Hand Surgery

Surgical repair is advocated for partial flexor tendon lacerations deeper than 70%. We compared gliding resistance with three different peripheral repairs in partial flexor tendon lacerations. Thirty flexor tendons and A2 pulleys were harvested from turkey toes. Gliding resistance was measured for all intact tendons. The tendons were then lacerated to 50% and repaired with a modified Kessler core suture and either a Silfverskiold or Halsted repair or a simple running suture and gliding resistance was measured. Compared to the intact tendon, the increase in gliding resistance after surgical repair was 100% with the Halsted repair, 80% with the Silfverskiold repair and 60% with a running suture (p = 0.05). In conclusion, a simple running suture caused less resistance to gliding compared to the other techniques when repairing partial flexor tendon lacerations and we recommend its use when surgical repair is needed.

Supracondylar fractures of the distal humerus are a common and serious paediatric injury, often accompanied by neurovascular compromise. Accurate neurovascular evaluation of the injured limb is essential in order to guide emergent treatment. To assess whether trainees are proficient in the assessment and management of supracondylar fractures, performance was audited against objective standards drawn from the literature.

The purpose of this study is to identify a possible correlation between statin administration and incidence of spontaneous distal biceps tendon ruptures. We retrospectively reviewed 104 patients with distal biceps tendon rupture that were treated surgically from 2004 to 2010, 102 males and two females with mean age 47 years (range, 22–78). Patients were divided based on the mechanism of injury and statin administration. After statistical analysis, it was found nearly two times more likely to have spontaneous distal biceps tendon rupture with use of statins. Patients in Group 1 (spontaneous tendon rupture) compared to Group 2 (provoked tendon rupture) were older, had weaker postoperative strength but similar postoperative ROM. Patients taking statins compared to those that were not taking statins were older, had same postoperative strength and similar postoperative ROM. Based on the results of our study we conclude that there is a trend of association of spontaneous distal biceps tendon ruptures with statin administration.

The objective of this study was to compare the clinical results of unstable distal radius fractures treated with ORIF with plate and screws compared to EF. Patients with unstable distal radius fractures treated with ORIF or EF from January 2005 to December 2010 were reviewed in terms of the Modified Mayo Wrist Score, range of motion, pain, grip strength, and radiologic parameters. Results showed that there was no difference in the Modified Mayo Wrist Score between ORIF (17 patients) and EF (11 patients) (p = 0.07). The ORIF group had better wrist flexion, wrist extension, pronation and supination compared to the EF group (p < 0.05). There were no significant differences in terms of radial and ulnar deviation, grip strength, pain and postoperative radiologic parameters (p < 0.05). Better wrist flexion, wrist extension and forearm rotation can be expected in ORIF compared to EF in the management of unstable distal radius fractures.

The purpose of this study was to evaluate the treatment results, with and without internal fixation of ulnar styloid base fractures associated with acute distal radius fractures. A total of 48 patients were enrolled, including 20 patients treated by internal fixation (fixation group) and 28 treated without internal fixation (non-fixation group). The evaluated parameters were postoperative range of motion, grip strength, DASH score, and the presence or absence of ulnar wrist pain over time. The outcome was assessed as "excellent" in 15 patients of the fixation group and 21 patients of the non-fixation group, and "good" in five patients of the fixation group and seven patients of the non-fixation group. There were no significant differences in the clinical outcomes or any of the parameters at the final evaluation between the two groups. However, the grip strength was significantly better in the non-fixation group than in the fixation group until 12 weeks postoperatively. The overall clinical outcome was good in both groups, with no significant difference between the groups.

We demonstrate various patterns of traumatic triangular fibrocartilage complex (TFCC) tears including some atypical that cannot be categorized under Palmer's classification. TFCC traumatic tears in 173 wrists were examined arthroscopically or macroscopically and divided into disk tears (subdivided into four types: slit tear, flap tear, horizontal tear and tear within the distal radioulnar joint) and peripheral tears (subdivided into six types: ulnocarpal ligament tear, dorsal tear, radial tear, ulnar styloid tear, foveal tear and distal radioulnar ligament tear). Combinations of these types were found in 32 wrists. Wrist arthroscopy revealed various traumatic TFCC tears that do not come under Palmer's classification; therefore establishment of a new classification for traumatic TFCC tears seems to be warranted.

We report outcomes and learning points from flexor sheath infection (FSI) cases presenting over one year to a United Kingdom (UK) hand unit.

Between August 2009 and August 2010, 16 FSIs were confirmed from operation note findings. Patient age ranged from 12 to 82 years. All patients were posted a quickDASH questionnaire. In all cases, surgery was performed within 24 hours, via distal and palmar incisions, with 0.9% saline irrigation. Seven patients (44%) responded to questionnaires. Of these, most achieved a good functional outcome, with a mean quickDASH of 7.14. Four cases (25%) had no triggering event. Beta-haemolytic streptococcus was cultured in three cases (18%). Its presence was significantly associated with a requirement for multiple operations (p < 0.032), and with prolonged admission of up to nine days (p < 0.009). We suggest that close liaison with microbiology services and early identification of beta-haemolytic streptococcus may predict the need for multiple washouts in FSI.

"Occupational overuse syndrome" is defined as the syndrome of work-related musculoskeletal disorders resulting from repetitive hand posture and motion. We looked at 867 employees in seven different factories to determine the groups suffering from trigger fingers, de Quervain's disease and carpal tunnel syndrome (CTS) from the period of January 2009 to November 2010. The inclusion and exclusion criteria were designated for the subjects in each group. We found the highest prevalence of the syndrome in the rate of CTS development. The differences in the hand spans and the grip strengths between the normal versus the diseased groups were statistically significant. The most common work patterns were a repetitive workload with the hand in a posture of a contracted grasping position. This accounted for 43.1% of the cases of trigger fingers, 38.1% in cases of CTS and this position with a contributing increased speed in the work pattern at 29.8% in the de Quervain's disease patients.

Ehlers-Danlos syndrome Type IV, the vascular type, is a rare hereditary condition. Major arteries are often affected in this type. In this paper, we present the first case report in the world in which forearm compartment syndrome caused by the bilateral ulnar artery rupture in this type. Successful treatment such as incision of the forearm fascia and ligation of the ulnar artery was performed.

We report a case of Linburg-Comstock syndrome, which is characterized with anomalous tendon slips connecting flexor pollicis longus (FPL) to the flexor digitorum profundus (FDP), usually at the index finger. The present patient started to be a carpenter and was suffering from his disability of flexing the thumb and the index finger independently when he handled the screws in his work. We surgically removed the tendinous connection of the FPL tendon and the index FDP tendon. After surgery, he could work as a carpenter without any difficulty. Surgical disconnection was effective treatment. Dynamic high-resolution ultrasound and three dimensions of computed tomography of the left distal forearm were helpful to confirm the diagnosis.

A 20-year-old man presented with an inability to flex the interphalangeal joint of the right thumb without simultaneous flexion of the distal interphalangeal joint of the index finger following a penetrating injury to the right forearm. With a clinical suspicion of intertendinous adhesions between the flexor pollicis longus and the flexor digitorum profundus to the index finger, surgical exploration under wide-awake anesthesia was performed. Intraoperatively, the intertendinous adhesions were identified and divided completely. Postoperatively, the patient achieved good, independent flexion of the interphalangeal joint of the thumb. This case demonstrates a clinical picture similar to that of Linburg-Comstock syndrome, which occurred following a forearm penetrating injury. We call this the Linburg-Comstock (LC) phenomenon.

Osteoid osteoma in the wrist and hand region is an uncommon but severely symptomatic primary bone tumour. We report the case of a professional athlete with a radial styloid osteoid osteoma who presented with significant wrist pain and stiffness resembling arthritis for which she was treated initially. The symptoms started after a fall on the outstretched hand and significant delay in the diagnosis occurred. Following detailed imaging evaluation of the tumour site excision biopsy was curative.

Osteochondromatas of bicipital tuberosity are rare, most commonly occurring as metaphyseal benign tumours of the long bones. The usual presenting symptoms are pain and reduced rotation of the elbow. A painful clunk in the wrist as a presenting symptom has not been described before.

We present a young lady with a two-year history of a painful clunk in her wrist. Her case presented a diagnostic challenge, as the pain and the click originated from her elbow and radiated down her forearm to the wrist. She underwent several radiological studies, and examination under anaesthesia confirmed the diagnosis. Excision was performed resulting in complete resolution of her symptoms.

Along with painful clunk in the wrist originating from the elbow, an enlarged radial tuberosity should raise a high index of suspicion, and MRI scans and examination under image intensification can aid in the diagnosis of radial tuberosity osteochondroma.

Primary synovial chondromatosis is a proliferation of cartilaginous bodies within the synovial membrane, tendon sheath or bursa. It is a rare orthopaedic entity especially when it occurs in the distal radioulnar joint. We report a 27-year-old man with recurrent synovial chondromatosis, nine years after his first operation. Although rare, synovial chondromatosis must be considered in the differential diagnosis in a patient with pain and swelling of the distal radioulnar joint. From our literature review, we report a 17% (5/30) recurrence rate for synovial chondromatosis involving the wrist joint which has not been documented in the medical literature previously.

Simultaneous avascular necrosis of multiple carpal bones is rare. Concomitant avascular necrosis of scaphoid and lunate has been reported only once. We report one more case of this rare condition which can be a cause of wrist pain. Steroid intake is a known risk factor for avascular necrosis but in our case the patient had been taking herbal medicines for joint pain the composition of which was not known. Probably the presence of steroid in these medicines was the cause of avascular necrosis in this case.

We herein present a case of radial wrist pain following trauma. Magnetic resonance imaging showed a large area of abnormal soft tissue in the scapho-trapezial joint. The patient was treated successfully by complete resection of the soft tissue. The soft tissue was diagnosed to be synovial fringe based on a histological study. Synovial fringe is frequently reported as a cause of knee and elbow pain, however, it is a rare cause of wrist pain at the scapho-trapezial joint.

Isolated avulsion fracture of the index finger metacarpal is rare. There have been only a few noted in the English literature. A review of literature shows that these injuries occur as a result of avulsion of the tendon of extensor carpi radialis longus. In our report we present a case of such an avulsion injury where the proximal fragment was pulled about 2 cm down. The patient was treated conservatively with early mobilisation.

The avascular necrosis of the metacarpal head is a rare disease. Therefore, although a variety of surgical treatments were performed in the sporadically published case reports, the optimal surgical treatment is still controversial. Open wedge osteotomy of the metacarpal neck was first reported in 2002. However, no other reports using the same procedure have been published. We presented 13-year-old girl case of the third metacarpal head necrosis having been treated by the open wedge osteotomy of the metacarpal neck. Four years later, she had no pain and gained full range of motion of the metacarpophalangeal (MP) joint. The plain X-rays and magnetic resonance images demonstrated sufficient bone remodeling of the metacarpal head. The open wedge osteotomy of the metacarpal neck is a useful option for the metacarpal head necrosis, especially when the dorsal articular surface of the head remains intact.

We report a case of paradoxical extension phenomenon of the little finger, so called "lumbrical plus deformity" due to repetitive trauma to the ulnar side of the palm. The adhesion between the flexor digitorum profundus tendon and the lumbrical muscle was the cause of this phenomenon. The lumbrical muscle release was sufficient to solve this rare problem.

Primary cutaneous lymphomas rarely present to the hand surgeon. Diagnosis of primary cutaneous lymphoma in the upper extremity can be difficult to make, as they are rare, and may be mistaken for other lesions. We report an unusual case of primary cutaneous lymphoma presenting in the upper extremity. This rare differential should be considered when encountered with a lump of similar appearance in the upper extremity.

Myxoinflammatory fibroblastic sarcoma (MIFS) is a rare low-grade sarcoma that occurs in the subcutaneous tissue of the distal extremities.

MIFS was first described in 1998. There are many differential diagnoses, and it can often be mistaken for several different inflammatory and neoplastic processes, which may require different treatment.

There is much literature published for pathologists, but only a few reports for orthopedic surgeons to treat such tumors.

It is significant and important to report this additional case of MIFS that occurred in the right ring finger and to acknowledge the very existence of the tumor as a differential diagnosis to be made by hand surgeons.

Hand surgeons need to be mindful of MIFS, its nature, and the appropriate treatment necessary for this unique tumor.

Masses within the fingers and hands are a common occurrence affecting patients of all ages. Although most will be benign conditions, rarer more aggressive tumours also occur. Two cases of rare hand tumours, a digital myofibroma and an aggressive digital papillary adenocarcinoma are reported here including a mini-review of the literature.

Although these two cases are quite different they highlight the importance of having a high index of suspicion for the presence of malignant change in masses that have been quiescent for considerable periods of time and thus the need for histological diagnosis in masses resected from the hands. The myofibroma, like other conditions such as giant cell tumours, although benign can have very worrying clinical features, most notably bony destruction. The aggressive digital papillary adenocarcinoma conversely can appear benign clinically but biologically is very aggressive with a high propensity for local and distant spread.

Glomus tumors are benign neoplasms that develop from normal glomus bodies. These tumors are most commonly found in the nail bed of the hands and are characterized by point tenderness, and temperature sensitivity. Histologically, they are classified into three groups, the least common is glomangiomyoma, which is a variant distinguished by its predominant smooth muscle cellular content. This report describes a patient with a subungual glomangiomyoma that was surgically excised with a favorable outcome. The tumor is unusual for this location; a location common for typical glomus tumors. It presented without the typical associated symptoms of point and temperature sensitivity. This may suggest that the histological type may be more important in predicting the clinical presentation than the anatomical location of the glomus tumor.

We report the case of a painless deforming subungual mass at the nail tip, progressively enlarging over three months. Radiographs showed an extra-osseous ossification. Intraoperatively this was found to be a bony mass arising from the sterile matrix. Unusual extra-osseous ossification in the finger is rare and this case highlights the need of this benign lesion to be considered when a patient presents with finger swellings.

On treating distal radius fracture with intramedullary nailing (MICRONAIL, Wright Medical), completed anatomical reduction is indispensable before inserting the nail. However, complete reduction in percutaneous pinning or in Kapandji intrafocal pinning is troublesome. Thus, majority of the operation time is usually spent on reducing the fracture appropriately. We have commenced the "intrafocal elastic-spring pinning" as a reduction technique and have simplified the reduction prior to nailing. First, curve the 1.5 mm Kirschner wire properly. Next, pins are introduced percutaneously and intrafocally into the marrow cavity. The nail is then inserted in a standard manner. With this technique, an average of 16 consecutive intraoperative surgical times was 32.1 minutes (range, 16–55); apparently shorter than other previous reports. The bending-induced tension in the pins counteracts the postero-lateral displacing forces, and is especially efficient in comminuted or osteoporotic fractures. The nail will just brush aside the elastic pins when the pins interfere with the nail insertion.

Purpose: Open fixation of acute fractures, delayed union and non-union of the hamate hook through a palmar approach has been reported. Minimal invasive fixation using a dorsal percutaneous approach and a headless cannulated mini-screw is another option not commonly considered. The authors present their case series of patients who underwent dorsal percutaneous fixation of acute fractures and delayed union of the hamate hook.

Methods: This study retrospectively reviewed six consecutive patients (five male patients and one female patient) with non-displaced acute fractures (< 8 weeks) and delayed union (8 to 12 weeks) of the hamate hook treated with dorsal percutaneous cannulated mini-screw fixation. The indications for surgery included wrist pain, patient refusal of conservative treatment, and prevention of non-union and hook excision. Exclusion criteria included displacement or inadequate size of the hamate hook, previous surgery, associated carpal injury, flexor tendon rupture, and median or ulnar nerve lesion in the carpal tunnel and Guyon's canal respectively. Each fracture was visualized by radiography and computed tomography before and after the intervention.

Results: Anatomically correct fixation of the hamate hook with central screw positioning was achieved in all patients. No displacement or disruption of the cortical shell of the hook was observed. The union rate was 100% with all patients being able to resume their pre-injury activities after an average of seven weeks from surgery.

Conclusions: This pilot study demonstrates that non-displaced acute fractures and delayed union of the hamate hook can be treated successfully by dorsal percutaneous cannulated mini-screw fixation with minimal morbidity and complications.

Although scaphoid fractures are relatively common encounters in orthopaedic and trauma surgery, the demographics of these injuries are not well studied. The classical teaching in the subject limits scaphoid fractures in the age between ten and 60 years (or 70 years in other sources). The incidence or the prevalence of scaphoid fractures in the elderly population is not focused on and not studied or explored.

We reviewed the literature for any available epidemiological studies of scaphoid fractures. We also sought the available data of scaphoid fractures in the elderly population in case series and case reports which have relevant data on the subject. Four epidemiological studies, two case series, and one case report are included. We discuss the available data in these articles and conclude that scaphoid fractures in the elderly, although rare, have been reported. However, there are not enough epidemiological studies to draw figures. Ignorance of this proportion of population could result in missed fractures in the elderly. Therefore, we encourage researchers to carry out epidemiological studies of scaphoid fractures with more focus on this population group.