Hand Surgery

Between September 1997 and September 2000, 32 patients (20 males and 12 females; average age 23.7 years) received arthroscopic surgery for dorsal wrist ganglion. Five of the patients (15.6%) experienced recurrences after open surgery. All patients complained of pain or a cosmetic problem due to the lump. Before the operation, they were all sonographically examined using a high-resolution 7.5 MHz real-time probe. After operation, they were followed-up by telephone after 15 to 37 months (mean 26.8 months). No recurrences occurred in our series. Arthroscopic resection is safe and addresses the anatomic pathology. Recurrences have been fewer than in the reported results of the open surgery. The approach is reasonable for operatively treating the dorsal ganglion.

This is a retrospective analysis of 21 patients with documented enchondroma of the hand. They were operated on between 1980 to 2000 with conventional curettage nd bone grafting. The objective of this study is to analyse the chance of recurrence and evaluate the effectiveness of surgical treatment.

One patient had recurrence after six years. Longer follow-up period is recommended as there is a possibility of recurrence even after five years. This study revealed that enchondroma of the hand is more common on the ulnar site.

The purpose of this study was to clarify the effect of an absorbable oxidised regenerated cellulose sheet (AORCS) for prevention of neural adhesion. Rabbit sciatic nerve was exposed at the middle of the thigh and the neural bed was coagulated by a bipolar coagulator to establish an adhesion model. Coagulation only was Group A (n = 8), coagulation and wrapping the sciatic nerve with an AORCS was Group B (n = 8), and an intact nerve was Group C (n = 16). Six weeks later, each group was estimated. Adhesion between the nerve and neural bed, and intraneural fibrosis were seen in Group A. However, there was little adhesion and fibrosis in Group B. Although the electrophysiological study showed a small significant difference, AORCS clearly prevented the adhesion in the histological study. Hence, AORCS might be useful as an additional treatment during nerve surgery.

Amputation of distal portion of the thumb is a frequent trauma and more emphasis should be placed on this. Reconstruction of the distal thumb with two neurovascular mini-flaps harvested from the ulnar and radial sides of the index and middle fingers, respectively was carried out in five patients. The results showed that the patients were satisfied cosmetically and thumb length was maintained; grip strength increased with time though sensory misreference required further rehabilitation.

For 30 years, silicone oil has been used for the management and rehabilitation of the injured hand. Its benefits accrue from its providing a non-irritant, bland, air-free medium in which the hand can undergo early movement, which prevents drying out of the tissues and helps in the separation of necrotic and infected tissue. It has been reported, however, that the silicone oil might act as a reservoir for nosocomial infection after two patients developed epidemic methicillin-resistant Staphylococcus aureus (EMRSA) infections.

Since no firm guidelines exist with regard to open and/or infected wounds and the continued use of the same oil, a prospective study was set up to study the bacterial colonisation of the silicone oil. Thirty-five consecutive patients were entered into the study. The oil for each patient was changed each week but if any wound became clinically infected the oil was changed earlier. Treatment was continued until the wound was healed or until the treatment was stopped by the referring doctor.

Bacteriology swabs taken from the wound and the oil before each treatment and from the oil after each treatment were analysed for bacterial colonisation. The results indicated that while bacteria were transferred into the oil from the wound, the inoculum was small and had no effect on wound healing. There was no evidence that wounds were being re-infected from the oil. The conclusion was that silicone oil remains a safe medium in which to exercise injured hands.

Twenty years ago, we concluded that it was useless to use suture material strong enough to allow early mobilisation, since material of this sort creates problems in the form of connective tissue reaction and even tendon necrosis. It is better to use what is called "the blocked suture", which abolishes muscle tension on the repair, and, therefore, makes it possible to bring the tendon ends accurately together by fine sutures too weak to resist any muscle fore.¹⁹

This statement, from Claude Verdan's Founders Lecture to the American Society for Society of the Hand only 30 years ago, highlights the dramatic rate of change in our understanding and clinical approach to flexor tendon repair. At the time these words were spoken, Verdan and some of his more adventurous contemporaries were challenging the currently accepted dictum that repair of flexor tendons divided in the digit should not be attempted. This early work on the primary repair of flexor tendons by Verdan,²⁰ Kleinert and associates,¹² and Kessler and Nissim,¹¹ among others, forever changed the landscape of Bunnell's "no man's land",and paved the way for the clinical advances and explosion of research into flexor tendon healing and repair that have occured in the last several decades.

The beautifully coordinated functions of the hand depend on the tendon apparatus acting on the articulated skeletal elements. The flexor muscles are situated on the antero-medial aspect of the forearm, with their tendons crossing the wrist and finger joints in a wonderfully arranged system to provide the infinite movements possible. The anatomical details of the extrinsic and intrinsic flexor apparatus are presented, with their functions described as anticipated by their origins, insertions, and the joints they cross and thus can act upon.

Tendon rehabilitation has evolved over the last several decades, and has been based on the evolving understanding of tendon nutrition and healing and the factors that influence it as well as on the development of surgical technique. This evolution is reflected in the progression in clinical practice from initial immobilisation of repaired tendons, to early controlled passive motion, to most recently, immediate active motion.

Tenolysis is a well-established salvage procedure, which can be applied when non-gliding adhesions form along the surface of a tendon after injury or repair and prevent gliding of the tendon in the performance of its intended function.^{8,15,17,29,30,39,40,44,49} Tendon adhesions will occur whenever the surface of a tendon is damaged either through the injury itself, be it laceration or crush, or by surgical manipulation.¹⁸ At any point on the surface of a tendon where violation occurs, an adhesion will form in the healing period.^20,26 When these adhesions cannot be mobilised by an adequate course of hand therapy, tenolysis should be considered.

This procedure is as difficult or more so than tendon repair itself and should not be undertaken lightly. It represents another surgical incursion into an area of previous trauma and surgery. If the procedure is not successful, the patient's hand may show no improvement or even be worse. The risk of further decreasing the circulatory supply and innervation to an already deprived finger is a real one. Rupture of the lysed tendon, a disastrous complication, is the major hazard of tenolysis.

Although this article was published over a decade ago, the methods presented then are still timely and make a positive and reliable result possible.

Superficialis finger function combined with the one-stage Hunter active tendon implant technique can produce a working hand with longevity of years. Active tendon implants have remained in place for as long as ten years to date, with continued restored function.

Any restoration of hand function following tendon and nerve injury has to include the repair or replacement of the hand's ability to perform a great many tasks. It is hard at first to appreciate fully the loss that occurs with flexor tendon injury. With loss of flexor tendons operating at the fingers or thumb, they cannot be fully closed and the hand is impaired for grasp and release as it interfaces with objects. But, sensibility can also be compromised from tendon injury even without direct injury to nerve, as object recognition in the absence of vision requires finger movement. When peripheral nerve injury is combined with flexor tendon injury, sensibility is directly impaired. There is a loss in the sense of finger or thumb position, pain, temperature, and touch/pressure recognition, in addition to the tendon injury.

Frequently used zone 2 flexor tendon repair splints are reviewed and classified according to the Amercian Society of Hand Therapists' Splint Classification System. These splints both restrict and mobilise digital motion and fall into two main groups: (1) splints that incorporate the wrist and digital joints as primary joints to allow predetermined increments of early passive or active motion at both the wrist and digital joints; and (2) splints that include the wrist as a secondary joint and the digital joints as primary joints, allowing early passive or active motion at digital joints but not at the wrist.

This article describes the indications for and the purpose and performance of the upper limb functional capacity evaluation (FCE) for persons who have sustained flexor tendon injury. It begins with the essential foundation concepts such as the U.S. Department of Labor Physical Demand Characteristics of Labor that clinicians use worldwide. The article explains how the clinician forms the plan for each FCE and the essential components that each FCE includes. While variation in the impact of upper limb injury makes a set format for performing the upper limb FCE impossible, even with a specific diagnosis, a general FCE outline with multiple options is presented. A discussion about relevant modifications to maximise function follows the identification of the critical factors to evaluate with flexor tendon injury. Importantly, the article provides insight into controversial issues such as assessment of endurance and inconsistent or sub-maximum effort. It addresses the challenge of documentation and report writing, and concludes with the issue of FCE validity.

This paper reviews the use of the Swanson finger prosthesis, concentrating on clinical results from the metacarpophalangeal (MCP) joint and modes of prosthetic "failure". While "failure" is generally associated with fracture, it is recognised that fracture does not always necessitate replacement of the Swanson prosthesis. Fracture tends to occur at the junction of the distal stem and hinge of the prosthesis. Initial improvements in ulnar deviation and range of motion (ROM) tend to be gradually reduced over the duration of implantation, and there is little evidence to suggest any long-term improvement in hand strength. Bone erosion and silicone synovitis have been seen but at a much lesser incidence than in other joints implanted with silicone spacers. An evaluation of retrieved Swanson prostheses, tied in with patient history and hand measurements might provide additional information to improve the design of the Swanson prosthesis itself and of other finger prostheses.

Aneursymal Bone Cysts (ABCs) involving the hand are a rare occurrence. We report a case of an ABC of the proximal phalanx of the thumb in a boy which was treated successfully with curettage and autologous bone grafting. When the diagnosis of ABC of the small bones of the hand is entertained, prompt therapeutic intervention is indicated because of the potential for aggressive local behaviour. In the paediatric patient, simple surgery to preserve the growth plate is recommended.

A rare case of an extra-abdominal desmoid tumour in the hand is reported. Its treatment and a short survey of the literature is given.

Acromegalic arthropathy may affect the hand joints with characteristic radiological changes. Sesamoid involvement in the hand may be presented with unusual changes. A case of a female patient with characteristic hand joint and sesamoid bone osteophytic changes related to acromegalic arthropathy is presented.

A case of primary Nocardial infection of the hand is presented. This case was notable for lymphocutaneous involvement, and the development of multiple ascending subcutaneous abscesses after healing of the primary lesion. This clinical entity is uncommon, and indicates an atypical infection. Prolonged cultures are required to isolate Nocardia. The infection resolved fully with multiple surgical debridements and prolonged antibiotic therapy.

Avascular necrosis (AVN) of the capitate is a rare condition. A case report is presented with a review of the literature.