Journal of Hand Surgery (European Volume)

Touch sensibility must be evaluated in most of our patients, and must be re-evaluated in many of them following surgery. Touch sensibility must be tested in our disability evaluations and in order to prognosticate regarding hand function. Touch sensibility evaluation can provide a non-invasive guide to acute compartmental syndrome management. Touch sensibility must be re-educated following nerve repair.

This essay describes the internal topographical anatomy of peripheral nerves and outlines the use of this information in the specific steps of nerve suture. Repair is detailed in the context of overall wound management and those factors are emphasized which can be controlled by the surgeon and which have a definite effect on the functional outcome.

Over 300 children a year are treated at the Royal Aberdeen Children’s Hospital for crushed finger tips. We estimate that 5.8% of children, under 13 years of age, suffer this injury, mainly in domestic (72.5%) or car doors (12%). The treatment of partial avulsions of pulp with nail dislocation is described.

The superficial sensory branch of the radial nerve appears prone to develop painful neuromas out of proportion to its likelihood for injury. Based on cadaver dissections and intraoperative observations, an anatomical mechanism for this “predisposition” is suggested. Exit of this nerve beneath dense fascia and the tendons of brachioradialis and extensor carpi radialis longus provide a proximal tethering against which tension develops as the distal fixation point (neuroma) is pulled through the long excursion of wrist are of motion. This long excursion and proximal tethering are not present anatomically for the dorsal cutaneous branch of the ulnar nerve nor the palmar cutaneous branch of the median nerve.

The transfer of sensitive dorsal rami of the ulnar nerve (two cases) and of two sensitive dorsal rami of the radial nerve (five cases) was accomplished in order to restore the sensitivity of the first three finger tips in patients suffering from serious and longstanding inveterate lesions of the median nerve.

The Authors describe the two surgical techniques in detail and, according to the satisfactory results obtained, specify the indications and advantages of this operation.

Dupuytren’s disease sometimes seems to arise from the tendon of abductor digiti minimi or the fascia overlying it. The normal anatomy of these structures is described and the tendon is shown to be of central importance in the organisation of the digital fascia. In particular, its connections with the superficial transverse palmar ligament, Grayson’s ligaments and the digital band are demonstrated.

General supportive measures, the ability to avoid infection, the natural tendency to improvement and the feasability of major reconstructive procedures later suggest that neonatal limb ischaemia should be managed conservatively at first, despite an alarming appearance. The number of infants at risk, especially due to prematurity and effective resuscitation, is theoretically increasing.

Two cases are described where a Dupuytren’s contracture has been released by injury.

In two patients with flexor paralysis of the elbow due to a lesion of the brachial pluxus, the entire latissimus dorsi muscle was transplanted to act as an elbow flexor, preserving its neurovascular pedicle. This flexorplasty proved useful for patients who had suffered a traction lesion of the upper trunk of the brachial plexus.

Fifty cases of resistant tennis elbow were studied, thirty seven of these had been treated by lengthening the tendon of extensor carpi radialis brevis, and thirteen by decompression of the radial tunnel. The two groups were well matched in terms of age, sex and pre-operative symptoms and signs. It was found that the results of surgery were very similar in the two groups and this observation is explained by anatomical study showing that surgical division of the fibrous arch of the superficial leaf of supinator will relieve tension on the lateral epicondyle and its adjacent structures thus allowing relief of symptoms independently of radial or posterior interosseous nerve decompression. This elaborates previously published work showing that there is no clinical or electrical evidence of radial nerve entrapment in resistant tennis elbow.

Pain developed after arthroplasty of the carpometacarpal joint of the thumb. It was due to perforation of the shaft of the metacarpal by the prosthesis, and was cured by a bone graft.

The results of tendon grafting following avulsion of the profundus tendon to the ring finger (“Rugby finger”) are described. Function in the hand was improved in all cases and this is a method of treatment which should be considered by the surgeon experienced in tendon grafting in those patients who are young and well motivated.

The exact reason for the common involvement of the ring finger is not clear but the unique lumbrical origin from that profundus may be an important factor tethering the tendon in the palm, and this is suggested as the possible cause of this injury.

Ulnar tunnel syndrome or compression of the ulnar nerve at the wrist is of two distinct types. In the first type compression is at the level of the pisiform with involvement of both sensory and motor fibres. In the second type compression is distal to the pisiform with involvement of the motor fibres only.

Although knuckle pads are histologically similar to the palmar nodules in Dupuytren’s Disease, they do not produce contraction. By considering the anatomical situation of the knuckle pad overlying the joint line and comparing it with a unique case of a dorsal nodule occurring between the joint lines, an explanation is profferred for this lack of contraction by knuckle pads. That contraction in the extensor mechanism was produced by the nodule between the joint lines is used to support further the “extrinsic” hypothesis of the pathogenesis of Dupuytren’s Disease.

Conventional immobilisation following surgery for claw hand reconstruction necessitates altogether more than six weeks of post-operative physiotherapy. Two to four weeks of physiotherapy was required for re-education of the transferred tendons and an additional period of physiotherapy was needed to overcome the interphalangeal joint stiffness seen in all hands—even those with no pre-operative I.P. stiffness.

Fifty hands with no pre-operative I.P. stiffness were immobilised post-operatively following claw hand correction by three different techniques, (Conventional technique 20 hands; Modification type 1, 10 hands and Modification type 2, 20 hands). Modification type 1 produced unsatisfactory results. Modification type 2 however, resulted in near total absence of I.P. stiffness with no additional physiotherapy required to overcome the minimal stiffness, without interfering with the results of reconstructive surgery. Type 2 immobilisation was achieved by a volar plaster slab extending from just below the elbow to the finger tips with circumferential plaster up to just beyond the metacarpophalangeal joints. Modification type 2 is recommended.

Experimental and clinical studies have been made on the function of the venous system in the replantation of the contused severed finger. In experiments on rats replantation of severed limbs was more successful in a group treated by continuous blood-letting and anastomosis of the artery alone, compared with controls in which only the artery was anastomosed. Histologically, in the first group there was less congestion, thrombus-formation, oedema and exudative haemorrhage in the initial stage; in the reparative phase there was less granulation and the degree of muscular degeneration was very slight. Clinically, contused, severed fingers were successfully replanted when venous anastomosis was impossible or incomplete, by using the fish-mouth incision for continous blood-letting. The resulting scar caused no problem aesthetically or functionally.

Three cases of aneurysmal bone cyst affecting the hand are reported. Some aspects of incidence, aetiology and treatment are discussed.

A case of pseudomalignant osseous tumour of the soft tissues of the finger is reported. The benign diagnosis is confirmed by the histologically characteristic zone phenomenon.

Solitary enchondromas obtained from the small bones of the hand were studied with transmission electron microscopy.

Three cell types were seen as follows: (1) young looking, active cells with extensive dilated rough endoplasmic reticulum and well defined Golgi and mitochondria; (2) older looking, degenerating cells with dilated rough endoplasmic reticulum, well defined Golgi, glycogen masses, vacuoles containing tropocollagen, lipid and myelin figures; and (3) dying cells showing loss of cell membrane and lysosomal-like bodies.

A young chondroblastic cell may try to mature, become a normal chondrocyte that produces normal matrix but it does not succeed and dies.

Enchondromal cells are not capable of forming tropocollagen or synthesizing proteoglycans for the matrix.

Of 40 patients with amputated thumbs referred for replantation to the Manchester Microsurgical Unit over five and a half years, 10 (25%) were not considered to be feasible replants, 6(15%) were abandoned at the primary operation, and 24 were replanted. Mode of selection of patients for replantation and operative methods are considered. The 14 thumb replants that survived were studied in detail and functional results are presented. Only one patient had a result that prevented normal activities, the remainder having returned to former occupations.