Hand Surgery

The aim of this study was to seek more potent evidences of collateral sprouting for both motor and sensory nerve fibres after end-to-side neurorrhaphy using a modified double-labelling retrograde tracing method and to investigate the function of regenerated motor axons with electrophysiological evaluation. Four groups (n=4 for each group) were used: end-to-end coaptation (six months postoperatively), end-to-side coaptation (four months and six months postoperatively) and normal control. Two fluorescent tracers (true blue and diamidino yellow) were applied to the proximal ends of tibial and common peroneal nerves, respectively after four or six months of nerve coaptation. Five days later, we only found single-labelled motor and sensory neurons in the normal and end-to-end coaptation groups, while some dual-labelled neurons can be identified in end-to-side coaptation groups. Four months after surgery, the motor nerve conduction velocity in end-to-side coaptation was significantly slower than in the normal control. But no difference was found in the sixth month. These results suggest that end-to-side neurorrhaphy can induce the functional collateral sprouting of both motor and sensory axons in the peripheral nerve.

An AO type C2 distal radius fracture was simulated in a cadaver model by creating a metaphyseal defect of 5 mm and an intra-articular defect of 2 mm. Five different methods of plate osteosynthesis were tested biomechanically in each of six fresh cadaveric hands. Biomechanical testing suggested that cement augmented plating plus screws in the distal fragment was the strongest. Dorsal and volar plating plus screws on both sides of the distal fragment had the same effect of restoring stiffness and load transmission pattern as fixation with double plating plus volar screws alone. Fixation with plating plus dorsal screws was significantly weaker than these three methods, and double buttress plating with no screws in the distal fragments was the weakest.

To guide reconstruction of scaphoid non-union, we attempted to create full-scale models of the scaphoid by three-dimensional computed tomography (3D CT) of the healthy side. In this study, we obtained 3D scans of 51 cadaveric hands and studied the difference in morphology between genders and between the left and right sides. The major axis length on a fixed plane and Fourier transformation curve were examined. Ten scaphoid images were also obtained with 3D CT before and after removal from the cadaveric hands. Our findings suggest good correlation between models produced using 3D CT images of the scaphoid alone, and this could serve as an accurate model if the magnification is corrected using the regression line. However, the model using 3D CT images of the intact wrist joint has a large margin of error and its use will not be practical.

We evaluated clinical results and postoperative problems associated with arthrolysis for post-traumatic contracture of the elbow joint. Arthrolysis was carried out in 47 elbows in 46 patients. Age at the time of arthroplasty ranged from 12 to 64 years (average 33 years). The period from time of injury to arthrolysis ranged from six months to six years (average 16 months). It was notable that scarring of the anterior capsule was pronounced in cases of long-term contracture. No apparent differences were observed in causes or age at operation, but the duration of preoperative symptoms and period of postoperative external fixation tended to affect the outcome. We conclude that arthrolysis is indicated irrespective of preoperative range of motion (ROM) and age, and that the surgery should be carried out before degeneration of cartilage and muscle atrophy progress. It was considered that long-term postoperative observation is also necessary, because in some cases there was postoperative progression of joint deformities, while in others there was decreased muscle strength after surgery.

Scapholunate (SL) instability is the most common cause of carpal instability. Pre-dynamic and dynamic type SL instability is difficult to diagnose and treat. This series reviews 17 soldiers with pre-dynamic or dynamic SL instability diagnosed by midcarpal arthroscopy and treated with dorsal capsulodesis and augmentation ligamentoplasty with partial dorsal radiocarpal (DRC) ligament procedure between 1997 and 2000. The sample included 14 males and three females. The dominant hand was involved in 15 patients. Moreover, the average patient age was 29.3 years (range 19–36 years). The diagnosis was based on clinical and arthroscopic criteria. Fifteen patients were followed up at our clinic regularly, with the follow-up period ranging from 12 to 39 months (mean 25.2 months). Fourteen patients had excellent or good results, and one patient had poor result based on Mayo Modified Wrist Score. Wrist motion in the flexion-extension plane loss averaged 18.4°. Grip force increased significantly following treatment, with improvement totaling 15% of normal side. No complications were found in this series. Consequently, dorsal capsulodesis and ligamentoplasty with partial DRC ligament is considered a valuable therapeutic option for cases of pre-dynamic and dynamic SL instability.

In this paper, we report on the advanced technique of distal tendon stump repair of a digit. A K-wire is used lengthwise to fix the distal and medium phalanxes, with the pull-out suture fixed on it. None of the cases repaired using this method was complicated with regional necrosis or tendon re-laceration. The advantages of advanced pull-out suture tied on a K-wire is that finger-tip pressure, which can lead to tissue necrosis, is avoided.

Healthcare information contained on the World Wide Web is not screened or regulated and claims may be unsubstantiated and misleading. The objective of this study was to evaluate the nature and quality of information on the Web in relation to hand surgery. Three search engines were assessed for information on three hand operations: carpal tunnel decompression, Dupuytren's release and trigger finger release. Websites were classified and evaluated for completeness, accuracy, accountability and reference to a reliable source of information. A total of 172 websites were examined. Although 85% contained accurate information, in 65% this information was incomplete. Eighty-seven per cent of websites were accountable for the information presented, but only 24% made references to reliable sources. Until an organised approach to website control is established, it is important for hand surgeons to emphasise to their patients that not everything they read is complete or accurate. Publicising sites known to be of high quality will promote safe browsing of the Web.

Seventeen Coonrad-Morrey semi-constrained total elbow replacements were performed on 14 Chinese rheumatoid patients. The elbows were reviewed retrospectively after a mean follow-up of 36 months (range 12–89 months.) After the operation, all patients were satisfied and there was no pain in 15 elbows. There was no radiological sign of loosening in the implanted prostheses and bone graft was incorporated in 93% of primary elbow replacements. The Mayo Elbow Performance Score was improved from an average of 40 (range 20–75) to an average of 93 (range 65–100). The arc of flexion was improved from an average of 89° (range 0°–125°) to 104° (range 35°–125°). The sizes of implants can be predicted accurately by the planning template in only four elbows (24%) and there were early complications in seven elbows (41%), with one prosthesis removed because of deep infection.

The objective of this study is to evaluate clinical and radiological outcomes of unstable or intra-articular Colles' fractures using the Pennig model of external fixation. The Pennig model of dynamic external fixation was used on 88 patients with 92 Colles' fractures. In 35 wrists, exercise was not performed during external fixation. In 57 wrists, exercise was initiated three weeks after surgery. Regarding radiological measurements, the degrees of volar tilt (VT), radial inclination (RI), radial length (RL) and ulnar variance (UV) were serially measured and evaluated. The clinical results were evaluated according to Sarminento's criteria. Favourable therapeutic outcomes (excellent and good) were obtained in 95.6% of the cases. However, when complicated by die-punch fractures, the outcome tended to be poorer. Postoperative re-displacement was often observed in patients over 50 years old. UV tended to increase and RL tended to decrease in the early motion group after the initiation of exercise. Neither VT nor RI significantly changed in either group during the postoperative observation period. Of patients in whom bone union of ulnar styloid fractures was not achieved, 32.2% complained of ulnar pain. Moreover, osteoarthritic changes were observed in two of 11 wrists with a step off of 1 to 2 mm or larger. In order to maintain the reduction position, it was important to determine the appropriate time for initiating exercise depending on the degree of fixation in each individual patients. The step off of the articular surface should be reduced to less than 1 mm and reductive fixation has to be performed additionally when complicated by ulnar styloid fractures.

One of the two English-language reports on the results of surgery for trigger finger reported frequent complications and poor results and the other, few complications and good results. We reviewed 72 patients with 84 operated digits 8½ (7–11) years after surgery. One patient was re-operated because of persisting symptoms, and another had a moderate recurrence. There were two transitory neuropraxias, but no permanent nerve damage could be detected. It was concluded that in cases where symptoms persist after steroid injection, surgery may be recommended. However, the risk of troublesome complications, even after this minor operation, should be borne in mind.

There are conditions that preclude the use of the posterior interosseous flap for reconstruction of the dorsum of the hand. Based on a series of 34 cases, these conditions are outlined and alternative solutions discussed.

The posterior interosseous flap was employed for closure in 30 cases. In four cases different methods were used due to severe trauma to the wrist and distal forearm with potential impairment of the pedicle, a complex defect requiring a composite flap and an anatomical variation. Thin free flaps were employed alternatively. All flaps survived but there was marginal flap necrosis in two posterior interosseous flaps.

The posterior interosseous flap proved its usefulness and reliability in reconstruction of the hand in this series. In four cases, free lateral arm and temporoparietal fascial flaps were employed. Flaps based on the main vessels of the forearm were not used due to their significant donor site morbidity.

The purpose of this study is to document the percutaneous Herbert screw fixation technique with free-hand method to stabilise acute unstable scaphoid fractures and evaluated the clinical results. Thirteen patients with less than 14 day-old fractures were fixed by percutaneous Herbert screw and reviewed retrospectively for a minimum of 24 months (average, 37 months). All were men with an average age of 22 years. According to Herbert's classification, all fractures were classified as of the acute unstable (B2). Fracture union was achieved in all cases at a mean of 9.2 weeks (eight to 12 weeks). Return to work or school ranged from one day to three weeks according to their occupation. This percutaneous fixation technique using Herbert screw is a reliable and effective alternative for acute scaphoid fractures, which enables the patient to use the hand earlier with high satisfaction and minimum complication.

The ligamentous structures of the triangular fibrocartilage complex (TFCC) and their attachments were examined anatomically and histologically using fresh and embalmed cadavers. The TFCC was observed to have a three-dimensional structure consisting of three palmar ligaments — the short radiolunate (SRL), ulnolunate (UL), and ulnotriquetral (UT) ligaments. In addition, the attachment site of the ulnocarpal ligament (UC), which had been previously unknown, was identified. The dorsal components of the TFCC have been previously reported to consist solely of the extensor carpi ulnaris (ECU) subsheath; however, the ligamentous components running from the ulnar styloid process to the triquetrum were found at a layer deeper than the floor of the ECU subsheath.

The UC has been reported previously as a two-dimensional structure, but there has been some disagreement as to its attachment sites.^2–6,14,15 It is suggested that the dorsal UT ligament should be considered as a separate ligament, based on its different direction and distal attachment site as compared with those of the ulnar collateral ligament (UCL) and ECU subsheath.

The ability to improve the technique for an accurate clinical diagnosis of the injury of interosseous membrane of the forearm (IOM) associated with forearm fractures and dislocations is important for its treatment and prognosis. Ultrasound examination of the IOM in 46 forearms from 18 normal volunteers, five patients with restricted forearm pronation and supination, and two preoperative cases was performed to determine the usefulness and reproductivity of this examination. The intact IOM was observed as a continuous, slightly convex anteriorly and hyperechoic structure between the radius and ulna with both transverse and longitudinal views. IOMs with histories of forearm injuries were distinguished by the findings, which demonstrated a loss of continuity and were seen as hypoechoic traces from the others. This study confirmed that it is possible to trace the entire IOM and to detect differences between intact and disrupted IOMs with transverse and longitudinal views.

Giant cell tumours of tendon sheath are common in the hand but multiple lesions are relatively rare. A case report of bilateral symmetrical involvement is presented and discussed.

Osteoid osteoma is a benign tumour of bone that rarely localises in the carpal bones. Its treatment by curettage and bone grafting is considered to be curative and its recurrence is thought to be rare.

We report a case of an osteoid osteoma of the lunate, which recurred seven years after the initial operation. Recurrent osteoid osteoma of the lunate bone has not been reported in the literature. We present this case report for its atypical presentation and diagnostic difficulty and also to alert the readers of the possibility of an osteoid osteoma as a cause of the chronic unexplained wrist pain in young adults.

A two-year-old boy with short finger-type symbrachydactyly involving the index, middle, and ring fingers was treated with intercalary nonvascularised toe phalanx transplantation into the middle finger to obtain stability of the middle finger before syndactyly release. He underwent syndactyly release one year after the transplantation. Two years after the transplantation, the clinical result was satisfactory, although X-ray showed fibrous union between the transplanted phalanx and the host phalanx. Intercalary nonvascularised toe phalanx transplantation is one of the way of stabilising a finger after syndactyly release.

We report a case of multiple schwannomas of the median nerve. Multiple schwannomas can be difficult to diagnose on clinical grounds and can be mistakenly diagnosed as carpal tunnel syndrome or ganglia as in our case. Nerve conduction studies helped locate non-visible tumours. Magnetic resonance imaging (MRI) is useful in the preoperative planning of these tumours. The appearances on scanning however can be sometimes confused for ganglia as in this case. Intraneural dissection of the schwannomas was carried out and the pathology is described.

We reported a case of trichilemmal cyst in the pulp of the index finger. Histopathological features and unusual MR images are discussed.

The management of very distal finger amputations when the amputated part is saved is still difficult and controversial. Both re-attachment of the amputated portion as a composite graft and microvascular anastomosis can fail in this distal location. Replantation is, in fact, associated with certain problems, such as technical difficulty, risk of failure because of the poor venous drainage, and costs. With the exception of children, amputations at the level of the lunula poorly survive direct re-attachment. Hirase has described a new replantation model without vascular anastomosis and used ice water and aluminium foil to enhance survival of the composite graft. Cooling the entire recipient site retards cellular degeneration in the graft until neovascularisation occurs. The present authors applied this method to seven cases in which a digit had been amputated between the tip and the lunula. In four cases the method proved to be completely successful, whereas in two an area of tip necrosis was observed. The Hirase method has proven to be a simple and reliable surgical technique for fingertip re-attachment.

Endoscopic release has been shown to be a safe and effective means of carpal tunnel decompression. The surgeon needs to be aware of the variations in the anatomy of the median nerve in order to minimise the risk of nerve injury. In this series of 748 endoscopic carpal tunnel releases, six were found to have variations in the median nerve anatomy, in two patients conversion to open release was necessary.

Anomalous variations of abductor digiti minimi are commonly found at Guyon's canal but rarely cause ulnar nerve compression. We report such a case with particular emphasis on the effectiveness of ultrasound to detect and delineate anatomical structures in this region.

The deep transverse metacarpal ligament (DTML) extends in radio-ulnar direction between the palmar plates of the metacarpophalangeal (MCP) joints of the second through fifth finger rays. On the radial aspect of the index and the ulnar aspect of the small fingers, the ligament merges with the collateral ligament of the MCP joints. The ligament has palmar grooves for the flexor tendons at the MCP joints and act as a support for the metacarpal arch. Closed DTML injury is an unusual case, but the physical findings of DTML injury are a decrease in grip strength, deviation of the finger in flexion and pain on the affected site of the hand. We have experienced a case of neglected DTML injury of left third interdigital space in a 23-year-old man.