Hand Surgery

Complex regional pain syndrome (CRPS), previously known as reflex sympathetic dystrophy, is attracting more public attention in Japan which is likely a result of the recent upsurge in lawsuits filed against medical institutes. A recent court ruling over a case of injection-needlestick-injury induced CRPS has touched off serious debates among both medical practitioners and legal professionals. Although the court rejected the plaintiff's claims, the high court admitted them in view of the evidence and the entire pleadings and ordered the defendant to pay compensation. As venipuncture is the most frequently conducted and minimally invasive procedure in daily clinical practice, this court decision has attracted tremendous interest throughout the nation, alarming medical practitioners, and encouraging attorneys. The purpose of this article is twofold: to highlight the patient's clinical course in summary based on an unofficial case law report¹ and to provide a scientific perspective on this issue based on recent relevant articles.

Background: We identified a subset of patients who had posterolateral rotatory instability (PLRI) following corrective osteotomy for asymptomatic cubitus varus deformity. We aimed to identify risk factors for PLRI in such patients by comparing this subgroup to patients who did not demonstrate PLRI following osteotomy.

Methods: We retrospectively reviewed the medical records and radiographs of 22 patients with cubitus varus that underwent corrective osteotomy at our institution between 2003 and 2010. All patients underwent surgery for cosmetic reasons, and no patient reported functional problems such as PLRI or ulnar nerve symptoms pre-operatively. We sought to identify differences between those that experienced an increase in PLRI after osteotomy (PLRI group) and those that did not (non-PLRI group) with regard to demographics, degree of deformity, amount of surgical correction, and final outcomes.

Results: Five patients had PLRI after osteotomy, and all five subsequently underwent lateral ulnar collateral ligament reconstruction using a triceps tendon graft. No statistically significant difference was observed between the PLRI and non-PLRI groups in terms of demographics, degree of deformity, amount of surgical correction, range of motion, and final Mayo Elbow Performance Index (MEPI) and the Disabilities of Arm, Shoulder, and Hand (DASH) scores. However, the PLRI group had marginally greater medial displacement of the distal fragment.

Conclusions: This study demonstrates that PLRI can become apparent after corrective osteotomy for cubitus varus in the absence of clinical symptoms of instability preoperatively. We suggest that careful examination for PLRI should be performed after surgical correction for cubitus varus deformity, and surgeons should be prepared to proceed with simultaneous reconstruction of the lateral ligaments of the elbow.

This study aimed to determine whether the extensor pollicis longus (EPL) or abductor pollicis longus (APL) can replace the function of thumb extension in hands in which the extensor pollicis brevis (EPB) is absent. Cadaver dissection was performed to examine anatomical association between the interphalangeal (IP) joint and metacarpophalangeal (MP) joint of the thumb, as well as extension mechanism in clinical cases.

EPB insertion could be classified into eight types, and the EPB was absent in 7.6% of all cases. In hands without an EPB, the width of the EPL tendon tended to be wider, and the number of APL tendons was significantly greater than in hands with an EPB.

In hands without an EPB, the EPL and APL may replace the function of the EPB. As a result, a greater load is imposed on these two tendons than in hands with the EPB.

This is a report on the 14 PIA flaps done in our centre for traumatic hand defects over both volar and dorsal aspects, as well as thumb reconstruction over a six-year period from 2000 to 2007. We were able to achieve reach to the DIPJ with the use of fascia extension and better flap survival with more perforators captured in the flap.

In anterior interosseus nerve syndrome, reconstruction of the paralyzed flexor pollicis longus is occasionally required. Traditionally, the brachioradialis has been used as a motor, but we utilised the palmaris longus, which is expendable. The palmaris longus tendon was transferred in an end-to-side manner, leaving the flexor pollicis longus in situ. The procedure was performed in three patients. All patients regained a full range of thumb interphalangeal joint motion and an average 90% of the pinch strength. The only complication noted was thenar pain due to the adhesion of the palmar branch of the median nerve with the transferred tendon in one patient. This can be avoided if the interlacing suture was placed more proximally. Palmaris longus transfer is a simple technique that gives a satisfactory result.

The purpose of this study is to investigate the structural changes of the carpal tunnel, median nerve, and flexor tendons in magnetic resonance imaging (MRI) before and after endoscopic carpal tunnel release (ECTR). We studied 36 hands undergoing ECTR. In MRI, the cross-sectional area of the carpal tunnel and the median nerve at the hamate and the pisiform levels were measured. The distance from the volar side of carpal bone to the median nerve or tendons and the volar displacement were measured. In post-operative MRI, the transverse carpal ligament could not be well delineated and the carpal tunnel was significantly enlarged both at the hamate and pisiform levels. The median nerve was enlarged at the hamate level. The median nerve and flexor tendons significantly moved to the volar side. The volar displacement of the median nerve and flexor digitorum superficialis in the long and ring fingers was greater than the other tendons.

Thumb opposition does not always represent the function of the median nerve due to variations in thenar muscle innervation. One hundred and thirty hands of 109 idiopathic carpal tunnel syndrome (CTS) patients with an undetectable compound muscle action potential of the abductor pollicis brevis (APB-CMAP) were classified into one of four groups; Type 1 (86.2%) had thenar muscle atrophy and could not perform thumb opposition; Type 2 (10.8%) had thenar muscle atrophy but could perform thumb opposition; Type 3 (2.3%) did not have thenar muscle atrophy and could perform thumb opposition, but needle electromyography of the APB showed neurogenic changes and Type 4 (0.8%) had no thenar muscle atrophy, could perform thumb opposition, and needle electromyography showed no neurogenic changes. Over 10% of severe CTS patients have mild or no muscle atrophy and intact thumb opposition. The purpose of this study was to investigate the variations in thenar muscle innervation in patients with severe CTS.

The gold standard treatment for Dupuytren's contracture is surgical excision of the cord. A non-surgical treatment with collagenase clostridium histolyticum injection is available but appears costly.

Objectives: To provide data on resource consumption related to surgical and non-surgical treatment for Dupuytren's contracture.

Design and Participants: Twenty patients with a single digit Dupuytren's contracture, 10 treated with surgical excision, and 10 treated with a single injection of collagenase.

Measurements: Minutes spent in theatre, number of follow-up appointments, time to skin healing, and patients return to normal activities of daily living.

Results: The injection group was significantly better regarding theatre time (p < 0.0001), follow-up appointments (p = 0.048), skin healing time (p < 0.001), and return to normal activities of daily living (p = 0.02) than the operated group.

Conclusions: There are significant personal and health economic differences between the two methods of treatment which may influence local choice.

Bibliometric analyses of the hand and wrist research have previously shown a significant increase in research productivity in Asia. We examined the key contributors to this change by performing bibliometric analyses regarding hand and wrist research in all Asian countries producing significant research. Original research articles from 1988 to 2007 were collected from seven English language journals based on the impact factor. Trends in research productivity were determined by country using linear regression analysis. Compared to the rest of the world, Asia produced fewer level I and basic studies, but more level IV studies. Significant increase in both research volume and productivity in Asia was observed, with Japan, Korea, and Taiwan having the highest aggregate productivity in hand and wrist research. From 1988 to 2007, the relative research production among Asian countries showed significant change, in contrary to that of Europe, Latin American, and the United States.

Purpose: Distal radius malunion is often seen after distal radius fracture. We performed a less invasive but secure corrective surgery using an intramedullary implant combined with percutaneous osteotomy. The purpose of this study was to evaluate the results of this surgical technique.

Patients and methods: Three patients with malunion of a distal radius fracture were included. We assessed the wrist joint disability scores pre-operatively and at the final follow-up an average of 21 months after surgery. We also performed radiological assessments of volar tilt, radial inclination, and ulnar variance.

Results: All three patients achieved excellent clinical results with an average joint disability score of 93.3 at the final follow-up. The radiological parameters improved without any post-operative correction loss.

Discussion: Intramedullary implant combined with percutaneous osteotomy provides sufficient stability after correction of distal radius malunion and avoids the complications associated with the use of a volar plate.

An intraosseous xanthoma is a very rare condition. It has an aggressive appearance on radiographs mimicking primary or metastatic malignant bone tumors. We report a case of intraosseous xanthoma of the distal radius in a 51-year-old male with no history of hyperlipidaemia. To the best of our knowledge, this condition has not been reported so far in the wrist and forearm region. The lesion was successfully excised and at last follow-up, there were no signs of recurrence and patient has been symptom-free.

The advantage of preserving the distal radioulnar joint in wrist disarticulation is that full forearm rotation is possible if the joint is intact, which improves the capability of the amputee. The Sauvé-Kapandji procedure has been performed to treat rheumatoid or post-traumatic chronic instability and/or arthritis of the distal radioulnar joint. We report a patient with wrist disarticulation that presented to us with limited supination of the wrist due to an injured distal radioulnar joint. We performed the Sauvé-Kapandji procedure, and the patient could regain functional supination of the forearm without losing the ulnar styloid flare that improved prosthetic suspension. This case suggests that the Sauvé-Kapandji procedure can be performed to maintain the advantage of wrist disarticulation even when the initial trauma involves an irreparable injury of the distal radioulnar joint.

We experienced two cases of simultaneous fracture of the scaphoid and the lunate. In two cases, both scaphoid and lunate fractures existed on the same plane, which may help us to understand the mechanism of proximal fracture of the scaphoid.

Triggering at the wrist with finger movement is an uncommon presentation. We present the case of a 46 year old male with painful wrist triggering with associated carpal tunnel syndrome caused by an intramuscular lipoma of the lumbrical muscle. As far as we are aware this is only the second documented case of wrist triggering caused by an intramuscular limpoma. Surgical removal of the tumour led to a resolution of the patients symptoms. We review the literature and discuss other published cases of this rare presentation.

Spontaneous rupture of the extensor pollicis longus (EPL) tendon is rare, and spontaneous non-traumatic rupture of both extensor pollicis longus (EPL) and extensor carpi radialis brevis (ECRB) tendons is not reported in literature. Rupture of EPL is usually associated with rheumatoid arthritis, systemic or local steroid injections, fractures of the wrist and repetitive and excessive abnormal motion of the wrist joint. We describe a case of spontaneous rupture of the EPL and ECRB tendons in a female patient, washerwoman by occupation, with no predisposing factor. Exploration of the tendons along with end to end tendon repair was done with excellent results. We describe the possible mechanism of the injury and result after one year follow up.

Giant cell tumour of the tendon sheath is rare in children. We present an unusual case of a recurring multifocal giant cell tumour of the tendon sheath in the hand and wrist of an 11-year-old boy. We are not aware of any similar report in the literature.

We report an extreme case of Mycobacterium kanasii flexor tenosynovitis with flexor tendon rupture in a healthy 65-year-old left-hand dominant Caucasian housewife.

This case highlights the diagnostic conundrum of atypical mycobacteria infections due to their insidious presentation, the need for a high index of suspicion to prevent worsening or delaying the diagnosis from inappropriate steroid use and that these infections can occur in otherwise healthy individuals.

The cases of two patients, a four-year-old boy and an eight-year-old boy, who had been incapable of active flexion of the little finger since birth, are presented. They were capable of active flexion of the metacarpophalangeal (MP) joint, but not of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints. They were diagnosed with a defect of the flexor digitorum profundus (FDP) tendon of the little finger and underwent surgery. In both cases, the FDP tendon turned into fibrous tissue proximal to the palm and lost continuity on this side. Reconstruction was performed by making an end-to-side anastomosis of the residual proximal end of the FDP tendon to the FDP tendon of the ring finger in the palmar region. Although one patient required repeated surgery due to post-operative tendon adhesion, good outcomes were achieved, with both patients becoming capable of active flexion.

Subcutaneous granuloma annulare is a benign inflammatory disorder consisting of deep dermal or subcutaneous nodules, and frequently occurring in the extremities and scalp in children. The occurrence of aggregated multiple nodules in a digit is quite atypical. This is a report of an eight-year-old girl who presented with increasingly asymptomatic multiple nodules on her middle finger over a period of six months. Definitive diagnosis of subcutaneous granuloma annulare was achieved with surgical biopsy and no aggressive growth subsequently and showed a tendency toward spontaneous resolution.

Penetrating sea urchin spine injuries, can lead to devastating, irreversible consequences. Persistent inflammation, cutaneous granuloma, neuroma, tenosynovitis, arthritis and destructive arthritis, leading to permanent loss of function and digit amputation, can occur. We present a case of a patient who developed sea urchin spine arthritis of the proximal interphalangeal joint. Only 17 cases of sea urchin spine arthritis of the hand have been documented in the medical literature. However, in this case, the article also includes sequential radiographs, histopathological slides, and intra-operative photographs.

Intraosseous epidermoid cyst is considered a rare benign inclusion cyst found mainly in the skull and phalanges. Once the cyst is differentiated from other similar lesions, the cyst can be treated with simple curettage, seldom requiring additional managements. We experienced this rare case that had been treated successfully without complication.

Even with the invention of locking plates, intra-articular fractures of distal radius with extreme comminution remain a challenge for orthopaedic surgeons. Osteochondral graft is a potential choice to reconstruct the articular defect. We report a patient who had a fracture of distal radius with costo-osteochondral graft for articular reconstruction which has not yet been described in the English literature. At nine-year follow-up, he was pain free and had full range of movement of the wrist. The authors suggest that costo-osteochondral graft could be an option with satisfactory result.

Wrist arthrodesis is exceptionally performed in children. The main indication is severe wrist flexion contracture resulting from Volkmann's ischaemia or spasticity. In such cases, a proximal row carpectomy is usually necessary to allow the wrist to be positioned in neutral position. In young children, it is essential to preserve the distal radius growth plate, to prevent physeal closure. In these very particular indications, with high stresses along the stretched palmar soft-tissues, Kirschner wire fixation provides poor stability, and plate fixation is contra-indicated. Radio-metacarpal external fixation is an excellent alternative, preserving the distal radius growth plate and offering sufficient stability. This technique was used in a seven-year-old girl suffering from Volkmann's ischaemic contracture, treated by first carpal bone resection and subsequent arthrodesis with radio-metacarpal external fixation. Bone healing was achieved in three months, with a five years follow-up preservation of the distal radius growth plate.

Several techniques are used for fixation of Bennett's fractures. The aim of this study was to assess a technique of arthroscopic-assisted reduction and percutaneous cannulated screw fixation of Bennett's fractures.

Seven patients (mean age 29 years) with three fractures Type I and four fractures Type II according to Gedda were operated under arthroscopic lavage, fluoroscopic screw fixation, and arthroscopic control of the joint reduction.

Arthroscopy, showed satisfactory joint reduction in all cases. At 4.5 months, the mean pain score was 1 (0–4), QuickDASH 15 (0–61), and Kapandji score 9 (5–10). Compared to the contralateral side, first web opening was 86% (58–100), key pinch 73% (45–89), grip strength, and 85% (40–100). Four secondary displacements were noted, two of which had a step of more than 1 mm.

Our results showed that the use of arthroscopy for percutaneous screw fixation of Bennett's fractures facilitates joint reduction but does not guarantee stability of fixation.

Flexor tendon injuries in zone II were treated in 14 fingers of 13 patients with our method. Firstly, a 2-strand core suture was made by the side-locking loop technique using a USP 2-0-sized braided polyblend polyethylene suture, then 7-strand peripheral cross-stitches were added using a USP 5-0-sized monofilament nylon suture.

Post-operative exercises included passive flexion and extension without external fixation on the next day of surgery. Average follow-up observation period was 18 months. As results, the Strickland method of assessment for surgical outcome showed excellent in eight digits and good in five digits, though there was a poor outcome in one digit. Our suture method enabled early post-operative mobilisation exercise without using a splint, while preventing adhesion between the repaired tendon and peripheral tissues, which is considered to provide far greater ultimate tensile strength and a smaller gap at the sutured site than by the conventional method.

Flexor sheath infection is a hand surgery emergency, and emergent washout is the accepted practice to prevent digital amputation. The authors describe surgical steps to optimize flexor sheath irrigation.

This review article describes the contribution of Australian authors to the basic science and clinical management of flexor tendon injuries.

Introduction: This study aims to gain a better understanding of current practice for the surgical management and rehabilitation of flexor tendon injuries in Australia, with the intent of establishing common guidelines for training of young surgeons.

Methods: A survey was distributed to the membership of the Australian Hand Surgery Society to determine whether a consensus could be obtained for: suture material and gauge; core and epitenon suture techniques; sheath and pulley management; and post-operative protocols for primary flexor tendon repair.

Results: The predominant materials used for core suture are Ticron^TM Suture (Tyco Healthcare Group LP, Norwalk, Connecticut, USA) (34%) and Ethibond^TM Polyester Suture (Ethicon, Somerville, New Jersey, USA) (24%). The two core suture configurations commonly used are the Adelaide (45%) and Kessler (32%) repair. The predominant materials used for epitendinous sutures are 6-0 Prolene^TM Polypropylene Suture (Ethicon, Somerville, New Jersey, USA) (56%), 5-0 Prolene^TM (21%) and 6-0 Ethilon^TM Nylon Suture (Ethicon, Somerville, New Jersey, USA) (13%); and the majority (63%) use a running epitendinous technique. The management of critical pulleys is variable, with 89% prepared to perform some release of A2 and A4 pulleys. Rehabilitation protocols vary widely, with 24% of respondents using the same method for all patients, while 76% tailor their approach to each patient. Some component of active motion was used by most.

Discussion: There exists some consensus on the management of flexor tendon injuries in Australia. However, the management of critical pulleys and methods of post-operative rehabilitation remain varied. For the training of young surgeons, a majority advise a 3-0 gauge braided polyester core suture of four strands, combined with a 6-0 Prolene^TM simple running epitendinous suture for increased tendon repair strength and smooth glide. Trainees should attempt to retain the integrity of the A2 and A4 pulleys. Post-operative rehabilitation should include a component of active flexion.

Earlier generations of wrist arthroplasty were limited to low demand patients. Bone fixation problems, excessive wear, and adverse designs resulting in loosening, imbalance, and dislocation led to the withdrawal of a number of models. Contemporary wrist prostheses aim at replacing wrist arthrodesis in the majority of patients with radiocarpal destruction, including high demand cases. Contraindications are wrist imbalance, insufficient soft tissue, or bone stock and infection. Various designs, fixation principles, bearing materials, and articulations have been employed. Some of the devises (RE-MOTION^TM, Motec^®) demonstrate promising short- to midterm results, and calls for cautious optimism.