Hand Surgery

To prevent adhesion between the tendon and the plate in hand surgery, a porous poly L-lactide-co-ε-caprolactone (P(LA/CL)) membrane was developed as a biologically absorbable anti-adhesion material. Our study aims to confirm the efficacy of this new P(LA/CL) membrane and its influences on the osteotomy site by performing a fundamental experiment assessing the possibility of clinical application.

We prepared a rabbit model of tendon-plate adhesion, and evaluated the efficacy of the P(LA/CL) membrane to pullout tendon strength, to be scored in terms of macroscopic, pathological results. Another rabbit model of osteotomy was prepared to confirm the P(LA/CL) membrane influences on bone union by radiological, mechanical and pathological evaluation. The result showed to be significantly lower adhesion in the P(LA/CL) membrane group than in the control group. Also there were no differences between the P(LA/CL) membrane group and control group in the results for bone union.

The DASH score is a universally accepted method for assessment of hand function. However, there are occasions when a pre-treatment DASH score is unavailable. This study provides a solution to this situation. An initial DASH score was obtained from all patients at the time of their first clinic visit. A second score was obtained at the time of final follow-up asking the patient to "Recall" their pre-treatment status. The two scores were compared with appropriate statistical analysis. Thirty-eight patients were included in the study and scores were obtained at an average time interval of 32 weeks (6–121 weeks). Excellent agreement was noted for the ability of the patient population to recall their scores with a group correlation of 0.86. This proves that the Recall DASH score is an excellent and useful research tool for use in hand surgery.

Distal radio-ulnar joint (DRUJ) instability is increasingly recognised and assessment can be subjective and difficult. Previous research has used cadaveric models or in-vivo with CT, with variable results. A test device was designed to establish normal values of in-vivo DRUJ dorso-palmar translation.

Twenty volunteers were recruited. Those with previous wrist/forearm injuries were excluded. The device held the elbow at 90° flexion and neutral forearm rotation, with the distal ulna secured. A dorso-palmar shear force was applied to the distal radius and displacement measured three times on each wrist alternately by the same operator.

The mean translation of the DRUJ is 5.5 mm. Same-sided mean measurements for two subjects taken days apart varied by 1 mm. The intra-class correlation coefficient was 0.93.

The device is reliable, reproducible and appears to be a simple valid test. Contralateral sides were comparable. It will primarily be a research device to guide clinical practice in DRUJ instability.

The triangular fibrocartilage complex (TFCC) has an important role in the stability of the distal radioulnar joint (DRUJ) stability. We designed a new method of TFCC tear repair that has satisfactory post-operative DRUJ stability. From May 2004 to August 2010, 14 patients who underwent this operation were reviewed. The average post-operative follow-up period was 8.2 months; 66.7% of the patients with TFCC tear in sigmoid notch had clinical DRUJ instability, while only 50% of tear in fovea and 16.7% of tear in base of ulnar styloid had clinical DRUJ instability. Transosseous suture via inside-outside technique was used for repair. At the final follow-up, all 14 patients have soft end point with < 5 mm translations of the DRUJ shown by the stress test. Based on this small sample with satisfactory outcome assessed by the Mayo modified wrist score and DRUJ stability, we recommend TFCC tear in sigmoid notch, which has a higher chance of DRUJ instability, to be repaired by transosseous suture.

Introduction: Untreated ununited scaphoid fractures will almost inevitably progress to radiographic and symptomatic osteoarthritis of the wrist. This may lead to subsequent morbidity and lifelong disability especially in young males in which the fracture scaphoid is more common. Patients and methods: Twenty-one patients presenting non-united fracture scaphoid were operated upon by using disto-proximal bone peg technique with average time between injury and operation as 11 months (6–18 months). All of them male with average age of 26 years (17–35 years). There were 17 patients with fracture waist (80.9%) and four patients with fracture proximal pole (19.1%). Results: Anatomy of the wrist was restored and radiological healing confirmed in 17/21, partial healing in 3/21 and non-union in 3/21 patients. Eighteen patients (85.7%) were graded as satisfactory, 5 patients (23.8%) were graded as excellent, ten patients (47.6%) were graded as good, and three patients (14.3%) were graded as fair. The remaining three patients (14.3%) were graded as unsatisfactory. Conclusion: We conclude that the disto-proximal bone peg technique of taking the graft from the ipsilateral ulna without using any metal work for fixing scaphoid non-union fracture is a reliable, easy, and inexpensive alternative method. However, we would not recommend it for the non-union of the scaphoid proximal pole fracture. Also we find the time lag before operation is one of the most important factors to achieve union in non-united fractures of the scaphoid. Level of evidence: Therapeutic case series, level 1V.

This study was undertaken to determine the incidence of and assess factors affecting nonunion of scaphoid distal pole fractures. A total of 193 established scaphoid nonunions were treated in our clinics between the years 1999 and 2004; of which, eight cases involved the distal pole of the scaphoid. These were further analyzed to determine factors that may have contributed to the development of nonunion. This study reveals that distal pole nonunions account for 4.1% of all scaphoid nonunions. We found inadequate initial treatment to be the cause for nonunion in 63% of patients. Type IIC fracture pattern according to Posser's classification was seen in 100% of patients and a persistent Dorsal Intercalated Segmental Instability (DISI) pattern in 100% patients. In addition, 100% of fractures occurred at the watershed zone between the two vascular networks of the scaphoid. We believe the key features leading to the likelihood of nonunion at the distal pole include a Type IIC fracture pattern associated with a continued deforming force that eventually leads to a DISI deformity. The watershed area between the proximal vascular network supplying the waist and the distal one supplying the distal pole is especially vulnerable to poor healing.

Introduction: Ganglia are the commonest cause of swellings of the hand and wrist; the documented success of outcomes varies considerably. There is little published data to help predict patients likely to benefit from each treatment modality. We sought to identify factors predicting success of each intervention to provide an evidence basis to inform referral criteria and treatment decisions. Materials and Methods: A retrospective series of 140 serial patients referred with confirmed hand and wrist ganglia between June 2005 and January 2011 was studied to a minimum of 12-month follow-up to determine predictors of successful treatment. Treatment was deemed to be successful if the patient did not develop recurrence. Analysis was completed for predictors of successful treatment at presentation; examining gender, presence of pain, duration of symptoms, anatomic location and treatment modality. Results: Treatment success rate following aspiration was 34% for wrist and 58% for finger ganglia and for surgical excision 7% for wrist and 4% for finger ganglia. Surgical excision was significantly more successful than aspiration (p < 0.01). Duration of symptoms greater than one year was significantly associated with increased recurrence rates (relative risk 2.33, p < 0.05) and male sex was associated with lower recurrence (relative risk: 0.54, p = 0.14). Subgroup analysis of different varieties of soft tissue ganglia did not show any statistically significant factors predictive of recurrence, although both painless presentation and male sex were of borderline significance. Discussion and Conclusions: Duration of symptoms less than one year and male sex can be used to identify patients likely to benefit from interventional treatments and guide treatment decisions. Surgical excision was significantly more successful than aspiration (p < 0.01).

Open carpal tunnel release is commonly performed under local anaesthesia. No study has compared intra-operative short- versus long-acting local anaesthetics as preemptive analgesics in carpal tunnel surgery. In this single-blinded prospective study, 100 consecutive carpal tunnel releases were performed by a single surgeon at one institution with either lignocaine (n = 50) or ropivacaine (n = 50). Allocation was performed via the method of alternation. Subjects were given a questionnaire to answer the following: (1) time to first incidence of pain, (2) quality of first night's sleep, and (3) mean numerical pain scores in the first 24 hours. The time to the first postoperative pain was significantly shorter in the lignocaine group (5.58 vs. 9.17 hours, p < 0.035). There were no significant difference in the incidence of poor first night's sleep (16% vs. 26%, p = 0.28) or mean pain scores in the first day (3.6 vs. 2.9, p = 0.16). Existing evidence advocates for long-acting intraoperative local anaesthetic because it results in a longer duration of postoperative analgesia, however, our study suggests that it may also result in a poorer first night's sleep.

We examined 57 hands referred with suspected carpal tunnel syndrome (CTS) using the second lumbrical-interossei nerve test (2L-INT) as well as standard test. Sensory nerve conduction velocity (SCV) was detectible in 67% of patients (38/57), the abductor pollicis brevis-compound muscle action potential (APB-CMAP) in 84% (48/57), 2L-CMAP in 96% (55/57) and the first interossei palmares muscle (INT-CMAP) in 100% (57/57). ABP-CMAP was not recorded in patients in whom severe atrophy of the abductor pollicis brevis muscle was evident. As 2L-CMAP is maintained even in the most severe cases of CTS, the 2L-INT method is a valuable test for improving the accuracy of preoperative diagnosis in the electrophysiological diagnosis of CTS.

Carpal tunnel decompression (CTD) is a common procedure amenable to procedure specific consent forms (PSCFs). These may help better inform patients and so increase patient satisfaction with the consent process. We assessed the use of a PSCF for CTD. The PSCF mentions eight complications of carpal tunnel surgery and alternative non-operative treatments.

Two groups of 40 patients each were compared prospectively. Patients in one group were issued with a PSCF prior to admission whereas those in the other group were not. After standard pre-operative consent, patients were interviewed prior to surgery and assessed for their awareness of complications and alternative treatment options. The patients who received a PSCF showed greater awareness of different complications and alternative treatments and reported greater satisfaction with the consent process. We conclude that using PSCFs is a very useful and inexpensive adjunct to improve patient awareness and satisfaction with the consent process.

We retrospectively analyzed clinical results of 107 hands of an elderly idiopathic carpal tunnel syndrome group (65 years old and older) and 234 hands of a younger group (under 65 years old) following endoscopic carpal canal release surgery. There were statistical differences in recovery rates for tingling, pain sensation and touch sensation (p < 0.01) and recovery periods of touch sensation (p < 0.05). There were no statistical differences in recovery rates, periods of thumb abduction muscle power, and recovery rates of electrophysiological examination results. Cervical spondylosis may affect postoperative recovery of subjective sensory disturbance, especially in the elderly group. From these results, in elderly patients we recommend primary minimally invasive endoscopic carpal canal release surgery and only apply primary opponoplasty in cases when the patient strongly wishes reconstruction faster than six months.

The purpose of this study was to evaluate risk factors for re-recurrent carpal tunnel syndrome (CTS) in long-term renal hemodialysis (HD) patients. Fifteen wrists of ten HD patients, follow-up period of minimum seven years after reoperation of CTS, were included in this study. Duration of HD, period from first operation to reoperation, shunt side was involved or not, presence of trigger finger and cervical destructive spondyloarthritis, and operative procedure performed during the reoperation (synovectomy was performed or not) were evaluated. Re-recurrent CTS was identified in four out of 15 wrists (27%). The period from first operation to reoperation, which was 3.8 years in the re-recurrence group and eight years in the no re-recurrence group, and the operative procedure had significant differences (synovectomy groups had no re-recurrence vs. no synovectomy groups had 82% re-recurrence). The results of this study suggested that synovectomy would be necessary for recurrent CTS in HD patients.

We have retrospectively reviewed 17 thumbs in 16 patients with osteoarthritis of the thumb carpometacarpal joints, for which arthroplasty was performed using Kaarela's method. Postoperatively, three thumbs in two patients had poor outcomes; both patients had a sharp slope of the base of the first metacarpal. Serial radiographic measurements suggested that this sharp slope affected the adducted position of the first metacarpal, and led to the appearance of a metacarpophalangeal joint hyperextension deformity of the thumb. This radiological finding could be a prognostic predictor after surgery for osteoarthritis of the thumb carpometacarpal joint.

Treatment of Rolando fractures remains a challenge for hand surgeons. We present a case series of 16 comminuted Rolando type fractures treated by controlled capsuloligamentous distraction (and over distraction by 2 mm) using the Pennig mini-external fixation system. Additional Kirschner wire(s) were used to maintain fracture reduction and stability. Average time of injury to surgery time was five days. Mean age of patients was 26 years. The mean follow-up was 20 months. Excellent fracture union was achieved in all cases. All except two patients were pain free at the final consultation. The mean grip and pinch strength of the affected thumb was 96% and 93%, respectively, of the unaffected thumb with a minimal loss of movements. This technique is simple and effective. It enables immediate mobilisation of the unaffected joints and prevents stiffness. We recommend this distraction technique for the treatment of significantly comminuted Rolando type fractures.

Eighty-two patients who were treated by suture repair for Zone I flexor tendon injuries over a ten-year period were identified, to determine the incidence of post-operative surgical complications and subsequent re-operations.

Eighty-five percent of patients completed 12 weeks follow-up post-surgery. Of these patients almost all had good to excellent outcome in terms of total active movement (TAM). However when assessing the range of motion at the distal interphalangeal joint (DIPJ), only 23% could be classified as having good or excellent results at final follow-up. A total of six patients (7.32%) required surgery for tendon repair complications.

This study illustrates that DIPJ ROM is more indicative of functional recovery after tendon repair in flexor Zone I. Given the DIPJ is important in providing a fine pinch and a span pinch grip movements, patients should be counselled for inability to perform these functions post-tendon repair.

We describe a rare experience with the treatment of a patient with finger flexion contracture caused by muscular involvement of sarcoidosis, who had been misdiagnosed as having a trigger finger and underwent surgical release of the A1 pulley of her little finger. This report serves as a reminder that muscular involvement of sarcoidosis can cause finger flexion contractures.

This case report describes a patient who experienced closed simultaneous rupture of the left Extensor Pollicis Longus (EPL)-, Extensor Digitorum (ED) and Extensor Digiti Minimi (EDM) tendons.

A case of a 35-year-old male with necrotizing fasciitis of the hand is presented. Clinical manifestations of necrotizing fasciitis are discussed and intraoperative findings are highlighted to illustrate the disease process that initially affects the deep layer of the superficial fascia.

Avulsion fractures at the base of the index finger or long finger metacarpals are rare. We found six cases in the English language of a similar injury involving the extensor carpi radialis brevis. All were treated surgically. We describe an isolated avulsion fracture injury of extensor carpi radialis brevis insertion treated satisfactorily without surgery. The patient healed uneventfully and returned to normal pain free activity.

Suspensionplasty was performed using the abductor pollicis longus tendon for osteoarthritis at the carpometacarpal joint of the thumb. The operated wrist had a full range of motion four months after operation; however, there was swelling on the dorsoradial aspect of the wrist and, upon terminal wrist extension, pain was present at the maximum dorsiflexion. Suddenly, one year after operation the patient could not extend the interphalangeal joint of the thumb. Surgical exploration revealed rupture of the extensor pollicis longus tendon. Tenosynovitis at the extensor carpi radialis brevis tendon, where the abductor pollicis longus tendon is sutured, might cause extensor pollicis longus tendon rupture. Late postoperative complications such as this extensor pollicis longus tendon rupture after suspensionplasty using the abductor pollicis longus tendon are extremely rare and this is the first case in the literature.

We report a case of rotatory subluxation of the metacarpophalangeal joint (MCPJ) of the finger. A 40-year-old man sustained an open injury to his index finger following an explosive injury. Radiographs showed rotatory subluxation of the index finger MCPJ. The index finger extensor digitorium was found interposed in the MCPJ, with a complete tear of the radial collateral ligament. Treatment was by open reduction and repair of the collateral ligament and the extensor tendon. A high level of clinical suspicion is needed to diagnose this entity.

Unlike mallet finger, mallet thumb is rare. We treated a case of mallet thumb with avulsion fracture using extension block Kirchner wire technique, and achieved excellent results.

This paper examines a case of extraskeletal chondroma in the hand of an 82-year-old female, first noticed about two years ago. Magnetic resonance imaging showed a mass in the carpal tunnel which extended from the wrist to the palm. The tumor was located between the thenar area and the hypothenar area at the palm level. There was no continuity to the carpal bone or radius bone. The entire size of the tumor was 120 mm × 45 mm × 42 mm. Although extraskeletal chondroma is sometimes seen, a large one in the hand is extremely rare. Since the tumor was too large to excise totally because median nerve entrapped it, it was divided into two parts and excised. After the operation, there was no neurological deficit or pain in the median nerve lesion.

The most common soft tissue sarcomas of hand are epitheloid sarcomas, synovial sarcomas and malignant fibrous histiocytomas which are high grade, aggressive tumors. Liposarcomas of the hand are extremely rare and to the best of our knowledge less than 20 cases have been reported so far in the literature. Well differentiated spindle cell liposarcoma is an extremely rare subtype of well differentiated liposarcoma/atypical lipomatous tumor which is different from the other subtypes clinicopathologically, genetically and prognostically. Palmar localization of this rare variant of liposarcoma at this site makes ours only the second case reported in the world literature so far. This recently described entity is low grade lesion and the hand surgeons need to adopt a less aggressive approach in the treatment of this subtype.

Angioleiomyomas are benign solitary soft-tissue tumors that originate from the vascular smooth muscle of vessels and rarely occur in the hand. Pain and tenderness are the only clinical characteristics. This report presents a rare case of angioleiomyoma arising from both the superficial palmar arch and a concomitant vein of the artery. The MRI findings lack specific radiological features. However, three-dimensional magnetic resonance angiography demonstrated the existence of a relationship between the tumor and its feeding vessels. The diagnosis was made after a histopathological study of the tumor. Adequate collateral circulation should be confirmed both before and during surgery if the lesion occurs within an artery. Angioleiomyoma should therefore be included in the differential diagnosis of painful vascular tumors with no neurological findings in the hand.

Embedded ring injury is rarely encountered in clinical practice, and most of the few reported cases share common features, including deliberate neglect, mental illness, poor social support, female gender, and adult age group. Ischemia has never been reported in such injuries. Here, we report the case of a 16-year-old girl who presented with a completely embedded ring in the right index finger and a partially embedded ring in the left ring finger. Revascularization after ring embedment probably explains the intact vessel that was observed on the outer aspect of the embedded ring during surgical exploration of the right index finger.

We report the case of an extra-articular fracture at the base of the proximal phalanx of the ring finger treated by plate and screw fixation using a modified trans-web approach. The combination of trans-web and mid-lateral approach provided a wide operative field and adequate visualization without marked damage to the soft tissues, and the operative outcome was excellent.

Malignant melanoma of the nail confers a higher mortality rate compared to other cutaneous melanomas, which is often attributable to delayed diagnosis. Two-thirds of nail melanomas present as longitudinal melanonychia (LM), longitudinally-oriented brown-black bands of pigment in the nail plate. This article delineates the appropriate clinical approach toward evaluation and management of a patient with longitudinal melanonychia, which includes determining risk factors for melanoma, recognizing scenarios in which biopsy is indicated, selecting the appropriate biopsy technique, and managing a patient in whom the diagnosis of nail melanoma has been made.