Hand Surgery

Computed tomography is the best imaging modality to assess bony architecture. Scanning in the longitudinal plane of the scaphoid provides a greater appreciation of the humpback deformity. CT scan provides superior assessment of union and has a higher correlation with operative findings. A limitation of CT scanning is partial volume averaging which may give a false impression of a partial union when a nonunion exists. Height-to-length ratio provides superior observer variability for the assesssment of the humpback deformity. CT is useful to be able to "template" the proposed surgery of the scaphoid. It allows the surgeon to determine whether a structural bone graft is required, the preferred screw fixation and whether a volar or dorsal approach is required.

This study attempts to classify scaphoid nonunions, identify the prognostic indicators of scaphoid nonunions and report the clinical, functional and radiographic results of scaphoid nonunions treated by Herbert screw and bone grafting. The patient population included 51 scaphoid nonunions in 50 patients treated by Herbert screw with or without bone graft. Group I was patients with delayed union; Group II was stable nonunions, Group IIIA consisted of unstable nonunions without DISI; Group IIIB included unstable nonunions with DISI deformity. Although the overall union rate was 84%, 87% stable nonunions (Groups I and II) united compared to only 60% unstable (Groups IIIA and B). This was statistically significant using the Chi-square test at p < 0.05. Thus, delayed unions and stable nonunions unite readily but unstable and displaced nonunions have significantly lower rates of union even after Herbert screw and bone grafting.

Nonunion of the scaphoid remains a significant problem in the management of scaphoid fractures. Recurrent persistent nonunion following attempts at internal fixation, and nonunions with sclerosis or avascular necrosis of the proximal pole of the scaphoid are particularly challenging. However, the aims of restoration of scaphoid anatomy and the achievement of union of the scaphoid remain the foundation pillars of scaphoid treatment. In recent years, several techniques for using vascularised bone grafts in the treatment of these difficult problems have been described. This article will review the currently described treatments, provide an overview of our unit experience with these techniques, and also describe a technique for in situ vascularisation of a conventional bone graft.

Percutaneous A1 pulley release is being increasingly used as an alternative to open surgical release and injection of local steroids for the treatment of the trigger digit.

In 31 cases (26 patients), a percutaneous release was performed with a 14-gauge intravenous catheter needle under local anaesthesia in the outpatient setting.

We report a 97% successful release and only one case of incomplete release. There were no digital nerve injuries, flexor tendon injuries, bowstringing or infections. By two months, all the patients had no pain at the operative site, and their preoperative range of motion had returned or improved.

The percutaneous release is a safe and effective technique which provides significant cost savings. We recommend the percutaneous technique for typical cases of trigger finger with a palpable nodule and reproducible mechanical triggering. We recommend a steroid injection for patients with tenosynovitis and those who do not have reproducible triggering at the time of presentation. The open technique is reserved for complicated cases such as florid tenosynovitis, locked digit, failed percutaneous release or those involving the thumb.

Multiple fixation techniques have been developed for distal interphalangeal (DIP) joint arthrodesis. Delayed and nonunion rates varying from 0% to 20% have been reported. The senior author has refined a technique for DIP joint arthrodesis by using an intramedullary Kirschner wire and an interosseous wire for fusion of the DIP joint and interphalangeal (IP) joint of the thumb. In 24 joint arthrodeses in 19 patients, the nonunion rate was 4%, and the minor complication rate was 12%. The advantages of this technique include the absence of protruding hardware that would necessitate removal; consistency in achieving osteosynthesis, with a low nonunion rate; and technical simplicity.

A retrospective review of severe flexion contractures (60° or more), involving 51 proximal interphalangeal joints in 40 patients with Dupuytren's disease, was performed. Thirty-two joints underwent aponeurectomy alone, 19 joints additional capsuloligamentous release. Mean follow-up was 12 months. No statistically significant difference was seen in the percentage of contracture correction in the capsulotomy group compared with the noncapsulotomy group.

Forty-four scaphoid fractures treated with open reduction and internal fixation using the Herbert screw were available for evaluation at an average follow-up period of 2.1 years and a range of 1 to 6 years. They were classified according to Herbert into 25 unstable (type B); 8 delayed unions (type C); and 11 nonunions (type D). Bone grafting was required in 22 cases. Sound radiological union was achieved in 42 cases at an average of 3.2 months. The two nonunions healed after revision grafting.

Using the Mayo wrist score, excellent results were achieved in 14 cases; good in 22; fair in 4; and poor in 4. Poor results were associated with nonunion in two; untreated scapholunate dissociation in 1; and screw protrusion in 1.

The functional anatomy of the interosseous membrane (IOM) of the forearm was studied in 15 fresh frozen cadavers. The IOM consisted of three components: the tendinous part; the membranous part; and the dorsal oblique accessory cord. The tendinous part was a thick and strong complex of three to ten bundles which run from the proximal one third of the radius to the distal quarter of the ulna. The membranous part was recognised as a soft and thin structure, adjacent proximal and distal to the tendinous part. The dorsal oblique cord was found as a single cord on the dorsal side of the IOM from the proximal quarter of the ulna to the middle region of the radius. This cord was distinct from the oblique cord, which existed on the palmar side of the forearm separated from the IOM. The IOM was flat in the neutral position, while it flexed along the rotation axis in pronation and supination. Since the prominence of the curvature in the IOM was almost in the same direction as the fibres of the tendinous part, the tendinous part demonstrated only bending, similar to partial bending of an elastic board. The bending position was changed with the forearm position and the tightened bundles in the tendinous part were altered during rotation.

To investigate whether the lunate morphology proposed by Watson predisposes to Kienböck's disease, we investigated 23 patients with Kienböck's disease and 24 normal controls. Lateral X-ray films showed 17 of type D (dorsally lower height) lunate; 2 of type P (palmary lower height); and 1 of type N (equal palmar height to dorsal). In the control group, there were 21 of type D; 2 of type P; and 1 of type N, among 24 patients. The mean wedge ratio was 1.17 (1.08–1.35) in type D of the Kienböck group, and 1.11 (1.03–1.41) in type D of the control group. There were no statistically significant differences between the two groups, and palmar and dorsal lunate morphology is not believed to predispose to Kienböck's disease.

Fifty-five localised pigmented villonodular synovitis (giant cell tumour of the tendon sheath) in the hands and wrists in 53 patients, treated in a local hospital over a 5-year period, were reviewed. The mean age at presentation was 39.9 years, with 84.9% of the cases being Chinese. There was a predilection for the ring finger and females. There was no significant association with antecedent trauma. 56.4% of patients had associated X-rays changes. All patients had complete excision of the tumour and 4 recurrences noted, giving a rate of 7.3%. Follow-up period range from 1 to 5 years. Postoperative morbidity consisted of two cases with mild stiffness. There was good local control with minimal morbidity and low recurrence rate.

We found an anatomical variation of the posterior interosseous nerve (PIN) in a cadaver. The PIN entered the supinator muscle 3 cm distal to the radiohumeral joint, but exited from two sites. 50% of the nerve exited under the distal edge of the supinator muscle. The other half of the nerve pierced through the supinator muscle, 4.2 cm distal to the articular surface of the radial head and then joined the remaining PIN as it emerged from the supinator muscle distally. We did not find variations concerning the order and the manner of branches to the muscles. This variation in the PIN could be an additional compression site for this nerve; and therefore responsible for some of the atypical presentations of symptoms and for partial recovery after surgical decompression. A careful surgical dissection should be recommended to avoid injury to this branch.

A case of metastatic hepatocellular carcinoma of the distal phalanx of the thumb is presented. This case illustrated a rare example of acrometastasis of hepatocellular carcinoma.

A case is reported of obstruction of the radial artery passing beneath the biceps brachii tendon. It may cause symptoms such as cold intolerance and ulcer formation. An elongation of the biceps with Z-plasty improved the circulation of the distal forearm.

We report a case of malignant fibrous histiocytoma of the middle finger in a 57-year-old male. The tumour arose from the perionychium of a digit, an extremely unusual occurrence