Hand Surgery

Background. Hand20 is an illustrated, self-administered questionnaire comprising 20 short and easy-to-understand questions to assess upper limb disorders. This study aimed to test the reliability, validity, and responsiveness of Hand20.

Methods. Eighty-five patients with three upper limb disorders (51 with trigger finger, 29 with ulnar impaction syndrome, and five with carpal tunnel syndrome) completed Hand20, the Japanese Society for Surgery of the Hand version of the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH-JSSH), and the 36-Item Short-Form Health Survey (SF-36). Reliability was assessed by internal consistency. To test the validity, a factor analysis of Hand20 was performed and the correlation coefficients between Hand20 and DASH-JSSH and those between Hand20 and SF-36 were calculated. Responsiveness was evaluated in 47 patients with trigger finger as the standardized response mean and effect size after treatment.

Results. A Cronbach's α coefficient of 0.967 confirmed the unidimensionality of Hand20. The correlation coefficient between Hand20 and DASH-JSSH was 0.84. The correlations between Hand20 and the SF-36 subscales ranged from -0.236 to -0.596. Moderate correlations were observed for "Role-physical" (r = -0.596) and "Bodily pain" (r = -0.557). The correlation between the Hand20 and "Physical functioning" was weak (r = -0.313). The standardized response mean and effect size of Hand20 was 1.50 and 1.60, respectively.

Conclusions. The Hand20 has evaluation capacities equivalent to those of DASH-JSSH. There was a moderate correlation between Hand20 and SF-36.

Purpose: Determining the patterns of brachial plexus injuries is challenging. Diagnostic methods have been used to facilitate diagnosis, but there is no consensus regarding which tool best complements physical examination (PE). Magnetic resonance imaging (MRI) and nerve conduction studies (NCSs) are instruments with widespread use and feasibility for everyday assessment. In this study, we evaluated the diagnostic performance of these diagnostic instruments and PE. We also assessed the agreement in the PE and diagnostic instrument findings of two experienced and certified hand surgeons.

Methods: We reviewed data gathered from medical records and compared these data with the results of operative findings. We divided data according to the site of injury and the root injury patterns for all three diagnostic instruments (PE, MRI, and NCSs).

Results: We considered 102 assessments. We found poor inter-observer agreement for the PE assessments and poor agreement among the PE, NCS, and MRI assessments. Diagnostic performance was higher for PE: sensitivity = 97.8 [95% confidence interval (C.I.) = 92.1–99.7]; specificity = 30.8 [95% C.I. = 9.1–61.4], and NCSs (sensitivity = 98.9 [95% C.I. = 93.9–100]; specificity = 23.1 [95% C.I. = 5–53.8]. MRI had inferior performance for all measurements. Separate analysis using pre- and post-ganglionic injuries revealed that PE had the lowest sensitivity, 46.7 (95% C.I. = 21.3–73.4) despite having the highest specificity, 81.6 (95% C.I. = 71.9–89.1).

Discussion: Low agreement among the findings using different diagnostic instruments demonstrated that PE is the most specific tool, despite its low sensitivity. Detailed PE is cornerstone for evaluating brachial plexus injuries and NCSs are better than MRI for scrutinizing injuries not found in PE.

Clinical Relevance: In our study, NCSs exhibited superior performance to MRI, and should be considered a more reliable supporting tool after detailed PE.

Anterior dislocation of the ulnar nerve is occasionally encountered after simple decompression of the nerve for treatment of cubital tunnel syndrome. The purpose of this study was to determine whether the incidence of dislocation of the nerve following simple decompression of the nerve is correlated with the patient's preoperative characteristics and/or elbow morphology. We studied 51 patients with cubital tunnel syndrome who underwent surgery at our institution. Intraoperatively, we simulated dislocation of the nerve after simple decompression by flexing the elbow after releasing the nerve in each patient. Univariate and multiple logistic regression analysis showed that young age and a small ulnar nerve groove angle are positively correlated with dislocation of the nerve. Our results suggest that patients who are young and/or have a sharply angled ulnar nerve groove identified radiographically have a high probability of experiencing anterior dislocation of the ulnar nerve after simple decompression.

Displaced distal radius fractures in active elderly patients with high functional demand present a clinical dilemma because current evidence is equivocal in the recommendation of treatment. Internal fixation is an increasingly popular option with proposed superior results. Our study aims to evaluate the results among a population of active elderly patients with displaced fractures managed with either cast immobilization or internal fixation with volar locking plate.

Seventy-five patients (35 cast immobilization and 40 internal fixation) with mean age of 74 ± 7.5 years with minimum of 12 months follow-up were studied. The radiological and clinical parameters were assessed at three, six, and 12 months. Functional outcomes (DASH, Green-O'Brien) were assessed at 12 months. Patients who underwent surgery regain wrist motion and grip strength earlier, but this was not statistically significant after six months.

The pronator quadratus muscle transfer combined with the Sauvé-Kapandji procedure was used to treat the distal radioulnar joint disorder in ten rheumatoid wrists for prevention against instability of the proximal ulnar stump. All patients were female with a mean age of 46.6 years. The mean follow-up time was 24.2 months. Postoperatively, supination increased in all patients with a mean of 50 degrees. Pain decreased significantly and none complained of prominence of the proximal ulnar stump in normal pronated position and during a tight grip. The wrist radiographs of both coronal and sagittal planes in normal and stress fisting views were used to evaluate the postoperative static and physiologic loaded stability of the proximal ulnar stump. It had shown this procedure provided good static proximal ulnar stump stability in both coronal and sagittal planes. However, in physiologic loaded condition, it was able to provide stability only in the sagittal plane.

Isolated dorsal scapholunate reconstruction may be inadequate to stabilize and restore physiological scapholunate kinematics in the setting of combined dorsal and palmar ligamental incompetence. To address this entity, a combined reconstruction that encompass both dorsal and palmar scapholunate reconstruction was performed in 20 patients followed up to 19.8 (6–84) months. Compared to the contralateral wrist, the results were extension (67 ± 1.6 to 85.7%, p < 0.01), flexion (84.5 ± 3.2 to 81 ± 2.3%, p = 0.38), grip strength (62 ± 1.6 to 88.3 ± 1.9%, p < 0.01), and pain score (rest: 1.55 ± 0.26 to 0.2 ± 0.09, p < 0.01; activity: 3.2 ± 0.09 to 0.4 ± 0.17, p < 0.01). Based on Mayo wrist score, five excellent, 13 good, and two fair results were reported.

Management of scapholunate (SL) instability remains controversial. The modified Brunelli procedure is a soft tissue procedure that recreates the stabilising forces of the SL ligament using a split flexor carpi radialis tendon graft passed from volar to dorsal via a tunnel in the distal pole of the scaphoid. Thirteen consecutive patients with an average age of 35 years underwent the modified Brunelli procedure. Pain improved from a mean visual analog score of eight preoperatively to 1.5. The DASH score improved from a preoperative score of 55.4 to 34.9 as did the grip strength from 40% to 75% respectively. All wrist ranges of motion were decreased post-operatively in particular wrist flexion. SL ligament reconstruction using the modified Brunelli procedure resulted in satisfactory outcomes. Post-operatively patients were relatively pain free, with improved grip strength. The range of motion was reduced postoperatively, however did not restrict return to work or premorbid activities.

The purpose of this study was to identify the clinical characteristics of neuropathic pain in patients with carpal tunnel syndrome. We retrospectively reviewed 143 hands in 127 patients with carpal tunnel syndrome. The neuropathic pain was determined by using the painDETECT as a self-administered psychometric questionnaire to distinguish neuropathic pain. There were no significant differences in the characteristics of the patients with and without neuropathic pain. However, there were significant differences in the pain scores between those with and without neuropathic pain (p < 0.01). Furthermore, there was a significant difference between the existence of night pain in these patients (p < 0.01). Based on the results of the current study, we conclude that it is important to be aware of, and consider the existence of neuropathic pain during the treatment of patients with carpal tunnel syndrome with night pain or a high score on the numerical rating scales of pain.

Thumb carpometacarpal joint (CMCJ) osteoarthritis is a common complaint that produces pain and disability within the hand. This study aims to ascertain whether joint injection with local anaesthetic and steroid is of predicative value in disease progression in thumb carpometacarpal osteoarthritis.

Forty-three patients were assessed at an average follow up of 24 months following ultrasound-guided injection. Fourteen patients (32%) progressed to surgery, at a mean interval of 8.6 months (range 4–14 months).

There was a statistically significant correlation between those patients who had on-going pain following injection at one week and progression to surgery (p = 0.025) with an odds ratio of 3.14 and positive likelihood ratio of 2.1.

Patients with thumb CMCJ osteoarthritis that does not respond favourably to injection at one week are likely to progress to surgery in the first year after the injection. This work offers a useful tool in predicting disease progression and patient counseling.

Purpose: The rehabilitation program after flexor tendon repair of zone II laceration varies. We designed a Prospective Randomized Controlled Trial of controlled passive mobilization (modified Kleinert) vs. Place and active hold exercises after zone 2-flexor tendon repair by two-strand suture (Modified kessler).

Methods: Sixty-four fingers in 54 patients with zone 2 flexor tendon modified Kessler repairs were enrolled in a prospective randomized controlled trial comparing place and active hold exercises to controlled passive mobilization (modified Kleinert). The primary outcome measure was total active motion eight weeks after repair as measured by an independent and blinded therapist.

Results: Patients treated with place and active hold exercises had significantly greater total active motion (146) eight weeks after surgery than patients treated with controlled passive mobilization (114) (modified Klinert). There were no ruptures in either group.

Conclusions: Place and hold achieves greater motion than controlled passive mobilization after a two-strand repair for zone 2 flexor tendon repairs.

This study presents the clinical outcomes of 35 hands with Dupuytren's Disease treated with the McCash technique between 1990 and 2009. Of the 31 patients (28 males and three females, mean age 53 yrs), four patients had bilateral involvement (12.9%). Thirty hands had no previous medical or surgical treatment for the disease, while the remaining five hands had been operated on at least once. The mean contracture of metacarpophalangeal (MCP) joint improved from 42.14° to 1.83°, while that of the proximal interphalangeal (PIP) joint improved from 62.60° to 7.09°. All wounds healed within a mean 9.8 weeks. Sensory evaluation revealed no permanent numbness. With realistic expectations, clear documentation, meticulous surgical technique and implementation of a demanding post-operative rehabilitation program, an acceptable outcome may be achieved with the McCash technique for Dupuytren's disease.

Purpose: To review the results and indications of simultaneous four finger metacarpophalangeal joint fusions.

Methods: The clinical records and X-rays of nine patients undergoing the above procedure were reviewed. The indication for surgery was to reverse severe metacarpophalangeal joint flexion deformities in eight patients, and following a traumatic four finger amputation in one. Seven patients returned for follow-up assessment. The fusions were performed with a tension band wire technique, aiming for 20 degrees of flexion for index and middle fingers and 40 degrees in the ring and little fingers. Time to radiological fusion and position of fusion, and improvement in function and appearance were assessed.

Results: All joints were radiologically fused between six and 12 weeks. The average position of fusion of index and middle fingers was 20 degrees (range: 15–30) and ring and little fingers was 40 degrees (range: 35–50). Appearance was improved in all patients. Improved function was reported by four patients, and improved ease of hygiene and general care in four patients with non-functioning or poorly functioning hands.

Discussion: Simultaneous fusion of all four finger metacarpophalangeal joints may be considered as a primary procedure to reconstruct destroyed metacarpophalangeal joints due to inflammatory arthropathy or trauma, and for inability to correct deformity or maintain the correction with soft tissue procedures for patients with cerebral palsy, adult brain injury and arthrogryposis.

Pyrocarbon arthroplasty of the proximal interphalangeal joint (PIPJ) has been reported to provide excellent pain relief when treating osteoarthritis of the hand. We retrospectively reviewed 20 PIPJ arthroplasties performed on 14 patients by a single surgeon using Ascension prosthesis. The mean follow up period was 3.5 years (range 1–7 years). Excellent pain relief was noted at the final follows-up. The mean range of motion improved from 40° pre-operatively to 70° post-operatively which was statistically significant. Twelve patients had significant improvement in quality of life and would consider similar procedure for other fingers. Radiological assessment revealed an average of 1 mm subsidence and there was no correlation noted between subsidence, migration and ROM at the final follow-up. Stiffness was the main complication and was comparable with other studies. The results of this series are encouraging and demonstrate excellent to good outcome in 86% of patients at the mid-term follow-up.

Proximal interphalangeal joint (PIPJ) fractures are a treatment challenge for hand surgeons. Poor treatment options may lead to stiffness, non-union and markedly reduced range of movement (ROM). We describe our experience using the Hoffman-2 micro static external fixation device (Stryker) in a case series of ten patients with closed comminuted intra-articular PIPJ fractures. The use of this device in the management of these fractures has not previously been described. The mean total active motion (TAM) of the injured joint had recovered to 80% of normal at the six-month follow up.

This paper examines a case of radial nerve palsy in a 13-year-old girl caused by nerve embedded in a humeral shaft fracture. An X-ray showed a mild angular-displaced humeral shaft fracture. Two weeks later, an intramedullary Ender nailing was performed. Because of brain injury due to traffic accident, the patient lost consciousness for one month. Once she regained consciousness, radial nerve palsy was discovered and closely observed. As the radial nerve palsy had not healed after five months, the radial nerve was explored and found to be interposed between fracture sites and totally entrapped in the fracture callus. During surgery, both the proximal and distal ends of the radial nerve were cut at the surface of the humeral bone. Then, the radial nerve stumps were end-to-end sutured because of their enough length. One year after surgery, the radial nerve palsy had completely recoverd.

Malignant schwannoma (MPNST) is a rare tumor. Many of these cases occur in patients with neurofibromatosis type I (NF-1) and they usually present as a mass lesion which rapidly increase in size with or without neurological symptoms. Here we present an unusual case of MPNST along the radial nerve in which the patient has no underlying neurofibromatosis type I.

Acute spontaneous compartment syndrome of the forearm is rarely reported in the literature. It is typically associated with trauma or thromboembolism in the acute setting and repetitive exertional stress in the chronic setting. However it is rare for it to present bilaterally with no apparent underlying cause.

We report the case of a young 31-year-old lady who presented to our Emergency Department with bilateral compartment syndrome of the forearm. Her presenting complaints included acute severe pain and swelling of the forearms bilaterally, with a decreased range of movement of the wrist and fingers. She also complained of numbness in all fingers.

She had no history of recent trauma and ultrasound scans showed no evidence of vascular compromise. Past medical history was notable only for idiopathic hypertension and coeliac disease.

The patient was taken to theatre urgently where flexor and extensor compartments and carpal tunnel were decompressed. Pronator Teres was found to be dusky initially but turned pink after decompression. All other muscles were normal.

An interesting fact of this case was that combination of the high compartment pressures and anaesthetic related hypotension caused the forearm pulses to become impalpable at induction, these returned intra-operatively.

The patient has been seen in the outpatient department following discharge. She is well apart from some mildly reduced grip strength in her right hand likely due to carpal tunnel decompression. No cause was found for the scenario after extensive medical investigation.

We report a case of intraneural malignant granular cell tumor of the upper extremity occurring in a child. This is an exceedingly rare tumor and the incidence has so far been reported only in adults. The tumor was successfully treated surgically and the patient has remained tumor free to date. We describe our approach to the problem so that it will serve as an index case for similar encounters in the future.

To the best of our knowledge, there are no previous reports on anterior interosseous nerve palsy (AINP) caused by a soft tissue tumor after fracture of the distal radius. We treated a case of giant forearm lipoma that caused AINP one day after internal fixation of a distal radius fracture.

Ganglions of the wrist and hand causing compressive neuropathies are rare clinical entities. Compression of the ulnar and median nerves in their respective fibro-osseous tunnels lead to characteristic patterns of motor and/or sensory deficits, which are directly related to the location of the lesion. We present a unique case of a "dumbbell" shaped ganglion invading both Guyon's canal and the carpal tunnel causing a dual compressive neuropathy of the ulnar and median nerve. We discuss the patho-anatomy, clinical assessment, investigation and surgical treatment of this condition.

We describe a case of Hajdu-Cheney syndrome affecting the scaphotrapeziotrapezoid joint presently being treated non-operatively. This syndrome poses the problem of non-union when surgical intervention is required.

We report a case of extensor tendon dislocation at the metacarpophalangeal joint of the middle finger in which it appeared that an ulnar translation force created by an end-to-side transfer contributed to the dislocation. We recommend alterations in technique or alternative method of extensor tendon reconstruction to avoid this complication if unfavorable factors for end-to-side transfer exist.

Mal-union of the proximal phalanx can result in stiffness and decreased grip strength. Corrective osteotomy is precarious, especially for mal-union of the neck, as complications like non-union and avascular necrosis may occur. We describe a simple technique of subcondylar fossa reconstruction for mal-union of the proximal phalanx to overcome these problems.

We present a case of synovial chondromatosis affecting the interphalangeal joint where the disease did not clearly manifest itself on pre-operative radiographs. Although rare, surgeons should consider articular synovial chondromatosis as a differential for pain and stiffness in any joint, even those of the hand.

Introduction: Trichilemmal cysts (TCs) are common skin lesions that occur in hairy areas. A TC involving a fingertip has not been previously described in the literature. We herein report a case of a TC occupying a fingertip region.

Case presentation: A 43-year-old woman presented with a 1.5 × 1.5 cm nodular lesion on the third fingertip. The lesion was completely excised, and histopathological examination revealed a TC.

Conclusion: TCs may involve atypical locations, such as fingertips, where there are no hair follicles. After surgical excision, a careful histopathological examination should be performed to differentiate TCs from proliferating pilar tumors.

We report the case of a traumatic amputation by circular saw of the ring and small fingers, associated with middle finger nail matrix loss and tendon, bone and joint exposure.

The replantation was not attempted with patient's consent. Since the nail unit from the ring finger was intact, we decided to harvest the ring finger nail unit for major finger reconstruction.

Although the principle of vascularized transfer from a severely damaged finger is widely recognized and the vascularized nail transfer from toe is a relatively common procedure, there is no description of a vascularized nail transfer from a non-replantable digit in the literature.

If fixation of an ulnodorsal fragment in an intra-articular fracture of the distal radius is not stable, it is sometimes caused by dorsal displacement after surgery. Hence, we recommend the volar plate fixation with an additional dorsal approach and fixation of irreducible ulnodorsal fragments using a low-profile dorsal mini plate. The details of the surgical procedure and indications are discussed in this article.

The aim of this study was to determine the path of screw placement to avoid breaching the articular surface of both lunate and scaphoid bones at the radiocarpal and midcarpal joints. An Acutrak screw was inserted into the right scapholunate joint of ten cadavers starting immediately distal to the tip of the radial styloid and aiming for the tip of the ulnar styloid. The articular surfaces of the scaphoid and lunate bones in all ten cadavers were exposed and examined. A computed tomography (CT) scan of four wrists was performed. Eight of the ten cadavers had no perforation or destruction of the articular surfaces. Screw stabilization of the scapholunate joint can be performed without perforation or destruction of the lunate or scaphoid surfaces. We recommend that if this form of fixation is being used then the screw should be inserted commencing at the radial styloid tip and aiming for ulnar styloid tip, under radiological guidance.