The Journal of Hand Surgery (Asian-Pacific Volume)

Background: The management of scaphotrapeziotrapezoidal (STT) joint osteoarthritis (OA) remains controversial. This systematic review aims to review the evidence for surgical interventions specific to STT OA.

Methods: Medline and Embase libraries were searched using a pre-defined search strategy in October 2014. All study designs and languages were included and evaluated by two reviewers (VMD and LM) against the inclusion/exclusion criteria. The study eligibility criteria included papers discussing surgical treatment of STT OA, and the review was conducted using the PRISMA guidelines.

Results: 295 unique results were identified from the search strategy after duplicates were filtered. 21 articles met the eligibility criteria.

Conclusions: Trapezial excision and partial trapezoidal excision is an effective treatment with low morbidity and complications, although can lead to weakness of the thumb. Distal scaphoid excision remains an effective pain relief treatment with improved grip and pinch strengths post-operatively. The procedure is technically less demanding than arthrodesis, does not carry the risks of non-union and complication rate of STT joint arthrodesis, and has a shorter immobilisation requirement. It produces reliable results, but is contraindicated if there is either scapholunocapitate pathology or midcarpal instability. STT joint fusion has a place, typically producing 75% range of movement of the non-operated wrist. However it has a higher associated complication rate, and simultaneous radial styloidectomy is recommended to reduce ongoing pain from impingement. Implant arthroplasty using a graphite-coated pyrocarbon implant has been used more recently. The patients gained significant pain relief, although there have been reports of implant dislocation secondary to surgical errors. A reduction in post-operative wrist extension and radial deviation has been noted. From this systematic review, we have composed a treatment algorithm for the surgical management of STT joint OA.

Background: The purpose of this study is to research the type of lesions to the hand and fingers in the sport of surfing.

Methods: All surfing related hand injuries reported to our hospital between January 2008 and September 2015 were analyzed.

Results: Thirty-seven patient files held a clear description of a trauma related to the surf sport. We found three finger sprains, five wounds needing suture, including one digital nerve lesion and one ring finger with flexor tendon injury, three fingertip amputations and twenty-six digital fractures. The fracture type was similar in twenty-one patients: an open extra-articular transverse fracture of the distal phalanx. Thirty-one injuries were caused by the surf leash.

Conclusions: From this case series we can conclude that surfing may lead to significant trauma to the fingers, mainly due to the leash. This can be caused by grasping the leash while it snaps to tension, which may lead to hyper flexion of the distal phalanx, resulting in a typical trans-phalangeal fracture. Also, when the leash is wrapped around a finger or grasped near the attachment of the leash to the board, ring avulsion-like trauma may occur, leading to open fractures or (partial) amputations. Recognizing that surf leash trauma causes a particular type of fracture to the distal phalanx, may lead to better education of surfers and the development of safer surfing equipment.

Background: Internal fixation modalities of unstable (>50 percent articular involvement) middle phalangeal volar lip fracture-dislocations include interfragmentary screw and volar buttress plating. This study investigates the mechanical properties (yield strength, ultimate tensile strength, and stiffness) of interfragmentary screw (IS), simple buttress plating (BP) and buttress plating with subchondral screw (BP+S).

Methods: Fifteen cadaveric digits (5 index, 5 middle, and 5 ring) were prepared by excising its skin envelope and flexor tendons while preserving the structures around the proximal interphalangeal joint. An oblique osteotomy involving 50 percent of the articular surface was performed, and this was fixed with based on its study group: interfragmentary screw (IS), simple buttress plating (BP) and buttress plating with subchondral screw (BP+S). These specimens were then loaded to failure.

Results: Yield strength was as follows: BP+S (33.5±9.76 N), IS (13.6±5.46 N), and BP (8.1±3.84 N). Ultimate tensile strength was as follows: BP+S (49.1±21.4 N), IS (15.6±5.19 N), and BP (8.86±3.99 N). Stiffness was as follows: BP+S (4.77±1.32 N/mm), IS (2.44±0.86 N/mm), and BP (1.84±0.71 N/mm).

Conclusions: A buttress plate and screw construct confers significantly more stability than either interfragmentary screw or buttress plate only fixation in an experimental model.

Background: Surgical repair is advocated for flexor tendon lacerations deeper than 70%. Repair can be undertaken with different suturing techniques and using different materials. Different materials used for tendon repair will have a different gliding resistance (GR) at the joint. Previous studies have compared strength of repair and gliding resistance for various braided suture materials and for 100% laceration of flexor tendons. We directly compare the GR of two monofilament sutures when used for a peripheral running suture repair of partially lacerated tendons.

Methods: Sixteen flexor tendons and A2 pulleys were harvested from Turkey feet. They were prepared, partially lacerated to 50% depth, and then repaired with a core suture (modified Kessler technique with 4-0 Ethibond) as well as an additional superficial running suture of either 6-0 Prolene or Nylon (half randomised to each). Gliding resistance was measured for all tendons before and after repair, at different flexion angles (40 and 60 degrees) and for different loads (2N and 4N).

Results: After surgical repair, gliding resistance was increased for all tendons (P < 0.01). The tendons repaired with Prolene had a higher mean gliding resistance than those repaired with Nylon (P = 0.02). Increased flexion angle and load amplified the gliding resistance (both P < 0.01).

Conclusions: 6-0 Nylon was associated with a lower gliding resistance than 6-0 Prolene but the minor differences bare unknown clinical significance.

Background: Nonunion involving the metaphyseal region of the distal radius is exceedingly rare, usually involving co-morbidity. Patients that have failed multiple prior conventional surgical interventions represent an even more difficult subset to treat; this investigation examined the utility of a specially designed free vascularized medial femoral condyle flap consisting of a central structural block graft with an extended corticoperiosteal sleeve to wrap around the junctions.

Methods: Six patients (5 males, 1 female) with a mean age of 52 years had failed to achieve union involving the distal radius metaphysis after a mean of 3.7 prior surgeries occurring over a mean period of 24 months. Comorbidities included smoking, alcoholism, chronic nutritional deficiency, and prior osteomyelitis. The unique descending genicular artery medial femoral condyle flap designed to address these patients consisted of a central structural block graft in continuity with an extended corticoperiosteal sleeve. The structural block filled the bone defect, and the corticoperiosteal sleeve wrapped around the bone junctions and the neighboring bone margins. The mean flap size was 5.3 (+/- 1.3) cm long by 4.5 (+/- 0.9) cm wide. Pre-operative to post-operative DASH scores were compared using the paired student’ s t-test, with p < 0.05.

Results: All flaps achieved union at a mean of 6.8 (+/- 2.1) weeks following surgery, using the criteria of bridging trabeculae on all 3 radiographs: coronal, sagittal, and oblique. The mean pre-operative DASH score of 63 (+/- 10) was statistically significantly different compared to the mean post-operative DASH score of 18 (+/- 8).

Conclusions: With few alternative solutions able to address this unique and difficult problem, the structural block of vascularized bone with the extended corticoperiosteal sleeve proved able to achieve a union that had failed multiple previous attempts and able to resist reactivation of infection, in a challenging group of patients with comorbidities.

Background: Whether percutaneous pinning or plate fixation is more appropriate for metacarpal fractures is still open to debate. Our study purpose was to review the current literature in an attempt to determine the optimal treatment modality for metacarpal fractures on the basis of functional outcomes, radiographic outcome and rates of complications.

Methods: We selected Pubmed, Cochrane library, EMBASE and the relevant English orthopedic journals and pooled data from eligible trials including four comparative studies and one retrospective review. Overall, the studies contained 222 patients with 231 fractures, 143 treated with pinning and 88 treated with plates and screws. Mean follow up was 7.5 months (4-12 months). Data were analyzed and the fixed effects are assumed for meta-analysis.

Results: Patients undergoing pinning for metacarpal fractures have higher motion scores when compared to open reduction and internal fixation with plate and screws. Functional scores, grip strength, radiographic parameters, time to union and complications were found not to be significantly different between the two groups.

Conclusions: There is evidence to support the use of pins over ORIF with plates and screws in the treatment of metacarpal fractures. This may have practical advantages, including minimal dissection, easier insertion and availability of the pins. The limitations of this study include the small number of eligible studies, lack of reporting of standard deviation value, and the lack of DASH score assessments at follow up. Further randomized controlled trials that include a larger patient numbers with longer follow up are needed to substantiate the superiority of one fixation method over another.

We developed a new internal fixation method for extra-articular fractures at the base of the proximal phalanx using a headless compression screw to achieve rigid fracture fixation through a relatively easy technique. With the metacarpophalangeal joint of the involved finger flexed, a smooth guide-pin is inserted into the intramedullary canal of the proximal phalanx through the metacarpal head and metacarpophalangeal joint. Insertion tunnels are made over the guide-pin using a cannulated drill. Then, a headless cannulated screw is placed into the proximal phalanx. All of five fractures treated by this procedure obtained satisfactory results.

Background: Fingertip amputations can be debilitating and challenging to treat, due to the need for both function and cosmesis. We studied the functional outcomes of patients receiving an antegrade homodigital neurovascular island flap for fingertip amputations.

Methods: From 2004 to 2013, we performed 13 cases of antegrade homodigital neurovascular island flaps. Functional outcomes were studied. Four had Allen Zone II and nine had Zone III injuries. Seven were performed as secondary surgery. The mean followup period was 36 weeks.

Results: All the flaps survived. Ten of 11 had less than or equal to 6 mm two-point discrimination. Five patients were noted to have mild flexion contracture at distal interphalangeal joints ranging from 5 to 10 degrees. There were three cases with nail deformity, three with fingertip hypersensitivity and four with cold intolerance. For patients injured on duty, the mean duration of sick leave taken was 18.5 weeks.

Conclusions: With careful patient selection, the antegrade homodigital neurovascular island flap is a reliable means of restoring the function of the fingertip after amputation injury with significant tissue loss. Flap survival, sensibility and mobile adjacent joint can be expected, even when performed as a secondary surgery and for patients with work-related injuries.

Background: Closed avulsion injury of the flexor digitorum profundus (FDP) tendon is a relatively common condition of the hand. Its present classification system seems to be deficient in including all possible patterns of injury, leading to improper selection of the best treatment method for the injury. We aim to provide a new classification scheme for this injury.

Methods: We developed a new classification scheme based on the possible pattern of FDP tendon injury. It consisted of three main types, and 10 sub-types. This was used to classify the injury of 34 patients, and help in choosing the best management approach. All patients underwent surgical treatment of their injury. The distal interphalangeal (DIP) joint extension deficit and total active motion (TAM) of the proximal interphalangeal (PIP) and DIP joints were considered as the main outcomes. Five orthopaedic surgeons used the new classification system for our cases, and the inter-rater reproducibility was tested with Fleiss' kappa.

Results: The multi-rater kappa for the classification was excellent. At the final follow-up visit 24 months following surgery, the mean loss of extension of the DIP joint was 13.76° ± 13.53° (range 0° to 45°), while the mean TAM was 148.88° ± 22.64° (range 94° to 172°). Based on the TAM score, 21 (61.76%), 8 (23.53%) and 5 (14.71%) patients had excellent, good and fair results, respectively. None of our patients had poor results.

Conclusions: Our new classification scheme of FDP tendon avulsion appeared to be comprehensive and useful in guiding the surgeon for the best treatment option. Nevertheless, this should be confirmed by using it for larger number of patients with different patterns of injury.

Background: Restoration of extra-articular and intra-articular parameters are important considerations during operative fixation of distal radius fractures. Restoration of volar tilt by using visual estimation and the ‘lift’ technique has previously been described. The aim of our study was to describe a mathematical technique for accurately restoring the volar tilt of the distal radius to acceptable anatomic values.

Methods: A retrospective review of cases performed using the trigonometry-integrated ‘ lift’ technique (TILT) was performed. This technique uses the pre-operative volar tilt angle as well as the dimensions of the implant to calculate the ‘lift’ required to restore volar tilt. Intra-operative angles were measured using a marked transparency overlay on fluoroscopic images. Pre-operative and post-operative volar tilt were measured and analysed.

Results: Twenty-seven fractures were included in the study, with 20 being classified as Arbeitsgemeinschaft für Osteosynthesefragen (AO) C-type. Pre-‘lift’ volar tilt ranged from 0° to -20°. Post-‘lift’ volar tilt ranged from 2° to 16°, with all but three cases ranging from 5° to 15°. The mean volar tilt achieved was 10.2°.

Conclusions: The trigonometry-integrated ‘lift’ technique resulted in reliable intra-operative restoration of anatomic volar tilt in distal radius fractures.

Background: Penetrating upper extremity injury is a common encountered cause of significant loss of labor force and it is generally caused by sharp items. This article presents five rare cases of penetrating hand and forearm injury caused by blunt-edged items in conjunction with a detailed discussion of the mechanism and management of the injury.

Methods: Five patients with a mean age of 37.6 were treated for upper extremity trauma caused by “blunt-edged items” such as corrugated iron fence, garden wires, iron stick or iron safety fence between 2009 to 2014. All patients were operated under general anesthesia after performing detailed physical examination and x-ray imaging.

Results: The explorative surgery of the affected limbs revealed no nervous or vascular injury. In two patients, partial tear of the muscles bellies of intrinsic hand muscles (opponens pollicis and adductor pollicis); in two patients, partial extensor digitorum communis tendon laceration and in the remaining patient, partial tear of the third annular pulley were the only encountered injuries. The physical examinations performed in the last visit of each patient revealed, complete healing of the affected limb without any functional, vascular or sensorial deficiency in a mean follow-up period of 19.2 months.

Conclusions: Despite their initial horrible appearance, injuries caused by “blunt-edged items” are quite harmless to the affected limb because they follow weak anatomic spaces of the extremity and cause minimal tissue damage leaving all vascular and nervous structures intact.

Background: Synthetic sutures such as Fiberwire used in flexor tendon repairs have high tensile strength. Proper application allows early mobilisation, decreasing morbidity from repair rupture and adhesions while preserving range of motion. Suture stiffness can cause poorer knot holding, contributing to gapping, peritendinous adhesions or rupture. Previous studies recommended more throws in knots tied on Fiberwire to prevent knot slippage. These larger knots are voluminous and prominent. In tendon repairs they can cause “catching”, increase friction and work of flexion. Other studies advocated certain complicated knots as being more secure. We evaluated several knots and their biomechanical properties with the aim of finding a compact knot with less potential for slippage to maximise strength potential of flexor tendon repairs using Fiberwire.

Methods: A series of different knots tied on Fiberwire 4-0 sutures were pulled to failure on a mechanical tester. Mean tensile strengths, knot volumes and tensile strength to knot volume ratios were compared.

Results: Tensile strengths and knot volume increased with more throws and loops. Four variations of the square knot (the 4=4=1, 2=2=2=2, 1=1=1=1=1, 2=1=1=1=1 knots) had tensile strengths greater than 35N. The specialised anti-slip knot had highest tensile strength and suture volume but lower strength-to-volume ratio.

Conclusions: The anti-slip knot had highest tensile strength but it also had the highest volume. The greater strength of repair may not translate into improved clinical outcome. The 1=1=1=1=1 knot has superior knot strength-to-volume ratio with good knot strength adequate for early active mobilisation in flexor tendon repairs.

Background: The medial epicondyle nonunion becomes symptomatic valgus instability with medial elbow pain and joint instability due to dysfunction of the medial collateral ligament (MCL), thus requiring surgical treatment. The purpose of the present study is to report the clinical result of the fragment excision and ligament reconstruction by free tendon graft in the treatment of symptomatic medial epicondyle nonunion.

Methods: A retrospective study of five consecutive patients was performed. All five patients had signs and symptoms of valgus instability of the elbow. The mean period of nonunion was 25 years, and their injuries progressed asymptomatically until symptoms developed in adulthood after a second injury.

Results: All patients were treated by fragment excision and MCL reconstruction. At the final follow-up, no patients exhibited pain or instability. The mean joint range of motion was 0o of extension and 138o of flexion, with an MEPS of 100 points in all patients.

Conclusions: By ligament reconstruction for MCL insufficiency and removing the bone fragments avoided irritation by the bone fragments, pain and instability disappeared, good range of motion was restored, and excellent outcomes were achieved in all patients. We believe that fragment excision and MCL reconstruction should be considered as the treatment option for symptomatic medial epicondyle nonunion of the humerus.

Background: To investigate asymptomatic flexor tendon damages after volar locking plate fixation of distal radius fractures in 32 wrists of 32 patients with distal radius fractures fixed using two plate types. Sixteen patients received the Acu-Loc volar distal radius plate, and the remaining 16 patients received the Aptus distal radius correction plate.

Methods: The flexor pollicis longus (FPL) tendon and flexor digitorum profundus were evaluated according to intraoperative findings at plate removal. Ultrasonography was used to measure the distance between the FPL tendon and distal edge of the plates (FPL plate distance) before plate removal, the distance between the FPL tendon and distal edge of the radius (FPL radius distance) after plate removal, in the contralateral wrist, and the angle between an extension line of a volar surface line on the proximal FPL tendon and a second volar surface line on the distal FPL tendon (FPL angles).

Results: Erosion of the FPL tendon was identified in four wrists, and erosion of the flexor digitorum profundus of the index finger was identified in one wrist. All five cases of wrists with flexor tendon damage had Acu-Loc plates installed. The average FPL angle before plate removal was 15.4° in the wrists with tendon damage, which was statistically significantly larger than the average FPL angle in the wrists without erosion.

Conclusions: The type of plate and larger FPL angle on ultrasonography may be the risk factors for flexor tendon damage.

Background: Finger injuries are common in the sport of hurling. Injury to the little finger distal interphalangeal joint (DIPJ) often occurs when a high dropping ball impacts on the outstretched finger. The little finger contributes to approximately 15% of grip strength. Injury therefore results in reduced grip strength and may impair the ability of players to grip or catch a ball.

Methods: Six elite hurlers with post-traumatic arthritis of their non-dominant little finger DIPJ underwent arthrodesis in 30 degrees of flexion. Kirchner wires were inserted for up to 8 weeks to achieve fusion of the joint. Patients were evaluated after recovery using a dynamometer to assess grip strength, the DASH questionnaire and a sport specific questionnaire.

Results: All arthrodeses achieved bony union without complication. All patients reported a resolution of their pain and recovery in their ability to catch & retain a ball. Measurements of grip strengths were comparable between hands. DASH scores improved by up to 47 points. All scores were less than 5 at final follow-up.

Conclusions: Grip strength decreases when fingers are immobilized in full extension. In sports that require catching or gripping a ball or a bat, arthrodesis of the DIP joint in flexion can improve grip strength and hand function. Fusion in 30 degrees of flexion for hurlers results in restoration of function and resolution of pain. Little finger DIPJ arthrodesis is a valid method of treating posttraumatic arthritis in ball and bat sports.

Background: This controlled randomized experiment tested the research hypothesis that providing the CTS-6 quantitative diagnostic information to hand surgeons affects the diagnosis of carpal tunnel syndrome.

Methods: Surgeon members of American Association for Hand Surgery participated in an online survey. Demographic and practice pattern information was collected. Few surgeons routinely use diagnostic questionnaires or algorithms. Each member was given four clinical scenarios. The respondents were randomized, The experimental group was given the same scenarios as the control group plus the quantitative results of the CTS-6 diagnostic tool.

Results: There were statistically significant differences between the groups in the diagnostic decisions. Using the CTS-6 quantitative diagnostic tool affected the diagnosis of carpal tunnel syndrome, especially for patients with the lowest number of findings associated with carpal tunnel syndrome.

Conclusions: While accurate diagnostic decisions are dependent on the incorporation of all of the pertinent information gathered during the history and physical exams, the results of the CTS-6 may help the clinician focus their thinking and revise their diagnostic probabilities.

A Taekwondo participant sustained a hand injury from punching an opponent that resulted in painful instability of the ring finger extensor digitorum communis tendon due to sagittal band damage. His symptoms resolved after reconstructive surgery on the sagittal band (SB) with stabilization of the extensor tendon over the metacarpophalangeal joint.

Deep-seated giant lipomas are rare relative to the overall incidence of the tumor and their occurrence grows more frequent with age. A case of an unusual deep-seated giant lipoma in the forearm of a four-year-old child is reported.

We report a case of phenytoin extravasation complicated by eschar formation. Pre-operative MRI study showed a large non-enhancing area over the dorsum of the imaged right wrist and hand corresponding with the site of phenytoin extravasation and raising the suspicion of subcutaneous tissue necrosis. The MRI findings correlated well with the intra-operative findings. We believe that pre-operative MRI in drug extravasation cases can characterise the type of soft tissue injury and define the extent of injury. This helps the surgeon in the surgical approach and treatment options.

Lymphoma involvement of peripheral nerves is rare and it may mimic benign neurogenic tumors or neuropraxic injury. This study presents three patterns of presentations in four patients with neurolymphomatous involvement of their peripheral nerves. We reviewed the clinical records of four patients who underwent exploratory brachial plexus surgery (n = 1), pronator tunnel decompression (n = 1) and peripheral nerve exploration (n = 2) and subsequently found to have neurolymphomatosis (NL). Histological diagnoses were diffuse large B-cell lymphoma (n = 3) and NK/T-cell lymphoma (n = 1). NL lacks pathognomonic clinical and imaging features that aid clinicians in diagnosis. Apart from a history of lymphoma, and high clinical index of suspicion, PET-CT scans appear to be a helpful adjunct in detecting high metabolic lesions occuring in situ or systemically. Intra-operative frozen section is helpful to detect round blue cells, before final cytological diagnosis.

Descriptions of multiple extensor slips and accessory extensor tendons of the hand are extensively published in the contemporary literature. Despite their varied anatomy, accessory tendons seldom have a functional implication for the patient. We report a case detailing a previously undescribed accessory extensor tendon of the hand, which resulted unusually in an aberration in the mechanics of a single digit. This was explored and corrected surgically, resulting in an excellent outcome for the patient.

We present a rare case of primary tuberculous tenosynovitis in a young patient with an acute history of non-penetrating traumatic injury. The patient had recently visited Pakistan and presented with sudden onset pain at the base of their right fifth digit after trying to catch a cricket ball. A provisional diagnosis of haematoma was made; however, ultrasonography revealed a mass attached to the A2 pulley. Surgical excision followed by histological examination and culture identified Mycobacterium Tuberculosis infection. This case serves to raise clinical awareness of this rare condition and highlight the importance of obtaining a travel history.

A 39-year-old man injured his left little finger and was diagnosed with chronic tendon mallet with -50° of extension and 80° of flexion at the DIP joint. We performed an anatomical reconstruction of the terminal tendon and both lateral bands with divided palmaris longus tendon grafting. Postoperative range of motion at the DIP joint improved to -5° of extension with no flexion loss. We demonstrated a novel surgical technique for chronic tendon mallet injury that might represent a useful choice for the treatment of chronic mallet finger injury.

We present a case of dislocation of the fourth carpometacarpal joint without associated fractures. This is the first case to be reported in the literature. Carpal injuries are uncommon; it is even rare for isolated carpometacarpal dislocation to occur without associated fractures. The injury is difficult to diagnose because of the swelling of the hand and may be missed on several occasions. A lateral radiograph of the wrist has been found to be mandatory to its precise diagnosis if suspected. Early recognition and anatomical reduction are essential in achieving good long-term outcomes.

We present a case of radiocapitellar impingement caused by osteochondral fragment after type II capitellar fracture. Painful extension limitation of the elbow was treated successfully by diagnostic arthroscopy and mini-open removal of loose body. A displaced type II capitellar fracture in children is extremely rare, but must be carefully diagnosed and treated.

We present a case of quadrilateral space syndrome (QSS) in a patient with left arm pain. The patient sustained a trauma to his left arm, and QSS was successfully diagnosed by physical examination, magnetic resonance image, electromyographic evaluation, and nerve conduction studies. Surgery was performed to decompress the axillary nerve and the patient recovered fully with minimal residual symptoms.

A nonspecific soft tissue mass of the hand can be difficult to diagnose due to the multitude of possible etiologies. In this case, we discuss our experience in diagnosing and treating intravascular papillary endothelial hyperplasia, or Masson’s tumor, of the hand. The wide range of differential diagnoses and the morphological resemblance to angiosarcoma make Masson’s tumor an important clinical entity to understand. The purpose of this study is to familiarize the reader with the appropriate diagnostic and treatment modalities that allow the clinician to recognize Masson’s tumor, differentiate it from similar clinical entities, and institute the appropriate management regimen.