Hand Surgery

Overall survival rate for 143 digits with complete amputation of the distal phalanx was 78%. Replanted digits that underwent venous anastomosis showed a very high survival rate of 93%. Loss of the distal interphalangeal joint function in subzone IV was significantly inferior to that in subzones II and III. Protective sensation was achieved in 96% of replanted digits. Sensory recovery in the absence of nerve repair was significantly worse for avulsion injury than for crush injury. Nail deformity tended to be increased for replanted digits in subzone III or with crush-type injury. Successful venous anastomosis appears to offer the best way to promote survival of replanted digits. If venous anastomosis is infeasible, a replanted digit can survive with any methods for venous drainage in subzones II and III, but does not survive in subzone IV. To minimise nail deformity, repair of the germinal matrix is necessary.

Six cases of culture-proven Mycobacterium chelonae tenosynovitis were identified through retrospective chart review. Fifteen cases were identified using computerised Medline search. Clinical features, treatment and outcome were described. Infection control was achieved in our patients with an average of 3.2 surgeries each and antibiotic treatment for six months to one year. Eleven published cases were managed by combined surgery and systemic antibiotics, with an average of 1.73 surgeries per patient and seven weeks to 24 months of antibiotics. All our patients were disease free on final follow-up. Thirteen cases were resolved. Functional outcomes were reported for eight cases. Comparison of functional outcome was not possible because different parameters were used in different reports. Aggressive debridement, susceptibility-guided antibiotics, and supervised rehabilitation resulted in infection control and acceptable hand function for our patients. Standardised data collection on subsequent cases would facilitate outcome monitoring and formulation of a treatment guideline for this disease.

Radiolunate fusion is a limited carpal fusion procedure used for patients with rheumatoid arthritis. However, this procedure inevitably causes decreases in range of motion, especially wrist flexion. Linscheid and Dobyns described the possibility of minimizing the decrease in motion at the radiocarpal joint by slight distraction of the joint. We hypothesized for our modified procedure that a corticocancellous bone graft was inserted between the radius and the lunate with a small amount of over-correction could provide slight distraction of radioscaphoid joint and protect the joint from decreased range of motion after arthrodesis. Twelve wrists in ten patients with rheumatoid arthritis underwent radiolunate fusion. Mean age at operation was 53 years old and mean follow-up period was 5.7 years. Clinical evaluation and radiological assessment showed that decrease in range of motion was minimized compared with other procedures. Because our modified procedure can minimize decrease in motion, it is recommended.

An unusual case of ulnar collateral ligament avulsion in association with carpometacarpal dislocation of thumb is described. Symptoms and deformity caused by dislocation can mask the presence of injuries such as damage to the ulnar collateral ligament of thumb. This may lead to long term disability. A high index of suspicion and good clinical examination allows correct diagnosis and management of these uncommon injuries leading to a good clinical outcome.

We report a case of a patient with rheumatoid arthritis undergoing revision surgery 30 years after primary metacarpophalangeal joint arthroplasty using a Swanson implant. Removal and replacement of the implant were successfully performed, and the patient was satisfied with the revision surgery.

A rare case of in situ rotational dislocation of the trapezoid was described after dislocation of the index and long carpal-metacarpal joints. Due to the difficulty in visualising the trapezoid on plain radiographs, there was a delay in assessing the full extent of the injury. However, after further imaging, the case required open reduction and internal fixation. Therefore, in cases involving high energy dislocations of the second and third metacarpal CMC joints, injury to the peri-trapezoid ligaments should be considered. A pre-operative CT scan or, if not available, open fixation of the CMC joints and trapezoid, is recommended.

We present a case of subcutaneous flexor tendon rupture of the index finger following malunion of a distal radius fracture. The cause of the tendon rupture was mechanical attrition due to a bony prominence at the palmar joint rim in the distal radius due to malunion. Corrective osteotomy and the Sauvé-Kapandji procedure were carried out for the wrist pain and forearm rotation disability and a tendon graft was carried out for the flexor tendon rupture. Recovery was satisfactory.

We present a case with irreducible simultaneous dislocation of both the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints in the little finger. A combination of the delay from injury to closed reduction and the entrapped flexor digitorum profundus (FDP) tendon at the PIP joint prevented closed reduction from being performed. To our knowledge, this is the first report of such a condition.

De Quervain disease is caused by a stenosing tenosynovitis in the first dorsal compartment, and the main aetiology is extensor pollicis brevis (EPB) tenosynovitis. We encountered three cases in which EPB tenosynovitis was absent and abductor pollicis longus (APL) tenosynovitis was confirmed during operation. In the treatment of de Quervain disease, APL tenosynovitis should be paid as much attention as EPB tenosynovitis.

Scaphoid excision and four-corner fusion is one of the treatment choices for patients who have stage II or III SLAC (scapholunate advanced collapse)/SNAC (scaphoid non-union advanced collapse) wrist arthritis. We report a case of ulnar-sided wrist pain which occurred after four-corner fusion for stage II SNAC wrist with a previously-asymptomatic ulnar positive variance, and was successfully treated by ulnar shortening osteotomy. This case highlights a possible coincidental pathology of the ulnocarpal joint in the setting of post-traumatic radiocarpal arthrosis.

Venous varix of the volar digit (VVVD) is a rare condition that is usually described as a firm, blue, and painful mass. However, the clinical features of VVVD are still unclear. We treated a patient who had a firm, normal-skin-colored, and painless mass on the volar aspect of a digit. The mass was removed and was diagnosed as VVVD by histological examination. Magnetic resonance imaging was useful for assisting with the pre-operative diagnosis. We also review 11 previously reported cases.

Avascular necrosis involving more than one carpal bone is rare, and the appropriate treatment for this condition has not yet been established. In this report, two patients with concomitant Preiser's and Kienböck's disease who also had severe wrist pain without obvious traumas were treated by closing radial wedge osteotomy (CRWO). Clinical evaluation showed that CRWO was effective against both conditions and indicated that it is more suitable for early stage than stage II diseases of the Hebert and Lichtman classifications.

We reconstructed the Blauth-IIIB hypoplastic right thumb of a 16-year-old girl with a vascularised metatarso-phalangeal (MTP) joint from her second toe combined with a dorsalis-pedis flap. Abduction was provided with an abductor policis long tendon advancement, and adduction, with an extensor indicis proprius tendon transfer. Opponoplasty was performed one year later using the flexor sublimis (IV) tendon. The transferred joint remained functional and non-osteoarthritic 28 years later. Radial and palmar abduction of the reconstructed thumb was 45° and 75° respectively. The index, middle, and ring fingers could oppose the thumb, however she grasped small objects between her index and middle fingertips. If a pollicisation using the index finger is not accepted, the reconstruction described here is one of the surgical options. However donor-foot morbidity is not negligible. Currently, we use a proximal-interphalangeal joint transfer with an opponoplasty using an abductor digiti minimi as a first choice, when planning a reconstruction of preserved hypoplasic thumb.

A typical case of Dupuytren's contracture confined to the interphalangeal joints of the right little finger, occurred in a 79-year-old man. No past history of risk factors or family history of Dupuytren's disease could be detected. Excisions of the abnormal cords lead to good clinical outcome.