Hand Surgery

Morphological and histological changes of 24 collapsed lunates in advanced Kienböck disease were investigated. Articular cartilage of a collapsed lunate were consistently attenuated or disappeared. The proximal articular cartilage facing the radius is generally more affected than the distal articular cartilage facing the capitate. There was one major fracture in addition to multiple minor fractures in the collapsed lunate. Fracture patterns were classified into three types according to the directions of major fracture, namely horizontal type, dual oblique type, and vertical type. There were viable and necrotic areas in the collapsed lunate. Active new bone formation was observed at the junction between the viable and necrotic bone area of the collapsed lunate in advanced Kienböck disease.

Purpose: To survey participants at various experience levels of different martial arts (MA) about upper extremity injuries sustained during training and fighting.

Materials: A 21-s question survey was designed and utilised. The survey was divided into four groups (Demographics, Injury Description, Injury Mechanism, and Miscellaneous information) to gain knowledge about upper extremity injuries sustained during martial arts participation. Chi-square testing was utilised to assess for significant associations.

Results: Males comprised 81% of respondents. Involvement in multiple forms of MA was the most prevalent (38%). The hand/wrist was the most common area injured (53%), followed by the shoulder/upper arm (27%) and the forearm/elbow (19%). Joint sprains/muscle strains were the most frequent injuries reported overall (47%), followed by abrasions/bruises (26%). Dislocations of the upper extremity were reported by 47% of participants while fractures occurred in 39%. Surgeries were required for 30% of participants. Females were less likely to require surgery and more likely to have shoulder and elbow injuries. Males were more likely to have hand injuries. Participants of Karate and Tae Kwon Do were more likely to have injuries to their hands, while participants of multiple forms were more likely to sustain injuries to their shoulders/upper arms and more likely to develop chronic upper extremity symptoms. With advanced level of training the likelihood of developing chronic upper extremity symptoms increases, and multiple surgeries were required. Hand protection was associated with a lower risk of hand injuries.

Conclusion: Martial arts can be associated with substantial upper extremity injuries that may require surgery and extended time away from participation. Injuries may result in chronic upper extremity symptoms. Hand protection is important for reducing injuries to the hand and wrist.

Aim: The aim of the study was to assess how adequately distal radial fracture reduction was reproduced and maintained with the distal volar radius anatomic DVR-A (Biomet, Inc) locking plate.

Methods: We looked at a consecutive series of 111 patients treated with the DVR-A plate at our institution from 2007–2010. The preoperative, intra-operative, and postoperative films were reviewed. The AO and Frykman classification was recorded. The sagittal tilt, radial inclination, and radial length were measured on intra-operative X-rays and compared with final follow-up X-rays. The last recorded range of motion at follow-up and a functional assessment using the Disabilities of the Arm, Shoulder, and Hand (DASH) score was recorded.

Results: At final follow-up a mean radial inclination of 22.22 degrees (11 to 38 degrees), radial height of 11.85 mm (6 to 18 mm), and sagittal tilt of 6.71 degrees volar (-9 to 19 degrees) was achieved. From initial post-operative films, to final follow-up X-rays there was a mean increase of 0.17 degrees in radial inclination, a mean loss of 0.36 mm radial height, and a mean loss of 2.17 degrees volar tilt. The mean extension was 46.8 degrees, flexion 48.3 degrees, pronation 77.4 degrees, supination 74.8 degrees, radial deviation 15.3 degrees and the ulnar deviation 19 degrees. The mean DASH score was 12.8 (0–68).

Conclusion: The DVR-A plate achieved a highly satisfactory reduction of radial length and radial inclination, with a small loss of volar sagittal tilt at final follow-up. A good functional outcome was reported, with a satisfactory range of motion achieved. The DVR-A plate is a safe and effective treatment for unstable and intra-articular displaced distal radius fractures, particularly in younger patients, in the short term.

Currently, volar locking plates are commonly used to treat distal radius fractures (DRF) because of their stable biomechanical construct and because they cause less soft tissue disturbance and allow early mobilisation of the wrist. Complications such as rupture of tendons have been reported to occur with use of volar locking plates. We describe six cases of rupture of extensor pollicis longus (EPL) tendons after the use of volar locking plates. EPL tendon injuries occurred in 2.1% (6/286) of cases after DRF surgery. The causes of EPL rupture after DRF surgery were protrusion of the head tip and insufficient reduction of the dorsal roof fragment of the distal radius. These were considered iatrogenic problems. The cause of EPL rupture was unknown in three cases. We should be extremely careful when determining optimum screw length and reducing displaced dorsal roof fragments to prevent damaging the EPL tendons.

We present the clinical outcome of patients who underwent RE-MOTION Total Wrist Replacement (TWR) for the treatment of Rheumatoid arthritis involving the wrist.

Ten patients were available for follow-up, ranging from one to five years after index surgery. Two patients required surgical intervention for wound breakdown, including one patient who required a radial forearm flap for skin coverage. No patients required revision surgery or conversion to fusion. Patients who did not have complications gained statistically significant pain relief and improvement in mean overall flexion.

In this small case series with short to medium results patients reported an improvement in terms of flexion and pain. Despite this, the question of efficacy of TWR compared to fusion in the long term remains unanswered due to the high rate of complications.

The purpose of this study was to establish a normal measure of scaphoid position in the radioulnar plane in standard neutral, radial and ulnar deviation posteroanterior radiographs. This measurement may allow indirect evaluation of the radiocarpal ligaments and comparison between normal and pathologic states (following radius fractures, perilunate dislocations). Measurements were trialed on 74 normal wrist radiographs and 25 cadaver wrists. We evaluated the distance between the radial styloid and the scaphoid and corresponding scaphoid width. The ratio of distance/width at the mid styloid level (0.35, imprecision SD = 0.1) had the lowest random error and is therefore the most precise measurement of true scaphoid translation. This measurement is independent of scapholunate ligament integrity and may provide a better assessment of the radiocarpal component of ulnar translational instability. Abnormal movement of the scaphoid in the radioscaphoid joint likely reflects ligamentous injury. Identifying and addressing these injuries may prevent the development of arthritis.

This prospective non-randomised two-cohort study compares the use of an absorbable suture (Poliglecrapone [Monocryl]: Group A) and a non-absorbable suture (Polyamide [Ethilon]: Group B) in wound closure after elective carpal tunnel decompression. The primary outcome was scar cosmesis as assessed by the Stonybrook Scar Evaluation Scale (SBSES); the financial cost of wound closure was compared as a secondary outocome. All fifty patients completed follow-up. At six weeks, there was no significant difference in the two groups regarding scar tenderness (p = 0.5), although residual swelling was more evident in the absorbable group (p = 0.2). The mean SBSES score at six weeks was 4.72 in Group A, and 4.8 in Group B (p = 0.3). The unit cost per closed wound of Monocryl was three times than Ethilon (p < 0.05). Ethilon is thus cost-effective without compromising the cosmetic outcome, and we recommend using this as the preferred suture for closure of carpal tunnel wounds.

Carpal tunnel syndrome (CTS) exists in a spectrum of severity and symptoms with a dynamic component. We aim to study dynamic nerve-tendon interrelationships in normal and mild CTS wrists during a fist motion, with dynamic ultrasound. We observed that in normal wrists, the nerve arcs in an ulnar-volar direction and changes from a circular shape to a flat oval during motion. In CTS candidates, however, the curvature and distance of the nerve's path are reduced, while nerve shape remains relatively constant. In all candidates, the nerve is compressed against the flexor retinaculum, with the nerve subject to less compression in normal candidates as it moves dorsally into a recess. These findings suggest that besides mechanical compression from increased carpal tunnel contents alone, a decrease in nerve gliding movement may lead to CTS symptomatology. Furthermore, we identified that maximum nerve deformation occurs mid-motion, supporting the use of wrist splints for symptom relief.

To compare the median nerve deformation indices between carpal tunnel syndrome (CTS) patients and controls, 60 wrists of asymptomatic volunteers and 40 wrists of idiopathic CTS patients were evaluated by ultrasound. CTS was diagnosed through clinical findings and nerve conduction studies. Deformation indices, which were determined by the ratios of the nerve cross-sectional area, perimeter, aspect ratio, and circularity in finger extension and flexion positions, were measured. The deformation indices were compared between patients and controls. The correlation coefficients between distal motor latency and deformation indices were measured in CTS patients. There were significant differences between patients and controls in the deformation indices of perimeter, aspect ratio, and circularity. There was a mild correlation between distal latency and deformation indices of the perimeter and circularity (correlation coefficient 0.315 and 0.342). The deformation indices of perimeter and circularity might be useful to identify the nerve conduction severity of CTS.

The purpose of this study was to compare the stiffness of the transverse carpal ligament (TCL) between healthy volunteers and carpal tunnel syndrome (CTS) patients using sonoelastography. We studied 17 healthy volunteers (four men, 13 women; range 37–84 years) and 18 hands of 13 patients with CTS (three men, ten women; range 41–79 years). Thickness and elasticity of the TCL were evaluated by sonoelastography. Elasticity was estimated by strain ratio of an acoustic coupler, which has a standardized elasticity as a reference medium, to the TCL (AC/T strain ratio). The AC/T strain ratios of the healthy volunteers and the CTS patients were 6.0 and 8.1, respectively (p = 0.030). The AC/T strain ratio showed a positive correlation with the duration of symptoms in the CTS patients (p = 0.035, r = 0.50). We concluded that increased stiffness of the TCL could be one of the causes for CTS.

We present results of four-corner carpal arthrodesis with the Acumed^® Hubcap^TM circular plate performed at our unit. Eight patients underwent eight procedures over five years, for scapholunate advanced collapse (five wrists) and scaphoid non-union advanced collapse (three wrists). Outcomes included range of motion, quickDASH scores, and visual analogue scores for satisfaction. At final follow-up, mean flexion-extension arc was 56°, mean radial-ulnar deviation 29° and mean quickDASH score was 23/100. Mean score for satisfaction was 7.7/10 (77%). Seven out of eight (87.5%) patients said they would have it done again, and would also recommend it to others. Radiological union was achieved in all cases. One screw broke in one arthrodesis without causing symptoms. The functional outcomes with our use of the Hubcap^TM are comparable to those reported in literature to date with other circular plates (e.g. Spider plate). There were no non-unions, which is the main reported complication with these plates.

Trapezium components from two uncemented total joint replacements were compared in a three-dimensional finite element model. A 100 N axial and angular load was applied in a normal and an osteoporotic bone model. The axial deformation and maximum periprosthetic stress are greater for the Elektra^TM than the Motec CMC^® cup. The Motec CMC^® design is less sensitive to changing bone quality. The Elektra^TM cup transmits more stress to the cortical bone rim in all load conditions, but under angular loading the proportionate increase in stress is lower. The Motec CMC^® design distributes the stress and contact pressure more evenly, whereas the Elektra^TM transfers most of the load to the cortical bone rim and the screw hole base. The design features that are believed to be of greatest significance for the differences are the raised centre of rotation of the Motec CMC^® cup and the collar acting as a lever arm.

Purpose: The purpose of the study was to assess the efficacy of the conservative management of proximal phalangeal fractures in a dorsal plaster slab.

Methods: Twenty-three consecutive patients with extra-articular proximal phalangeal fractures were included in this prospective study. Fourteen patients (62%) presented with fractures considered unstable. The fractures were reduced and the position was held with a dorsal plaster slab for three weeks. The patients were followed up for an average of seven weeks (range 2 to 45) after the injury. Range of motion of the finger and radiological evidence of union, non-union or malunion was documented after removal of the plaster.

Results: Ninety-one percent of fractures maintained an acceptable reduction. All cases measured less than 15° of angulation. On average 1,1 mm of shortening was measured. In two (9%) cases the reduction was not accepted on follow up assessment and the fractures were managed surgically.

Conclusion: Most extra-articular proximal phalanx fractures can be managed conservatively with acceptable results.

Purpose: To report the outcomes of mallet fractures treated with our modified tension band wiring technique.

Methods: Eleven men and two women (mean age; 33 years) with mallet fractures in which happened more than five weeks before surgery, or with fracture fragments involving more than 2/3 or less than 1/3 of the distal phalanx articular surface or with previous surgical intervention, were subjected to this study. The fracture fragment was fixed with a modified tension band wiring technique using a stainless steel wire and an injection needle.

Results: All patients achieved bone union in nine weeks in average. All patients had no pain except one with mild pain. No patient showed a gap or step-off greater than 1 mm.

Conclusions: Our tension band wiring technique can be used regardless of the size of the dorsal fracture fragment or the interval between injury and surgery.

Necrotising soft tissue infection is a rare and rapid process with devastating consequence. We report one case of necrotising soft tissue infection in a bilateral upper limb with uncommon oral bacteria. Radiological imaging revealed the presence of gas in upper limb soft tissues, and an MRI showed the localised signal changes in the biceps muscle of the right upper arm, and the subcutaneous tissue of the left elbow. The patient was treated with surgical resection of the infected muscle and wide debridement of the subcutaneous tissue. Antibiotics were initiated. The patient recovered immediately without functional deficit. The unique features of this patient were possible to observe in the progression of the necrotising soft tissue infection in the bilateral upper limb with intentional injection of oral bacteria, and the effect of biceps brachii resection in a prime age worker.

We present a case of rotational restriction of the forearm due to abnormal configuration of the pronator quadratus muscle. A 20-year-old man developed right wrist joint pain on pitching of a baseball game and thereafter displayed rotational disorder of the forearm. Magnetic resonance imaging (MRI) revealed a space-occupying lesion from the volar side of the radius to the dorsal side of the ulna. The lesion was iso-hyperintense on T1-weighted (T1W) images and showed a mixed pattern of high intensities on T2-weighted (T2W) images. His symptoms were immediately reduced after removal of the mass. Histological examination showed that the mass contained much skeletal muscle and revealed myxoid degeneration of striated muscles. We assumed that his pronator quadratus muscle had been a divided form of deep layer and superficial layer tissue, possibly congenitally. We supposed that the deep layer had degenerated due to chronic stimulation and had extended around to the dorsal side of the ulna, which caused rotational restriction from the resulting impaired distal radioulnar joint. To our knowledge, there has been no similar case reported in the literature.

We present a case of isolated Abductor Digiti Minimi (ADM) palsy caused by an anomalous branch from the ulnar artery. Electrophysiology suggested selective involvement of the motor branch to the ADM in the Guyon's canal. Surgical exploration revealed an anomalous branch of the ulnar artery causing a pincer effect on the nerve to the ADM. Division and ligation of this branch effectively decompressed the nerve and the patient recovered satisfactorily. This report highlights the need to consider vascular aberrations as a differential diagnosis for ulnar neuropathy in Guyon's canal.

Skoog and others have concluded that the Skoog fibres, or transverse ligament of the palmar aponeurosis (TLPA), are never involved in the Dupuytren's disease process. Here we present a case in which this clearly occurs. Whilst for the vast majority of Dupuytren's cases the Skoog's fibres delineate the required deep extent of dissection for pretendinous cords, this case proves an exception, highlighting an occasional need to beware of accepting the conventional wisdom.

Background: Hyperextension of the first metacarpophalangeal (MCP) joint and adduction of the first web space of the hand are features of advanced stages of carpometacarpal (CMC) joint arthrosis. Restoration of mechanical efficiency in such patients requires stabilization of both the CMC and MCP joints. This study describes a patient with bilateral secondary hyperextension of the MCP joint greater than 50° who displayed good functional outcome following staged bilateral MCP joint arthrodesis with simultaneous CMC joint reconstruction.

Case Report: Excision of trapezium, formation of a Weilby sling utilising flexor carpi radialis, and insertion of a Swanson's prosthesis forms the basis of CMC joint reconstruction. Fusion of the MCP joint involved placement of longitudinal K-wires and tension band wiring. The patient underwent an initial right-sided procedure in 2008 and subsequently elected for the same procedure on the contralateral side 26 months later. Good functional improvement was achieved with a pre and postoperative DASH score of 49 and 8 respectively. Follow-up and radiological imaging at 34 months from her initial surgery confirmed good positions of the prostheses and solid MCP joint fusions. The patient developed postoperative interphalangeal joint pain, which responded to steroid injection.

Discussion: There is currently limited evidence available addressing the management of severe hyperextension deformity greater than 50° of the MCP joint in the presence of CMC joint arthrosis. Staged bilateral fusion of the MCP joint and simultaneous CMC joint reconstruction in this case illustrates good, reproducible functional results and patient satisfaction with reduced postoperative return to function.

Venous varix on the volar aspect of the digits or the hand is a rare subcutaneous lesion that is usually described as a firm, blue, and painful single nodule that contains thrombus. However, there have been no reports about venous varix on the dorsal aspect of the digits or the hand, so its features are unknown. We treated two patients who each had a soft blue painless mass on the dorsal aspect of the thumb that became enlarged with the tourniquet test. Ultrasonography and/or magnetic resonance imaging were used for assisting with the preoperative diagnosis, and showed each lesion was composed of two or more varicosities. Each mass was removed and was diagnosed as a venous varix without thrombus by histological examination.

Macrodystrophia lipomatosa is a rare, non-hereditary form of congenital local gigantism characterised by enlargement and hypertrophy of all mesenchymal tissue components with a disproportionate increase in adipose tissue. This form of macrodactyly has been reported in association with other anomalies including polydactyly, brachydactyly, syndactyly, and symphalangism. We describe a previously unreported case of bilateral upper extremity macrodystrophia lipomatosa with syndactyly in a 23-month-old boy. In this report, we emphasise the importance of establishing a diagnosis with imaging and review the described surgical approaches to treating this difficult condition.

A three-year old patient with symbrachydactyly (didactyly type) presented with a little finger that was too short to allow pinching and consisting of a floppy soft-tissue envelope with hypoplastic phalanges, although the thumb was functional. As the proximal phalanx was too small to permit distraction lengthening or conventional bone grafting, on-top plasty using a 4th metacarpal graft with a cartilage head was undertaken for lengthening the proximal phalanx of the little finger for pinch reconstruction. At ten weeks after surgery, the patient achieved satisfactory pinch function due to the lengthened and bone-stabilised postoperative digit and reconstruction of functional proximal interphalangeal joint. In addition, the grafted metacarpal demonstrated satisfactory bone growth throughout the six-year follow-up period.

Critical defects distal to the proximal interphalangeal joint are usually treated by heterodigital or reverse-flow homodigital flaps. Drawbacks of the former are potential donor digit stiffness and scarring, while the latter might be complicated by flap congestion. A bipedicled neurovascular island transposition flap design that preserves both proximal and distal extent of digital nerve and artery was employed to treat critical dorsal skin defect in two patients with encouraging results. Technical details and cadaveric study concepts are presented.

Finger tourniquets are used in a variety of operative procedures in both the trauma and elective setting. A wide range of methods are used in clinical practise as there is no standardised method. Many of the methods in use have significant drawbacks such as the inability to exsanguinate the digit or the more concerning problem of inadvertently leaving the tourniquet on the digit on completion of the procedure. We discuss two techniques that are quick, cheap and easy that do not have these drawbacks. There is a brief discussion of the literature assessing the various attributes of published methods. We feel that the adoption of these methods could result in easier and safer finger exsanguination and haemostasis.

A retrospective study for the combination of suture anchor and selective sesamoidectomy for treating volar instability of the metacarpophalangeal joint (MCPJ) of the thumb. Eleven patients with hyperextension of the MCPJ of the thumb underwent volar plate repair using a volar or voloradial approach. All the patients were reviewed radiologically and clinically using both objective and subjective criteria. The patients presented with sesamoid fractures (n = 2), sesamoid subluxation (n = 1), isolated volar plate laxity (n = 4), isolated sesamoid fracture (n = 4), and metacarpal condyle fracture (n = 2). The inner intersesamoid distance was 4.6 mm and the outer intersesamoid distance was 14.2 mm. The Disabilities of the Arm Shoulder and Hand and Michigan Hand Outcomes Questionnaire scores showed improvement. Volar plate repair using a suture anchor and selective sesamoidectomy is effective with regard to pain relief and stabilisation of volar instability of the thumb.

Radial or ulnar oblique amputations treated by nailbed levelling and local digital flap reconstruction can result in significantly shortened fingertip, narrowed pulp and nail shape distortion. A VY type flap containing bone, sterile matrix, and skin was conceptualised to restore nail and pulp contour for coronal oblique amputations. Technical details and a clinical case are discussed.