Journal of Hand Surgery (European Volume)

Open fractures of the distal phalanx commonly present to the Accident and Emergency Department. Controversy surrounds the use of prophylactic antibiotics in treating this injury. A double-blind, prospective, randomized placebo-controlled study was undertaken comparing the use of prophylactic flucloxacillin to placebo in addition to meticulous wound toilet. One hundred and ninety-three adult patients with an open fracture of the distal phalanx were studied. Seven patients developed superficial infections, an overall infection rate of 4%. No patient developed osteitis or a deep wound infection. There were three cases of infection in the 98 patients (3%) in the antibiotic group and four cases of infection in the 95 patients (4%) in the placebo group. A difference of proportion test confirmed no significant difference. It is concluded that the addition of prophylactic flucloxacillin to thorough wound toilet and careful soft-tissue repair of open fracture of the distal phalanx confers no benefit.

Fractures of the little finger metacarpal are common, and are often associated with significant soft-tissue swelling and the appearance of rotational malalignment when the fingers are flexed. Our hypothesis is that soft-tissue swelling causes this apparent rotational deformity of the flexed little finger. The fourth intermetacarpal spaces of three of the authors’ non-dominant hands were injected with saline. Following injection, all the hands exhibited the appearance of internal rotation of the little finger. The mean change in rotation was 16° and the maximum was 25°. There was no change in the plane of the nail plate in extension in any hand. We conclude that soft-tissue swelling can cause the appearance of internal rotation of the flexed little finger in the absence of fracture.

Three amputated thumbs were reconstructed with a composite osteocutaneous groin flap and a neurovascular island flap. The average age at the time of surgery was 28 (range 25–35) years. The level of the amputation was distal to metacarpophalangeal joint in two cases and proximal in one case. The injury mechanism was avulsion in all cases. The postoperative follow-up periods ranged from 27 to 30 months. There were no cases of skin necrosis, bone resorption or infection. Radiographs and three-phase bone scans showed union of the iliac bone block and the stump without any resorption in all three patients. This surgical procedure is reliable and simple and the functional results are satisfying. We reserve this technique for the treatment of thumb amputations which cannot be replanted, particularly as it does not result in bone resorption.

Eighty-five patients were reviewed 7 years after prospective randomization to bridging external fixation or plaster immobilization for treatment of a Colles’ type distal radial fracture. The Gartland and Werley score showed that most patients in each group had an excellent or good outcome and patient satisfaction was comparable and high in both groups. The fixator group had significantly less radial shortening (P < 0.05 ). Despite a high level of radiographic malunion (50%) overall function, range of movement and activities of daily living were not limited. Twenty-five per cent of patients had minor radiological signs of post-traumatic arthritis although only one patient was symptomatic. We conclude that, in the long term, external fixation of distal radius fractures does not confer an improved outcome when compared to plaster immobilization.

Since the popularization of microvascular toe transfer, there has been a tendency to relegate osteoplastic reconstruction techniques for the thumb to history. A case is presented which shows that a successful and well-planned osteoplastic thumb reconstruction can match microsurgical reconstruction in all functional activities. Cosmetically, the toe transfer is the better reconstructive option but it may cause significant donor site morbidity.

This report describes the results of latissimus dorsi transfer for weakness of shoulder external rotation in 12 children with obstetric brachial plexus palsy. Selection criteria for the muscle transfer procedure included good passive external rotation of the shoulder, normal skeletal development of the shoulder joint, and adequate power of the deltoid. In addition to measuring the ranges of motion of joints before and after surgery, a modified Mallet grading system was utilized for the functional assessment of shoulder external rotation. At a mean follow-up of 4 years, two of the 12 children had recurrence of the shoulder deformity. In the remaining 10 children, the mean active external rotation was 30° (range, 20–60°), mean shoulder abduction was 140° (range, 90–170°), and all children had achieved a modified Mallet score of 4.

Three cases of irrevocable loss of sensation on the ulnar side of the thumb tip are presented in which switch of the radial pulp of the thumb tip to the ulnar side restored sensibility to this critical area, providing a useful functional reconstruction.

A 45-year-old orthopaedic surgeon sustained a complete thumb amputation and severe injuries to his index finger in a lawn mower accident. He was treated with a combined second toe transfer and an index finger pollicization.

This prospective randomized trial compared a non-bridging external fixator with a bridging external fixator system for the treatment of severe comminuted intra-articular fractures of the distal radius. The results did not demonstrate a statistically significant difference in the radiological and clinical outcomes achieved with these two treatments.

Recently French rheumatologists have repopularized fasciotomy using a percutaneous needle technique. This blind approach has been claimed to be plagued by numerous complications. We reviewed the charts of 211 patients treated consecutively on 261 hands and 311 fingers to assess the rate of postoperative complications. The first 100 patients were evaluated with a mean follow up of 3.2 years to assess the rate of recurrences and extension of the disease. In the whole group the mean age was 65 years and delay between onset and treatment was 6 years. Division of the cords were performed only in the palm in 165 cases, in the palm and finger in 111 and purely in the finger in 35. Complications were scarce without infection or tendon injury but one digital nerve was found injured during a second procedure. Postoperative gain was prominent at metacarpophalangeal joint level (79% versus 65% at interphalangeal level). The reoperation rate was 24%. In the group assessed at 3.2 years follow up, the recurrence rate was 58% and disease “activity” 69%. Fifty nine hands need further surgery. The ideal indication for this simple and reliable technique is an elderly patient with a bowing cord and predominant MP contracture.

An unconstrained surface metacarpophalangeal joint replacement was developed with metal metacarpal and polyethylene phalangeal components, fixed by uncemented finned polyethylene plugs which allowed some metacarpal component motion. Clinical and radiological results in 13 joints in eight patients are presented after 5 years. One infection required revision at 3 months. There were no further complications. At final review there were no implant failures. Two of 13 joints showed lucency around the phalangeal component and one showed 2 mm subsidence of the metacarpal component. No other adverse radiological features were observed. Seven patients had no pain and one had minor discomfort. Joint movement had improved from an arc of 27° to 60° and disability, assessed using the P.E.M. questionnaire, had improved from 77% to 9%.

In nerve compression syndromes restricted nerve sliding may lead to increased strain, possibly contributing to symptoms. Ultrasound was used to examine longitudinal median nerve sliding in 17 carpal tunnel syndrome patients and 19 controls during metacarpophalangeal joint movement. Longitudinal movement in the forearm averaged 2.62 mm in controls and was not significantly reduced in carpal tunnel syndrome (CTS) patients (mean=2.20 mm). In contrast, CTS patients had a 40% reduction in transverse nerve movement at the wrist on the most, compared to least, affected side and nerve areas were enlarged by 34%. Normal longitudinal sliding in the patients indicates that nerve strain is not increased and will not contribute to symptoms.

Proponents of endoscopic carpal tunnel release have been advocating the technique for more than 10 years but there is still debate about its efficacy, safety and cost-effectiveness. We have performed a randomized, prospective, blind trial to compare early outcome after single portal endoscopic or open carpal tunnel surgery and to assess the cost-effectiveness of the procedures. There were no significant differences in symptom and functional activity scores, grip strength or anterior carpal pain in the first 3 months. For those in employment, we found a statistically significant difference between the two treatment groups with the endoscopic group returning to work, on average, 8 (95% CI, 2–13 days) days sooner than the open group. This translates into a cost saving to industry. There were no major neurovascular complications in either group. On the basis of these findings, we recommend that endoscopic carpal tunnel release should be considered in the employed as a cost-effective procedure, but perhaps not in the general population as a whole.

Two hundred and seventy-three patients with carpal tunnel syndrome without advanced neurophysiological changes (distal motor latency below 11 ms) were randomized to treatment by open carpal tunnel release with, or without, epineurotomy. Patients were examined clinically and by nerve conduction studies preoperatively and at 3, 6 and 12 months postoperatively. We found no statistically significant difference between simple decompression and decompression combined with epineurotomy with regard to either the clinical or the neurophysiological outcome.

This prospective study compared the sensitivities of a scored questionnaire and electrophysiological examination in the diagnosis of carpal tunnel syndrome. Patients were assessed by a hand surgeon using a scored questionnaire, and then underwent an electrophysiological assessment by an experienced neurophysiologist (blinded to the questionnaire results). Patients diagnosed as having carpal tunnel syndrome by either the questionnaire, the electrophysiological examination or both underwent decompression. Symptom relief was taken as the “gold standard” for true carpal tunnel syndrome.

The results showed a sensitivity of 85% for the scored questionnaire and 92% for nerve conduction studies with a positive predictive value of 90% for the scored questionnaire and 92% for nerve conduction studies.

The authors recommend that a scored questionnaire can replace nerve conduction studies in the initial assessment of whether patients presenting with dysaesthesiae in the fingers should undergo surgery. This will give major time, personnel and cost benefits.

The speculated pathological causes of tennis elbow and the part work might play in its causation are briefly reviewed. The excellent surgical results, whatever operative technique was employed in those surgical series reported prior to the wave of work-related upper limb disorders is noted. One hundred and eight consecutive patients with tennis elbow who were also litigants (seeking compensation) were reviewed and the result of treatment and specifically surgery, analysed. Disappointing results of surgery were found in litigants and recommendations are made as to the management of litigants epicondylitis.

Fibroblast migration is an integral component of the processes resulting in the formation of restrictive adhesions in the injured tendon, especially in Zone II.

Pre-requisites for cell migration are an intact cytoskeleton and an ability to biochemically degrade the extra-cellular matrix. The relative characteristics of fibroblasts from the fibro-osseus sheath (SC), the tissue surrounding the tendon in Zone II, and the endotenon (TC) with respect to morphology, cytoskeletal structure and ability to produce matrix metalloproteinases (MMPs) 2 and 9 were compared in vitro.

It was found that SCs were larger in size and demonstrated greater amounts of intra-cellular alpha-smooth muscle actin (α-SMA) and intra-membranous vinculin. Filamentous actin (F-actin) fibres in SCs were more densely packed and concentrated, resulting in stress fibres. The SCs also produce greater amounts of MMP-2 and MMP-9 compared to TCs.

These observations imply that SCs play an active role in adhesion formation and should be specifically targeted to inhibit or treat tendon adhesions.

The cross-stitch peripheral suture has good strength, but the large amount of exposed suture on the tendon surface has restricted its clinical usage. We report a method of embedded cross-stitch that incorporates cross-stitches into peripheral sutures and reduces the amount of exposed suture on the tendon surface. Thirty-three fresh pig flexor tendons were divided equally into three groups and repaired with cross-stitch, embedded cross-stitch, or modified Halsted sutures. The tendons were tested in an Instron tensile machine to assess the mechanical performance of these repairs. With an identical number of strands across the repair site, the gap formation and ultimate forces of the embedded cross-stitch method were statistically greater than those of the cross-stitch and modified Halsted methods. The embedded cross-stitch method also had significantly greater stiffness and energy to failure than the cross-stitch method. The embedded cross-stitch method, with little suture exposure on the tendon and sufficient strength, presents an alternative to the current cross-stitch peripheral repair.

We carried out a biomechanical study comparing tensile strength after using round-bodied or cutting needles for tendon repair. Swine tendons were repaired in three groups: Group 1 core suture repair only; group 2 core and circumferential suture repair; and group 3 isolated circumferential suture repair. The tendons were tested at longitudinal stress to failure at 5 mm/minute. No significant differences were found between the round-bodied and cutting needles in any group. Equal numbers in the core suture repair group failed by suture pullout when comparing cutting and round-bodied needles. We conclude that the choice of needle has no effect on the outcome of tendon repair if there is consistency of surgeon’s skill and experience.

We performed a study to evaluate the tensile properties of partial tendon lacerations and the effects of peripheral sutures on the tendon strength. Seventy-two fresh pig flexor digitorum profundus tendons were divided equally into eight groups. Tendons in four of the groups were subjected to partial lacerations (60%, 70%, 80%, and 90%) and were not repaired. In the other four similar groups partial lacerations were repaired with running peripheral sutures. The tendons were subjected to load-to-failure tests in an Instron tensile machine to determine the initial, 1 mm, 2 mm gap formation forces and the ultimate strength. The tendons with lacerations of 80% and 90% had a remarkably lower tensile strength than those 60% and 70% lacerations. Running peripheral sutures increased the gap formation forces and the ultimate strength of all the tendons, though particularly those with 80% and 90% lacerations.

Shoulder deformities are the most frequent sequelae of birth palsy. In this paper, previous classification systems for secondary shoulder deformities are reviewed and a new classification is offered.

A retrospective survey of the medical charts of all 36,518 patients attending the Accident and Emergency Department of the VU University Medical Centre, in Amsterdam, from January 1 to December 31, 1996 was performed. Of these, 4303 sustained one or more fractures, and hand fractures accounted for 19% of all fractures. Patients with hand fractures were typically men aged between 15 and 35 years. The right hand was involved as often as the left. Most of the hand fractures involved the metacarpals but, as a group of bones, the combined phalanges were most commonly fractured. The little finger ray was most commonly injured of the hand. We found no seasonal variability in the incidence of hand fractures.

Twenty patients treated with a Herbert screw for scaphoid fractures (acute or non-union) were reviewed and X-rayed 5–10 years later to assess whether there were degenerative changes in the scapho-trapezial joint due to insertion of the screw. Six had some irregularity in the lateral part of that joint, three of which followed backing-out of the screw. Two others were described as showing irregularity all round the scaphoid but, apart from these, no radiological abnormalities were seen in the central or ulnar part of the scapho-trapezial joint, or on the proximal tip of the scaphoid.

We present two coronal fractures of the proximal scaphoid which were both missed in the acute stage as interpretation of initial radiographs was difficult. In both cases, recognition of the so-called “Proximal Ring Sign” on the PA ulnar deviation radiographs may have helped diagnosis. CT scans were necessary to fully demonstrate the fractures. Open reduction and internal fixation, performed 2 and 4 months after the injury, resulted in union in both cases.