Hand Surgery

Many authors have reported various clinical provocation tests for diagnosis of carpal tunnel syndrome, however, some tests cannot be administered correctly on patients who suffer from restricted wrist joint movement. We compiled positive rates from a new diagnostic provocation test (Okutsu test) carried out on 3474 hands, and compared them and their success rates with results from other provocation tests performed on these same hands. The Okutsu test positive rate was 72.4%. There were statistical differences between Phalen test (69.8%) and wrist-extension test (60.2%) results. The Okutsu test success rate was 99.9% and there were statistical differences between Phalen test (52.8%) and wrist-extension test (56.8%) results. There were no statistical differences between percussion test at the wrist results in positive rate (71.1%) and in success rate (99.7%). The Okutsu test positive rate is high and it serves as a reliable screening test for clinical diagnosis of carpal tunnel syndrome.

Katz and Stirrat devised a hand diagram, which uses subjective information from the patient for the diagnosis of carpal tunnel syndrome (CTS). They reported a good result. We tested the inter-observer and intra-observer reliability of this hand diagram.

Twenty five consecutive patients with a diagnosis of CTS, 25 with other common hand and wrist problems but CTS and 25 healthy individuals were prospectively recruited. Each patient filled in a hand diagram. Two experienced hand surgeon scored the diagrams blindly on two different sittings four-week apart. The intra-class correlation coefficient (ICC) and Cohen's Kappa were used for intra and inter-observer reliability respectively.

The intra-observer agreement was poor (ICC 95% 0.33–0.65) and inter-observer was fair (Kappa = 0.241).

This study does not support the use of Katz and Stirrat Hand Diagram for the diagnosis of carpal tunnel syndrome in place if a thorough clinical examination.

This study compares results of endoscopic carpal tunnel release using the two-portal technique in two groups of patients based on whether or not they were receiving workers' compensation. There were 50 patients in the worker's compensation group and 63 in the nonworker's compensation group. Mean follow-up was 40.8 months and 44.8 months, respectively. Duration of symptoms before surgery was statistically different in the two groups, 13.6 months in the worker's compensation groups compared to 26.2 months in the nonworker's compensation group. Worker's compensation patients tended to be younger, have shorter duration of symptoms before surgery, report lower postoperative activity levels, have more subsequent surgeries, and have mediocre results when compared to nonworker's compensation patients. There was no statistically significant difference in the rate or timing of return to work. Our series of 113 patients who had endoscopic carpal tunnel release indicates that careful patient selection is necessary to achieve satisfactory outcomes in worker's compensation patients.

Carpal tunnel syndrome and trigger finger (TF) are common ailments managed by hand surgeons, but it is unclear whether these conditions are related. The purpose of this study was to determine whether there are risk factors for the new-onset of TF after carpal tunnel release (CTR). A retrospective chart review was performed on 792 CTR surgeries and multiple variables were compared between patients who did and did not develop TF after CTR. The incidence of new-onset TF after CTR was 6.3%. Multivariate regression analysis showed that osteoarthritis and undergoing an endoscopic procedure were the only two independent risk factors. Based on these results, we recommend that for endoscopic CTR, the higher incidence of TF should be discussed preoperatively as a potential sequelae. Further, patients with osteoarthritis should be informed of their greater risk of developing TF postoperatively and should be monitored closely for expeditious detection and management of new-onset TF.

Twenty-six patients with mean age of 38.5 (range 18–59), from 1998 to 2005, with ulnar impaction syndrome who failed nonoperative treatments were included in our study. Patients' age, history of previous wrist fracture, presence of MRI signs and ulnar variance were recorded as variables. Also, patients' postoperative strength (compared to the contralateral wrist) and pain relief were collected as outcome measurements. Twenty-two patients (84.6%) had either good or excellent pain relief (median 4, range 1–4). Significant correlation was found between MRI findings and postop pain relief (r = 0.53, p ≤ 0.01). History of previous distal radius fractures was negatively correlated with pain relief (r = -0.50, p ≤ 0.01). No correlation was found between postop strength and any of the variables. Presence of MRI signs of UIS is a predictor of good outcome in arthroscopic wafer resection.

Purpose: Loosening is an important cause of failure of upper limb arthroplasty and improvement in cementation techniques may limit this. The currently accepted medullary canal preparation techniques use saline washing and gauze drying. Another method of bone preparation uses carbon dioxide compression gas jet which blows debris from the canal, whilst simultaneously drying the bone. We compared the push out strengths of cement plugs in sections of human cadaveric radii that had been prepared using either syringed saline or carbon dioxide jet cleaning.

Methods: Following bone preparation, four radii in each group, were cemented in a standardised fashion, and cut into 1 cm sections. An Instron materials testing machine was used to measure the force needed to push the cement plug out of the bone section.

Results: The force needed to push out the cement plug was significantly higher in the carbon dioxide jet (median 580.61, IQR 429.10–650.05) as compared to the saline group (median 366.57N, IQR 271.05–502.23), P = 0.009. The mechanism of failure of the bone-cement interface also differed between the two groups, with 100% of the sectioned cortices fracturing prior to cement extrusion in the carbon dioxide jet group, but only 23% of the sectioned cortices doing so in the saline group.

Conclusion: Our results suggest that there is a statistically stronger macro-interlock at the bone-cement interface after preparation of the medullary canals of radii using a carbon dioxide compression gas jet as compared to saline irrigation.

Partial width tendon grafts are commonly used in upper limb reconstructive surgery. Different techniques are described to harvest the graft including a "cheese wire" technique to split the tendon along its fibres with a filament. However no study has looked at the best material for this purpose. Fresh flexor tendons from pigs' trotters were used to analyse the splitting qualities of 11 different suture materials. The qualities assessed were: whether the suture material was successful in splitting the tendon, the average force required to split the tendon and the resulting quality of the spilt tendon graft. Whilst wire sutures produced a high quality of graft, they were awkward to use as they necessitated handling with a holder due to the higher forces required to split the tendon. Fibrewire provided the best result with respect to graft quality and ease of method as it combined the cutting strength of wire with the handling characteristics of a braided suture.

We discuss a combination of established and modern techniques in the investigation and management of traumatic flexor digitorum profundus rupture ('Rugger Jersey Finger') in seven cases (male rugby players ranging from 15 to 30 years of age; mean = 26). We discuss the use of X-ray and ultrasound investigation followed by various surgical repairs including intraosseous sutures, suture anchors, tendon lengthening and "pull-through suture over button" repairs. Functional outcome at outpatient follow-up is discussed in each case. Type I, II and Vb injuries were identified. Patients presenting early attained good functional outcome. Six patients received surgery within ten days of injury and attained satisfactory outcome at follow-up. One patient presented late and required a tendon lengthening procedure to manage myostatic contracture. Ultrasound imaging proved valuable in diagnosis and pre-operative planning. Numerous surgical repairs were used and all associated with a positive outcome providing there is adequate patient compliance.

The management of anticoagulated patients requiring surgery presents a challenge to hand surgeons. The risk of bleeding related complications needs to be weighed up against the increased risk of thrombotic events if anticoagulants are altered or ceased. There is literature reporting the safety of hand, skin, eye and dental surgery on patients taking anticoagulants, and there is literature highlighting the risks associated with altering regular anticoagulant medication. However, it is common practice to cease or alter patients' anticoagulants peri-operatively for hand surgery.

We report a prospective study of 107 patients taking anticoagulants who underwent 121 hand operations from December 2005 to August 2009. There was only one significant complication, that being a haematoma which occurred in a patient taking clopidogrel. We conclude that interruption to therapy with warfarin (provided the INR is not greater than 3.0), clopidogrel or clopidogrel with aspirin is unnecessary for patients undergoing hand surgery.

Some tumors or tumorous conditions causing posterior interosseous nerve palsy are well documented, but myositis ossificans causing the palsy of this nerve has not been described. We present a case of posterior interosseous nerve palsy caused by myositis ossificans of the supinator muscle.

This is the first report in the literature of a patient treated with a DRUJ replacement after Sauvé-Kapandji procedure failed due to pain and instability. The DRUJ replacement is an unconstrained, biomechanically more advantageous implant which can confer stability in cases where soft tissues are inadequate. We describe the treatment and outcome of persistent ulnar instability with a distal radio-ulnar joint replacement following failed salvage procedures for a malunion of a distal radius fracture.

We report a case of injury, simultaneous fractures of scaphoid, distal radius and radial head. It was treated by fixation operatively, and then early active range of motion exercise was started.

Benign fibrous histocytoma of bones is a very rare tumour and only a few cases have been reported. We report a case of 40-year-old patient with no significant previous medical history who presented with a painful lesion in his right wrist joint. Incision biopsy was done and there was a histological picture similar to a metaphyseal fibrous defect (non-ossifying fibroma). This was managed with excision of the lesion and filling the defect with cancellous and cortical bone grafts from the left iliac bone. To our knowledge, this is the second case report of a benign fibrous histocytoma involving the distal radius in adult. In this case report, we review similar cases in the literature and discuss the differential diagnoses of this lesion.

Acute cutaneous leishmaniasis is a parasitic infectious disease prevalent in tropical areas. Most doctors in non-endemic countries are not familiar with this disease. Spontaneous tendon ruptures occurring by different mechanisms have been described in the literature but a tendon rupture caused by a skin ulcer secondary to a parasitic infection has not been reported before. In this article clinical and diagnostic features of cutaneous leishmaniasis are reviewed and a case with spontaneous extensor tendon rupture due to cutaneous leishmaniasis is presented.

Triggering of extensor pollicis longus (EPL) tendon is an uncommon phenomenon with a few reports in the previous literature. Because of its rarity, the recommendations for management are sparse. We report a case of triggering EPL tendon secondary to the tendon nodule in a 42-year-old woman treated with the surgical decompression. The intraoperative findings, surgical technique and outcome of this case are described.

We present here two cases wherein we performed radiolunate fusion using vascularized radius graft with the vascular pedicle of the fourth extensor compartment artery (fourth ECA) for the treatment of Bain's grade 2A Kienböck disease with incongruity of the radiolunate joint. The dorsodistal radius graft was levered out and mobilized on the pedicle of the fourth ECA; then the vascularized dorsodistal radius was shifted 1 cm distally and bridges were created between the radius and the lunate. The radiolunate joint was completely fused in both cases at three months after surgery. The capitolunate joint maintained congruity after surgery. The Mayo wrist score was 75 points, and the DASH (JSSH version) score for the two cases was 2.5 and 4.2 points, respectively. Radiolunate fusion using the vascularized radius bridging procedure is one of the satisfactory methods for treating advanced Kienböck disease, especially in Bain's grade 2A cases.

Mucous cysts on the fingers are commonly treated by excision followed by a rotation flap or skin graft. However, such procedures require skin donors or large incisions. Therefore, a less invasive procedure is needed. Here, we report a surgical treatment method that does not require the excision of the cyst. A skin flap was made around the cyst and raised; the pedicle of the cyst was then electrodesiccated or ligated, and the contents of the cyst were evacuated. If the pedicle could not be clearly identified, the backside of the flap was electrodesiccated to break the connection between the cyst and the distal interphalangeal joint. The skin flap was replaced and sutured. The flaps became almost normal during the follow-up period. No complications or recurrences occurred in any of the six cases that were treated. Our procedure appears to be an effective and less-invasive treatment for mucous cysts of the fingers.