The Journal of Hand Surgery (Asian-Pacific Volume)

Volar locking plate fixation has been widely accepted method for the treatment of unstable distal radius fractures. Although the results of volar locking plate fixation are encouraging, it may cause implant-related complications such as flexor or extensor tendon injuries. In depth understanding of anatomy of the distal radius is mandatory in order to obtain adequate fixation of the fracture fragments and to avoid these complications. This article will review the anatomic characteristics of the distal radius because selecting proper implant and positioning of the plate is closely related to the volar surface anatomy of the distal radius. The number and the length of distal locking screws are also important to provide adequate fixation strength to maintain fracture fixation. We will discuss the pros and cons of the variable-angle locking plate, which was introduced in an effort to provide surgeons with more freedom for fixation. Finally, we will discuss about correcting radial length and volar tilt by using eccentric drill holes and distal locking first technique.

The conventional corrective osteotomy for malunited distal radius fracture that employs dorsal approach and insertion of a trapezoidal bone graft does not always lead to precise correction or result in a satisfactory surgical outcome. Corrective osteotomy using a volar locking plate has recently become an alternative technique. In addition, the use of patient-matched instrument (PMI) via computed tomography simulation has been developed and is expected to simplify surgical procedures and improve surgical precision. The use of PMI makes it possible to accurately position screw holes prior to the osteotomy and simultaneously perform the correction and place the volar locking plate once the osteotomy is completed. The bone graft does not necessarily require a precise block form, and the problem of the extensor tendon contacting the dorsal plate is avoided. Although PMI placement and soft tissue release technique require some degree of specialized skill, they comprise a very useful surgical procedure. On the other hand, because patients with osteoporosis are at risk of peri-implant fracture, tandem ulnar shortening surgery should be considered to avoid excessive lengthening of the radius.

Most distal radius fractures are the result of low-energy mechanisms that can be successfully treated either non-operatively or with a variety of operative techniques if indicated. Complex distal radius fractures occur most commonly in high-energy injuries with extensive comminution or bone loss and associated soft tissue or vascular injuries. These high-energy fractures can present many challenges in reconstructing the distal radius. Effective restoration of the bony architecture requires a thorough knowledge of distal radius anatomy, understanding of the goals of treatment, versatility in surgical approaches, and familiarity with multiple fixation options.

The distal ulna is composed of the ulnar styloid, ulnar head, and distal ulnar metaphyseal area. Most of distal ulnar metaphyseal fractures are associated with distal radius fractures and this incidence tends to be greater in osteoporotic elderly. Consideration of the treatment of distal ulna metaphyseal fracture should be addressed after treating a distal radius fracture. If it is stable, cast immobilization is preferred, however, if it shows malalignment or instability, an operative method should be considered. More than half of distal radius fractures are combined with an ulnar styloid fracture, and considerable cases of ulnar styloid fractures result in nonunion. However, ulnar styloid nonunion usually does not cause any problems on the wrist. Recent studies of distal radius fractures treated using a volar locking plate have reported that neither the initial displacement nor the size of a concomitant ulnar styloid fracture affects clinical outcome, which suggests surgical approaches may usually not be indicated for ulnar styloid fractures.

Background: The statistical concept of minimal clinically important difference (MCID) enables the interpretation of small but meaningful changes that result from an intervention. This retrospective study aimed to examine the factors that influence the achievement of MCID after a distal radius fracture.

Methods: A total of 45 patients (mean age: 54.2 ± 16 years) were included. Of these, 27 patients started rehabilitation within 3 days of surgery (Early group), and 18 patients underwent immobilization for 2 weeks after surgery, before starting rehabilitation (Non-early group). Functional outcomes and DASH scores at 4 weeks (baseline) were compared with those measured at 8 and 12 weeks for both groups, to determine whether the MCID had been achieved.

Results: Our results showed that at 8 weeks after surgery in the early group, the grip strength, ulnar flexion, and baseline DASH score were significantly different between the groups that did and did not show an MCID ($p<0.05$). There was also a significant difference in the baseline DASH score at 12 weeks after surgery ($p<0.05$). None of these factors were significant in the non-early group. Logistic regression analysis revealed that the DASH score at 4 weeks (baseline) was an independent predictor for achieving a DASH MCID at 8 weeks postoperatively in the early group (odds ratio: 1.193). Those achieving a DASH MCID at 12 weeks postoperatively were completely separated by the baseline DASH score (≥ 29 points).

Conclusions: If it is assumed that the effectiveness of rehabilitation depends upon achieving the DASH MCID by promoting functional recovery, early initiation might be recommended.

Background: Open excision of the olecranon bursa has been performed traditionally. However, surgical complications such as wound healing problems and recurrence may occur after the surgery. The purpose of this study was to report on the clinical outcomes of endoscopic olecranon bursal resection performed in both septic and aseptic olecranon bursitis.

Methods: We retrospectively reviewed 30 patients who underwent endoscopic olecranon bursal resection from June 2007 to January 2012. There were 20 males and 10 females. The ages ranged from 22 to 80 years, with an average age of 57.4 years and the average follow-up was 21.1 months (6–61.5 months). There were 15 cases in the septic group. The treatment outcome was measured according to the following; the rate of recurrence, range of motion, complications associated with surgery, VAS and QuickDASH.

Results: There were no complications such as postoperative infection or neurovascular injuries. In the septic group, the VAS and QuickDASH scores were significantly improved from 5.6 to 0.1 and from 28 to 1.3, respectively. In the aseptic group, the VAS and QuickDASH scores were improved from 0.6 to 0.1 and from 25.7 to 0.5, respectively. In all cases, there were no recurrences and no limitations of joint motion until the final follow-up.

Conclusions: We were able to obtain excellent outcomes without recurrence by performing endoscopic olecranon bursal resection in both septic and aseptic olecranon bursitis.

The distal radioulnar joint (DRUJ) allows forearm rotation and load transmission across the wrist. Post-traumatic and degenerative joint disease of DRUJ may cause pain and disability. Deficiency of the soft tissue or bony supports may result in DRUJ instability. Various techniques have been developed to address arthritis and / or instability of the DRUJ. A comprehensive review of the spectrum of surgical techniques and arthroplasty options is presented. The concepts of these procedures are discussed in detail, with a focus on special points of interest to optimise outcomes and to avoid complications. The salvage of the complications of arthroplasties is also presented in detail.

Background: Our main goal was to see if treatment with collagenase injection is safe and effective and to assess patient satisfaction with this new treatment.

Methods: We prospectively followed 77 consecutive patients, treated for contracture in 91 fingers and 142 joints that received total of 109 collagenase injections. The patients were reviewed on the first and second day and at 4 and 12 months. A contracture reduced to five degrees or less at 12 months after the last injection, was considered to be a successful outcome.

Results: A mean of 1.2 injections were used per patient and 0.8 injections per joint. There was a significant improvement in mean passive extension deficit. Out of the 142 joints treated, 84 (59%) met our criterion for a successful outcome; 56 (80%) out of 70 MCP joints and 28 (39%) out of 72 PIP joints. There were also significant improvements in both hand function and pain. No serious adverse events were observed. The mean patient satisfaction with the treatment at the 12-month follow up was a VAS score of 78 (0 = none; 100 = complete) and only 11% stated that they would not have consented to the treatment if they had known the outcome in advance.

Conclusions: Treatment of Dupuytren's disease with collagenase injection is both safe and effective. It is now our primary treatment for Dupuytren's disease.

Background: Review of the recent literature suggests substantial use of the Internet by patients seeking health care information despite questionable accuracy and readability of information presented on some websites. The purpose of our study was to assess the accuracy, quality, and readability of online information regarding trigger finger.

Methods: Three terms (“trigger finger”, “stenosing tenosynovitis”, and “finger locking”) were used to query three Internet search engines to evaluate websites regarding information about trigger finger. Three hand surgery fellows independently assessed website accuracy and quality using standardized scoring criteria. The Fleisch-Kincaid reading grade level score was used to assess website readability. Website authorship and commercial association were also noted.

Results: Sixty-nine unique websites were assessed. Internet information obtained using the search term “stenosing tenosynovitis” was written at a significantly higher reading level than information found using “finger locking” or “trigger finger”. Website quality and accuracy were both significantly better in websites authored by physicians compared to websites authored by non-physicians. However, website accuracy was significantly poorer in websites featuring commercial association. Additionally, websites presenting information written below the 8^th grade reading level demonstrated poorer accuracy.

Conclusions: Search term has a significant effect on the readability of online information regarding trigger finger. Despite the terminology used in searches, most websites are largely inaccurate and may not be easily understandable by the general population. This demonstrates a substantial barrier to accessing accurate health care information and may impact patient outcomes. Hand surgeons should direct patients towards websites presenting accurate information with easily readable content.

Background: The purpose of our present study was to examine the recovery of the postoperative wrist function, and to compare the range of motion among each direction ofthe wrist joint during the same time periods after surgery for distal radius fractures.

Methods: Twenty patients treated with a volar locking plate were evaluated. The active range of motion and grip strength were assessed at four weeks, six weeks, three months, six months and one year after surgery.

Results: The ratio of the range of motion in pronation and supination recovered significantly earlier than for any other directions within six months after surgery (p = 0.0205), however, the ratio of the range of motion among the six directions was not significantly different at one year after surgery (p = 0.0823). The recovery of the range of motion in flexion was 96.8% compared with the contralateral wrist at one year after surgery, and it was not significantly lower than that in extension, radial deviation or ulnar deviation (97.8%, 93.5%, 94.4%, respectively). The grip strength of dominant hand recovered from 50% after four weeks to 66% after six weeks, 83% after three months, 91% after six months and 106% at the examination performed after one year compared with the uninjured non-dominant hand. The grip strength of non-dominant hand recovered from 52% after four weeks to 59% after six weeks, 79% after three months, 84% after six months and 94% at the examination performed after one year compared with the uninjured dominant hand. The mean DASH score was 5.3.

Conclusions: The range of motion in flexion can achieve similar improvement to that in the other directions by obtaining the appropriate postoperative parameters. The optimal postoperative radiographic parameters were thus identified to be essential for successfully obtaining a recovery of the wrist function for unstable distal radius fractures.

Background: Limited wrist arthrodesis with scaphoid excision is a useful treatment for scapholunate advanced collapse (SLAC) of the wrist. Multiple Kirschner wires were originally used for internal fixation of the four carpal bones, however long-term cast immobilization, pin tract infection, and hardware removal are still problematic. We introduce and evaluate the clinical outcomes of an internal fixation technique; triangle fixation for four-corner fusion, using three headless screws, as an alternative to conventional multiple Kirschner wires for the treatment of SLAC wrist.

Methods: Five male patients with SLAC wrist secondary to three scaphoid nonunions and two scapholunate dissociations were treated with four-corner fusion using triangle fixation with three Double-threaded Japan screws. The mean age was 59.5 years (35–79 years) and the mean follow-up period was 40 months. After surgery, short arm splints were applied for 3–4 weeks, and then range of motion exercises were initiated.

Results: Wrist range of motion and grip strength both improved postoperatively. At the final follow-up evaluation, bone union was completely achieved and satisfactory pain relief was observed in all patients.

Conclusions: Compared with the conventional Kirschner wire technique, the present technique shortens the period of splint immobilization due to a strong compression force in a skewed position, does not require pin removal or cause pin tract infections, and provides satisfactory results.

Background: Acquiring competence in microsurgical suturing is a basic requirement for any trainee aspiring to perform clinical microsurgery. New methods and simulation platform continue to evolve, but the assessment of the quality of microsurgical suturing is largely subjective. We present the concept of computer aided assessment of standardised microsurgical task, using a novel training platform. The platform comprises of a simulator (hardware) that provides the trainee standardised microsurgical tasks, which are then evaluated using a customised software.

Methods: A cohort of trainees attending a five day microsurgery training course was selected. The trainees performed three standardised exercises on the platform, on the first third and the fifth day of the course. All the exercises were subjected to computer aided assessment.

Results: Trainees demonstrated a learning curve over the five day period through the evaluation system, with initial increase in performance followed by a plateau. Eighty four percent of the trainees were able to achieve acceptable scores. Sixteen percent of the trainees were unable to perform a suturing of acceptable quality at the end of the training (fifth day).

Conclusions: The mean scores correlated with the level of difficulty of the exercise. We conclude that computer aided assessment can provide an objective view of the quality of suturing as well as skill maintenance in for trainees.

Background: We consistently observed the presence of anechoic spaces on standard ultrasonographic imaging of the carpal tunnel inlet in normal subjects. These spaces change in size during finger flexion and have not been characterized in a large sample of normal individuals. Ultrasonographic quantification of these spaces may indicate the available space in the region of the carpal tunnel, which allows the normal motion of tendons and the median nerve.

Methods: Transverse ultrasonographic images of the carpal tunnel inlet from 33 asymptomatic volunteers were obtained at Position A (fingers in extension) and B (fingers in flexion). Cross-sectional area (CSA), perimeter and position of anechoic space relative to median nerve were recorded.

Results: Analysis showed a 75.4% prevalence rate of a single anechoic space. Two discrete patterns were observed. 89.1% had a decrease in CSA and perimeter of anechoic space from Position A to B while 10.9% exhibited an increase. Mean position of the anechoic space is ulnar (7.49 ± 3.57 mm) and dorsal (2.18 ± 1.28 mm) to the median nerve.

Conclusions: A consistent anechoic space at the carpal tunnel inlet is seen in 75.4% of normal hands and can be quantified (cross sectional area 11.75 ± 7.36 mm²). It allows for the accommodation of flexor tendons during finger flexion.

Background: Groin flap has been considered the workhorse flap for hand reconstruction. However it has certain drawbacks when covering defects over elbow or proximal forearm. Pedicled oblique paraumbilical perforator (OPUP) based flaps provide a good alternative in such cases.

Methods: We performed OPUP flap in 11 cases of complex upper limb reconstructions over the past one year. We report our experience with this flap.

Results: All flaps survived. One patient had marginal necrosis of 1 cm in the proximal end after flap division. Three patients had donor site scar hypertrophy.

Conclusions: OPUP flap is superior to groin flap for larger defects or defects around the elbow. The major disadvantage is the donor site scar which is prone to hypertrophy.

Background: We report a variant of paediatric trigger thumb which is locked in extension rather than flexion.

Methods: Eleven children with 14 trigger thumbs (three bilateral) locked in extension were reviewed retrospectively over a 12-year period. The number of flexed trigger thumbs encountered over this period was established from the operating room database.

Results: All children were treated with release of the A1 pulley. Nine children achieved a full range of motion at the interphalangeal joint. One child with bilateral extended trigger thumbs required bilateral dorsal capsulotomy and another child developed temporary mild triggering in flexion.

Conclusions: Approximately 1% of trigger thumbs treated operatively at this institution presented as the extended variant. Trigger thumb locked in extension should be considered in a child presenting with inability to flex the thumb.

Background: A significant number of patients on long-term treatment and users of biologics complain of wrist pain due to synovial proliferation and arthropathic changes. Synovectomy or joint arthroplasty is often indicated for such patients, but many refuse surgery. For these patients triamcinolone acetonide was injected into the dorsum of the wrist, and evaluated the clinical benefit and safety of the wrist joint.

Methods: We injected triamcinolone acetonide into the dorsum of the wrist. We evaluated the clinical benefit and safety of intraarticular triamcinolone acetonide by analyzing data on (1) the number of injections, (2) decrease in visual analog scale pain, (3) changes in carpal height ratio, radio carpal distance ratio, and radial rotation angle in X-ray imaging, and (4) the adverse reactions of triamcinolone acetonide injection on the subcutaneous tissue and extensor tendons.

Results: 1. The number of injections per patient over 3 years 8 months was 1 for 44 wrists, 2 for 21 wrists, 3 for 17 wrists, 4 for 6 wrists, 5 for 3 wrists, 6 for 3 wrists, 7 for 2 wrists, 9 for 2 wrists, 12 for 4 wrists, and 13 for 1 wrist. 2. The overall mean VAS improved from 79 mm at baseline to 11 mm post-injection. 3. In the grade I and II group, CHS, RCDR and RRA were not statistically significant. In the grade III and IV group, CHR showed a significant decrease. 4. Neither subcutaneous atrophy nor extensor tendon rupture was reported.

Conclusions: More than 90% of patients of all disease grades responded to an average of 1 to 4 injections per year.

Background: Distal ulna groove morphology is likely to have a significant role in extensor carpi ulnaris (ECU) tendon stability. The development of a robust anatomical classification system, would be beneficial to further research into ulnar sided wrist pain and would be of use in rationalising treatment regimes.

Methods: Cadaveric specimens as well as MRI scans of patients with non-specific wrist pain were analysed independently by 3 orthopaedic surgeons twice to test the integrity of the classification system. The following classification system was developed for the distal ulna groove; Flat = L-shaped slope, S slope = S shaped, Reverse C = C-shaped slope. Findings were then subjected to Fleiss Kappa statistical analysis to evaluate how robust the classification system was.

Results: From the cadaveric arm of the study, 61 patients had their distal ulna groove morphology categorised according to types C, L, and S. For the MRI arm of the study 103 MRI scans were classified. ECU grove subtype C showed 8% dislocation compared to 33% and 47% for the L subtype and S sub type respectively.

Conclusions: Our classification system of ECU groove morphology will help identify different components to ulnar sided wrist problems and may help establish guidelines for treatment. This classification system has been validated for both cadaveric specimens and the MRI scans. It showed substantial agreement to almost perfect agreement in the data tested, thus proving good interand intra-observer reliability. It is a useful tool to help in further research into ulnar sided wrist pain and ECU instability, and may help develop further treatment strategies in the future.

Extensor pollicis longus tendon entrapment is a rare complication of volarly displaced pediatric distal radius fractures. The few pediatric case reports have described tendon entrapment associated with conservative fracture treatment, or have been recognized at subsequent revision surgery after failure to achieve closed fracture reduction. A case of extensor pollicis longus tendon entrapment after open reduction and volar plate fixation of a pediatric distal forearm fracture is reported. This complication may also occur secondarily after open reduction and volar plating of the distal radius.

We report two rare cases of osteochondral dissecans of the humeral capitellum, each associated with a large subchondral cyst. The procedure employed for reconstruction of the massive bone defect yielded excellent clinical and radiological outcomes in both cases, and therefore seems promising for treatment of osteochondritis dissecans.

Intramuscular hemangioma is a rare type that has been reported in less than 0.8% of all hemangiomas. In particular, there are few reports of intramuscular hemangioma in the upper extremity. Authors describe the experience of complete excision of the hemangioma of the pronator quadratus muscle of the forearm with good functional recovery.

Open carpal tunnel decompression is a common procedure with potential long-term complications such as scar tenderness, pillar pain and neuroma. We present the case of a 65 year-old male with chronic lipomatous hypertrophy of the wrist and chronic flexor tenosynovitis after open carpal tunnel release for its rarity and severity of symptoms that required further surgery.

Fibro-osseous pseudotumor of digits (FOPD) is an uncommon histological diagnosis. Clinical and imaging findings may resemble high-grade sarcoma or infection. We describe a patient with progressive pain and swelling at the dorsal surface of the first web space. MRI and CT imaging revealed an intramuscular heterogenous soft tissue mass defined by a mineralized peripheral ring. Core needle biopsy diagnosed FOPD. Eight months later a matured ossified nodule that was quite smaller than the initial soft tissue mass was excised. The patient is symptom free without local recurrence at 1 year follow up. Soft tissue masses of the hand pose a challenging diagnostic and therapeutic issue. An in depth interpretation of clinical, imaging and histology findings is important to avoid erroneous diagnosis and treatment.

We present the case of a closed traumatic disruption of the thumb radial sagittal band (RSB) that sonographically mimicked rupture of the extensor pollicis longus (EPL) tendon. This injury was treated with primary repair of the RSB and lead to a good functional outcome for the patient. This case report highlights how early recognition and treatment can lead to a good functional outcome.

Collateral ligaments are difficult to repair due to large amount of fraying in detached ligaments and attenuated stumps that may not provide enough strength after the repair. Although strong locking sutures are used to repair the ligament with proper tension, these damages can cause pull-out failure or relaxation of the repaired ligaments even from undersized load that may extend postoperative splinting or casting time. Furthermore, current suture techniques can repair varus or valgus instability of the elbow and radial or ulnar instability of the fingers, but these techniques do not offer rotatory stability of these areas. We have developed a novel suture anchor technique that has overcome this problem of current suture techniques, and this can be used to correct rotatory instability in the elbow and fingers. We used this procedure in seven cases with injury of collateral ligament in the elbow and eight cases with detached collateral ligaments of finger joint. No patient experienced rerupture or any kind of residual instability. We believe that the proposed method can produce much stronger repair and may shorten the postoperative immobilization period.

Technical steps to avoid incomplete proximal release of the carpal tunnel are described. Local anaesthesia is infiltrated as a subcutaneous bleb over the distal wrist crease and extending 2–3 cm over the forearm fascia. Tumescence of local anaesthesia into the subcutaneous plane helps create a pocket between the forearm fascia and subcutaneous tissues. Intraoperatively a subcutaneous pocket is made above the transverse carpal ligament and antebrachial fascia with blunt dissection. A retractor is placed under the pocket, which facilitates optimal visualization to allow reliable complete proximal release of compression.The authors have found that this technique is reproducible and reliable across their collective experience.