Hand Surgery

Arthroscopy was used to help to reduce intra-articular fractures of the distal radius and treat soft tissue injuries in 33 acute cases. The fractures were treated by reduction under arthroscopic control and percutaneous fixation either with or without external fixation. The triangular fibrocartilage complex (TFCC) was torn in 18 of 33 patients (54%). All tears were peripheral and were repaired with arthroscopic procedures. Scapholunate (SL) ligament injuries prevailed in six (18%) patients; most of them exhibited instability in the SL joint. They received SL ligament debrided and transfixed with K-wires. Four (12%) of the patients suffered lunotriquetral (LT) ligament injuries; three of them also received transfixation with K-wires. Six (18%) of the patients exhibited chondral fractures. All fractures healed without measurable incongruity of joint surface and at follow-up (24 to 36 months), 11 patients displayed excellent results and 22 patients displayed good results according to the Mayo modified wrist score.

A retrospective study was carried out to compare the functional outcome in two groups of patients who were 60 years old or older. One group had Colles' fractures, which had been reduced and did not redisplace. The other group's fractures redisplaced and were treated conservatively. Of the 11 patients in the first group, 82% had excellent or good functional outcome, which was not significantly different when compared with the second group of 25 patients with 68% having excellent or good functional outcome.

We treated eight patients with Kienböck's disease (two patients each with stage 1, 2, 3a and 3b disease by Lichtman's classification) by removing a pedicled, vascularised bone segment from the dorsal aspect of the distal radius and engrafting it into the lunate. Additional shortening of the radius was performed in patients with the ulna-minus or null variant. Shortening of the capitate and capito-hamate fusion were also performed in patients with stage 3 disease. All patients were relieved of their wrist pain at rest and during movement, and the mean grip strength increased from 37% of that in the contralateral hand before surgery to 80% after surgery. The mean post-operative range of motion in the affected wrist was 92% of that in the opposite wrist in patients with stage 1 and 2 disease, and 53% in patients with stage 3 disease. Post-operative assessment revealed that four patients had excellent results, three had good results, and one had a fair result.

A two-dimensional time-of-flight magnetic resonance angiography was performed in 29 arms in 25 pediatric patients with congenital hand abnormalities, whose average age was three years and eight months. Venous structures were eliminated with presaturation technique and the remaining arterial system was evaluated. Magnetic resonance angiography demonstrated major arteries in the forearm well but not their branches. Even the biggest branch of the artery sometimes could not be detected. Magnetic resonance angiography and Allen test were consistent in determining patency of the palmar arch in 62% of the cases but the sensitivity was only 28%. Our experience showed that non-invasive, convenient, two-dimensional time-of-flight magnetic resonance angiography was useful for detecting continuity and spatial localisation of the major arteries in a child's forearm. However, it was not a complete alternative to conventional angiography and was unsatisfactory in delineating the vascular anatomy in the hand.

The nail is supported by the dorsal tuft of the terminal phalanx. Following distal fingertip trauma, varying amounts of nail support may be lost resulting in the nail curving palmarwards. This curvature is dependent upon the degree of bony loss, the amount of remaining nail bed and the degree of scar contracture at the hyponychial-pulp interface. The parrot beak or hooked nail deformity is most commonly caused by tight closure of a fingertip amputation and excessive palmar tension at the hyponychial-pulp suture line. A simple technique using a hypodermic needle, that eliminates tension from the suture line at the fingertip pulp-hyponychial interface and prevents hooked nail deformity is described. This allows healing to take place without any palmarwards pull of the scar and a subsequent parrot beak deformity.

The rabbits' sciatic nerves were lengthened by 30 mm in increments of 2.0 mm/day (2-mm group) and 4.0 mm/day (4-mm group). In the 2-mm group, the phosphorylated neurofilament (p-NF) immunoreactivity of axons was similar to that of the control group. However, in the 4-mm group, number of p-NF positive axons decreased. The number of p-NF positive cells at the seventh lumbar dorsal root ganglion cells of the 4-mm group was significantly larger than that of the control group. Abnormal p-NF immunoreactivity in the 4-mm group suggested an impairment of the axonal flow. Leakage of Evans blue-albumin into the endoneurial space, which meant destruction of the blood-nerve barrier function, was clearly evident in the 4-mm group, but minor in the 2-mm group. A speed of 2.0 mm/day, therefore, appears to be critical for safe nerve elongation in this model.

The purpose of this study was to evaluate the effect of oral prostaglandin E₁(PGE₁) on the patency of the microvascular anastomosis of the carotid artery in rat. A total of 48 rats were used, and divided into three groups. The first group (A) was used as a control with no medical agent being used after anastomosis, the second group (B) was medicated with aspirin, and the third group (C) was medicated with oral PGE₁. In each group, four rats were sacrificed serially on every post-operative 3, 5, 10 and 15 days after arterial anastomosis. Patency and histologic evaluations at the anastomotic site were observed. The results revealed that the PGE₁ therapied group showed highest patency rate (100%), lesser formation of mural thrombosis, and also minimal changes in the intimal hyperplasia and medial fibrosis. From these findings, we could conclude that PGE₁ has superior effect on maintaining the patency after microvascular surgery.

Pre- and post-operative classification systems for cubital tunnel syndrome are discussed in this study. Although there are several pre-operative evaluations, a suitable system should be easy to categorise, simple, reliable and reproducible. McGowan's grading system has been widely used for these reasons; however, grade II included complicated cases. Accordingly, McGowan's grade II is divided into two groups, such as grade II-A (relatively good prognostic group) and group II-B (relatively poor prognostic group). As far as the post-operative classification system is concerned, 4 grade (excellent, good, fair, and poor) classification is the most useful and easy to understand.

Membranous tissue under the flexor carpi ulnaris (FCU), hypertrophy and fascia of the FCU were examined in 90 patients with cubital tunnel syndrome; it (submuscular membrane) was found in all patients, excluding five whose data were incomplete. Impressions on the nerve under the FCU were noted in 75 patients. In 43 patients, the submuscular membrane was judged to be the cause of neural compression. These 75 patients included 60 and 15 cases whose fascia of the FCU were judged to the thick and thin, respectively. Among the 58 with a thick submuscular membrane, 56 patients had an impression under the membrane. Fifteen patients had a flat impression on the nerve in the proximal compartment of the FCU, which was formed by ligamentous and bony floor and thick fascia of the FCU. It is believed that increased presure in the compartment is the cause of a flat impression. Slight compression of the nerve under the FCU with compressions in proximal and distal part of the nerve can cause symptoms of the nerve compression by multiple crush effect.

A new technique of endoscopic release of the ulnar nerve at the elbow was designed for cubital tunnel syndrome. After three 5 mm incisions were made along the line of the ulnar nerve, the skin and subcutaneous tissue were lifted up using a fine tape to produce a provisional space. An endoscope was inserted through the one incision, and the constricting ligaments and fascia were released using a retrograde knife inserted through the other incision under endoscopic vision. Eight patients were treated using this method, and successful results were achieved. No neurovascular complications occurred, and all pre-operative complaints were resolved within three weeks. Our surgical series indicated an earlier return to work and daily activity due to early healing of incisions and minimal post-operative pain.

In this paper, we report on a new operation for ulnar neuropathy caused by friction at the elbow. The operation consists of ulnar groove plasty proximal to the cubital tunnel. The ulnar nerve is replaced into this reconstructed groove. Patients are relieved of discomfort, and motor and sensory functions are recovered. The nerve is kept stable throughout the full range of elbow motion and showed neither irritation nor adhesion. Friction ulnar neuropathy is traditionally treated by anterior transpositon or medial epicondylectomy. The ulnar nerve may become entrapped in scar tissue after these operations. We believe that this anatomical position is optimum for the nerve and that this procedure is essential for treatment of friction neuropathy.

Advances in understanding the biology of rheumatoid arthritis (RA) have opened new therapeutic avenues. One of these, gene therapy, involves the delivery to patients of genes encoding anti-arthritic proteins. This approach has shown efficacy in animal models of RA, and the first human, phase I trial has just been successfully completed. Hand surgery featured prominently in this pioneering study, as a potentially anti-arthritic gene encoding the interleukin-1 receptor antagonist was transferred to the metacarpophalangeal joints of subjects with RA one week before total joint arthroplasty. This study has confirmed that it is possible to transfer genes safely to human joints. It should pave the way for additional application of gene therapy to arthritis and other orthopaedic conditions.

Symphalangism is a rare condition which manifests in either PIP or DIP joint congenital fusion. Symphalangism may be with some other skeletal deformities. In our case, all PIP joints of both hands were fused with bilateral hypoplasia of carpal bones and Minaar type III lunatotriquetral coalition congenitally. No motion was detected in PIP joints with absence of cutaneous creases over all PIP joints. Radiologically, carpal hypoplasia and lunatotriquetral coalition were seen in all fingers with the absence of PIP joints. The patient's skeletal survey revealed no other pathology. He had no complaints related to his hands. So, regular follow-up was recommended. This pathology was presented as rarely observed although clinical problem is usually not so much.

A 20-year-old golf player who developed recurrent dislocation of the extensor carpi ulnaris (ECU) tendon is reported. The patient was successfully treated by release of the extensor retinaculum and partial resection of the ulno-dorsal ridge of the ulnar head, because the methods caused no redislocation and required only a brief period of rehabilitation.

The Hair-Thread-Tourniquet syndrome is a rare disorder with merely 17 cases of finger involvement reported so far. This is a report of one such case of accidental digital constriction, which presented as late as three months after injury. This is the longest reported duration between injury and detection. The constriction band was in the form of an eschar lying in an epithelialised crease. Treatment involved excision of the crease followed by multiple z-plasties to close the resulting defect. This is the first case in English literature to report epithelialisation of the crease and consequently the first case to require excision of the band followed by z-plasty.

The authors present the case of a 47-year-old female who presents with bilateral Dupuytren's disease of the wrist. To date, three English language papers reporting on the occurrence of Dupuytren's disease at the wrist have been presented. These reports represent cases in males with unilateral involvement of their wrists where there has been primary Dupuytren's disease of the palm apparently spreading to the wrist in continuity. Our case demonstrates isolated bilateral Dupuytren's disease of the wrist in a female.

The authors feel that this clinical presentation is rare and that consideration should be given to the diagnosis of Dupuytren's disease when there is a painful lesion of the soft tissues adjacent to the wrist. The presence of bilateral lesions at the wrist should further heighten the suspicion of Dupuytren's disease even in the absence of associated disease in the palm or fingers. A discussion of the previous reports is included.

Metastatic tumours of the hand are uncommon. The majority of these tumours affect the phalanges and the primary tumours are usually bronchogenic in origin, with breast and kidney tumours next in frequency. Metastatic gastrointestinal to the hand is rare and usually from the colon. We report a case of poorly differentiated adenocarcinoma of the stomach antrum presenting with a metastatic lesion to the right 4th metacarpal bone. A review of the literature is included.