Hand Surgery

It has been shown that the tropic factors at the end of a distal nerve segment attracts growing axons. Subsequently, it was shown that this attraction enables intact axons to sprout into a recipient end-to-side anastomosed nerve in rats. We have demonstrated that this ability of a donor nerve also occurs in the non-human primate as well as in the human.

Three Chacma baboons (6 end-to-side anastomoses at the wrist level) consistently confirmed collateral sprouting on histology and recovery of function (motor and sensory) on electro-conduction tests.

Preliminary results in 21 human patients (21 end-to-side anastomoses in a variety of procedures) demonstrated clinically and by electro-conduction tests that sensory and motor recovery occurs satisfactorily.

End-to-side nerve suture (also called terminolateral neurorrhaphy) has been extensively examined clinically, histologically, electro-physiologically and electron microscopically in the rat and non-human primat (Chacma baboon: Papua ursinus). We have demonstrated good to excellent sensory in motor function results in the human patient for a variety of nerve injuries.

The simplicity of the procedure, the relative wide tolerance of the operative technique and the virtual consistent early recovery of both sensory and motor function, makes this method ideal for nerve injury surgery. Nerve grafts to a large extent are obviated and brachial plexus surgery gets a whole new meaning. The first 22 patients are presented.

Forty-four patients underwent surgery for chronic ulnar-sided wrist disorders. Their diagnoses were malunion of distal radial fracture in 25 patients, ulnocarpal abutment syndrome in 11, and primary distal radioulnar joint (DRUJ) osteoarthrropathies in eight. The procedures performed included Darrach's procedure in three patients, ulnar shortening in 17, hemiresection interposition arthroplasty in six, and Sauvé-Kapandji's procedure in 18. Each case was assessed preoperatively and postoperatively using a modified Cooney's score. The overall result included 17 excellent outcomes, 12 good, 13 fair, and two poor. In order to select the best procedure for patients with disorders of the ulnar wrist joint, preoperative assessment of DRUJ congruity and stability is essential. In ulnocarpal disorders without DRUJ incongruity, ulnar shortening should be selected. In cases with DRUJ incongruity but stable, hemiresection interposition arthroplasty is indicated. In cases with an unstable, incongruous DRUJ, Sauvé-Kapandji's procedure is recommended. Darrach's procedure is indicated only in elderly, inactive patients.

We reviewed 17 patients with an arthroscopic repair of ulnar avulsions of the TFCC: 12 are considered good, 2 fair and 3 poor.

No major complications occurred. The grip forced averaged 71.5% of the contralateral side.

These results equal those of open procedures, without the necessity of an extensive approach.

A new stabilisation technique has been developed by the authors for the prevention of instability of the distal ulna after performance of Bower's hemiresection-interposition technique in rheumatoid patients, is described. This technique consists of the transfer of the extensor carpi ulnaris over the dorsal aspect of the distal ulna and suturing it to the soft tissue over the distal ulna. Operation was performed in 16 rheumatoid patients with 20 wrist joints. The results were evaluated in terms of both subjective (pain during rotation, pain on compression of the ulna) and objective evaluations (wrist/forearm range of motion, grip strength). After the operation, the pain almost disappeared in all but two cases which had insufficient bone excision. Wrist extension/flexion and pronation/supination improved after operation. Average grip strengths also improved. None of the cases showed instability of the distal ulna after the operation. Wrist extension strength did not decrease after operation in spite of tenodesis of the extensor carpi ulnaris. This technique is simple and useful for prevention of instability of the distal ulna after hemiresection-interposition technique has been carried out in rheumatoid patients.

Complete rupture of the scapholunate ligament was treated by open reduction, ligament repair and internal splintage with a Herbert bone screw. After an average of 12 months, the screw was removed to allow full loading of the repair. In 33 procedures, there were 22 good and 11 poor results. In five cases with a poor outcome, the screw pulled or fractured out of the scaphoid or lunate. Grip and range of wrist motion improved in patients with a good outcome, and repair of the ligament was noted at all revision and open screw removal surgeries. A comparison of the good and poor results leads us to recommend this technique for patients with relatively recent injuries and light to moderate activity levels. Longstanding injuries and heavy occupational wrist loading led to poorer results.

The anterior interosseous nerve syndrome was first described in 1948. It comprises less than 1% of all upper extremity nerve palsies. Patients have a characteristic pinch deformity, with paralysis or weakness of the muscles innervated by the anterior interosseous nerve, flexor pollicis longus, radial portion of the flexor digitorum profundus, and pronator quadratus. Electromyograms are positive in most patients presenting with motor complaints. Treatment is related to the specific etiology. Conservative treatment includes avoidance of strenuous forearm work, immobilization, steroid injections, and anti-inflammatory medications. If the presentation suggests nerve compression, and the EMG reveals evidence of axonal interruption, then surgical decompression should be performed. We present a series of six patients seen over a 7-year period. Improvement was noted in all the patients postoperatively.

The etiology of the necrosis of the lunate bone is still unclear. In today's theories, the necrosis is explained by impairment of the arterial bone circulation or fracture following mechanical overloading. In this study, six specimen in different stages of the disease were investigated histologically. In all the specimens, focal necrosis was detected, but also signs of regeneration, i.e. immature bone formation. No signs of fracture were seen in all stages of the disease. These findings are not compatible with sudden interruption of arterial blood supply or fracture of the lunate bone as a primary lesion. Comparable histological patterns are known in the necrosis of the femoral head. The etiological model of necrosis of the femoral head is well investigated and postulates primary marrow hypertension, induced by impairment of the venous drainage. Our results are contradictory to the etiological theories of fracture or breakdown of the arterial blood supply as a primary lesion in Kienböck's disease, and support the assumption that the model of intraosseous hypertension is transferable to the necrosis of the lunate bone.

A variety of flaps have been reported for the reconstruction of finger tip injuries. The volar advancement flap was first intoduced in 1964. Recently, this technique was combined with V-Y closure and has been applied in the treatment of thumb tip injuries. We treated seven thumb-tip injuries and five finger-tip injuries using the volar advancement flap with V-Y closure. The flaps were advanced an average of 14 mm (range: 10 to 18 mm). All flaps survived completely. The static two-point discrimination in the flaps ranged from 5 to 8 mm (average 6.3 mm). One of the advantages of this procedure is the single-stage reconstruction of the pulp defect with preservation of sensation. In addition, skin graft coverage of the donor site is not required. The result was excellent with less postoperative complications in thumb-tip injury cases. In finger-tip injury cases, however, several postoperative complications occurred such as the PIP joint contracture, cold intolerance of the dorsum of finger tip, and claw-nail deformity. Accordingly, the indication for this flap should be limited to the thumb injury case.

The pulp of the toe provides a unique source to cover the fingertips with the same texture and mechanical receptors. Free microsurgical transfer is technically possible. Sensory reeducation can improve the discrimination of the donor site. We reviewed with a 7-year follow-up of 44 patients having a simple or composite toe pulp transfer. Mean age of the population was 22 years. 2PD was an average of 12 mm and Semmes Weinstein was 4.31 in 80% of cases. The result was not influenced by age, smoking habit, dominance, ray reconstructed or ischaemia time. Of significance was the number of arteries feeding the transfer, job activity and type of trauma.

The classifications of lunate necrosis used by Decoulxet al. (1957)³ and Lichtmanet al. (1977)⁷ and Lichtman and Degnan (1993),⁶ respectively, do not refer to early changes in MRI nor to changes to the carpal architecture, but do attribute the onset of the disease to the presence of a fracture. A recent publication of Lichtman and Ross (1994)⁸ did not solve the problem of a precise description of the disease. This necessitates a new, reliable classification based on the true natural course of the disease.

In a prospective study of 49 patients and in a retrospective analysis of 125 lunate necrosis, the findings obtained prove the regular natural course of the disease. It starts with normal x-ray appearance but the intensity of the signal in T1-weighted MRI is decreased; a fracture line is part of the latter course and not the beginning. It precedes the collapse of the lunate, followed by the collapse of the carpus and the arthritis of the wrist.

Melorheostosis is an uncommon disorder characterized by soft tissue contractures and sclerosis of bone. The sclerosis appears to flow along the long axis of the bone, akin to candle wax dripping down one side of a candle. Numerous reports of lower extremity involvement exist, but there are few detailed reports of melorheotosis involving the hand. This condition is benign but slowly progressive and can usually be managed conservatively. Loss of function of the hand from swelling, pain, or stiffness, however, may necessitate operative intervention. Two recent cases prompted a review of the literature relating to melorheostosis and the hand.

A case of two-and-a-half years old unreduced, irreducible dislocation of the interphalangeal joint of the thumb, treated initially by gradual external distraction and later by interphalangeal joint arthrodesis is reported. The advantages of gradual external distraction over open reduction in cases of unreduced and irreducible dislocations are discussed.

The authors have experience of a case of simultaneous dorsal dislocation of the interphalangeal joints of the PIP joint and CM joint of the little finger. The latter case of finger dislocation was combined with a wound at the volar aspect of the PIP joint. Results of both cases were acceptable.

We report findings on plain, gadolinium (Gd) diethylenetriaminepentaaetic acid (DTPA) enhanced, and dynamic MR images of an epithelioid sarcoma in the forearm.

Suprascapular nerve entrapment is an uncommon condition. It is not often included in the differential diagnosis of shoulder pain and is therefore probably underdiagnosed. The nerve may be compressed at either the suprascapular notch or spinalglenoid notch.

The clinical presentation is often unremarkable with poorly localised pain over the posterolateral shoulder, which tends to become persistent. There is often a history of minor trauma or repeated exertion. Weakness of external rotation and abduction may be present and in advanced cases there is wasting of the supraspinatous and infraspinatous muscles. There may be tenderness over the suprascapular notch. Diagnosis is established with EMG findings of delayed nerve root conduction and/or denervation potentials in the involved muscles.

Trigger finger was observed in a patient with a healed laceration at the palmar-digital crease of the left long finger. Examination revealed complete transection of the ulnar slip of the FDS tendon. The proximal ulnar slip was excised and the cut edge tapered, which restored a full range of motion without triggering.