Hand Surgery

We investigated nerve regeneration of rat sciatic nerves after chronic injury of 15 mm-defect by the gradual lengthening of proximal and distal nerve stumps. Thirty days after the primal injury, both stumps were grasped and lengthened at a rate of 1 mm per day using external nerve-lengthening devices for 15 days. Then end-to-end neurorrhaphy was performed. After the lengthening, both stumps were evaluated by immunohistochemical analysis. Nerve regeneration was evaluated by electrophysiological and histological studies at 12 weeks after the repair. In the lengthened proximal stump, Schwann cells and axons existed along the whole nerve stump. In the lengthened distal stump, Schwann cells exist along the overall length. The whole nerve trunk was lengthened. The nerve regeneration was comparable with the delayed end-to-end suture without nerve defect. We showed the feasibility of direct gradual lengthening of proximal and distal nerve stumps for the treatment of chronic segmental nerve defect.

Flexor tendons of white Leghorn chickens (n = 25) were used for this study. One chicken was used as a normal control (no surgery), and the remaining 24 were used for experiments. After partial tendon-severing in both legs of 24 chickens, the right and the left leg were treated differently, thereby creating two groups: Group I, in which the tenosynovium was preserved, and Group II, in which the tenosynovium was removed. Hematoxylin-eosin staining was performed to observe adhesions; immunohistochemical analysis was used to localize HA. HA production was noted in granulation tissue invading between the tendon stumps in both groups; however, HA expression in the tenosynovium was observed only in Group I where adhesion formation was minimal. The HA-producing tenosynovium plays a crucial role in preventing adhesion formation in this model of flexor tendon injuries.

Purpose: Many studies comparing the morphology of native radial head with the prosthesis have been published. However, there is limited information regarding the postoperative alignment of the articular surface following the radial head replacement. The purpose of this study is to evaluate the alteration of the end-plane angle in the modular radial head prosthesis with a press-fit cementless cylindrical stem.

Methods: The study used 36 cadaveric radii. The press-fit size prosthesis with cylindrical stem was inserted into each specimen. The end-plane angles of the radial head before and after prosthetic replacement, were measured in coronal and sagittal planes with a digital inclinometer. The data were analyzed by paired t-test.

Results: From paired t-test, there were statistically symmetrical end-plane angles before and after radial head replacement in both coronal and sagittal planes (p-value < 0.01). The mean of radial head end-plane angle alteration in the coronal plane was 3.62° (SD, 2.76°) (range, 0.3°–8.9°). In the sagittal plane, the mean of alteration was 5.85° (SD, 3.56°) degrees (range, 0.3° – 14.2°).

Conclusion: The modular radial head prosthesis with cylindrical stem is in vitro able to restore the native end-plane angles of radial heads statistically when used in a press-fit fashion.

Resection of the radial head frequently causes instability of the proximal end of the radius. To prevent this instability, we performed a stabilization technique using an anconeus muscle flap. Since 2003, six patients with radiocapitellar joint dysfunction have been treated with radial head resection combined with stabilizing its proximal end using an anconeus muscle flap. At a mean follow-up of 51 months, all patients were free from elbow pain and the mean Mayo Elbow Performance Score and the Disabilities of the Arm, Shoulder and Hand score significantly improved. Radiographic findings showed no apparent instability of the proximal radius. The anconeus is useful as a reliable muscle flap for preventing instability of the proximal radius after a radial head resection. This procedure does not require any microvascular techniques and makes it possible to apply a pedicled muscle flap using a relatively simple technique without any considerable risks of elbow dysfunction.

Radial head dislocation secondary to obstetric brachial plexus palsy is a rare complication that may occur a few years after birth. Five cases were examined and a comprehensive literature search was performed. Although it is a concern for parents, the dislocation resulted in mild or minimal functional impairment for all five children. Surgical interventions such as biceps tendon transfer, radial head open reduction or excision and annular ligament reconstruction were largely ineffective in significantly improving ranges of motion. Clinicians should be aware of the potentially futile outcomes and risks associated with the surgical treatment of radial head dislocation.

Purpose: To report the epidemiology, mechanism, anatomical location, distribution, and severity of open extensor tendon injuries in the digits, hand, and forearm as well as the frequency of associated injuries to surrounding bone and soft tissue.

Methods: Retrospective chart review was conducted for patients who had operative repair of open digital extensor tendon injuries in all zones within an 11-year period. Data was grouped according to patient characteristics, zone of injury, mechanism of injury, and presence of associated injury. Statistical analysis was used to determine the presence of relevant associations.

Results: Eighty-six patients with 125 severed tendons and 105 injured digits were available for chart reviews. Patients were predominantly males (83%) with a mean age of 34.2 years and the dominant extremity was most often injured (60%). The thumb was the most commonly injured (25.7%), followed by middle finger (24.8), whereas small finger was least affected (10.5%). Sharp laceration was the most common mechanism of injury (60%), and most of these occurred at or proximal to the metacarpophalangeal joints. Most saw injuries occurred distal to the metacarpophalangeal joint. Zone V was the most commonly affected in the fingers (27%) while zone VT was the most commonly affected in the thumb (69%). Associated injuries to bone and soft tissue occurred in 46.7% of all injuries with saw and crush/avulsions being predictive of fractures and damage to the underlying joint capsule.

Conclusions: The extensor mechanism is anatomically complex, and open injuries to the dorsum of the hand, wrist, and forearm, especially of crushing nature and those inflicted by saws, must be thoroughly evaluated. Associated injuries should be ruled out in order to customize surgical treatment and optimize outcome.

Background. Recent medical advancements in the treatment of rheumatoid arthritis (RA) can prevent joint damage and tendon involvement. The authors evaluated patterns of extensor tendon ruptures in RA patients that presented to hand surgeons over a recent five-year period.

Methods. Medical records and radiographs were retrospectively reviewed, and telephone interviews were conducted with 38 patients that had experienced extensor tendon ruptures in a rheumatoid hand during the study period and were operated on at one of five tertiary referral hospitals in South Korea. Patterns of tendon ruptures were compared in patients that did or did not receive medical treatment.

Results. Twenty-nine of the 38 patients (76%) had tendon ruptures in more than two digits. When multiple digits were involved, mean duration between first and latest rupture was 2.9 months. When patients treated with medications by rheumatologists (24 patients) were compared with those not treated (14 patients), no significant differences were found for; number of ruptured tendons, time from first to last rupture, disease duration, or radiographic RA severity.

Conclusions. RA patients who once experienced a tendon rupture are still at risk of sequential tendon ruptures despite recent advancement of medical treatment. Education of the risks of sequential tendon ruptures and timely consultation to hand surgeons continue to be necessary in RA patients.

The purpose of this study was to evaluate the radiographic changes of the carpus for rheumatoid wrists in patients who underwent the Sauvé-Kapandji procedure by examining the clinical results and comparing pre- and postoperative radiographic measurements. We studied 43 wrists in 37 patients who showed vertical laxity in the radiocarpal and midcarpal joint on preoperative carpal stretch test. Pain was improved in all patients and the forearm rotation angles of the wrist were significantly improved after the operation. The carpal collapse ratio was significantly reduced after the operation. The carpal collapse reduction rate was significantly greater in the group with than that in the group without midcarpal joint vertical laxity on the carpal stretch test. Although the Sauvé-Kapandji procedure was not sufficiently effective in preventing carpal collapse, it did have a protective effect against ulnar carpal shift. The results of our study showed that vertical laxity of the midcarpal joint was the risk factor of the carpal collapse after Sauvé-Kapandji procedure.

Little finger metacarpal fractures are the most common type of metacarpal fractures and the treatment is quite variable as it is a multifactorial entity comprised of subcapital, metacarpal shaft and base fractures. These fractures are common presentations in the fracture clinics and the general orthopaedic surgeons treat them until a complex case warrants specific decision making by a hand surgeon. The management of many of these fractures is still a matter of debate and differ widely in the various parts of the United Kingdom. The aim of this study was to investigate the current practice of little finger metacarpal fractures among upper limb surgeons in the UK. We conducted an online survey among 278 upper limb orthopaedic specialist surgeons throughout the UK. Our response rate was 58%. There are various factors which dictate the treatment as suggested by these respondent upper limb consultants. For example, for fifth metacarpal neck fractures, it was generally recognised that 43% of upper limb surgeons prefer neighbour strapping alone for non-operative management of little finger metacarpal fractures. For little finger metacarpal shaft fractures, 39.3% of surgeons suggested that they would contemplate intervention, i.e. manipulation under anaesthesia/surgery if beyond 30° of volar angulation is present. For little finger metacarpal neck fractures, 33.7% would only consider surgical intervention beyond 60° of volar angulation. 91.6% of upper limb specialists agreed that they would operate on little finger metacarpal base fractures only if it was a fracture dislocation, while 71.8% suggested that they would proceed to operate on even a pure dislocation. We have illustrated the various permutations and combinations of these fractures with the results of our survey in this article in detail. The vast majority of metacarpal bone fractures are stable and treated conservatively. The different types of injury patterns must be recognised by the orthopaedic surgeons and appropriate treatment then should be executed to serve the patient optimally in due course.

Ten consecutive patients with digital enchondroma were treated by curettage and calcium phosphate bone cement (CPC) injection under digital nerve block. Mean patient age at surgery was 39 years old (range, 26–54), and the mean follow-up period was 19 months (range, 12–31). Two patients had a pathologic fracture at the first visit. Active finger motion was allowed at three days postoperatively and all patients returned to work within four weeks of surgery. The surgical procedures were uneventful in all patients, and no complications were encountered during follow-up. The mean total arc of motion of the PIP joints and MP joints of the affected fingers was 93% of and 99%, respectively, of the arcs of the corresponding joints of the contralateral unaffected fingers at final follow-up. CPC injection is a good option for the treatment of enchondroma of the finger.

We recently developed continuous negative pressure therapy with irrigation (NPI) and successfully applied it to an infected digit with a narrow wound. With this technique, however, the dressing circumferentially wraps the digit or hand, and the pressure that the digit or hand receives and the influence on peripheral circulation are unclear. In this report, we evaluated the external pressure that a digit and hand received during NPI in vitro. Under circumferential NPI dressing, the skin perfusion pressure (SPP) of the peripheral portion was measured. Pressure was maintained at 1.3 mm Hg, and suction pressure ranged from -50 to -200 mm Hg. The pressure that a digit or hand receives during NPI is much lower than that at which tissue may be damaged (40–50 mm Hg). The SPP of the peripheral portion was much higher than 40 mm Hg, which is the pressure at which wound healing may be predicted. In clinical cases, NPI has been useful for wound bed preparation.

For reconstructing an injured fingertip, a reverse pedicle digital island flap can restore excellent function and appearance. However, postoperative flap congestion may lead to flap necrosis. We tested a method for dissecting the vascular pedicle to prevent congestion and to provide more reliable results. Between August 2002 and December 2010, we reconstructed 14 fingertips in 13 patients (average age, 43 years; range, 24 to 68 years; 9 men). Through a small zigzag incision, the digital artery and a 4-mm-wide subcutaneous venous network were elevated in retrograde fashion to facilitate venous drainage. All flaps healed completely without severe congestion or necrosis. Slight flexion contractures remained in the PIP (mean, 12°) and DIP (mean, 14°) joints. Our procedure is simpler and more reliable than other techniques, such as adding a narrow skin bridge to the pedicle or a venous anastomosis to prevent venous congestion, and it assures the survival of the flap.

Ulnar nerve entrapment at the elbow is the second most common upper limb entrapment neuropathy other than carpal tunnel syndrome. There have been many causes identified ranging from chronic aging joint changes to inflammatory conditions or systemic disorders. Among them, uncommon anatomical variants accounts for a small number of cases. Here, we report our experience in managing ulnar nerve entrapment caused by a rare vestigial structure, anconeus epitrochlearis ligament, and provide a brief review of the literature of its management.

Arthrogryposis is a syndrome of multiple joint contracture and subluxation that is present at birth and is characterized by a nonprogressive disorder. Patients with lack of active elbow motion show the typical elbow motion with passive assistance, such as the trunk-sway and cross-arm techniques. We describe our experience with the treatment of an arthrogryposis patient with cubital tunnel syndrome caused by the passive elbow motion. The ulnar nerve was entrapped by a thick fibrous band at the cubital tunnel, and simple decompression of the ulnar nerve brought the patient a good recovery from the palsy.

Calcium pyrophosphate dihydrate deposition disease typically involves the wrist joint in the form of calcifications of the triangular fibrocartilage and the distal radioulnar joint. We describe an 87-year-old male who presented to us with asymptomatic form of deposition with multiple flexor tendon calcifications causing chronic median nerve compression. Simple carpal tunnel decompression relieved his median nerve symptoms.

A case of radial and volar perilunate trans-scaphoid fracture dislocation in which the proximal fragment of the scaphoid was dislocated dorsally is presented.

The occurrence of osteoid osteoma of the carpus is rare, particularly of the trapezoid. We present a case of a ten-year-old girl with osteoid osteoma of the trapezoid in whom surgical excision of the lesion was successful. Useful information for the diagnosis of the lesion was mainly provided by dynamic magnetic resonance imaging.

A 73-year-old female suffered spontaneous rupture of the extensor pollicis longus (EPL) and extensor pollicis brevis (EPB) tendons, for which she presented for treatment three to four weeks later. At that time there was no active metacarpophalangeal (MCP) or interphalangeal (IP) extension, leading to severe functional impairment of her hand. Since both the EPL and the EPB tendons were ruptured, transfer of the extensor indicis proprius (EIP) tendon was carried out for the EPL and transfer of the accessory abductor pollicis longus (AAPL) was carried out for the EPB. After a three-month period of follow-up, the thumb motion was restored and the patient was able to resume all activities of daily living. Although concomitant spontaneous rupture of both the EPL and the EPB is rare, transfer of the EIP and the AAPL tendons, respectively, seems to be the treatment of choice for anatomic reconstruction of such injuries.

In patients presenting to our unit with recurrent or aggressive Dupuytren's disease (DD), we favour the technique of radical excision and resurfacing popularised by Logan, who has described its use for the ulnar two digits of the hand at the same operation.¹ In patients in whom dermofasciectomy may be indicated in three or more digits, we have previously advised patients that the quality of the surgical attention and the post-operative physiotherapy might be better delivered by a staged approach. However, we demonstrate here with a case report that the technique can have excellent outcome when used for three digits at the same time. We are unaware of similar previous reports.

An unusual case of suppurative tenosynovitis involving all five digits up to distal forearm in a 20-year-old male with no known risk factors is reported. We highlight the strategy of extensile skin incisions from the wrist to all five digits that allowed flexor sheath debridement, synovectomy, and infection resolution without causing skin flap ischemia. At three months, total active motion of 70% of contralateral hand was achieved.

We report an unusual case of proximal interphalangeal joint locking of the ring finger due to the neglected flexor digitorum profundus avulsion. Although rare, it should be noted that locking is a potential complication after this injury.

Traumatic metacarpophalangeal joint (MCPJ) volar plate attenuations are often managed non-operatively in adults. However, the management of these situations in children is a less commonly encountered challenge. We present a systematic review of the evidence describing the management of these injuries in the paediatric population. We also present our experience of managing painful thumb MCPJ volar plate attenuation in three children who presented to a single UK hand unit.

Hand tumors are not common and a swollen finger poses considerable diagnostic dilemma. We present a case of a middle-aged farmer who had presented with a painless swelling of the middle finger of the right hand without any neurovascular deficit or evidence of metastasis. An X-ray of the finger showed cortical expansion and bony erosion of the proximal phalanx. A fine needle aspiration cytological examination was inconclusive. He underwent a digit amputation in view of subsequent morbidity and chances of recurrence following local excision. Biopsy proved it to be a giant cell tumor of the proximal phalanx. Following six months of treatment he is doing well. We herein highlight an unusual tumor of the finger and its diagnostic and treatment challenges.

We report a 75-year-old man who presented with a painless friable mass in the index finger pulp mimicking pyogenic granuloma. Complete excision of the mass was done. The radiological and the histopathological findings suggested giant cell tumor of the tendon sheath. The patient had no recurrence at the end of a two-year follow-up. This unusual clinical presentation of the giant cell tumor of the tendon sheath was our study base and adds up to its variant presentation in the literature.

This case report demonstrates and emphasises the unusual radiographic appearance of silver nitrate treatment in a 30-year-old patient, who subsequently underwent excision biopsy of a presumed potentially malignant lesion.

Hepatocellular carcinoma (HCC) is a common cancer with a high rate of metastasis to sites, such as, lung, bone, and regional lymph nodes. However, metastasis of HCC to the hand is rare and the majority of reported cases involve hand bones. Here, the authors report a rare case of finger skin metastasis from HCC without bone involvement. This case highlights that patients presenting with a nodule or granuloma-like tumor of the hand should generate a suspicion of metastasis when there is a history of HCC.

Digital finger amputation with soft tissue injury is a frequent accident in Reconstructive Surgery. Several techniques about reconstruction of digital finger amputation are described in literature. However replantation is difficult when large segments of the arteries are missing. This is especially true for distal finger phalanx amputations, where replantation is done in selected patients such as artists or musicians. In this article a microsurgical replantation techniques of a distal artery and proximal vein anastomosis is presented in a distal phalanx amputation, which successfully solved the problem of venous reflux without venous anastomosis.

Dystrophic nail changes without a skin lesion is a rare form of psoriasis. We describe a patient that presented with a chronic nail onychomycosis and a destructive thumb interphalangeal joint which was initially considered as onychomycotic joint infection, and was later diagnosed as having dystrophic nail changes in psoriatic arthritis and coexistent onychomycosis. The nail changes were completely normalized after methotrexate treatment.

Four-corner fusion is an accepted surgical treatment for established SLAC and SNAC wrist. We describe a technique of bone grafting to be used in conjunction with any of the standard fusion techniques. A step by step, illustrated approach allows the easy placement of an autograft which is in contact with all surfaces of the bones involved in the fusion.

Fingertip amputations can lead to both functional and aesthetic problems. We present the results of our preferred technique to address fingertip amputations in zone 1 and zone 2 which have been deemed non-replantable by microsurgery. It is based on the "reposition technique" described by Dubert et al. in 1997¹ and the free perionychial graft technique suggested by Netscher and Meade in 1999.² The technique that we prefer is best described as a combination of an advancement flap and a composite graft. So far seven patients have been treated with this method and our results have been satisfactory in all of them. It is a simple and quick technique that does not require advanced skills and can be done by a well-trained resident or fellow. It allows preservation of finger length, retains the nail and is functionally and aesthetically pleasing.

There is no consensus regarding the optimal mode of managing the acute traumatic subungual haematoma in the hand. In this context the medical literature was searched systematically and the results analysed. The final dataset consisted of four articles. The complication rates of all forms of treatment were low. The outcome in terms of nail cosmesis was generally good, although the method of outcome measurement was variable in nature. There was no difference in cosmetic outcome when comparing nail bed repair with simple decompression. In conclusion the outcome in terms of nail cosmesis does not appear to be affected by the mode of treatment. The acutely painful subungual haematoma should be decompressed, whether this be done by trephining or nail removal. Future research includes the potential for a randomised controlled trial to compare nail bed repair with trephination.