Hand Surgery

Scaphoid fracture is the most common fracture in carpal bones. Although the reported union rate of conservatively-treated fractures is more than 90%, there is a controversy over the most appropriate treatment. In recent years, many reports have compared the clinical outcomes of conservatively-treated scaphoid fractures with the results of operatively treated ones using randomized controlled trials and meta-analyses. However, there is no consensus regarding the optimal treatment. In this paper, based on literature review, we provide an overview of the management of the acute scaphoid fractures particularly focusing on the issues related to conservative treatment.

Optimal treatment of acute scaphoid fractures is a necessary goal for many reasons. One is that the scaphoid is the most commonly fractured carpal bone. Another is that a missed diagnosis of an acute scaphoid fracture leads to the more challenging situation of a delayed union, non-union and risk for premature radiocarpal arthrosis. Because the scaphoid has an inherent risk for nonunion due to its the tenuous blood supply, timely diagnosis and appropriate treatment are considered critical to achieving acceptable results and to avoiding the consequences of failed union.

The difficulty in healing scaphoid nonunions is challenged further by the dynamic, unstable nature of the fracture-fragment interface. Recently, several investigators have introduced a minimally invasive technique for scaphoid nonunion repair, which has the advantages of minimal morbidity and accurate articular reduction, resulting in less postoperative stiffness and increased functional outcomes. However, failure to recognize the critical steps during minimally invasive surgery can result in incorrect treatment or limit any chances for successful bone repair. We reviewed the selected literature pertinent to arthroscopic techniques in the treatment of scaphoid nonunions. Furthermore, we presented a new arthroscopic approach that can be used in place of traditional formal open exposures in challenging cases of nonunion.

The scaphoid is the most common fractured bone in the wrist. Despite adequate non-surgical treatment, around 10% to 15% of these fractures will not heal. Untreated scaphoid non-union can cause a scaphoid non-union advance collapse (SNAC), this is a progressive deformity and can cause degenerative changes in the wrist. Surgery is focused on achieving consolidation, pain reduction and a good position of the scaphoid while preventing osteoarthritis in the long-term. Surgery consists of reduction and fixation of the scaphoid with a non-vascularized or vascularized bone graft. An overview of the most used vascularized and non-vascularized bone grafts and their indications are presented.

Fluoroscopy is a commonly used tool in hand surgery. There have been recent advances in the technology and its clinical utilisation. Indications include assessment of joint and fracture fixation and stability, particularly when combined with minimally invasive techniques. Recent developments include surgeon operated mini C-arm image intensifiers. We present a review of the clinical utilisation of fluoroscopy in hand surgery including recent developments, Australian legislation, safety issues, strategies to reduce radiation exposure and clinical examples for imaging distal radius and scaphoid fracture fixation.

The aim of this study is to introduce the classification of Swanson for congenital anomalies of upper limb modified by the Japanese Society for Surgery of the Hand (the JSSH modification) in English. The Swanson classification has been widely accepted by most hand surgeons. However, several authors have suggested that complex cases, particularly those involving the complex spectrum of cleft hand and symbrachydactyly, are difficult to classify into the classification schemes. In the JSSH modification, brachysyndactyly, so-called atypical cleft hand and transverse deficiency are included under the same concept of transverse deficiency. Cleft hand, central polydactyly, and syndactyly are included in the same category of abnormal induction of digital rays. We believe that the JSSH modification system is effective in providing hand surgeons with the clinical features and conditions for congenital anomalies.

Background: To evaluate the effectiveness of the Robert view in assessing trapeziometacarpal arthrosis and to compare the accuracy of the Robert and lateral views in staging trapeziometacarpal (TM) joint arthrosis.

Methods: Patient demographics were obtained. Four participating raters reviewed 62 randomly selected thumb x-rays of patients presenting with thumb TM joint pain. Lateral and Robert-hyperpronation views were assessed using an analysis of 13 criteria.

Results: X-rays of 62 thumbs for 58 patients were evaluated. The average patients' age was 64 (47-87) and 51 (80%) were females. The majority of X-rays evaluated fell into stage 3. Stage 2 was the second most common level of arthritis encountered and the least was stage 1. More osteophytes were encountered in the trapezium than metacarpal on both the Robert and lateral views. The Robert view was superior in detecting osteophytes on the trapezium than the lateral view. Osteophyte size varied from 1.7 to 2 mm. The lateral view displayed 61 cases with dorsal metacarpal subluxation (98%). The Robert view displayed 48 cases (77%) with radial metacarpal subluxation and 9 cases (15%) with ulnar metacarpal subluxation. Thumb metacarpal adduction deformity was encountered on the lateral view in 20 cases (32%) whereas on the Robert view it was encountered in 14 cases (23%). Subchondral sclerosis was encountered on the Robert view in 56 thumbs (90%) while it was seen on the lateral view in 52 thumbs (84%). Pantrapezial arthritis involving the STT joint was encountered equally in 16 cases (26%) on the Robert view and the lateral views. The study found a moderate level of interrater reliability on both the lateral and Robert views. With the exception of osteophytes encountered on the trapezium versus the metacarpal, there were no other statistically significant findings.

Conclusions: This study confirms that each of the Robert and lateral views offer unique information and combining both views enhances the ability to assess radiographic disease severity, and should be the recommended set of X-rays for assessing TM osteoarthrosis.

Background: Ulna nerve compression at the elbow is the second most common neuropathy of the upper limb. It has been suggested that nerve conduction tests are required to correctly make the diagnosis. The aim of this study was to assess whether patients with normal nerve conduction testing benefitted from surgical release of the ulna nerve.

Methods: 56 patients with symptoms of ulna nerve compression at the elbow were evaluated prospectively. All patients underwent electrophysiology testing followed by ulna nerve decompression irrespective of the results of the electrophysiology testing. Functional scores using the QuickDASH and PEM score were collected up to 12 months post-surgery.

Results: No difference was found between the group with normal and the group with abnormal electrophysiology studies.

Conclusions: We conclude that patients who clinically have ulna nerve compression still benefit from ulna nerve decompression despite normal nerve conduction tests.

Background: Flaps have been used in upper limb surgery for varied indications including coverage of soft tissue defects, interposition and to provide a pliable bed for gliding structures among others.

Methods: We report our use of the radial artery perforator based adipofascial flap in nine patients, five with rigid radioulnar synostosis, three with recalcitrant carpal tunnel syndrome and one with a soft tissue defect.

Results: All our patients with radioulnar synostosis regained good functional rotations of the forearm with no recurrence at follow up. The patients with recalcitrant carpal tunnel also had resolution of symptoms with no recurrence. The flap healed well in all the patients.

Conclusions: We propose this flap as a viable, versatile reconstructive option for the hand and upper limb.

Background: The purpose of this study is to compare the outcome of the conical fully threaded headless screw to that of a smooth shaft headless screw in a series of scaphoid nonunions requiring screw fixation to determine if screw design had an influence on union rates.

Methods: We retrospectively reviewed 104 cases of surgically treated scaphoid nonunions. After eliminating cases with our exclusion criteria, the study cohort had 40 cases for analysis. A comparison and analysis of union rates was undertaken between the fully threaded Acutrak 2 mini screw and the smooth shaft Herbert screw.

Results: Overall union rate for screw fixation was 88%. The fully threaded conical screw fixation had a significantly lower union rate of 50% compared to 97% for the smooth shaft screws.

Conclusions: Our data revealed that the fully threaded conical screws were associated with significantly lower union rate compared to the smooth shaft Herbert type screws.

Background: Perilunate dislocations are severe uncommon carpal injuries. They are sometimes missed with a reported incidence of up to 25%. Neglect for a period of time allows for soft tissue contractures, as well as bony changes that make reduction extremely difficult. For neglected cases, procedures such as staged open reduction, proximal row carpectomy, and wrist arthrodesis have been offered. The objective of this study was to examine whether scaphoid excision and four-corner fusion could be used to treat neglected perilunate dislocations.

Methods: Ten patients with neglected perilunate dislocations were managed by scaphoid excision and four-corner fusion. The dominant hand was involved in eight cases. Graft material for the fusion was obtained from the excised scaphoid. Results: Six patients had complete relief of pain both at rest and during stressful activities. Two patients had no pain at rest and mild pain on stressful activities. The remaining two patients had mild pain at rest and moderate pain on stressful activities. The arc of extension/flexion of the wrist and grip strength both improved as compared to their preoperative levels. The average postoperative Quick DASH score was 12.5.

Conclusions: Scaphoid excision with four corner fusion could be used to treat neglected perilunate dislocations with good pain relief and good hand function.

Background: The surgical aims in managing displaced intra-articular fractures of the base of the middle phalanx include early joint reduction, maintaining congruence and early mobilization. Achieving this can be a challenge. However dynamic external fixators offer a solution. The study aim was to evaluate the use and outcomes of the Ligamentotaxor external fixator in patients with such injuries.

Methods: A total of 12 patients were managed with this device and outcomes were assessed. All patients reached clinical and radiological union.

Results: An average range of movement to the proximal interphalangeal joint of 63° was noted along with an average end of care-cycle quick-DASH score of 9.1. Two patients developed pin-site infections.

Conclusions: The outcomes seen support the use of the Ligamentotaxor in the management of middle phalanx intra-articular fractures. It is simple to apply, potentially avoids the secondary complications of open reduction and gives reproducible results. However judicious patient selection is advised.

Background: We aimed to determine the degree of contracture in the ring and little fingers at which hand function became importantly impaired.

Methods: Five activities of daily living were incorporated into a newly developed and validated Dupuytren’s assessment tool (DAT). Sixty healthy participants were assessed with the DAT wearing a range of 12 dorsal blocking splints. Half wore them on their right little finger, the other half on their ring finger. These induced flexion deformities mimicking DC of the MCPJ, PIPJ and a combination of the two. The angles of flexion deformity at which important hand disability occurred were calculated using receiver operating characteristic curves.

Results: Clinically important hand disability occurred for the little finger MCPJ, PIPJ and combined MCPJ and PIPJ angulation at 52.5, 67.5, and 75 degrees respectively. For the ring finger joint, the angulations were 52.5, 67.5 and 75 degrees respectively.

Conclusions: This information will provide information for clinicians and patients as to when clinically important disability tends to occur in DC.

We present a 58-year-old right-handed man, who consulted us with an 11-year history of Dupuytren’s disease. To correct contracture of the little finger, we performed regional fasciectomy, skin grafting, and distraction arthrolysis of the proximal interphalangeal (PIP) joint using an external fixator. Preoperative or postoperative skeletal traction has been advocated to treat potential or residual stiffness of the PIP joint in Dupuytren’s contracture, but its intraoperative use has not been reported before. Our method has the advantage of treating each problem caused by Dupuytren’s disease. A good range of painless PIP joint motion is achieved by our intraoperative distraction technique without interfering with the skin graft and without reducing extensor tone, while the healing period is shortened by performing all procedures simultaneously.

A 55-year-old woman with incomplete spontaneous posterior interosseous nerve (PIN) palsy underwent interfascicular neurolysis and tendon transfer, 17 years after its onset. After one year, her nerve function partially recovered electrophysiologically. This case suggests that incomplete spontaneous PIN palsy may recover by interfascicular neurolysis, even with a long preoperative delay.

Since irreducible dislocation of the distal interphalangeal joint (DIP joint) is dorsal dislocation, irreducible palmar dislocation of the DIP Joint is very rare. This case was associated with a closed degloving injury of the distal phalanx of the little finger and required operative treatment.

Giant cell tumors of distal radius are locally aggressive tumors with a high rate of recurrence. Though surgery remains the mainstay of treatment, reconstruction remains a challenge in cases of recurrence. Recurrences of GCT in autogenous fibular grafts have been rarely reported and pathological fractures through such grafts are even rarer. Ulnocarpal arthrodesis has never been described as a limb preservation procedure in such a recurrent lesion in distal radius with pathological fracture through a well incorporated fibular graft. A case of pathological fracture in a well incorporated autogenous non-vascularized fibular bone graft in recurrent GCT of distal radius and its successful management with ulnocarpal arthrodesis is reported. In such a scenario where other reconstructive options like allograft or prosthetic reconstructions are not likely to succeed, ulnocarpal arthrodesis may be considered as a salvage procedure.

Vascular leiomyoma is a rare soft tissue lesion in the upper limbs. We reported a case of vascular leiomyoma in a 77-year-old female. It presented with a large painless slow growing lesion in the finger, which had grown to size up to 4 × 3 cm. X-ray and MRI were performed pre-operatively. Surgical excision was performed and the histological findings confirm the diagnosis.

We present an unusual case of a closed perilunate dorsal-dislocation of the carpus, with an associated scaphoid fracture. In this extreme case, the proximal scaphoid pole was extruded volarly and proximally. After closed manipulation, the proximal pole of the scaphoid was further dislocated dorsally, a phenomenon not previously described in the literature. At open reduction this fragment was noted to have no soft tissue attachment but after reduction, distal radius bone graft and compression screw fixation the scaphoid went on to unite with a good functional result. This case highlights a rare but serious injury to the wrist with an unusual dislocation pattern not previously described. It demonstrates that early surgical intervention to fix such fractures with an avascular fragment can still achieve fracture union, despite the severity.

Ganglion is a common benign lesion that usually arises adjacent to the joints or tendons of the hand. However, an intratendinous ganglion is a rare condition. We report two cases of intratendinous ganglion of the extensor tendon of the hand which were treated with excision.

Closed avulsion of the flexor digitorum profundus (FDP) tendon is classified based on the impact of injury on the management plan. In this report, we present a case with unclassified pattern of FDP tendon avulsion. The injury involves an intra-articular fracture of the volar part of distal phalanx of the little finger resulting into two bony fragments, one attached to the retracted avulsed tendon and another separated and incarcerated at A4 pulley, and an intact dorsal cortex of the phalanx. Based on that, we recommend the development of a new classification scheme for this condition.

We report of a pathological fracture of the middle phalanx of the little finger due to periosteal chondroma. The periosteal chondroma occupied an extensive area of the middle phalanx extending to the proximal interphalangeal joint, and the fracture involved the distal interphalangeal articular surface. The fracture was internally fixed using a strut bone grafting after resection of the chondroma. One year and four months after the operation, remodeling of the phalanx had completed without recurrence and functional loss.

We report a rare case of combined fracture dislocations of the trapezoid and multiple carpometacarpal joints that became chronic due to inappropriate treatments. Although an acceptable clinical result was obtained with limited intercarpal fusion, correct diagnosis and initial treatments including anatomical reduction and fixation for obtaining a good clinical result, are important for complex trapezoid injury.

This case report details the osteonecrosis of the interphalangeal (IP) joint of the thumb two months after a rattlesnake bite. It describes the clinical presentation, imaging studies, histological review, pathology review, and review of literature. Our patient was a fifty-one year-old male who obtained a poisonous snakebite to the thumb. While in the hospital for acute treatment, a blood blister was debrided. He was seen two weeks after discharge for further debridement of epidermolysis. Patient presented one month later with a hand x-ray demonstrating bony erosions, and a bone scan showing active changes in the IP joint of his right thumb. He was taken to the OR for further debridement and definitive diagnosis. Pathology results confirmed osteonecrosis with negative bone cultures. The clinical presentation, diagnosis, and operative management of osteonecrosis offer a unique challenge, especially in a patient presenting with osteonecrosis from a poisonous snakebite.