Hand Surgery

Cubital tunnel syndrome is the second most common nerve entrapment neuropathy. When non-operative treatments fail, surgical intervention is indicated. Although there remains no consensus between simple decompression and anterior transposition, there is a growing recognition of improved clinical outcomes in the latter. Few details of ulnar nerve branches around the elbow are available however and their sacrifice may be necessary to facilitate anterior transposition. Therefore, ten cadaveric upper extremities were dissected to delineate the course and branching pattern of the ulnar nerve around the elbow joint; anterior transposition was also performed in the cadaveric specimens. Digital photographs of the dissection study were analyzed using the Image J package. Results show that distal ulnar nerve branches are distributed more laterally towards the olecranon and may potentially restrict transposition more than has been recognized; proximal branches may also overlap incision lines of such transposition procedures.

This study aims to analyze the bacteriology and antibiotic resistance in hand infection between 2000 and 2009 at a local hospital in Asia. It is a retrospective study involving all adult patients with hand infections that were treated surgically, with tissue or wound culture sent. A total of 100 cases in 2000 and 98 cases in 2009 were included in this study. Standard epidemiology information, bacteriology, antibiotic sensitivity and treatment outcome were analyzed. Particular interest was given to diabetic hand infection. There was no significant difference of outcome in hand infection between the two years. The outcome of diabetics was not statistically worse than the non-diabetics. Comparing the patients in 2000 and 2009, more younger patients were affected with hand infection in 2009. While length of stay is shorter in 2009. Mixed infection was more common in diabetics in 2009. There was trend of clindamycin resistance in methicillin-sensitive staphylococcus aureus in 2009.

This anatomical study was designed to assess the distribution of a solution (injectate) made up using local anesthetic, steroid and dye into the carpal tunnel using a commonly used injection technique. Dissections were undertaken in 29 embalmed cadaveric wrists. The cadaveric specimens were dissected 24 hours after injection to observe the effect of time on diffusion patterns in both superficial and deep planes.

Eighteen of the 29 specimens showed the presence of the injectate in the superficial plane and three preferential patterns of distribution were noted in the deep plane: free in the carpal tunnel, exclusively in the tendon sheath and mixed.

This is the first study investigating the delayed diffusion pattern of injectate in the carpal tunnel and illustrates its variability. The findings of variable degree of superficial diffusion and different patterns of intracarpal spread help to offer some explanation regarding the variability of the response following carpal tunnel injection.

We have analyzed postoperative long-term follow-up results of five years or more from idiopathic carpal tunnel syndrome patients that underwent our complete carpal canal release and decompression procedure that uses the Universal Subcutaneous Endoscope system. In this series, 203 hands were followed up both clinically and electrophysiologically. Final follow-up times were determined by the most recent electrophysiological measurements. Mean follow-up period was nine years. Tingling, pain (using a 3 gm needle) and touch (using a 2 gm von Frey hair) at all median nerve distribution areas recovered to normal in 92.9, 98.2, 95.2%, respectively. Abductor pollicis brevis muscle power improved from preoperative manual muscle testing of 0, 1, 2 to post-operative 4 or 5 in 82.6%. Mean detectable distal sensory latency improved from 4.3 (n = 130) to 3.1 msec (n = 200). Mean detectable distal motor latency improved from 6.2 (n = 189) to 4.1 msec (n = 200). Complication and recurrence rates were 0% and 0.5% respectively.

In replantation surgery, the use of continuous brachial plexus blockade (CBPB) is popular as it improves postoperative analgesia and vascular flow. The aim of our study was to determine whether CBPB may affect the odds of survivability of replanted digit(s).

A four-year retrospective chart review was performed and various parameters affecting replant survival were examined. Outcome was recorded as successful if the transplanted digit(s) survived six months after discharge. All the independent variables were forced into a regression model without using a specific variable selection algorithm.

The data for 146 patients was obtained from our chart review. The success rate of replanted digits in the patients reviewed was 65.8%. The logistic regression model showed a relation between the number of digits injured and replanted digit(s) survival.

Our study showed that CBPB has no effect on the survivability of the replanted digit(s) till six months after hospital discharge.

The purpose of this study is to highlight a cohort of patients with a comminuted volar shearing type of distal radius fractures (AO B3.3) with the volar ulnar fragment that is prone to re-displace, resulting in volar subluxation of the radiocarpal joint. We report our experience with two such patients with re-displacement of the fragment and joint requiring repeat surgery; one of whom required a third procedure to stabilize that fragment. Three subsequent patients were successfully treated with one surgery when particular attention was paid to stabilize the volar ulnar fragment. This highlights the importance of stabilizing this fragment at the primary procedure.

We reviewed 17 patients 64 (range 29–123) months after dorsal radioscaphoid capsulodesis for scapholunate dissociation. Mean loss of key pinch was 13%, grip strength 18%, wrist flexion 22% (p < 0.001), and total wrist ROM 17% (p < 0.005). VAS (0 = best; 100 = worst) was 30(±28) for pain, 43(±30) for function, and 33(±33) for general satisfaction with the outcome. Mean Quick-DASH and PRWE scores were 27 and 34, respectively. The mean scapholunate gap was 3.5 mm before surgery, 1.9 mm after surgery, and 3.3 mm at review. The corresponding scapholunate angles were 63°, 46°, and 70°, respectively. The mean radioscaphoid angle with the wrist maximally flexed was 84° (69–99) for the patients and was 91° (77–103) in ten wrists of volunteers. Six patients had changed their jobs because of the wrist. Three patients stated that they would not have consented to operation if they had known the outcome in advance. Radioscaphoid capsulodesis does not prevent volar flexion of the scaphoid.

The vast majority of devices used for internal fixation of the scaphoid are metallic. This two-center study aimed to report the results of scaphoid fixation using a cannulated, bioabsorbable device made from a hydroxyapatite and poly-L-lactide composite in 29 consecutive patients. Fixation was performed for seven acute fractures and twenty-two established non-unions. Union was achieved in 72.4% of patients. Six of the acute fractures and fifteen of the non-unions united successfully. Modified Mayo Wrist Score ranged between good to excellent in all patients who successfully united, whereas patients who failed to unite ranged between poor to excellent, with one poor and two moderate scores. No adverse biocompatibility reactions were seen. Two failures with broken screws were re-explored and one of these was thought to be due to screw mal-placement. The device used is an alternative to conventional metal implants and produces comparable union rates to metallic devices in the short term.

The Gilula's test suggests the presence of ulnocarpal translation when 50% or more of the lunate lies medial to the ulnar edge of radius. The purpose of this study was to examine the reliability of this semiquantitative test as there was inconsistency between the previous publications in regarding 50% as the cutoff value for the normal lunate uncovering ratio (LUR).

We utilized the Picture Archiving and Communication System to investigate radiographs of 299 normal adult wrists and emphasized defined radiographic landmarks for accurate quantitative measurement. Our mean LUR was 35%(SD8) with a range of 8 to 49%. Therefore we re-affirmed the reliability of the Gilula's test since none of our normal wrists had a LUR of 50% or greater.

Hamate hook fractures are rare injuries but appear to occur frequently in underwater rugby, the reason for which was investigated in this study.

High-level underwater rugby players with hook fractures diagnosed during a five-year interval (2005–2010) were studied retrospectively. Medical data on these patients were reviewed for information on the mechanism of injury, type of fracture, radiological imaging, treatment, and outcome.

In ten patients, hook fractures of the leading hand were confirmed by computed tomography, all of which were associated with specific injuries during underwater rugby games. Conservative treatment resulted in delayed healing or non-union, wherefore fragment excision and open reduction and internal fixation was performed in ten and five patients, respectively, while two patients declined surgery. After surgery, all patients were able to play underwater rugby again.

In underwater rugby, hook fractures occur frequently due to high and repeated forces applied to the leading hand during games.

Purpose: To investigate the long-term (> 10 yrs) outcomes of trapeziectomy with ligament reconstruction and tendon interposition (LRTI).

Methods: We reviewed 15 cases of trapeziectomy with LRTI performed for the treatment trapeziometacarpal osteoarthritis. Mean follow up was 13.5 yrs (range, 10.5–17.5 yrs). We assessed a number of subjective and objective outcomes. A good outcome was a participant who did not require revision surgery, was satisfied with the outcome of their surgery and did not experience rest pain.

Results: No patients had revision surgery and only two patients were unsatisfied or very unsatisfied with the outcome of their surgery. Pain with activity was the strongest predictor of participant satisfaction.

Discussion: Approximately half the participants in this study experienced good long-term outcomes. Some participants were experiencing long-term symptoms, particularly pain, despite reporting that they are satisfied with the outcome of their surgery. Alternative techniques should be investigated that provide superior long-term outcomes.

Trapeziectomy and Weilby ligament reconstruction is a recognized treatment for osteoarthritis of the trapeziometacarpal joint. Studies published using this procedure have limited follow-up post-surgery. In this series of 24 cases assessed objectively and 36 subjectively with a minimum follow-up of five years, patients continue to have pain relief and function comparable to the opposite non-operated hand. Patient satisfaction is high at 92% and the rate of complications is low. Despite these encouraging results the need for interposition arthroplasty and/or ligament reconstruction in addition to trapeziectomy alone is discussed.

Surgical treatment for trigger finger involves division of the A1 pulley. Some surgeons perform an additional step of traction tenolysis by sequentially bringing the flexor digitorum superficialis and flexor digitorum profundus tendons out of the wound gently with a Ragnell retractor. There is currently no study which states whether flexor tendon traction tenolysis should be routinely performed or not. The objective of this study is to compare the outcome in patients who have traction tenolysis performed (A group) versus those who did not have traction tenolysis (B group) performed. It was noted that even though the mean total active motion (TAM) for the B group in our study was lower preoperatively, it was consistently higher than the A group in all the 3 post-operative visits demonstrating a better outcome in the B group. Even though it was not statistically significant, our data also showed that patients with traction tenolysis appeared to have more postoperative pain compared to those without.

Introduction: To identify the strongest peak load resistance among four mallet finger fracture fixation methods (Kirschner wire, pull-out wire, tension-band wiring and the JuggerKnot™ (Biomet) soft anchor fixation).

Methods: Fixation techniques were assigned among 24 specimens from six cadaveric human hands in a randomized block fashion. Peak load resistance was tested at 30°, 45° and 60° of flexion of the distal interphalangeal joint.

Results: The mean peak load of tension-band wiring was 67.8 N at 60° of flexion which was most superior. The JuggerKnot™ fixation had mean peak loads of 13.35 N (30°), 22.51 N (45°) and 32.96 N (60°). No complications of implant failure or fragmentation of the dorsal fragment was noted.

Conclusions: Tension-band wiring was the strongest fixation method but was most prominent on the skin surface as seen in three specimens. The JuggerKnot™ soft anchor fixation had similar peak load resistance as k-wire fixation and pull-out wiring.

Introduction: Non-union of radial neck fractures is not common in adults, and surgical treatment is rarely required. This case report documents non-union of the radial neck with persistent pain around the elbow joint and tenderness over the neck of the radius, limited range of motion for 12 months. The authors performed an iliac bone graft and temporary K-wire fixation for non-union of the radial neck after an isolated radial neck fracture.

Case presentation: A 54-year-old woman slipped with her hand outstretched 12 months prior to presentation. She was diagnosed with a radial neck fracture, but her injury was eventually diagnosed as a non-union fracture, and she was transferred to our hospital. The patient had tenderness of the radial head and neck and an increasing tendency of pain in the forearm during external rotation with resistance. Flexion was a maximum of 80°, extension was limited to 20°, and internal rotation and external rotation were decreased to 60°. On plain radiographs, a clear radiolucent shadow was present between the bone fragment and radius. After the autogenous iliac bone graft, a temporary K-wire was fixed, and at eight weeks postoperatively, the bone was united. The patient is in the month 24 of postoperative follow-up and is able to perform daily activities without tenderness.

Conclusion: If elbow joint pain, tenderness, and limitation of range of motion are present in non-union of radial neck fracture, surgical treatment is necessary. If there is no injury to the ligament around the elbow or instability, the authors consider bone graft and temporary K-wire fixation as an excellent treatment option for bony union and early exercise of the joint.

Anomalies of Flexor carpi ulnaris (FCU) are uncommon and predominantly consist of abnormal insertion or extra tendinous bands. The presence of two separate bellies of FCU muscle with separate tendons has been termed as Digastric FCU. It is a very rare anomaly with only six previously reported cases and no report of clinical use of such anomalous muscle. We describe a case of anomalous FCU found incidentally in a patient operated for complex Post Volkmann's ischemic contracture deficits. On table each head of FCU was found to form separate belly and tendon. One tendon was used for the thumb opposition while the other for index finger flexion. Postoperatively, the patient had independent movement of thumb and index finger. This is the first reported case of clinical application of digastric FCU. We reviewed the literature for supernumerary FCU in general and digastric FCU in particular. We propose a new classification for supernumerary FCUs based on the clinical appearance and the probable embryological basis of the anomaly: Type 1 (Split tendons) — single muscle with two tendons; Type 2 (Digastric FCU) — for each head of FCU forming separate muscle bellies and tendons; and Type 3 (Accessory FCU) — abnormal muscle adjacent to normal FCU with combined features of FCU and Palmaris longus.

We report a case of an elderly female who sustained a severely comminuted distal radial and ulnar fracture, treated by shortening of the forearm, combined with a primary Sauvé-Kapandji procedure and volar plating of the distal radius.

In this study, we report a case of a 60-year-old woman with diabetes mellitus, who had a left distal radius fracture and could not flex the interphalangeal joint of her left thumb after we performed an open reduction and internal fixation procedure using minimally invasive plate osteosynthesis. Nine days after the first operation, we explored her wrist. We observed that the flexor pollicis longus tendon was compressed by the inserted plate. Then revision surgery and tendon repair were performed. Three months later, the fracture was healed and flexor pollicis longus function recovered well without sequelae. Approach through the interval between flexor carpi radialis and radial artery is preferred to prevent tendon entrapement.

A linear constricting scar around the wrist in the presence of a discharging sinus raises clinical suspicion of a forgotten band around the wrist. A 3-year-old girl presented with an encircling scar, swelling and discharging sinus over the right wrist since last three months. There were no trophic ulcers and gross sensations were intact. Wrist radiographs showed the "constriction" sign in the radial epiphysis. MRI confirmed the diagnosis of encircling band inside wrist abutting the bone. A coloured rubber band was surgically extracted lying deep to restored and continuous tendons and neurovascular structures. Wound healing was uneventful. Examination at 14 months revealed residual ulnar nerve palsy. If aware, the clinical diagnosis is fairly accurate in rubber band syndrome. MRI aids in establishing diagnosis preoperatively. The reparative potential of a child's tissues is amazing. Although the lesion heals well after extraction of encircling band, the clinician should be wary of residual neurological changes.

Carpal tunnel syndrome is a common condition; however, it has not been previously reported in patients with hemihypertrophy. A 67-year-old woman with left-sided hemihypertrophy presented with carpal tunnel syndrome of the left hand. Magnetic resonance imaging showed enlargement of the median nerve proximal to the transverse carpal ligament. Carpal tunnel decompression was performed, and pain was immediately relieved by decompression of the carpal tunnel. At the six-month follow-up examination, the patient experienced relief from numbness and improvement in thenar muscle atrophy was noted.

We report a case of closed rupture of the flexor tendons of the little finger caused by calcium pyrophosphate dihydrate crystal deposition disease of the pisotriquetrum joint. The patient could not flex the little finger and did not have wrist pain. Plain radiographs of the affected wrist joint showed severe arthritic changes of the pisotriquetrum joint and calcification around the joint. At operation, the pisotriquetrum joint capsule was ruptured and involved the flexor tendon of the little finger. The distal stump of the flexor tendon was transferred to the flexor tendon of the ring finger, and the pisiform was resected. Histological examination with polarized light microscopy revealed crystals showing weakly positive birefringence in the calcification.

Hamate hook non-union is a relatively rare, but on the increase. We encountered a 25-year-old male baseball instructor with hamate hook non-union, and treated it with debridement of the fractured region and osteosynthesis using a break-away screw. Splint fixation was applied for three weeks after surgery, and active/passive range of motion exercises were actively performed thereafter. Bone union was noted three months after surgery. Transient ulnar paralysis resolved, and the patient could return to the same sports activity as that before injury six months after surgery. Since break-away screws are capable of loading a strong pressure on the fractured region and these screws can be inserted by preparing only a surgical field for guide wire insertion, requiring no soft tissue dissection to prepare a region for applying fixation materials, break-away screws are useful for the fixation of small bone fragments and osteosynthesis in a deep surgical field.

A successful replantation of an index fingertip in an 8-month old girl is reported. A literature review of replants in very young children suggests this is one of the youngest patients ever to undergo digital replantation and possibly the youngest finger replant performed.

We report a rare case of limitation of active flexion and subcutaneous bow-stringing as a result of flexor pulley rupture after repeated corticosteroid injections for trigger thumb. Complete rupture of the A1 and oblique flexor pulleys was confirmed during surgery, and the pulley system was reconstructed with a "three-loop technique" using a free palmaris longus autograft. This technique provided enough strength to allow early mobilization and prompt recovery to full range of motion.

Metallosis is a well-documented phenomenon in hip and knee arthroplasty from metal on metal bearing joint replacements. However, few cases of metallosis of metacarpophalangeal joint replacements have been reported.

We present the case of a 49-year-old lady with rheumatoid arthritis who had previously undergone MCP joint replacements over 20 years ago. The decision was taken to revise her middle MCP joint after she developed pain and ulnar drift. At revision, the joint exhibited severe metallosis presumably arising from the grommet component of the replacement. This required considerable debridement and removal of the components and revision to a new upsized implant without grommets. It is of note that there were no external signs of metallosis with full flexion of the finger and a good roll up.

The advantages of using multiple joint sparing antegrade intramedullary wiring for displaced, transverse and short oblique fractures of the small long bones of the hand has been well documented. This technique provides stable three-point fixation and permits early range of motion exercises to prevent hand stiffness. But in some revision cases where there is a breach or deficiency of subchondral bone due to previous intramedullary wiring or in old neglected juxta articular fractures of the metacarpal, proximal phalanx or middle phalanx with disuse osteopenia, there is a high chance of inadvertent joint penetration with intra medullary wiring, inspite of using blunt tipped bent K wires. This could happen intraoperatively or later in the follow up due to collapse of the fracture ends. We describe an innovative fixation technique which ensures stable fixation, no joint penetration and enables early range of motion to prevent hand stiffness.

Lipoma of the hand is a common lesion, but lipoma arising from the flexor tenosynovium is a very rare tumor that induces peripheral nerve disorders. Only four cases of synovial lesions that comprised mature fat at the wrist and imitated carpal tunnel syndrome have been described in the literature. We herein report an unusual case of a lipoma arising from the flexor tenosynovium at the level of the ring finger just proximal to the A1 pulley that was responsible for a sensory disturbance of the ring and middle fingers secondary to compression of the common digital nerve at the palm. The patient was completely relieved of the symptoms after lipoma excision.

Retiform hemangioendothelioma is a rare, intermediate-grade, locally aggressive vascular tumour that involves the skin and soft tissues of the trunk and extremities (1–10). Macroscopically it appears as a plaque or an exophytic lesion. Involvement of the hand or upper extremity is rare, with only Three cases reported in the literature (2, 3, 9). Treatment usually involves surgical excision or amputation (2). We present the case of a middle-aged woman with a retiform hemangioendothelioma of the small finger, successfully treated with surgical excision with no signs of recurrence at 4 years of follow-up.