Journal of Hand Surgery (European Volume)

The safety of the endoscopic technique for carpal tunnel release remains a major concern. Serious complications such as division nerves, tendons or vessels may occur. In this study the topography of the carpal tunnel was studied in fresh cadaver hands after the introduction of the blade assembly of a one portal system. By using a plastination method, it was possible to study the in situ relationships in detail by serial cross sections. Furthermore a modified Spalteholz method allowed the position of the blade to be viewed in whole specimens.

A prospective study was performed in 100 consecutive endoscopic carpal tunnel releases (ECTR) to assess the effect of a number of anthropometric measures on the ease of introduction of the ECTR system into the carpal tunnel. Ease of access to the carpal tunnel correlated with the wrist circumference, height and age of patients. Surgeons should be aware that ECTR is likely to be more difficult in small patients with small wrists and should have a higher threshold for conversion to the open technique to avoid neurological complications.

The purpose of this study was to evaluate the reported rate of complications after endoscopic carpal tunnel release by means of an analysis of 54 publications, reporting a total of 9516 endoscopic and 1203 open releases. Endoscopic release was comparable to open release in the rate of irreversible nerve damage (0.3% and 0.2% respectively) but case reports may indicate a small risk of unacceptable complications with endoscopy, such as transection of the median nerve. Reversible nerve problems were more common after endoscopic release. Tendon lesions were extremely rare (0.03%) and the rate of other complications (reflex sympathetic dystrophy, haematoma, wound problems, etc.) was about the same with endoscopic as with open release.

Quantitative analysis of three-phase bone scintigrams was done in 70 patients with reflex sympathetic dystrophy (RSD) and in 30 patients who did not have RSD after injury to the hand or wrist. Regions of interest were selected and the uptake ratios (affected/unaffected) were calculated. Significant differences between affected and unaffected patients were seen in the metacarpal area in phase 2 of the scintigrams as well as in the metacarpophalangeal joints and metacarpal bones in phase 3. Combination of these images had the greatest diagnostic value. Sensitivity and specificity of 80% were achieved in the regions of interest in phase 3. The duration of RSD and the predisposing injury significantly affected the results of bone scintigraphy. It was also noted that a fracture may cause increased fixation of the tracer in each phase of three-phase bone scintigraphy in asymptomatic patients.

Magnetic resonance imaging (MRI) of the triangular fibrocartilage complex (TFCC) of the wrist was performed in ten healthy volunteers using spin echo T1-weighted (SE-T1), fast spin echo T2-weighted (FSE-T2), gradient echo T2*-weighted (GRE-T2*) and fat suppression spin echo T1-weighted (FS-T1) images. The images were obtained in the coronal plane and were compared to the corresponding histological coronal sections obtained from five fresh frozen cadavers. In our analysis, the FS-T1 pulse sequence visualized the details of the TFCC best, followed by the GRE-T2* images. Delineation of the TFCC on the SE-T1 and the FSE-T2 was poor. The coronal morphology of the TFCC represented on the fat suppression image was almost identical to the corresponding histological sections. We conclude that the fat suppression MRI clearly shows the complex structure of the TFCC and is useful for the morphological evaluation of the TFCC.

The purpose of this study was to evaluate the long-term effectiveness of wrist fusion on the relief of pain and also the functional capacities of the upper limbs in patients with rheumatoid arthritis (RA). Eighteen patients were assessed at a mean of 7 years after wrist arthrodesis and a mean of 17 years after the onset of RA. Radiological measurements, pain assessment and impairment rating of the upper limbs were made of the fused and non-fused sides. The average position of arthrodesis was 8° of extension and 9° of ulnar deviation. All patients were pleased with the procedure and had satisfactory pain relief. Impairment ratings did not detect any significant difference in the sensory and motor function of the hand when the fused and non-fused groups were compared. We conclude that in patients with rheumatoid arthritis, wrist arthrodesis is a reliable procedure that provides predictable pain relief and a high degree of satisfaction without additional functional loss in the upper limb.

We report a short term review of 26 patients after Biaxial total wrist replacement. The mean follow up was 33.6 months (range, 24–62). All except one patient with psoriatic arthropathy had either seropositive or negative rheumatoid arthritis. A significant improvement in the range of motion was obtained; however, only 14 of 26 achieved a “functional” range. Eighteen obtained an excellent or good result when graded using the Hospital for Special Surgery score. Two radial and three carpal components showed radiolucent lines. Follow-up, however, was too short to determine whether this indicates progressive loosening.

We found neural loop penetrations by digital arteries in 47 of 51 dissected palms. They were classified into four types according to morphology. The most frequent type was observed in the proper digital nerves of the second to fourth interdigital spaces just after branching from the common digital nerves. If neural loop penetrations are not carefully identified at operation they may be damaged and therefore it is important for hand surgeons to recognize the existence of these structures.

Nerve allografts are highly antigenic and require the continuous use of immunosuppressive drugs. Neurotoxic complications from immunosuppressant therapy with FK 506 have been noted in the central and peripheral nervous system although an increased rate of axonal regeneration has also been noted. Regeneration of peripheral nerve grafts was assessed in a rat model clinically and morphometrically after treatment for 2 and 6 weeks with two different doses of FK 506. Good regeneration was noted in all groups at 6 weeks. A significantly higher axon count was observed in both the FK 506 groups after 2 weeks regeneration compared with controls. This beneficial effect was not evident after 6 weeks of regeneration. Whether this is related to a pruning mechanism or to a down-regulation of regenerative processes in the nerve due to possible neurotoxic effects of FK 506 remains unknown.

Seven children were operated on for pronation contractures of the forearm due to obstetric brachial plexus injuries. All underwent extensive preoperative evaluations to determine the extent of injury, secondary deformities, and capacity to perform a few basic tasks. Sequential video studies were used to document these findings. Operative procedures performed included various combinations of tendon/muscle lengthenings and/or transfers. Postoperative evaluations focused on function rather than gains in active range of motion and the patient/parental assessment of the benefit of the procedure by response to a questionnaire. All patients were followed for a minimum of 1 year following surgery. The average gain in active supination was 45°. Each patient showed significant functional gains with a high degree of satisfaction.

The aim of this study was to assess long-term results of extensor indicis (EI) to extensor pollicis longus (EPL) transfers and to assess donor site morbidity. A specific EI-EPL evaluation method (SEEM) was used to measure EPL function after transfer. The outcomes in 17 patients are presented. Results were assessed by the Geldmacher score, the SEEM, mobility and strength of thumb and index finger, pinch and grip strength, and a questionnaire, comparing the operated and non-operated hands. Based on the SEEM, the results were excellent to good in 11 of 17 patients. There was no marked loss of independent extension of the index finger and only a 38% loss of extension strength.

For the restoration of thumb opposition many types of tendon transfer techniques have been described. The flexor digitorum superficialis (FDS) of the ring finger is commonly selected as a motor. On occasion, however, the quality of the flexor muscles of the fingers or wrist is not good enough for tendon transfer and another available muscle must be selected. In this situation, we have preferred to use an extensor carpi radialis longus (ECRL) or brevis (ECRB) transfer to restore opposition of the thumb. Follow-up examination, at an average 5 years and 10 months after operation, showed that the results of ten of 11 transfers were excellent and the other was good.

We reviewed seven thumbs in six children at a mean of 43 months after repair of the flexor pollicis longus tendon in zone 2. Using the classification of Buck-Gramcko et al. (1976) the results were excellent in six and good in one.

This study was designed as a pilot investigation of the effect of pulsed electromagnetic fields (PEMF) stimulation on early flexor tendon healing in a chicken model using a similar stimulus to that used clinically. The PEMF used caused a decrease in tensile strength and an increase in peritendinous adhesions.

This report discusses the Daphne® prosthesis for the metacarpophalangeal joint on the basis of the mechanical, chemical and biological performance of the materials employed. The Daphne® prosthesis is a mobile device. The main body is made of a new generation polymethylmetacrylate, while the hinge is made of AISI 316 L stainless steel. Biocompatibility tests were performed on the materials employed. Systemic toxicity, cytotoxicity and contact tests have given favourable results. Mechanical engineering tests have been used to investigate the performances and reliability of the selected materials. The polymethylmetacrylate used in Daphne® behaves in a ductile fashion. No mechanical failures were encountered in fatigue tests after 10 million cycles.

A new method of bone fixation is described, using a small stainless steel device to provide compression between fragments with a single drill hole. The Bone Tie uses an old architectural principle to hold bone fragments together with minimal surgical dissection for access. The technique has been used in 14 cases, and the results are presented. In ten cases the outcome was good. Complications were encountered in four, mostly through technical error, although the final outcomes were acceptable.

Eighteen acute grade III collateral ligament injuries were treated by using the Mitek bone suture anchor. Seven were thumb metacarpophalangeal joint injuries, and eleven were finger proximal interphalangeal joint injuries. Seventeen patients were followed more than 12 months after surgery. All patients were able to use the digits in daily living activities within 5 weeks after surgery, and return to their original work or sports activities within 12 weeks. Pain was completely relieved in 15 patients. Loss of joint motion averaged 7°. In all joints the postoperative lateral stress angle was within 10° of that of the contralateral digit.

Twenty-two displaced metacarpal shaft fractures in 19 patients were stabilized with multiple intramedullary K-wires. These were inserted percutaneously through a small window in the base of the metacarpal and were buried in the bone. No external splintage was routinely used postoperatively and all patients were encouraged to mobilize their fingers immediately: formal physiotherapy was not usually required.

All the fractures that we were able to follow-up united, but the K-wires bent at the fracture site in two instances, producing 20° angular deformities. The buried K-wires had to be removed in one instance as a result of protrusion into the carpometacarpal joint.

Since the mallet finger that is treated with isolated splinting of the distal interphalangeal (DIP) joint can be moved freely proximal to the DIP joint, we sought to determine whether such motion might cause a tendon gap that could explain the extensor lag that often follows treatment. Experiments were performed on 32 cadaveric fingers with open mallet finger lesions, immobilizing either the DIP joint alone or both the DIP and PIP joints, while repeatedly flexing and extending the more proximal finger and wrist joints. For each experiment, the gap in the extensor tendon was measured. Joint motion proximal to the DIP joint and retraction of the intrinsics did not cause a tendon gap in a finger with a mallet lesion, supporting the convention that only the DIP joint needs to be immobilized.

Percutaneous scaphoid fracture fixation has many advantages over the open method of fixation. We describe the anatomical basis for a safe percutaneous approach.

Cannulated screws were inserted into 32 cadaveric scaphoids through 1 cm palmar incisions under fluoroscopic control. We then measured the distance between the entry point in the scaphoid and important local neurovascular structures. We also measured the angle of entry of the guide wire in two planes. The mean distance of the entry point from the main radial artery was 14 mm (range, 7–24 mm); from the radial nerve 19 mm (range, 7–35 mm); from the recurrent branch of the median nerve 29 mm (range, 14–45 mm); and from the superficial branch of the radial artery 5 mm (range, 0–8 mm) The mean radial angle of insertion was 34° and the mean palmar angle of insertion was 58°.

Percutaneous fixation of scaphoid fractures puts the superficial palmar branch of the radial artery at risk. We recommend a 1 cm incision centred over the scaphotrapezial joint and dissection under direct vision to the entry point in the scaphoid rather than a completely percutaneous approach.

In a randomized prospective trial, treatment of extra-articular distal radial fractures by closed reduction and plaster application was compared with Kapandji-pinning. Closed reduction and plaster cast was used in 50 patients, Kapandji-pinning in 48 patients. According to the Cooney score, good and excellent results were found in the closed reduction and plaster cast group in 74%, compared with 75% in the Kapandji-pinning group.

After measuring the maintenance of reduction as well as the functional outcome at 1 year follow-up, no statistically significant differences could be found between the two groups. We conclude that both techniques can be used in treating extra-articular fractures of the distal radius.

Radiocarpal fracture-dislocation is an uncommon but complex injury that is often the result of high energy trauma. The combination of ligamentous and osseous injuries demands meticulous attention to restoration of anatomy, especially of the radial styloid. Open reduction and internal fixation is often necessary to restore the relationship of the end of the radius to the carpus and distal ulna. We present a retrospective review of 12 patients treated over a 10-year period and review the literature.

Twenty-one intraarticular palmar displaced fractures of the distal radius operated on between 1990 and 1995 were reviewed with a mean follow-up of 27.3 months (range, 8–54). Fifteen fractures were treated with palmar T-plates, two in combination with an external fixator. Five fractures were treated with external fixators and K-wires, and one fracture was treated with percutaneous K-wires and a cast. In six patients cancellous bone graft from the iliac crest was used. The most satisfactory clinical and radiological results were obtained by anatomical reconstruction of the articular surface. The favoured method remains stabilization with palmar T-plates. K-wires with a cast should only be used in simple articular fractures with a large palmar fragment.

This randomized prospective study assessed whether multiple puncture of the ganglion wall improves the results of simple ganglion aspiration. We found that 32% of ganglia resolved after aspiration alone in comparison with 22% after aspiration and multiple puncture. This difference was not significant. However, only 18% of patients requested formal surgical excision, suggesting that aspiration allays fears of malignancy and allows the patient to accept a minor cosmetic embarrassment.

A clinical and radiographic review was performed on 18 patients (19 wrists) with dorsal carpal ganglia and associated positive scaphoid shift test. All patients underwent excision of the ganglion followed by 2 weeks of postoperative immobilization with the wrist in 20° extension. All patients had wrist pain, a painful clunk on the Watson scaphoid shift test, localized tenderness on palpation of the scapholunate articulation and normal radiographs. Patients were assessed postoperatively by questionnaire and physical examination. Improved functional activity and decreased pain were noted in all patients. In 17 of 19 wrists, the positive preoperative Watson scaphoid shift test become negative. We believe that dorsal wrist ganglia are frequently associated with a positive scaphoid shift test and that excision of the ganglion followed by 2 weeks immobilization may lead to resolution of the signs and symptoms of instability, at least in the short term.

We report the results of treatment of benign bone tumours in the hand with curettage and sintered bone implantation using bovine sintered bone (True Bone Ceramics). There were 22 patients who underwent sintered bone implantation in our department in 1984 or later. The follow-up survey period varied from 9 months to 11 years and 2 months (mean, 5.8 years). Recurrence of tumours and complications such as infection or fracture were not observed, and there were no clinical symptoms. X-rays revealed new bone formation connecting the implanted blocks to bone. Sintered bone was not absorbed, and lucent zones around the implants or other abnormal findings were not observed. Bone union was achieved in all patients who had pathological fractures before surgery.

We report a 13-year-old boy with a rapidly recurring benign chondroblastoma in the epiphysis of the distal end of the radius.

We report a condition we call the “plastic bag syndrome” in which pressure on the neurovascular bundles causes temporary ischaemia in the distal part of the finger together with a neuropraxia of the digital nerves. Although in most cases the discomfort or numbness is fleeting, requires no medical assistance and is readily forgotten, in some instances the symptoms are such that medical advice is sought. Since the injury can lead to permanent damage and subsequent limitation in the use of the finger, we believe that the public should be advised to take simple precautions to prevent it from happening.

A number of techniques exist for the removal of rings from swollen fingers. An improved method is described using ribbon gauze and a paper clip. It is cheap, quick and effective and can be used in the presence of minor lacerations and abrasions.

We report a case of onychomatricoma, which is a rare benign tumour originating in the germinal matrix of the nail. The diagnosis can be made on the typical clinical findings and confirmed by histology. Complete excision is the treatment of choice.

Although granular cell tumours have been demonstrated to have a neural origin, they rarely arise in peripheral nerve trunks. We report a case of granular cell tumour of the ulnar nerve in a 51-year-old man. Though dissectable from the nerve, this intraneural tumour showed microscopic involvement of focal nerve fibres. This tumour tended to infiltrate the nerve in the same manner as a neurofibroma.

Posterior interosseous nerve palsy associated with pseudogout of the elbow joint in a 71-year-old woman is described. Local steroid injection and administration of a nonsteroidal anti-inflammatory drug was effective in treatment.

We present a case of myositis ossificans of the hand and review the clinical, radiological, and histological presentation, as well as the appropriate therapeutic management.

A case of a glomus tumour of the distal segment of the ring finger, with four apparent recurrences in an 8-year period, is described. The patient was treated by two different surgeons (two and three times respectively) and obtained pain free intervals of between 4 and 11 months before recurrence. Histological examination confirmed the diagnosis of a glomus tumour in all five procedures. The location of the glomus tumour was defined preoperatively by high resolution MR imaging.

Osteoid osteoma is a benign primary tumour of bone occurring in the first two decades of life. It presents with pain and is uncommon in the hand, particularly so in the metacarpals. We report a painless osteoid osteoma affecting a metacarpal.

A case of post-mastectomy lymphangiosarcoma is reported. Lymphangiosarcoma is an extremely rare but highly lethal complication of chronic lymphoedema. Our patient was treated by amputation and died 6 months later. Treatment of post-mastectomy lymphangiosarcoma is still unsatisfactory. Early recognition and radical ablative surgery seem to provide best chance for survival.

We report the case of a woman with a previous history of breast carcinoma, treated with a left radical mastectomy and axillary clearance, who developed lymphoedema in the left arm following a carpal tunnel decompression complicated by a superficial wound infection.