Journal of Hand Surgery (European Volume)

A total of seven antenna procedures for hooknail deformity were performed between 1990 and 2000. At a mean follow-up of 3 years 4 months there were no major complications, all patients had an improvement in their deformity (subjectively and objectively) and were pleased with their results. Some residual deformity remained in all cases including shortening of the nail, contour defect of the pulp and flattening or residual curvature of the nail.

This pseudo-randomized study was performed to compare the pulmonary function and biceps recovery after intercostal (19 cases) and phrenic (17 cases) nerve transfer to the musculocutaneous nerve for brachial plexus injury patients with nerve root avulsions. Pulmonary function was assessed pre-operatively and postoperatively by measuring the forced vital capacity, forced expiratory volume in 1 second, vital capacity, and tidal volume. Motor recovery of biceps was serially recorded. Our results revealed that pulmonary function in the phrenic nerve transfer group was still significantly reduced 1 year after surgery. In the intercostal nerve transfer group, pulmonary function was normal after 3 months. Motor recovery of biceps in the intercostal nerve group was significantly earlier than that in phrenic nerve group.

We conclude that pulmonary and biceps functions are better after intercostal nerve transfer than after phrenic nerve transfer in the short term at least.

We compared the incidence of significant Dupuytren’s disease in men across occupational social classes in England and Wales, using data from the National Morbidity Survey. We found that manual occupational social class was not associated with an increased incidence of Dupuytren’s disease. In fact, the incidence rates of Dupuytren’s disease in the elderly were higher in non-manual than in manual social classes.

We present a prospective study, with 3-year follow-up, of the role and outcome of fasciectomy plus sequential surgical release of structures of the proximal interphalangeal joint in Dupuytren’s contracture of the little finger.

Our treatment programme involves fasciectomy for all patients followed by sequential release of the accessory collateral ligament and volar plate as necessary.

Of the 19 fingers in the study, eight achieved a full correction by fasciectomy alone, and in these cases there was a fixed flexion deformity of 6° at 3 months and 8° at 3 years. The remaining 11 fingers (initial mean deformity 70° flexion) were left with a fixed flexion deformity of 42° after fasciectomy which reduced to 7° with capsuloligamentous release. This increased to 26° at 3 months but then remained relatively stable, increasing only to 29° at 3 years.

In our experience sequential proximal interphalangeal joint release has led to consistently good results with few complications in the correction of severe Dupuytren’s disease of the little finger.

5-Fluorouracil reduces proliferation rates of fibroblasts, myofibroblast differentiation and contractility of ocular fibroblasts in vitro. This double-blind randomized clinical trial assesses whether intra-operative topical treatment with 5-fluorouracil reduces the recurrence rate after limited excision of Dupuytren’s tissue. Patients with two-digit disease were randomized to having 5-fluorouracil (25 mg/ml) treatment for 5 minutes on one digit and placebo on the other.

Fifteen patients were enrolled with 18 months follow-up. There were no peri-operative complications. Wound healing was not delayed and there was no deterioration in the flexion deformity of the 5-fluorouracil treated digits. Patients were subsequently assessed by joint angle measurement at 3, 6, 12 and 18 months. There was no significant difference between control and 5-fluorouracil treated digits.

Over a period of 4 years, in various circumstances commonly seen in hand surgery, 100 patients underwent 127 soft tissue attachments to bone using the Acufex wedge tag system (Acufex Microsurgical, Inc, Mansfield, MA), a non-metallic bone anchor. No failures to maintain the attachment of the desired soft tissue to bone were identified. While less robust than the Mitek anchor, the other commonly available system of bone anchoring, and therefore possibly inappropriate for general orthopaedics, the Acufex wedge tag proved adequate for the smaller forces of hand surgery.

Ultrasound was performed in 116 wrists of asymptomatic volunteers to determine the prevalence and morphology of anomalous muscles in Guyon’s canal in the normal population. The size of the muscle was correlated with sex, hand-dominance and occupation. Anomalous muscles were identified in 47% of volunteers and 35% of wrists (male prevalence (50%); female prevalence (21%)). All were variants of abductor digiti minimi. Bilateral muscles were present in 50% of index cases in both sexes. Mean muscle thickness was 1.7 mm overall with no inter-sex variation. Muscle thickness did not vary with hand dominance or manual employment. The prevalence of anomalous muscles is higher than previously reported and may be sex-linked. The size of the muscle may be an important factor in determining whether an anomalous muscle is significant in cases of ulnar nerve compression at Guyon’s canal.

We performed a randomized double-blind case–control study in 64 consecutive patients undergoing open carpal tunnel decompression under local anaesthetic to assess the pain experienced on injection of plain lidocaine (pH 6.4) compared with lidocaine buffered with sodium bicarbonate (pH 7.4). The results showed no statistical difference in the pain scores reported by patients. The mean pain scores for all patients were low, and most patients reported that they were “not at all anxious” about receiving a similar injection in the future.

This study investigated the effects of alkalinization and warming of lidocaine 1% on injection pain in patients undergoing carpal tunnel decompression. Sixty-four adult patients were randomly allocated into one of three groups: Group A (n=20) received plain lidocaine 1%, Group B (n = 22) alkalinized lidocaine and Group C (n = 22) warmed and alkalinized lidocaine. Pain on needle insertion and on infiltration was assessed using a 100 mm Visual Analogue Scale (VAS). There was no significant difference regarding pain on needle insertion whereas significant differences were noted in reference to infiltration pain. In Groups B and C (alkalinized lidocaine) the VAS scores on skin infiltration were significantly lower than in Group A, while the pain score in Group C (alkalinized and warmed lidocaine) was significantly lower than in Group B.

Key pinch force was measured preoperatively and at follow-up (mean 25 months) in patients treated for basal joint arthritis by either trapziectomy with ligament reconstruction and tendon interposition (n=26) or total joint arthroplasty (n=27). There was a significant increase in key pinch strength with both treatments, but no difference between the two treatments. Total joint arthroplasty does not appear to produce stronger key pinch than trapziectomy with ligament reconstruction and tendon interposition.

The present anatomical and clinical literature is not detailed enough for a clear understanding of the three-dimensional anatomy of the trapezium. It lacks descriptions of identifiable landmarks needed for the interpretation of two-dimensional radiographs. Fifty dry cadaver trapezia were assessed and an extended surface anatomy described. New consistent landmarks were described and the tubercle of the trapezium was redefined. The incidence of the salient osteological features in Caucasian trapezia was recorded.

This study describes the MR imaging appearances of the supporting ligaments of the thumb carpometacarpal joint in asymptomatic volunteers and in a group of patients following joint injury. Fourteen patients with 11 acute and three chronic injuries underwent MR imaging. The anterior oblique ligament was the most commonly injured ligament, usually on the metacarpal side where it was disrupted, or allowed dislocation because of subperiosted stripping from the base of the thumb metacarpal. The dorsal radial ligament was occasionally avulsed or partially torn from the trapezoid. Following chronic injury, MR imaging can evaluate ligamentous laxity, ganglion cyst formation or osteoarthritis. Accurate evaluation of ligament injury may identify patients who would benefit from surgery.

The effect of combined pronator teres rerouting and flexor carpi ulnaris transfer on forearm rotation was prospectively studied by comparison of pre- and postoperative three-dimensional analysis of forearm range of motion in ten patients with cerebral palsy. One year postoperatively, surgery had improved maximal supination of the forearm in all patients by an average of 63°, but there was also a mean loss of 40° pronation. Forearm range of motion increased by a mean of 23°. The centre of the range of motion on average shifted 52° in the direction of supination. Based on these results of objective forearm range of motion analysis, we conclude that the common combination of pronator teres rerouting and flexor carpi ulnaris transfer in patients with cerebral palsy effectively facilitates active supination but impairs active pronation.

This prospective study assessed the results of a custom-made thermoplastic splint for treatment of mallet finger deformity. From April 1999 to April 2000, 42 patients with mallet finger deformity were recruited. All patients were seen within 1 week and treated with a thermoplastic splint custom made by the hand therapy department. The splint was simple to make, easy to fit and suitable for all finger shapes and sizes. It improved the deformity in 30 out of 34 cases, and caused no skin irritation.

Twenty-one patients (17 women and four men) who underwent operative treatment for a solitary enchondroma of the hand were examined at a follow-up of between 2 and 18 years (mean, 9 years). Radiographs showed normal cancellous bone at the site of surgery in 11 cases, three had recurrent enchondroma and seven had bone defects so that recurrence could not be excluded. Two of the three recurrences underwent reoperation.

Previous studies have regarded persistent bony defects as evidence of complete excision without recurrence. However, in view of the slow asymptomatic growth of this tumour this opinion is incorrect. As shown in this study, recurrences may occur in these defects many years after excision surgery and go undetected until they cause widening or cortical erosion.

We recommend periodical radiological re-examination for asymptomatic recurrences before weakness of bone leads to pathological fracture.

Some authors attribute recurrences of giant cell tumours to biological factors which are only expressed in some tumours. Grover et al. (1998) suggested that the risk for recurrence is associated with the down-regulation of the nm23-H1 gene. We reviewed the charts of the 154 patients operated on for giant cell tumours of the tendon sheath and selected a group of patients with recurrence (ten cases) and a group of patients who did not have a recurrence after a minimum follow-up of 3 years (13 cases). Immunohistochemical detection of nm23-H1 was performed blindly of the clinical outcome on the paraffin-embedded specimens of these patients and no correlation was found between nm23-H1 expression and the risk for recurrence.

The purpose of this retrospective study was to evaluate the clinical outcome of distraction lengthening of the thumb metacarpal without bone grafting in seven patients with traumatic thumb loss. The distraction was stopped after 57 (range, 42 to 91) days, giving a median lengthening of 28 (range, 20–36) mm. It took an average of 155 (range, 118–196) days for bony consolidation to occur. The mean pinch power was 72% of that of the uninjured hand. The two-point discrimination on the pulp of the reconstructed thumb was 10 (range, 8–12) mm. There were no major complications.

Intraarticular phalangeal fractures are difficult to treat. The advantages of using dynamic external fixation devices include distraction of impacted fracture fragments and reduction in joint stiffness by allowing early joint mobilization. Previous reports have concentrated on pilon fractures and dorsal fracture dislocations affecting the proximal interphalangeal joint. We report our experience using a dynamic external spring fixator in the management of 15 patients with a variety of fracture patterns affecting the metacarpophalangeal, proximal interphalangeal and distal interphalangeal joints. In three cases the device spanned two adjacent joints. Long-term follow-up has shown excellent range of joint movement and no major complications. We consider that this device is an effective tool in the management of a range on complex intraarticular phalangeal fractures.

The average of three consecutive measurements is the most frequently used method for grip strength assessment. The purpose of this study was to compare the consistency of the maximum value with that of the average value of three consecutive measurements of grip strength. One hundred healthy volunteers participated in this study. Three measurements of grip strength were taken on two occasions separated by 2 weeks. For each hand, two average values and two maximum values were obtained. Ninety-five per cent limits of agreement for the average method were – 8.3 (−23%) to +7.2 (+20%) kg and for the maximum method were – 8.8 (−23%) to + 8 (+21%) kg. Both methods of grip strength assessment were found to be highly consistent with no statistically significant difference.

Unambiguous description of anatomical structures is essential to communicate information either in the clinical or research context. In view of this and following recommendations by the Nomenclature Committee of the International Societies for Surgery of the Hand (IFSSH), the booklet “Terminology for Hand Surgery” was published in 2001. The aim of this study was to identify whether the nomenclature used in the papers published in the Journal of Hand Surgery (British and European volume) followed its recommendations.

The study showed that we still continue to use traditional terminology. The most common “mistake” is numbering of the metacarpals instead of naming them. Usage of newer terms would improve the clarity of information distributed.

A case of high-temperature, high-pressure injection injury of the hand is reported. The injury is particularly severe in that it involves both a high-temperature thermal insult and a pressure effect, either of which, alone, can result in major disability. It is evident that the high temperature of the injected material considerably reduced the pressure required for penetration of the tissues.

We report a case of palmar dislocation of a finger metacarpophalangeal joint. Disruption of all the supporting structures of this joint and rupture of the flexor tendon sheath caused marked instability. Treatment was by open reduction and repair of the collateral ligaments.