Hand Surgery

A study of the degenerative changes in the distal radioulnar joint compared with morphological measurement of that joint using 91 joints of the hand from 51 systemic anatomy cadavers was conducted. X-ray images of the joints of the hand were taken followed by measurement of radial inclination, ulnar variance, volar tilt, sigmoid notch inclination and ulnar seat inclination. Macroscopic observations of the ulnar notch of the radius and surface of the distal radioulnar joint of the ulnar head were made by dividing them into six and nine areas, respectively. These were then used to classify the degree of cartilage degeneration. In addition, the status of the triangular fibrocartilage complex (TFCC) was also observed.

Arthropathic changes of the distal radioulnar joint were associated with factors including TFC degeneration and UV(+), SNI(-) and USI(+).

The correlation between the residual dorsal intercalated segmental instability (DISI) deformity and symptoms of the wrist was investigated in 20 patients with healed scaphoid non-union who had open reduction and bone grafting. In seven patients, inlay corticocancellous bone grafting (modified Russe procedure) was performed. In four of the seven patients, an additional Herbert bone screw was used for internal fixation. The remaining 13 patients were treated with open reduction, anterior bone grafting, and internal fixation with Herbert bone screw. Average duration of follow-up period after operation was 20 months (range, 6 to 57 months). The average extension-flexion arc of the injured wrists was 129°, which was 31° less than that of the uninjured wrists. The average grip strength of the injured wrists was 89% of that of the uninjured wrist. Before the operation, all 20 patients were symptomatic and complained of wrist pains. Post-operatively, three patients experienced mild pains and only one complained of moderate wrist pains. Post-operative radiolunate angle ranged from 0° to 34° (average 10°). DISI deformity remained uncorrected in eight patients. Post-operative symptoms were compared amongst the eight patients who had DISI deformity and 12 patients who had no deformity. There was no significant difference in range of motion, grip strength, and incidence of pain between these two groups of patients. The presence of DISI deformity after bone grafting for a symptomatic scaphoid non-union was not predictive of post-operative symptoms of the wrist.

We describe a modification of the technique for arthrodesis of the joints between the scaphoid, the trapezoid and the trapezium (the S-T-T joint) described by Sandow, that involves the en bloc resection of a cylinder of bone incorporating a portion of each of the scaphoid, trapezoid and the trapezium, using a hollow mill, and replacing it with a cylindrical graft of exactly the same size taken from the distal radius. The procedure is relatively quick and easy with a high rate of fusion and must be regarded as a preferable alternative to other, more complex procedures.

The trophic effects of systemically applied Rh insulin-like growth factor-1 (rhIGF-1) on peripheral motor nerve regeneration following transection and epineural repair in rats median nerve have been examined. RhIGF-1 (0.5 mg/kg/rat) was administered subcutaneously to the neck region of the repaired side for 14 days post-operation. Motor recovery was tested with the grasping test that is an objective quantitative behavioural assessment of regeneration of the rats median nerve. Muscle twitch tension and muscle weight were measured in the flexor digitorum sublimus muscle. No significant differences between experimental and control animals regarding onset of muscle function, recovery of muscle power, and muscle weight were found. These results demonstrate that subcutaneously applied rhIGF-1 cannot improve functional motor recovery after nerve transection and repair in the rat as has been demonstrated after nerve crushing injury. This is regarded as a consequence of specificity failure during reinnervation, which occurs after nerve transection and repair, whereas after crushing injury specific reinnervation is a common feature.

Multiple entrapment neuropathy is compression of more than two nerves in the same extremity. In this case series, 169 patients (208 upper extremities) with this condition were identified, and 124 patients (138 upper extremities) had surgical decompression after an ineffective course of conservative treatment. There were 31 men and 93 women. Average age was 41 years (range 20–87 years). Follow-up averaged 23 months (range 12 to 60 months). Our rating system included patients' self-assessment of overall symptom improvement and return to activity and a physician assessment of strength (grip and pinch) and sensibility (recovery of two-point discrimination). A total of 92 patients (67%) achieved good to excellent results. The clinical features of multiple entrapment neuropathy in our series were presented with a variety of nerve compression syndromes and with a high incidence of regional musculotendinous syndromes. In our surgical treatment, we emphasise simultaneous release of all possible compression sites with a minimally invasive endoscopic approach to achieve better results.

Forty hands of 36 patients who had undergone endoscopic carpal tunnel release (ECTR), utilising Chow's two-portal technique after being diagnosed with idiopathic carpal tunnel syndrome, were subjected to longitudinal median nerve conduction studies. The distal motor latency (DML) was examined pre-operatively on all the hands, which were re-examined at the post-operative 1st, 3rd, 6th and 12th months. Rapid improvement of DML was observed post-operatively in the first three months. These improvements patterns are not much different from those after open carpal tunnel release (OCTR) reported in the literatures. We consider that the data reported herein can be used as standards of DML course after ECTR.

Radial and ulnar arterial catheterisation have become frequently used methods of monitoring in neonatal and pediatric intensive care units. Minor complications are common and temporary ischaemic changes in the form of blanching are well described. However, permanent ischaemia in the infant has rarely been reported. This series is the first in the hand surgery literature to address the issue of digital ischaemia following radial artery catheterisation in the infant population and adds three to the six previously reported cases in the English literature. One patient had fingertip necrosis to the distal interphalangeal joint level of the middle, ring and little fingers, while two other patients required amputation at the carpometacarpal joint level.

We investigated the chronological changes in the plain radiographs of the hands and wrists of 32 patients who underwent hemodialysis for ten years. Digital image processing (DIP)⁹ and quantitative computed tomography (QCT) were conducted to examine bone density.

Fourteen patients underwent Magnetic Resonance Imaging (MRI) of the wrists, and the relationships between MRI findings and plain radiographic findings and association of carpal tunnel syndrome (CTS) were investigated. Twenty-one patients with bone lesions revealed by plain radiography were classified into four groups — cystic lesion, bone resorption, mixed, and no-lesion groups.

Subperiosteal bone resorption was seen in 17 patients at ten years, of whom one showed a marked improvement of bone lesion observed at five years. Twelve patients had cystic lesions at ten years, most often observed in the middle phalanx and lunate. Seven of those 12 patients suffered from CTS, in contrast to only one case with CTS in each of the bone resorption and no-lesion groups. DIP and QCT revealed the most severe bone atrophy in the cystic lesion group. In six patients, MRI revealed bone lesions not detected by plain radiographs.

Three patients with severe fixed flexion deformity of the fingers caused by trauma were reported. As an alternative treatment, a new mini external fixator was used to correct the deformities. The use of this device has made treatment of contractures simpler and more predictable. Gradual distraction and straightening was applied to loosen and extend the joints, followed by a period of mobilisation while still on the device. In all the three patients, this experimental device and approach led to improvement of the fixed flexion deformities. With use of this device, surgical release may not be necessary.

The technical details of open reduction and internal fixation with double plating for a patient with comminuted intra-articular fractures of the distal radius were described. The vital steps included the exposure, initial dorsal reduction, ventral reduction and fixation, checking of reduction, return to dorsal surface with final reduction and X-ray check, and wound closure. Special attention and other technical tips were also highlighted, and hopefully will shorten the learning curve of others who would like to use this rather demanding technique for their patients.

Among wrist injuries, scaphoid fractures are second only in number to fractures of the distal radius, while Galeazzi fractures are relatively infrequent. It is rare for the two fractures to occur concomitantly. We report such a case in a 65-year-old woman.

A case of pronator teres syndrome associated with mononeuritis multiplex in polyarteritis nodosa is reported. External neurolysis of the median nerve at the proximal forearm and prednisolone were effective for treatment of the disease.

Basal joint arthritis is a common hand condition presenting with pain and swelling, often requiring surgical treatment in the late stages. Surgical options include arthrodesis, excision arthroplasty, implant arthroplasty and ligament reconstruction, and tendon interposition arthroplasty.

A patient with bilateral basal joint arthritis underwent K-wire arthrodesis of the left basal joint. Subsequently, she developed complications due to impingement of the K-wire on the median nerve, superficial radial nerve, and flexor tendons of the index finger. The diagnosis was made three years post-operatively and she then underwent reconstructive surgery. Eventually she recovered with good movement and sensation of the affected digits.

Although K-wire arthrodesis of basal joint is a simple and effective procedure used primarily in treatment of arthritis, this case highlights the importance of appreciating surgical anatomy and post-operative clinical features and investigations.