Hand Surgery

We previously reported that our repair and/or reconstruction of the scapholunate interosseous ligament reduced the scapholunate dissociation and improved the clinical results. Re-evaluation of these patients after three years revealed that malrotation of the scaphoid advanced significantly although the clinical results declined only slightly. To prevent progression of scaphoid malrotation, a modified dorsal capsulodesis was subsequently added to the ligamentous repair of scapholunate dissociation. The records of 17 patients were available for this study. The time lapse from injury to surgical treatment ranged from four days to one year and six months. All but three patients were operated less than two months after the injury. All patients were followed for more than one year, with an average of 49 months. Clinical results were expressed by a modification of the point score method of Green and O'Brien. Scapholunate angles were measured on lateral X-ray films with the wrist in neutral position. Overall clinical results averaged 83 points (range: 25–100). The scapholunate angles averaged 49° (range: 45–60). In the three patients, in whom the operation was performed more than 11 months after the injury, the clinical results averaged 38 points and scapholunate angles averaged 54°, respectively. These clinical and X-ray results suggest that early repair of the scapholunate interosseous ligament along with a modified dorsal capsulodesis is a useful procedure in the treatment of scapholunate dissociation.

This study is to assess the effectiveness and outcome of the AO titanium volar distal radius plate (Synthes) in the treatment of peri-articular volar rim fractures of the distal radius. It was conducted on 22 patients with distal radius fractures who underwent open reduction, internal fixation using the AO titanium volar distal radius plate between July 1998 and December 1999 at the Changi General Hospital. The radiographs of the patients were analysed upon fracture union and assessment of wrist function was done using Gartland and Werley criteria. There were four extra-articular AO Type A2(1) and A3(3): the remaining 18 intra-articular fractures consisted of AO B3(2), AO C1(11), AO C2(2) and AO C3(3). The average follow-up period was 12.6 months (range 7–23). Radiological review showed bone healing in 21 patients (95.5%) and good articular congruity for all intra-articular fractures with less than 2 mm step-off. Three patients defaulted follow-up. Complications were few with one wound infection, one tendon rupture and three neuropraxia of the superficial radial nerve. Wrist function was excellent in three patients, good in 12 and fair in four. The AO titanium plate with its distal buttressing ability is an effective treatment modality in patients with distal radius fractures involving the peri-articular volar rim.

Radial deviation and limited flexion of the wrist joint and a lack of abduction of the thumb have been noticed after the Riordan's procedure. Therefore, Tsuge et al. modified the Riordan's procedure, and their procedure includes transfer of the pronator teres to the extensor carpi radialis brevis, the flexor carpi radialis (FCR) to the extensor digitorum communis (EDC), and the palmaris longus to the extensor pollicis longus, along with tenodesis of the abductor pollicis longus. We reviewed the charts of 21 patients with isolated radial nerve paralysis who were treated with the Tsuge's procedure. Mean follow-up period was 11.3 years. Postoperatively, patients showed good extension of the metacarpophalangeal joint measured at the middle finger, useful flexion of the wrist joint, and decreased radial deviation of the wrist. The FCR transfer to the EDC is an excellent procedure for extension of the fingers. However, reconstruction of active abduction of the thumb remains controversial.

Fifteen patients underwent arthrodesis of finger distal interphalangeal joint (DIP) and/or thumb interphalangeal joint (IP). Only Herbert screw intramedullary compression fixation was used. There was one faulty proximal thread placement with some pain, but the patient refused further surgery. Full union was achieved in 14 of the cases, with prominent hardware in one and intolerance to cold in two.

End-to-side nerve suture (ETSNS) is a viable option to re-innervate a paralysed biceps muscle. The host or donor nerve could be any of the adjacent large nerves including the brachial plexus. It is important to adhere to certain principles when performing ETSNS, e.g. epineural window only, suture line without tension, the recipient nerve should not "kink" in any way and complete immobilisation for at least three weeks. The earlier this ETSNS is done after injury the better the outcome. Patient co-operation and motivation is of the utmost importance. The post-operative rehabilitation programme is essential to "awaken" and strengthen the dormant muscle. Our results are based on five patients. Good elbow flexion, i.e. biceps contraction can be regained after ETSNS of, for example, the musculo-cutaneous nerve into an appropriate viable host nerve.

The phenomenon of lateral sprouting of axons into an end-to-side sutured recipient nerve is well documented. The exact nature, however, still needs further investigation. Since 1996, we have been continuously involved in primate research as well as using this end-to-side nerve suture (ETSNS) method in clinical practice. Fifty-six patients with a variety of conditions, ranging from brachial plexus avulsion to digital nerve lesions, have been operated. From our experience, it seems that the best results achieved are proximal motor re-innervation (e.g. biceps) and distal sensory re-innervation (e.g. volar skin of the hand). The discussion will cover various aspects for ETSNS in the human patient, such as indications, parameters, technique, and the importance of rehabilitation. ETSNS restores function in conditions previously difficult to operate, and may replace nerve grafting in many instances. It provides an additional method in our armamentarium in peripheral nerve surgery.

Although new techniques and innovative approaches in hand surgery are increasing in number and popularity, the ultimate aim of achieving improved functions may not be fulfilled. On the other hand, perfect functional results are not achieved, not because of inability to use recent technology, but because of deficient skills, e.g. on basic incisions, tendon repair, or nerve repair.

Twenty patients (14 males, six females) were assessed at an average of 32 months (ten to 156 months) after ray amputation using the disability shoulder, arm, hand (DASH) questionnaire, physical examination and functional testing. There were 14 border (eight index, six little) and six central ray (five middle, one ring) amputations. Our results showed on average 27% less grip and 22% three-point pinch strength in the operated hands. Peak power output was 22% and average work output 14% less on the operated side than the contralateral hand. The DASH function score was 29.2 (range 3.3–74.2). Nine patients returned to their previous occupation, two had to change jobs and two did not return to work. Six patients were not working, one was of school age. The ensuing disability remained within limits reflected by our measurements and the acceptance of the patients.

Nineteen fresh frozen adult human flexor digitorum profundus (FDP) tendons in Zone II were studied to compare the differences in material properties between the dorsal (dFDP) and palmar (pFDP) side of each tendon biomechanically, biochemically and histologically. We have found that tissue from the dorsal side of each flexor tendon has (1) greater strength; (2) less collagen crosslinking (hydroxypyridinium); and (3) a larger single bundle cross-sectional area than tissue from the palmar side of the same tendon. These data clearly demonstrate that the dorsal and palmar sides of the adult human (FDP) tendon in Zone II differ materially. These differences suggest that there may be biomechanical advantages in placing core sutures dorsally when repairing flexor tendons, a technique that we have previously described.

Mini-open carpal tunnel release has been the focus of recent attention for surgical decompression of carpal tunnel syndrome. Other techniques such as standard open carpal tunnel release and endoscopic release have been well established, and outcomes, complications and results for these operations have been published widely. Our study uses the validated Levine Katz questionnaire for carpal tunnel syndrome to measure patient subjective outcomes at one year follow-up after mini-open carpal tunnel release. Thirty-four consecutive hands were enrolled prospectively with preoperative and postoperative questionnaires. Mean symptom severity scores per question improved from 2.8 to 1.3 and mean function severity scores per question improved from 2.6 to 1.3. Comparing our data to the historical cohort of Levine et al., there was a statistically significant improvement in postoperative outcomes in our population (p < 0.0001).

The results of three different surgical techniques used for the treatment of 46 ruptures of the distal biceps brachii tendon in 45 patients were evaluated and compared. Mean follow-up time was 14 months. The 46 ruptures were categorised according to the surgical technique used for treatment. In Group I, 17 arms were treated using two incisions and transosseous suture fixation; in Group II, 19 patients were treated using bone-anchor fixation; and in Group III, ten patients were treated using a tie-on-button technique. After treatment, 41 patients (89.1%) had full active range of motion (ROM) and 38 patients (82.6%) had excellent or good strength. The results after treatment in all three groups were satisfactory. Though the outcomes of these techniques were similar, operative time, time to return to regular activity, and time to return to work was shorter in the bone-anchor and tie-on-button groups than that in the two-incision transosseous fixation group.

Driving with an arm protruding through a window can result in limb threatening injury. A series of seven upper limb injuries sustained during motor vehicle accidents (MVAs) with a limb protruding from the vehicle window is described. The severity and complexity of these injuries are related to the ultimate functional recovery for the limb. This study serves to highlight the severity of injury and morbidity following these modalities of trauma, which although rarely fatal, carry extensive consequences and could be easily prevented with appropriate education programmes and legislation.

We have devised a reconstructive procedure to repair chronic injuries to the collateral ligament of metacarpophalangeal (MCP) joints. It comprises palmaris longus tendon grafting into a bone tunnel and suturing onto the base of the residual ligament without involving fixation of the tendon graft stump.

Thirteen patients were treated for injured MCP joints: thumb/ulnar, ten cases; thumb/radial, two; and middle finger/radial, one. All patients had pain and instability of average 41° in the affected MCP joints. The patients were followed at an average period of five years and nine months. Pain and joint instability disappeared in all patients. The mean MCP joint range of motion (ROM) was 1° on extension and 58° on flexion. The tip pinch strength averaged 4.8 kg.

The gratifying results obtained using this method are attributed to the fact that optimal tension of the ligament and satisfactory ROM can be achieved during the course of rehabilitation.

Congenital synostosis between the fourth and fifth metacarpals is a rare congenital anomaly. We present a case of type IIIB metacarpal synostosis according to the Buck Gramcko's classification with the camptodactyly of the little finger. It was treated successfully with the phalangeal angulation osteotomy and soft tissue release procedures.

We report a case of a rare injury, lateral fracture dislocation of the second and third carpometacarpal joints, which presented late and was managed by fusion of the involved joints.

A case with spontaneous extensor tendon dislocation was treated operatively. Right hand was more severely affected with contracture of the metacarpophalangeal joints. Centralisation of the extensor tendons and sectioning of ulnar intrinsic muscles sufficed correction of the pathology. No recurrence occurred in the last 24 months.

Embedding ring injury is a very rare injury. Patients will mental illness should be considered at risk.

This article presents an exceptional clinical manifestation of gout in the wrist. The patient suffered from an association of septic and urate-crystal-induced arthritis. At the time, the serum uric acid concentration was still normal. The association of septic and urate-crystal-induced arthritis has been reported in other locations. The pathophysiology of the precipitation of urate crystals in the presence of an infectious process is discussed.

Between 1994 and 2000, the senior author performed 1245 endoscopic carpal tunnel decompressions. There were 291 bilateral cases. A telephone review was conducted of those patients who had not had an early excellent result, or conversion to an open procedure. Ninety-four per cent follow-up of patients in this group was achieved; 88% had an early excellent result with no subsequent problems. In 33 hands (3%) the carpal tunnel was opened, because of abnormal anatomy or poor view. A further 5% had a late excellent result. Seventeen hands (1%) have required subsequent open decompression, with adherence of the median nerve often found at revision surgery. Another 24 hands (2%) had a poor result. Fourteen hands (1%) had minor symptoms and 26 (2%) had another diagnosis of upper limb pathology. In contrast to other series, there was only one case of damage to an important structure — the radial digital nerve of the thumb.

Acute carpal tunnel syndrome is an orthopaedic emergency that requires prompt surgical treatment. We describe two rare cases of this condition, one secondary to pyogenic infection and one secondary to prolonged pressure on the upper limb brought on by overdose.

After a successful Littler procedure (spiral oblique retinacular ligament reconstruction) for swan-neck deformity, a 14-year-old patient developed progressive boutonnière deformity. We propose that the problem arose from gradual tightening of the tendon transfer as the finger grew.

A case of gout first presenting as carpal tunnel syndrome due to intratendinous and lumbrical muscle involvement with tophi is reported. Surgical decompression with excision of tophi and diseased muscle produced symptomatic relief.

During a 15-year period, 145 patients presenting with cubital tunnel syndrome were operated upon. They are divided into two groups: (1) Primary tunnel syndrome — 27 cases (18.6%), with a "pure" past history, and (2) secondary — 118 cases (81.4%) with the lesion occurring after a known causative event. Investigation of 100 healthy persons, 50 men and 50 women (200 extremities) show, when elbow flexes, the ulnar nerve moves around the epicondyle in 50% of men, whereas in the remainder nerve subluxation or dislocation anteriorly to the epicondyle occurs. In women, the figures are 72% and 28%, respectively. Apparently in men, the nerve being more mobile is more sensitive to gliding impairment in the tunnel compared to women. In the series of 145 patients, there is a 4.5 : 1 men-to-women ratio, the men being affected much more often. The role of traction in the pathomechanic is further suggested by two facts: the presence of elbow flexion contracture (52%) of the patients and firm ulnar nerve adhesions to the tunnel wall (73%).

Skin electroresistance assessment using a high-sensitivity microamperimeter was conducted in 100 patients. Skin electroresistance may remain within normal limits even in cases of expressed sensory and motor impairment. This points to the great resistance of sympathetic fibres against the compression and traction within the canal. Concerning the type of anterior transfer, a combined procedure was used by placing the nerve subcutaneously for the proximal part, and intramuscularly for the distal one. Nerve recovery may proceed even ten years after anterior transfer.

The surgeon may, on occasion, wish to perform a relatively minor procedure on a single finger with some types of tourniquet at the base of the finger. A potential complication of a digital tourniquet is neurovascular damage due to excessive tissue pressure and prolonged application time. We presented a case where a hand surgery and digital tourniquet was forgotten on the finger for one and a half days. Although neurovascular compromise had occurred, the left index finger was successfully saved after extensive medical treatment and leech therapy.

Pseudarthrosis of the capitate bone is extremely rare. In this case, the injury and pseudarthrosis was so old, the bone with a nutrient vessel was grafted, and bone union and excellent results are obtained.

We reported on an acute carpal tunnel syndrome that occurred two hours after the internal fixation of scaphoid. Operative exploration showed median nerve compression caused by flexor digitorum superficialis muscle bellies within the carpal tunnel. Symptoms were relieved immediately after the carpal tunnel release. This case was very rare because acute carpal tunnel syndrome was caused by swollen muscle bellies within the carpal tunnel after the initial operation for the trans-scaphoid perilunate dislocation. This clinical situation should be distinguished from compartment syndrome of forearm.