Hand Surgery

Sural nerve withdrawal in peripheral nerve surgery is commonly performed for grafting nerve lesions with gap. Notwithstanding its popular use, this procedure is not entirely without fault as painful neuromas can occur after the withdrawal.

We have treated 24 cases of painful neuromas of sural nerve after withdrawal; 11 of which were treated surgically.

A safe procedure to cure and to prevent such neuromas is described — the electrical coagulation of the stump of the nerve by slowly increasing the intensity of the current. This procedure has been devised based on the fact that electrically burnt patients do not produce painful neuromas.

An experimental histological study performed on rats demonstrated that slow electrical burning of the stump of a severed nerve prevents the formation of intraneural fibrosis which, on the contrary, forms abundantly when the cut nerve is not coagulated.

The opportunities offered by the Internet are employed increasingly in medicine. To obtain data on the extent to which the Internet is used by hand surgeons, survey forms were sent to 1043 participants of the Congress of the IFSSH in Vancouver in 1998. Ninety-four per cent of the respondents use the Internet. Most of the participants use the World Wide Web for literature searches, information on events and to read scientific articles. E-mail is used for general and scientific communication with colleagues and also for transmission of patient-related data. Perceived apprehensions include secure transmission of sensitive data, slow data transmission, and the lack of structure and of an authority to control the contents of the Internet. Virtual congresses and a newsgroup on hand surgery seem to be worthwhile future goals. Some problems pointed out in this survey have already been solved, at least partially, and possible solutions for the rest are discussed.

Few studies have focused on the relevance of early motion exercise on repair of the flexor pollicis longus tendon. We evaluated 29 patients with flexor pollicis longus tendon lacerations treated by direct end-to-end suture, and statistically assessed the clinical factors that influenced the results by using a multivariate logistic regression model. Association with age, vascular damage and timing of repair did not affect the results. Patients with flexor pollicis longus tendon lacerations in zone II or with the tendon stumps retracted proximally had a significantly high risk of unsatisfactory results. Postoperative passive flexion and active extension exercise using rubber bands significantly decreased the risk of unsatisfactory results in these conditions. Results of this study indicate that early postoperative motion is useful after every FPL tendon repair, particularly in patients with zone II laceration or retraction of the proximal tendon stump.

Cubital tunnel syndrome is the second most commonly encountered compression neuropathy of the upper limb. Multiple techniques for surgical management have been proposed but no universally accepted algorithm for management exists. Six cadaveric upper limbs underwent ulnar nerve decompression and anterior transposition into subcutaneous and then submuscular positions. After marking nerves with tungsten, radiological examination of nerve motion was performed and nerve angulations were measured in the region of the flexor carpi ulnaris (FCU) origin. Comparison of ulnar nerves in each position revealed statistically significant greater angulation after subcutaneous transposition than after submuscular transposition with the elbow held in full flexion. This point of angulation may act as a secondary point of compression or as a focus for neuritis and scar formation. This finding can contribute to the understanding of why differing outcomes may be observed after different forms of anterior transposition.

We present a case of revision Swanson wrist arthroplasty staged via a wrist fusion in a patient with rheumatoid arthritis. Due to extensive bone loss in the rheumatoid patient, it may not be possible initially to revise a wrist arthroplasty; however after fusion with a bone graft to regain bone stock we have demonstrated that this is possible. It may even be possible to convert such a fusion to a total wrist arthroplasty.

Sarcoidosis of the phalanx is rare and is usually associated with severe systemic disease. We present a patient with recurrent phalangeal sarcoidosis and new evidence of a changing radiological pattern. The clinical presentation and outcome is discussed. High dose steroid treatment and careful long-term follow-up is recommended.

This prospective study investigated static scapholunate dissociation (SLD) in wrists associated with distal radius fractures. SLD was detected as a widening of the scapholunate (SL) joint interval by SL gap view. Ninety-six distal radius fractures and 154 normal wrists were investigated by SL gap view, which is better for detecting SLD than the standard posteroanterior (PA) view. Incidences of non-symptomatic SLD detected by SL gap view in normal wrists increased by age. In the young age bracket, incidences of SLD in distal radius fractures were significantly higher than in normal wrists. Our results indicated that in patients younger than 30 years old, SLD in distal radius fractures was a fracture-caused abnormality. In those over 30, ascribing SLD to the fracture was difficult. Close examinations, like arthroscopy and dynamic cineradiography, need to be made in patients with SLD associated with distal radius fractures, especially in those younger than 30.

We report two cases of Kienböck's disease associated with systemic lupus erythematosus SLE. The characteristics of these cases associated with SLE differed from those previously reported for Kienböck's disease. Corticosteroid may be a cause of Kienböck's disease in SLE.

Sixty flexor carpi radialis (FCR) tendon interposition arthroplasties were done using a modified incision from Froimson's approach for osteoarthritis (OA) of thumb carpo metacarpal joint (CMCJ) The tendon was made to resemble an anchovy fillet to preserve pillar length (average 7.5 mm). There was no incidence of injury to the superficial branch of the radial nerve. Graded mobilisation was commenced at two weeks. Our average follow-up for five and a half years shows good results, viz. pain relief (100%), power grip (21 kg), pinch grip (4.2 kg), tripod grip (5.5 kg), key grip (6.5 kg), ability to touch base and tip of little finger (91.6%) and (96.6%), respectively. Activities of daily living (ADL) without pain in turning a key (96.7%), opening jar top (100%), bottle top (93.4%), wringing cloth (86.7%), and using scissors (88.4%). None of them suffered reflex sympathetic dystrophy (RSD) and mobility was almost equal to the non-operated hand. Our experience with this modified incision and technique of interposing with early mobilisation has shown good functional outcome with no significant operative or postoperative complications.

Occupational therapists in Hong Kong have been very active in the management of patients with traumatic hand injuries due to industrial accidents. Splints have been prescribed as an adjunct to the exercise programme in rehabilitation. Other than the conventional thermoplastic splinting materials, metal hinges, coils and plastic strapping were used in splinting. The ultimate goal is to maximise the hand functions such that these workers could resume their work roles.

The terminology in describing splint or orthosis has been reviewed but there is no one single system adopted universally. Joint efforts by doctors, therapists and orthotists had been set up to review the classification of splint. Four ways of classifying hand splints have been introduced: namely, eponym, acronym, descriptive classification system and the classification system proposed by the American Society of Hand Therapists. These systems include the use of rote memory or logical deduction in grouping of splints. This paper describes the advantages and disadvantages of each classification system. Neither one of the systems stands out to be the best. A combination of the advantages of different systems, such as precision and logical deduction, may be an option for developing a new system. Moreover, communication, documentation and other environmental factors should also be considered.

Evidence-based medicine has been practised in the early 1990s in the Western countries and its model has aroused interests in the Asian countries including Hong Kong in the late 1990s. The need for evidence-based practice was called upon by Sackett and his colleagues^14–16 mainly because of the exponential growth of new evidence of treatment effectiveness. There is a great demand for clinicians to search for the best evidence and to incorporate into the daily practice so as to ensure the best quality and standard of treatment. This paper is to review the development and process of evidence-based practice in the area of hand splinting for our local clinicians. Some major problems were identified in the delivery of clinical evidence-based practice, and suggestions have been made to overcome these problems with a view in supporting its model in the local clinical field.

The aim of this article is to review the biological sequence of wound repair and the rationale of using splintage to modify the healing process. Appropriate use of splintage and controlled stress can prevent adhesion and periarticular fibrosis. Splinting prescribed at appropriate timing and methods will enhance wound healing and tissue remodelling. In reverse, it will cause permanent damage to the tissues.

Mallet finger injury, ligamentous sprain and dislocation of proximal interphalangeal (PIP) joint of fingers are very common types of simple hand injuries. Immediate correction of alignment and protection of the injured area will facilitate early joint movement while maximising functional recovery. This article is to introduce the fabrication of three simple finger splints to tackle these injuries for quick and effective conservative treatment. They are the mallet finger splint, buddy splint and dorsal finger block splint.

The indications and functions of the three types of splints are discussed. The fabrication process will be illustrated; including materials needed, pattern drafting and steps of molding. Wearing regime and precautions will be highlighted to ensure effective patient compliance to splinting programme for the finger injuries.

Splintage is commonly used in conjunction with pressure therapy to tackle the contracted scars, make it supple and thus minimise dysfunction. A static or dynamic splint can provide valuable therapy that goes beyond any treatment session. The patient's active participation in the splint programme can facilitate early recovery. A good splinting design and wearing regime often depends on the therapist's understanding and integration of visco-elastic properties in soft tissues, maturation process of hypertrophic scars and mechanical principles in splinting. Different types of splints serve different functions at different stages of rehabilitation. A suitable and efficient application of splints can minimise most of the corrective surgical intervention and alleviate psychological trauma. This article attempts to highlight the clinical rationale and special considerations when applying different splintage on burns patients with upper limbs involvement.

It is beyond doubt that splinting programmes have often been an integral and important part of the rehabilitation process in tendon injuries. Over the past three decades, hand splints for tendon injuries of various designs and different mobilisation programmes have been developed in the hope of pursuing better clinical and functional outcome for patients. In this paper, the development of different splinting programmes in flexor and extensor tendon injuries and the current practice in some acute hospitals in Hong Kong were discussed.

The prognosis and speed of peripheral nerve recovery depend very much on the level of injury, severity of injury, the surgical intervention and the subsequent rehabilitative process. Many high level injuries may take years or months for the affected peripheral nerve to recover. Prolonged muscle imbalance causes joint contractures and over-stretching of denervated muscles. Without proper care, hand function recovery may be limited even the nerve regenerated afterwards.

During the nerve regeneration period, splinting is one of the most useful modality to minimise deformities, prevent joint contractures and substitute loss motor control. Proper splinting encourages early use of the injured hand in daily activities. There are different types of splinting design for median nerve palsy, ulnar nerve palsy and radial nerve palsy. Dynamic splinting techniques are frequently employed to allow early prehension activities. Other therapeutic techniques, including pressure garment and sensory re-education are useful to enhance better functional return after nerve repair.

Joint stiffness, resulting from a variety of complications after hand injuries, remains a common problem. Prolonged swelling, scar formation and shortening of soft tissue after prolonged period of immobilisation are the major causes leading to the loss of joint range of motion. Treatment used to improve the joint stiffness should be integrative and problem-focused. Pressure therapy, active and passive mobilisation through remedial activities and corrective splinting should be started as soon as problems arise. Applying low-load stress through prolonged periods of time onto the shortened tissue at its maximum tolerable range is the main principle in restoration of passive joint range of motion. The greater the joint limitation becomes, the longer the time the splint should be applied. Therapists should understand the process of tissue healing and different functions of splints before a correct and effective splint can be prescribed properly.

Percutaneous cannulated screw fixation (PCSF) of acute scaphoid fractures has been shown to consistently produce good results. It is less invasive and avoids damage to the radiocarpal ligaments. The scar is good. The procedure could be performed under Bier's block anaesthesia. No cast is required after the operation and the range of wrist motion is regained early. Most recently reported series achieved more than 95% primary radiological fracture union. The functional results were good. The surgical technique of PCSF is described in detail and special tricks for difficult problems are highlighted.

Fracture of the distal radius is a common injury. Functional recovery correlates well with restoration of anatomy and early motion. Various fixation methods have been proposed to achieve this. To evaluate the stability of different treatment options, a cadaveric model for biomechanical study of fixation methods for AO type C2 fracture of distal radius was designed and its efficacy assessed in the present experiment.

A case of primary lymphocutaneous nocardiosis caused by Nocardia otitidiscaviarum in a 69-year-old previously healthy woman is described. The organism was identified in cultures of pus specimens. The patient was treated with a six-month course of oral trimethoprim-sulfamethoxazole chemotherapy following incision and drainage, and the infection completely resolved.

In the case presented below, we observed abductor pollicis longus (APL) dividing into five sections shortly after exiting the first compartment. Many variations of APL may be seen and it is essential to know these variations in the practice of hand surgery.

Two newborns with history of difficult birth were diagnosed within 24 hours after birth with isolated radial nerve palsy. Both newborns recovered completely. Awareness and multidisciplinary approach is essential.

Basal cell carcinoma (BCC) is the most common skin malignancy arising from cells of the basal layer of the epithelium or from the external root sheath of the hair follicle. BCC of the digit is a rare entity. The article presents one such case of bowenoid BCC of the thumb which required amputation at the MP joint.

Herein is described a haemodialysis patient with bilateral carpal tunnel syndrome suffering from recurrence unilaterally after undergoing numerous surgeries of varying methods. On the left side, she received carpal tunnel release via open method in our clinic, and has not suffered from recurrence in eight years. On the right side, she received endoscopic carpal tunnel release twice in seven years, and subsequently underwent open carpal tunnel release in our clinic for recurrence. For carpal tunnel syndrome in haemodialysis patients, we recommend open surgery rather than endoscopic surgery.

We report three cases of digital nerve grafting using the terminal branch of posterior interosseous nerve.