Hand Surgery

The development of hand surgery in Hong Kong can be largely divided into three phases: the early years, the 1960s and 70s, and the present. In the immediate post-World War II years, incidence of infectious diseases was high; there were many patients with tuberculosis, poliomyelitis, leprosy and osteomyelitis. In the 1960s and 70s, the light industry revolution brought along many patients with serious hand injuries caused by machines. Dr Yen-Shui Tsao was the first local surgeon trained in hand surgery. Prof. SP Chow and Prof. PC Leung were the two pioneers who developed this subspecialty and microsurgery during that period.

At present, with the change in economic environment, the disease pattern has also changed. Despite our heavy clinical involvement, we have been very active in academic researches. The Hong Kong Society for Surgery of Hand was formed in 1986. For the past 15 years, the society organized Workshops and Annual Congresses attended by overseas speakers, including surgeons from China. It also provided scholarships for Fellows of the Asia-Pacific countries. In addition, the society provided the participants with the chance to exchange ideas and forge friendships. Hong Kong has thus been and will continue to be the meeting point of the East and the West.

A consecutive series of 20 joints in 13 patients underwent arthroplasty with the RMS PIP joint surface replacement implant. Twelve joints were treated for painful osteoarthritis (all females). Two joints were implanted for rheumatoid arthritis, two for post-traumatic pain and stiffness, two for post-traumatic stiffness and one each for post-traumatic pain and pain-free post-traumatic instability. Excellent, often total long-term pain relief was obtained in 18 joints. The other two patients with (compensible work-related) post-traumatic pain and stiffness reported "50–70% pain reduction". No patients lost movement and 14 out of 20 joints were pain-free with a 73.1° average arc of motion. Six joints from the first half of the series had poor motion (average arc of 19.6°), even after open extensor tenolysis or manipulation under anaesthesia. As experience was gained, reliably better results were achieved with a more intensive regimen of hand therapy, particularly within the first post-operative week.

Leri-Weill syndrome (LWS) is a dominant (pseudoautosomal) skeletal dysplasia with mesomelic short stature and bilateral Madelung deformity, due to dyschondrosteosis of the distal radius. It results from the loss of one copy of the Short Stature Homeobox Gene (SHOX) from the tip of the short arm of the X or Y chromosome. SHOX molecular testing enabled us to evaluate the histopathology of the radial physis in LWS patients with a documented SHOX abnormality. A widespread disorganisation of physeal anatomy was revealed with disruption of the normal parallel columnar arrangement of chondrocytes. Tandem stacking of maturing chondrocytes within columns was replaced by a side-by-side arrangement. The presence of hypertrophic osteoid with micro-enchondromata in the radial metaphysis suggests abnormal endochondral ossification. The Vickers' ligament was confirmed to blend with the triangular fibrocartilage complex (TFCC). This histopathological study demonstrates that the zone of dyschondrosteosis in LWS is characterised by marked disruption of normal physeal chondrocyte processes and that a generalised physeal abnormality is present.

We reviewed 30 patients with subungual glomus tumours of the hand operated on between 1964 and 1997. Seven patients were male and 23 were female. Their age ranged from 16 to 78 years. A transungual approach was selected in 27 patients, and a periungual approach in three. Pre-operative pain subsided in all of the patients, but recurrence of the pain was observed in nine. Nail deformities were observed in nine patients before surgery. After surgery, it disappeared in three patients, persisted in six, and new deformities developed in five. To avoid recurrence of pain, it is important that the accurate pre-operative localisation of the tumour and a complete extirpation should be performed. To avoid nail deformity, it is better to apply a periungual approach for tumours developing in the peripheral region, and a transungual approach followed by meticulous repair of the nail bed for tumours developing in the central region.

The purpose of this study is to clarify the vulnerability of the gradually elongated peripheral nerve. Rabbit's sciatic nerves were gradually elongated to 30 mm at the rate of 2.0 mm/day and 4.0 mm/day. Immediately after elongation, the sciatic nerve was exposed and compressed for 30 minutes at various forces, 15, 30 and 60 g/0.1 cm². Immediately after elongation and compression, 2, 4 and 8 weeks after compression, each group was electrophysiologically and histologically estimated — 15 g/0.1 cm² caused no damage to the control group, neurapraxia to the 2.0 mm/day group, and axonotmesis to the 4.0 mm/day group; 30 g/0.1 cm² caused neurapraxia to the control group and axonotmesis to the 2.0 mm/day group; 60 g/0.1 cm² caused axonotmesis to the control group and slowly recovered axonotmesis to the 2.0 mm/day group. This study shows that though mild compression, does not cause nerve injury to the intact nerve, it can sometimes cause severe damage to the gradual elongated nerve.

Rat models with different division of nerve roots of the brachial plexus were designed to assess whether single or two nerve roots of the contralateral normal brachial plexus can be divided as donor nerves in treatment of brachial plexus root avulsion. Two hundred and fifty-two SD rats were randomly divided into 13 groups, i.e. five groups with single nerve root division, seven groups with two nerve roots division, and one group with three nerve roots division. Post-operative evaluation by electroneurophysiology and muscular histology was performed at two weeks and two months. Results showed that in groups with single nerve root division, the experimental limb function did not show an apparent damage; in groups with non-neighbouring two nerve roots cutting, it did show a harmful repercussions on the limb at two weeks, but most of them recovered to normal at two months; in groups with neighbouring two nerve roots division and with non-neighbouring three nerve root cutting, the limb function showed a persistent damage. In conclusion, division of nerve root alone or even non-neighbouring two nerve roots of the brachial plexus did not affect the forelimb function of the rat permanently.

Ganglion of the wrist is one of the the most common lesions of the hand. The cause of pain in an occult dorsal wrist ganglion has been linked to compression of the posterior interosseous nerve at the wrist. A case is presented in this paper and the pathoanatomy discussed. Ultrasound-guided aspiration after hyaluronidase instillation provided a useful alternative to surgery with a high success rate. Arthroscopic decompression for dorsal and palmar wrist ganglia offered the patient the benefit of smaller surgical scars and a high success rate. A description of the surgical techniques, pathoanatomy, and early results of the authors and a review of the literature is presented.

Allografts were used to replace excised bone segments affected by giant cell tumour of the hand in three patients. The tumour involved the second, third and fourth metacarpals and the capitate in one case; the first metacarpal and the trapezium in one, and the proximal phalanx of the index in one.

All had histological confirmation of diagnosis. One patient had recurrence one year after marginal resection of his third metacarpal and required resection of the two adjacent metacarpals and the capitate. He had no recurrence two years after the secondary treatment. The other two had no recurrence at two and three years after their primary procedures. Their affected hands were functioning well.

This paper presented clinical examples of some rare or uncommon presentations of tumours of the hand, including glomus tumour, intraosseous dermoid, fibrolipoma of the radial nerve, blastomycotic cyst and synovial sarcoma. Each lesion is illustrated by review of case histories, radiological and pathological features.

Function preserving management of a dominant thumb metacarpal chondrosarcoma is reported, with a literature review for this uncommon neoplasm. Wide local excision of the metacarpal followed by temporary silicone block interposition and definitive iliac crest bone grafting was performed. A persistent wound defect was managed by a radial artery forearm flap. The functional result was acceptable. In the literature, there were seven cases of thumb metacarpal chondrosarcoma reported; two were treated by ray amputation, and the other five were treated by excision of the metacarpal. Three of those five had bone graft and the other two had simple resection. Of these seven cases, three had local recurrence and one a distant metastasis.

Whilst osseous coalitions of the lunate and the triquetrum are known to be asymptomatic, fibrocartilage lunate-triquetral coalitions can present an uncommon cause for ulnar-sided wrist pain. To diagnose this condition a high degree of suspicion is needed. We present a case with painful post-traumatic disruption of a fibrocartilage lunate-triquetral coalition that was primary misdiagnosed to be a disruption of the interosseous lunotriquetral ligament and was initially treated arthroscopically. Persistent symptoms lead to X-ray examination of the opposite wrist, revealing a complete osseous lunate-triquetral coalition. CT and MRI investigations demonstrated the fibrocartilage coalition of the affected wrist. Subsequently, lunotriquetral fusion using a cannulated Herbert screw was performed and settled the symptoms completely.

We present a case report of a 15-year-old kendo (Japanese fencing) player who suffered a stress fracture of the ulnar styloid process. Exercise of the kendo requires the athlete to flex his non-dominant wrist repeatedly in an ulnar direction, and causes the disorder. Excision of the osteochondral fragment relieved the symptoms. This lesion is likely to occur with other sports or activities which demand similar motion of the wrists.

We presented two cases of a transstyloid radiocarpal dislocation which required operative treatment and resulted in satisfactory outcomes. This lesion has been liable to confuse with some types of intra-articular fractures of the distal radius such as Barton's fracture. Previous reports were also critically reviewed.

Treatment of hand deformities in a long-term survivor with dermolytic bullous dermatosis-recessive is described. An "open method" is sufficient for dealing with volar skin defects. There is still no effective treatment for perfect control of blister formation. But appropriate surgery, followed by careful post-operative rehabilitation can give reasonable hand function.

Flexor digitorum profundus (FDP) tendon avulsion from the distal phalanx is a well recognised injury, which usually follows a hyperextension force to a flexed distal interphalangeal (DIP) joint. It is commonly seen in contact sport athletes, with a predilection for the ring finger.^2,4 Avulsion of the FDP tendon from pathological bone is an infrequent occurrence. It has, however, been reported to occur in association with an enchondroma of the distal phalanx.^2,3 To our knowledge, an FDP tendon avulsion through a recurrent enchondroma has not been reported. We present the case findings of such an event.