexor carpi ulnaris tendon transfer to either the extensor carpi radialis longus or extensor carpi radialis brevis has become a standard procedure to improve function in patients with cerebral palsy. In this retrospective study of the procedure, we have compared preoperative and postoperative wrist position, analysed potential outcome predictors and assessed function by objective and subjective measures.

Sixteen children, with flexor carpi ulnaris transfer to extensor carpi radialis longus or brevis or extensor digitorum, were tested at an average follow-up of 4 years (range, 1–9). General resting position improved and the centre of the arc of motion averaged 6° pronation and 9° extension. Subjectively, 14 of 16 parents felt there was an improvement in function, 16 of 16 felt that cosmesis was improved, 14 of 16 would recommend the procedure to others, and 15 of 16 were satisfied overall.

One hundred and thirty patients with 339 divided flexor tendons affecting 208 fingers were studied prospectively between 1988 and 1996, to assess a regime of primary flexor tendon suture and active postoperative motion, combined with a modified Kleinert dynamic traction splint. The tendon suture technique used was a high-strength multistrand technique using a modified Kessler core and a Halsted peripheral stitch. The results were influenced by the zone in which the tendon was divided, by the physiotherapy and to a lesser extent by the grade of surgeon operating. Overall results by Strickland criteria were 92% excellent or good, 7% fair and 1% poor. There were 43 complications in 31 patients including five zone 2 ruptures (5.7%) and one further rupture in zone 5.

This method of flexor tendon repair requires good physiotherapy and splint-making capability but gives good results with minimal need for further surgery.

We assessed the applicability of tendon excursion measurement by means of Colour Doppler Imaging (CDI) on human specimens, and also assessed the correlation between values measured by Doppler and by displacement meters. Muscles were separately connected to a mass of 1 kg with a steel wire running over a pulley. This weight moved the telescopic end of a digital displacement meter up and down during passive extension and flexion of the fingers. Excursion was measured with a pulsed multi-channel CDI scanner on the same arm. Assessment of finger tendon excursion with CDI correlated well with the mechanical micro displacement meter, the latter being considered the most accurate method in cadaver studies.

Five sheep underwent repair of the median nerve along with the establishment and repair of a brachial artery defect adjacent to the site of nerve injury. The defect in the brachial artery was of similar length to the nerve defect and lay in parallel with it. It was repaired using a reversed vein autograft harvested from one of the superficial veins of the arm. A further five sheep underwent similar treatment with the repair of the nerve delayed for 30 days after the establishment of the complicating vascular injury. Six months after the nerve repair, each group of sheep was assessed using electrophysiological and morphometric methods in order to establish objective indices of nerve recovery and regeneration. These results were compared with those from other sheep which had undergone nerve repair both immediate and delayed with no complicating injury and groups in which the complicating injury consisted of a cavity, fibrosis and haematoma. It was found that delay in the nerve repair and the presence of a complicating arterial injury, both separately and additively, contributed to a poorer outcome in recovery of nerve function and maturation. The effect of an arterial injury, in both of these respects, was to produce a worse outcome than the presence of a cavity with fibrosis and haematoma.

Six sheep underwent repair of the median nerve in the forearm using freeze-thawed muscle autografts, along with the establishment and repair of a “fracture” adjacent to the site of nerve injury. The “fracture” was created by making a transverse osteotomy of the radius. It was repaired using an 8-hole dynamic compression plate. A further six sheep underwent similar treatment with the repair of the nerve delayed for 30 days after the establishment of the long-bone injury.

Six months after the nerve repair, each group of sheep was assessed using electrophysiological and morphometric methods in order to establish objective indices of nerve recovery and regeneration. It was found that delay of the nerve repair and the presence of a complicating long bone injury, both separately and additively, contributed to a poorer outcome in recovery of nerve function and maturation.

The aim of this study was to assess the changes which occurred in the rat in target muscles after the injury and repair of a specific peripheral nerve, using several clinically-appropriate surgical techniques.

There were alterations in the size, shape, morphology and cytochemical architecture of the fibres of the target muscles. These changes were marked when transection and repair of the nerve was compared with the less-severe crush injury. The method of repair did not correlate significantly with the occurrence of changes in muscle cytoarchitecture.

The results suggest that the extent of cell loss and the changes in muscle fibre architecture were influenced by the type of injury, rather than by the method of repair.

The subcutaneous distribution and number of Pacinian corpuscles were studied in ten fresh cadaver hands. They were found to cluster close to nerves and vessels at the metacarpophalangeal joints and the proximal phalanx. The total mean number in the hand was 300 (192–424). The percentage of the total was 44 to 60% in the fingers, 23 to 48% in the metacarpophalangeal area and 8 to 18% in the thenar and hypothenar regions. Corpuscles in palmar skin overlying the distal phalanx were smaller than receptors in the metacarpophalangeal area. The lowest density of corpuscles was along the nerves and vessels of the middle phalanx.

The forearms and hands of 40 fresh-frozen cadavers were dissected under the microscope to study the palmar cutaneous branch of the median nerve (PCBm) and the palmar cutaneous branch of the ulnar nerve (PCBu). Branches of the PCBm innervating the scaphoid were typically found, but in no specimen did we find a ‘typical’ cutaneous branch of the ulnar nerve. According to our findings, standard incisions for open carpal tunnel release carry a significant risk of damaging branches of the PCBm or PCBu. The chance of injury to these sensory nerves can be minimized by using a short incision in the proximal palm or a twin incision approach, which we describe. Because the PCBm is closely associated with the ulnar side of the flexor carpi radialis (FCR) sheath, this sheath should be opened on the radial side during harvest of the FCR tendon for transfer. When transferring the palmaris longus tendon, it should be cut proximal to the distal wrist crease to avoid possible damage to the PCBm.

Release of the origins of the adductor pollicis muscle is used to treat adduction contractures of the thumb. A knowledge of the anatomy of the adductor pollicis muscle is therefore the basis for this technique. A study of 20 specimens showed that the origins of the adductor pollicis are more extensive than generally described. This must be taken into account in release procedures in the first web space.

The blood supply of the lumbrical muscles was studied in 100 upper extremities from fresh human cadavers. Layer by layer dissection revealed the existence of different types of vascularity for the four muscles. The injection of coloured latex or Indian ink solution with gelatin showed the complex arterial network of these muscles together with their various sources of blood supply. Four separate sources of blood supply for each of the muscles were found: the superficial palmar arch (SPA), the common palmar digital artery, the deep palmar arch (DPA) and the dorsal digital artery. It was established that there were no anastomoses between the blood vessels of the tendons of the flexor digitorum profundus muscle and those of the lumbrical muscles. Considerable differences were observed in the details of the blood supply of the individual lumbrical muscles.

An anomalous muscle crossing the wrist joint is described. The morphology and clinical relevance of this and other unnamed muscles occurring at the wrist are discussed.

Twenty-seven patients with intraarticular fractures of the distal radius with a step of more than 1 mm in the joint surface after attempted closed reduction, were treated by reduction under arthroscopic control and percutaneous fixation. All fractures healed without measurable incongruity of the joint surface and at follow-up 3 to 38 months after surgery 19 patients had excellent and eight patients good results according to the Mayo modified wrist score.

Twenty-two patients with unstable Frykman grade 7 or 8 intra-articular fractures of the distal radius were treated with an external fixator. The distal pins were inserted into the distal radial fracture fragments, permitting movement of the wrist and hand.

Eleven patients were male and 11 female, with a mean age of 50 years. All patients had regained full function with good range of motion at mean final follow-up of 12 months. However function, pain and range of motion had returned to acceptable levels 4 weeks after removal of the external fixator. This method of external fixation provides a reliable method of maintaining fracture reduction whilst allowing early return of function.

In a prospective study of Colles’ fractures, 100 patients with Older type 1 and 2 fractures were randomized in two groups. One group was immobilized for 3 weeks and the other one for 5 weeks. Both groups were immobilized with a below-elbow plaster splint. At 1 year follow-up, there were 73 patients with 74 fractures. Dorsal angulation, radial length, wrist motion, grip strength and pain were measured. There was no significant difference in the measured parameters in the two groups. We found that 3 weeks of immobilization is a satisfactory treatment for Older type 1 and 2 Colles’ fractures.

The ability of single-injection radiocarpal arthrography and magnetic resonance imaging (MRI) to detect full-thickness tears of the triangular fibrocartilage were compared with wrist arthroscopy in 102 patients with wrist pain. The sensitivity of arthrography was 85%, and of MRI was 73%. Specificity was 100% for arthrography and 72% for MRI. Accuracy was 92% for arthrography, and 73% for MRI. Although future advances in MRI technology will probably improve its usefulness, single-injection wrist arthrography currently is superior to routine MRI for the detection of full-thickness triangular fibrocartilage tears.

From 1990 to 1994, nine proximal row carpectomies were done through a palmar approach. With an average follow-up of 20 months, seven of the nine patients were completely painfree. Average range of wrist flexion/extension remained unchanged, and average radial/ulnar deviation increased from 25° to 46°. All the patients demonstrated an increase in grip strength in the operated hand. Four cases showed a slight reduction in articular space and subchondral sclerosis in the radiocapitate articulation, in spite of good function. Dynamic studies demonstrated no sign of radiocarpal instability. All the patients were very satisfied with the results and returned to their previous work within 2 months, on average.

A new method of assessing capitolunate alignment is presented. Three anatomical carpal reference points were evaluated on lateral radiographs using triangulation. Connecting these three points forms a triangle with dorsal, palmar and somewhat vertical sides. One hundred normal lateral wrist radiographs were measured. The overall dorsal limb (DL) to palmar limb (PL) ratio was found to be 0.74 (SD 0.07) over a range of 40° extension to 42° flexion. As the DL to PL ratio approached 1.0, a dorsal intercalated segment instability (DISI) deformity developed. Conversely, as the DL to PL ratio approached 0.5, a palmar intercalated segment instability (PISI) occurred. This method appears useful for evaluating static lateral radiographs for intercalary carpal alignment and possibly instability.

The clinical features and results of treatment were reviewed in 17 traumatic palsies of the posterior interosseous nerve. Variations in clinical features depended on whether the recurrent branch or descending branch of the posterior interosseous nerve was injured. Seven patients had nerve repair, and two were treated by tendon transfers. Eight patients were treated conservatively. Sixteen of 17 patients recovered to more than M4 motor power at final follow-up. Associated muscle damage worsened the functional result.

A case in which a glass foreign body caused a delayed posterior interosseous nerve palsy is described.

We report on three patients with radial nerve compression in the region of the supinator muscle caused by an occult ganglion. After excision of the ganglion and decompression of the posterior interosseous nerve, the nerve palsy resolved completely in all cases.

An 8-year-old boy presented with Staphylococcus aureus osteomyelitis affecting the left (non-dominant) scaphoid. Surgical drainage resulted in the expulsion of the primary ossification centre as a sequestrum. Seven years later the wrist function was minimally impaired and X-rays showed complete ossification of the cartilage remnant with a relatively normal scaphoid.

We report a case of dysplasia epiphysealis hemimelica in the left wrist of a 9-year-old girl. This resulted in symptomatic carpal instability which was relieved by excision of the abnormal bone.

We present a case of a ganglion arising from the palmar aspect of the metacarpophalangeal joint.