Hand Surgery

We investigated the neuropathy induced by leg lengthening histological evaluation using teased nerve fiber specimens and electrophysiological evaluation. Indirect elongation of the sciatic nerve associated with leg lengthening was performed at 1 and 3 mm/day over 30 mm in rats. Electrophysiological evaluation was performed immediately and 60 days after the end of elongation, teased nerve fiber specimens were prepared, and the mean axonal diameter was calculated. The electrophysiological results were more wrong, and the recovery was poorer, in the 3-mm than in the 1-mm group. In the 1-mm group, the nerve conduction velocity (NCV) and the duration of the compound nerve action potential (C-NAP) recovered to a level close to the intact side, but the decrease in the amplitude of the C-NAP persisted. In the teased fiber study, while paranodal demyelination was observed in both groups immediately after elongation, demyelination was decreased in the 1-mm group indicationg recovery compared to the 3-mm group. Paranodal demyelination caused by indirect nerve elongation is considered to have induced electrophysiological disorders.

Electrophysiological and morphological damages appeared to be more severe according to elongation speed. The nerve disorder were remained even at 1 mm per day in 60 days.

Volar locking plates are increasingly used in the management of distal radius fractures. As with any new implant, understanding the rate and type of potential metalwork related complications is important. In this study, we reviewed 114 distal radius fractures treated with volar locking plating. Our aim was to determine the type and rate of metalwork complications requiring reoperation. In our series, 12 cases (10%) underwent further surgery for metalwork related complications mainly for screw protrusion into the radiocarpal joint following fracture collapse. Our results suggest that volar locking plates are associated with a high rate of metal work related complications requiring further surgery. Technical aspects to reduce such complications are discussed.

Introduction: The distal radioulnar joint (DRUJ) is commonly affected in rheumatoid arthritis and is associated with significant functional morbidity. The aim of our study is to review our results with matched hemi-resection interposition arthroplasty in patients with DRUJ arthritis.

Methods: This was a retrospective study of 39 patients with 51 wrists that were treated at Queen Mary Hospital in Hong Kong from 1989 to 2007. All patients underwent matched hemi-resection interposition arthroplasty and dorsal wrist synovectomy. Long arm hinged elbow brace was used for three weeks followed by intensive rehabilitation up to twelve weeks. The indicators of outcome included range of motion assessment, pain, wrist stiffness, grip of strength and need for revision assessed during follow-up. Statistical analysis was performed with student t-test.

Results: The average age of patients was 50.5 years (25 to 77 years) and there was a 35:4 female to male ratio. The average follow up was 4.5 years ranging from 1 to 18 years. Associated extensor tendon ruptures were found in 31.4% patients. The average increase in supination was from 73 degrees preoperatively to 81 degrees at long term follow up (p = 0.10 at 1 year and 0.13 at long term follow-up). The average increase in pronation was from 68 degrees preoperatively to 74 degrees on long term follow up (p = 0.57 at 1 year and 0.02 at long term follow-up). There was evidence of painless, relatively stiff but functional wrist in 37.25% of patients. There was an increase in grip strength from an average of 6.1 kilogram force preoperatively to an average of 11.5 kilogram force at follow-up (p = 0.004 at 1 year and 0.15 at long term follow-up). Complete relief of ulnar sided pain was seen in 43 wrists (84%), partial relief was seen in 7 wrists (13.7%) and no relief was found in one wrist (1.9%).

Conclusions: DRUJ arthroplasty is a rewarding procedure and most of the patients obtain pain free movement.

Kienböck's disease is known for its difficulty in being diagnosed and treated at early stages; option treatments are few and most of them quite aggressive. The author describes his experience with arthroscopic assisted lunate bone grafting. Three patients with diagnosis of stage I avascular necrosis of the lunate (average age: 45 years), were treated. Before surgical procedure, the patients underwent to a conservative treatment. After harvesting the bone graft from the volar surface of the radius, arthroscopic bone grafting was performed.

At an average follow-up of 13.5 months (9–15), all the patients show a normal density of the lunate and no arthritic changes in radiographs. The MRI confirmed the lunate vascularity.

The number of patients is definitely small, due also to the rarity of the disease and the difficulty in diagnosis, but, despite the very high learning curve, could be the proper first choice of treatment.

Zone two flexor tendon repair remains challenging with significant outcome variation using recognised techniques. Tendon adhesion formation results in poor outcomes and rehabilitation regimes aim to limit this. Some repairs augment strength, but increasing bulk mitigates against movement. This novel epitendinous technique causes tendon inversion with potential gliding benefits and improved outcomes.

60 porcine tendons were randomised to a 2-stranded modified Kessler or a 4-stranded Adelaide repair, then sudivided into three different circumferential technique groups: locked running, Silfverskiold, or a new inverting repair. Tendon load to failure (LTF), 2 mm gap formation, bulking effect and method of failure were analysed during digital tensiometry.

Four-stranded repairs demonstrated better LTF than 2-stranded techniques. The inverting epitendinous and Silfverskiold repairs showed higher LTF characteristics than the locked running suture, and better tissue holding capacity.

The inverting repair has similar properties to commonly used suturing methods and the conformation creates a smooth inverted repair.

We present an operative technique and the results of intramedullary fixation of proximal phalangeal shaft fractures through a volar extra-tendon sheath approach. A J-shaped nail, which is a curved Kirschner wire sharply bent at the proximal end, was inserted from the palmar aspect of the proximal phalangeal base. Six fingers of the six patients (all male) were treated with this method. The mean age of the patients was 51 years (range, 20–69 years). There were four open and two closed fractures. All fingers attained successful fracture union and one of them had correction loss. No patient complained of pain at the final follow-up, and the average of total active motion was 223° (190° – 255°). This method may be an alternative for treatments of the proximal phalangeal shaft fractures because of its less invasive nature, although it does not offer anatomical reduction.

Giant cell tumours of tendon sheath of hand present a surgical dilemma due to their high incidence of local recurrence. We present a case series of 46 patients with 47 histologically confirmed giant cell tumours of tendon sheath over a ten-year period from 1998 to 2008. The mean follow-up was 47 months (range 25–124 months). We identified tumours with bony erosions and piecemeal resections as predictors of recurrence. Our recurrence rate of 9% was at the lower end of spectrum of previously published reports (range 7%–44%). We recommend "en-masse" excision of these tumours. All the patients with suspicion of these tumours should have preoperative radiographs to identify erosions. A thorough curettage of the bone should be done in cases with osseous erosion to prevent recurrence. Patients with these risk factors should be followed up annually for five years and be warned about recurrence.

Three cases are presented in which neurosurgical reconstruction of a Neonatal Brachial Plexus Palsy was combined with orthopaedic reconstruction of a posterior glenohumeral dislocation. The authors believe that a combined procedure is indicated if the neurological deficit meets the criteria for neural reconstruction and the complication of a posterior glenohumeral dislocation has occurred prior to nerve surgery. Two children with C5–6 lesions and a third child with a pan-plexus lesion obtained good shoulder function following the combined reconstruction.

A rare case of neurogenic thoracic outlet syndrome secondary to subacute osteomyelitis (SOM) of clavicle is presented. It was treated successfully with scalenectomy combined with clavicle and first rib resection and reconstruction of the clavicle using vascularised seventh rib transfer. Various issues involved in the diagnosis and management of such a case are discussed.

Permanent nerve palsy is an extremely rare but critical complication after embolotherapy of arteriovenous malformations of the extremities. The authors present a case of permanent ulnar nerve palsy after embolotherapy of an arteriovenous malformation around the elbow, and caution that transcatheter embolotherapy of arteriovenous malformations located close to major neurovascular structures must be carefully planned and individualized.

We report a case of spontaneous partial posterior interosseous nerve palsy where the ganglion adjacent to the nerve was not the main cause of the compression. Instead, a thick fascial band deep to the distal edge of the supinator was found responsible. This case illustrates the importance of completing the nerve exploration to fit with the clinical picture.

We describe here an unusual case of volar dislocation of the radiocarpal joint due to a complete tear of the dorsal radiocarpal ligament. Plain radiographs taken at initial presentation did not reveal any obvious abnormality. There was no associated bony lesion or intrinsic wrist ligament injury. Radiocarpal dislocations should be considered in the diagnosis of high-energy wrist injuries, even when initial radiographs look normal. The importance of a high index of suspicion in high velocity wrist injuries and need for further evaluation and imaging is highlighted.

Wrist arthroscopy has been successfully used with many modifications and improvements. However, distal radioulnar joint (DRUJ) arthroscopy is still uncommon. We experienced 2 cases of ulnar-sided wrist pain due to isolated triangular fibrocartilage complex (TFCC) disk tear within the DRUJ. DRUJ arthroscopy in these cases showed horizontal tear and fibrillation of TFCC disk without TFCC tear at the radiocarpal joint. Foveal attachment was intact in both cases. These were treated with debridement, which relieved pain after surgery and achieved good functional recovery. Although DRUJ arthroscopy is technically difficult, it is mandatory for making a diagnosis and treating ulnar-sided wrist pain.

Osteochondroma rarely develops from the carpal bones. We report a first case in which a dorsal osteochondroma of the lunate caused attritional rupture of the tendon of the extensor indicis proprius and a tendon of the extensor digitorum communis of index finger.

Isolated trapezoid fractures are rare. We present a case of severe isolated trapezoid fracture associated with bone loss and proximal migration of the second metacarpal, which was treated successfully by open reduction and internal fixation with bone grafting and joint fusion.

We report a case in which simultaneous flexion of the thumb, index and middle finger occurred 6 months after the surgical reconstruction of the adductor (AM) and first dorsal interosseous (IO) muscles. An anomalous connection in the form of tendon slip associated to fibrous adhesions between the flexor pollicis longus (FPL) tendon, flexor digitorum profundus indicis (FDPI) and middle finger (FDPM) tendons were found. Either ultrasound (US) examination or magnetic resonance imaging (MRI) were unable to detect the site of adhesion. Excision of the slip and radical tenosynoviectomy led to early functional recovery.

Finger extensor tendon dislocation at the metacarpophalangeal joint is caused by various etiologies, such as trauma, congenital anomaly, or rheumatoid arthritis. When the dislocation occurs with no etiology, this is called spontaneous dislocation. Although spontaneous extensor tendon dislocation in one, two or three fingers has been described, to our knowledge, simultaneous dislocation in four fingers has not been reported. In this paper, we report a spontaneous ulnar dislocation of all the extensor tendons in the index, long, ring, and small fingers. Repair of the radial sagittal bands of the extensor digitorum communis of the middle and ring fingers reduced dislocation of all the extensor tendons in four fingers.

We treated a rare case of locked metacarpophalangeal joint of the little finger due to a hyperextension injury. The mechanism of the occurrence was considered to be closely similar to those that happened in the thumb, and the locking was successfully released by a manual reduction without complication.

Secondary chondrosarcomas according to malignant transformations of the solitary enchondromas were extremely rare in the hand.

The aim of this study is to present a case of a 43-year-old male having rare malignant transformation of the solitary enchondroma treated with total excision and replacement with iliac bone graft.

We report a case of avulsion of the flexor digitorum profundus secondary to recurrent enchondroma. The tumor was curetted with bone grafting of cancellous bone from the distal radius, and the fragment avulsed by the flexor digitorum profundus tendon was fixed to its original site using a pullout suture through the distal phalanx to the nail. The lesion healed and function recovered 6 years after surgery.

Congenital duplication of the thumb is usually reconstructed by 18 months of age. This paper reports satisfactory outcome following reconstruction of two Wassel Type IV duplicate thumbs in adults aged over 40. Both achieved a good outcome based on Tada's criteria and a subjective Visual analogue score 8.

We present a hitherto unreported condition of a bipartite distal phalanx in a child. The condition mimics a fracture and may even lead one to suspect a non-union. Potential pitfalls of such a mistaken diagnosis can include unnecessary splinting or even surgery. This could potentially cause injury to the growth plate with resultant growth arrest. Careful clinical and radiographic examination of both hands combined with an awareness of this condition can help avoid such problems.

Prophylactic plating of donor site in osteocutaneous radial forearm free flaps have demonstrated improvement in fracture rates. Previous series used conventional plating systems which rely on plate-bone friction forces to generate stability and can result in iatrogenic fractures if not accurately contoured. Locking plates have superior stability and do not require contouring. This retrospective series reports our experience using locking plate fixation augmented with calcium phosphate mineral cement. Twenty patients' records were reviewed; 13 were alive and reviewed clinically. Mean radiological follow-up was 28.2 months. Two deceased patients had donor site fractures diagnosed on the first postoperative radiograph. These fractures were related to technical fixation errors and failure to apply correct locking fixation principles. None of the other patients with proper locking fixation had fractures or metalwork related complications. We believe that locking fixation augmented with mineral cement can provide more biological stability and enhance restoration of bone structural strength.

Distal radius fracture alignment and stabilization can be a surgical challenge in the face of severe comminution and bone loss. We describe a technique using a calcium phosphate/sulfate bone cement, as an adjunct to internal fixation. This bone cement is biocompatible, osteoconductive, and sets quickly with an isothermic reaction. The use of bone cement eliminates the need for primary autologous bone grafting and allows for easier reduction and retention of reduction at the time of surgery. Bone cement is employed for the following purposes in comminuted fractures: (1) to fill a void due to lost or crushed cancellous bone, (2) to hold larger unstable fragments while hardware is placed, and (3) to retain fragments too small to take hardware. Available bone cements, studies involving the use of bone cement for distal radius fractures, indications, and surgical technique will be reviewed.

We report a novel method of debridement for penetrating trauma to the hand involving bone using a sterile hand drill. This provides a means for adequate clearance of debris which may otherwise be left in-situ due to poor access to the contaminants when conventional techniques of debridement are used.