The Journal of Hand Surgery (Asian-Pacific Volume)

Background: De Quervain tenosynovitis (DQT) has been associated with repetitive movements of the radial first dorsal compartment. Since 2007, smartphones have become ingrained in society. Their functionality is primarily performed by dexterity of the user’s thumb(s). The aim of this study was to review the current literature regarding the correlation between DQT and smartphone usage as a systematic review has not previously been presented.

Methods: A literature review was conducted electronically using the EMBASE, PubMed, Cochrane and MEDLINE search libraries during May of 2019. Studies eligible for inclusion were English-language studies assessing the link between mobile phone use and DQT. Included studies were required to report on focused outcomes. Only original data studies were included. Case studies, those with data sets collected prior to 2007, foreign language research were excluded.

Results: A positive Finkelstein’s result within the cohorts was found in a mean of 51.54% of participants. Odds ratios (OR) of 1.5 to 2.3 were found with increasing frequency of text messages and DQT. Females were found to have a higher frequency of text messages daily. Internet browsing and gaming on mobile phones were associated with an OR of 2.21 and 2.61 respectively. DQT associated pain correlated to a mild disruption in daily tasks. On a visual analogue scale, this pain was represented as a 4 out of 10.

Conclusions: In conclusion, there appears to be a linear association between frequency of text messages and incidence of DQT. Additionally, there is an association between DQT pain and a mild disruption to daily activities other than mobile phone use.

Background: Palmaris longus tendon is often used as a donor tendon by surgeons in tendon grafts. It is one of the flexor muscles of the forearm and documented well for its variations in both morphology and number of tendons. Prevalence of absence of this muscle varies among the individuals of same population and individuals of various ethnic groups. The aim of this study was to assess the existence of Palmaris longus muscle within a group of students and its association with side of the limb and gender of the individual.

Methods: Three hundred medical students of 150 males and 150 females with age group of 18–21 years were clinically assessed. The standard Schaffer’s test was used for the assessment of PL tendon. If the tendon was not found in this test, the confirmation was done by other four tests.

Results: Results of this study shows that an overall absence of palmaris longus muscle in both sexes was found to be 32%, out of which 21% absence was found in males and 43% absence found in females. Among the males, the unilateral agenesis was seen in 16% and bilateral agenesis in 4% and in females the unilateral agenesis was seen in 29% and bilateral agenesis seen in 14%.

Conclusions: To conclude; in the present study, prevalence of Palmaris longus muscle agenesis was found to be more in female subjects on their left side. Surgeons who plan for tendon reconstructive procedures should know variations of Palmaris longus muscle and its clinical assessment.

Background: Trapezius transfer has shown promise to restore shoulder movements and has stood through the passage of time. We here in describe a modification of trapezius transfer technique and review the current literature available.

Methods: The modified trapezius transfer in which the trapezius muscle is extended with folded tensor fascia lata graft and attached as distally possible to the deltoid insertion was done in twelve patients at tertiary health care centre in India. Post-operative splinting and staged physiotherapy were given.

Results: Results were described in the form of improvement in degree of shoulder abduction and Disabilities of the Arm, Shoulder and Hand (DASH) score. Six months post-surgery there were improvement in shoulder abduction and DASH score with mean 116 degrees (10–180 degree) and 38 (23–58) respectively. One patient showed poor results due to poor compliance in post-operative period. There were no major complications observed.

Conclusions: The modified technique of trapezius transfer described here is a feasible option with good biomechanical outcomes. The technique is simple and can be adopted easily by emerging brachial plexus surgeon as a technique for secondary reconstruction of shoulder joint.

Background: Polydactyly of the thumb is the most common congenital anomaly of the hand, but there have been few reports regarding Wassel types V and VI. The purpose of this study is to present our surgical strategies and outcomes for cases of Wassel types V and VI polydactyly of the thumb.

Methods: Twenty-nine thumbs of 29 patients were included in this study; 17 cases were Wassel type V and 12 cases were type VI. Our strategies for initial surgery were appropriate tendon and muscle relocations. Opponensplasty with the abductor digiti minimi or the flexor digitorum superficialis and osteotomy were not performed in the initial surgery. We evaluated pinch motion ability and the number of additional surgical procedures. The first web space and radial instability of the metacarpophalangeal (MCP) joint were measured by radiography while the patient held a polystyrene foam cone.

Results: Twenty-two patients were able to perform a pulp pinch. Narrowing of the first web defined as the angle between the first and second metacarpus (1–2 MCA) < 40° occurred in five cases. Radial instability of the MCP joint defined as the angle between the first metacarpus and thumb proximal phalanx (1 MPA) > 20° occurred in seven cases. Additional surgery was performed in seven cases (24%) to improve insufficient thumb opposition, radial instability of the MCP joint, and narrowing of the first web. Patients in all reoperation cases were able to perform a pulp pinch.

Conclusions: Our strategies for initial surgery often had satisfactory outcomes, but careful follow-up observations and appropriate reoperation for cases with poor initial outcomes were more important.

Background: Tenosynovial giant cell tumor (TSGCT) is the second most common benign tumor of the hand. Even though it is a benign lesion there is still a high incidence of local recurrence (range, 7%–44%) according to data in published papers. In this study, the clinical and epidemiological features of 173 patients who underwent excision of localized TSGCT, the recurrence rates and possible reasons for recurrence were examined in the light of current literature.

Methods: Medical records of 173 patients with TSGCT were reviewed. Data on demographic characteristics as well as clinical and intraoperative findings were collected. Patients were asked about the recurrence of the TSGCT and the QuickDASH scoring was applied at the final clinical evaluation after mean follow-up of 81 months.

Results: Females were predominantly involved (73%). Patients aged mean 44 years at the time of surgery. There were 93 tumors in flexor zones and 80 tumors in extensor zones of the hand. Of the tumors with flexor zone localization, zone II was most predominantly involved with 46 tumors, and 18 of these were on the index finger. The extensor zones III and IV were mostly involved with 9 tumors each on the middle and ring fingers. A total of 12 recurrences (6.9 %) were determined over the mean follow-up period of 81 months.

Conclusions: The characteristics of our patients identified were similar to the previous studies. Surgical excision provides good outcomes in the treatment of TSGCT especially when clear margins are obtained.

Background: Perineural adhesion is a potential complication of manipulating peripheral nerves. Using a model of median nerve manipulation in the carpal tunnel, perineural adhesion preventive effects of an alginate gel formulation were examined.

Methods: After exposing carpal tunnels of Japanese white rabbits and dissecting the median nerve, the gliding floor was excised as much as possible and the transverse carpal ligament was repaired to induce a perineural tissue reaction. Prior to wound closure, 0.5 ml of alginate gel formulation was administered into the right carpal tunnel (formulation group) and 0.5 ml of physiological saline was administered into the left carpal tunnel (control group). At 1, 2, 3, and 6 weeks after treatment, electrophysiological evaluation of thenar distal latency, macroscopic evaluation with adhesion score, and pathological evaluation of carpal tunnel cross sections were performed (N = 4–5 at each time point).

Results: Although distal latency tended to be low in the formulation group, there was no significant difference between the groups according to electrophysiological evaluation. Macroscopic evaluation revealed that the adhesion score was always lower in the formulation group than in the control group; over the course of treatment, it remained unchanged in the formulation group, but peaked at 3 weeks after treatment in the control group. In pathological evaluation, neural perfusion peaked at 2–3 weeks after treatment in both groups; neural perfusion tended to be lower in the formulation group than in the control group.

Conclusions: Results suggested that the peak tissue response associated with nerve dissection occurred 2–3 weeks after treatment and that the repair process started subsequently. The alginate gel formulation modified the surrounding environment of the nerve and promoted repair by acting as a physical barrier against perineural fibrosis. The preventive effect of alginate gel on perineural adhesion may improve treatment outcomes of constrictive neuropathy.

Background: The vast majority of acute closed tendinous mallet injuries are treated with a splint. Very few studies have directly compared splinting versus pinning the distal interphalangeal joint for this injury. The aim of this cohort study is to determine the outcomes of both methods.

Methods: A total of 59 patients with acute tendinous mallet injury were retrospectively enrolled (29 patients in conservative treatment and 30 patients in surgical treatment). Conservative treatment was performed using custom-made thermoplastic splint and surgical treatment was conducted with oblique K-wire fixation of the distal interphalangeal (DIP) joint. The DIP joint was immobilized for eight weeks in both treatments. Active ranges of motion of the affected finger and Miller’s classification were evaluated postoperatively.

Results: The mean extension lag of the DIP joint in the surgical treatment group was significantly better than it was with conservative treatment (2.1° vs 13.8°). Three patients who were noncompliant with the splint showed poor results, while no patients in the surgical treatment group had a poor result.

Conclusions: Surgical treatment with K-wire fixation leads to satisfactory results for acute tendinous mallet injury.

Background: The purpose of this study was to identify the optimal pin insertion point to minimize finger motion restriction for proximal phalangeal fixation in cadaver models.

Methods: We used 16 fingers from three fresh-frozen cadavers (age, 82–86 years). Each finger was dissected at the level of the carpometacarpal joint and fixated to a custom-built range of motion (ROM)-measuring apparatus after skin removal. The pin was inserted into the bone through four gliding soft tissues: the interosseous hood, dorsal capsule, lateral band, and sagittal band. Then, each tendon was pulled by a prescribed weight in three finger positions (flexion, extension, and intrinsic plus position). Changes in the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) angles were measured before and after pinning. We compared the differences between the insertion points using the Tukey-Kramer post hoc test.

Results: Placement of pins into the sagittal band significantly restricted MCP joint flexion, while placement into the dorsal capsule and lateral band significantly restricted PIP joint flexion. Only placement into the interosseous hood showed no significant difference in joint angles between the three finger positions compared to pre-pin insertion. There were no significant effects on MCP, PIP, and DIP joint extension.

Conclusions: The ROM of the MCP joint was obstructed due to pinning in most areas of insertion. However, pin insertion to the interosseous hood did not obstruct the finger flexion ROM compared to that of other gliding soft tissues; therefore, we believe that the interosseous hood may be a suitable pin insertion point for proximal phalangeal fixation.

Background: Finger joint arthrodesis is a common operation which has many indications including acute trauma, post traumatic condition, osteoarthritis, and rheumatoid joint deformity. The objective of this study was to evaluate factors which may influence bone union in arthrodesis of the distal interphalangeal (DIP) joint of the fingers and interphalangeal (IP) joint of the thumb.

Methods: A total of 310 arthrodesis (221 finger DIP and 89 thumb IP joint) were analysed retrospectively. We used variables related to the patient and to the operative technique in univariable and multivariable regression analysis. Outcome events were bone union within 90 days, established non-union, infection and re-operation.

Results: Of the 310 operations 280 resulted in a favourable outcome while 30 resulted in bone non-union. In the univariable analysis the most important negative predictor variable for bone non-union was an operation done by other than hand surgery specialist (OR = 3.75, 95% CI = 1.727–8.140, p = 0.001), which also predicted the indication for re-operation (OR = 4.705, 95% CI = 1.563–14.163, p = 0.006). Because of insufficient event rate of bone non-union multivariable analysis was not possible for bone non-union. In the multivariable analysis rheumatoid arthritis had negative influence on bone union within 90 days (OR = 0.45, 95% CI = 0.219–0.925, p = 0.03) and none of the variables predicted infection.

Conclusions: In our cohort finger DIP and thumb IP joint arthrodesis generally resulted in favourable outcome in terms of bony union regardless of the underlying medical condition or technical details of the surgical operation. Overall the results emphasize the importance of adequate surgical skill and practice even with a simple surgical operation.

Background: We sought to independently validate published data that volar cortical integrity (VCI) is an independent predictor of maintenance of closed reduction in a series of non-surgically treated distal radius fractures, while simultaneously investigating previously reported predictors of instability. Our null hypothesis was that volar cortical integrity would not affect maintenance of reduction.

Methods: Four hundred thirty-three adult distal radius fractures were screened from our Orthopedic database with 112 meeting inclusion criteria. Two groups were determined on the basis of maintenance of reduction (MOR) or loss of reduction (LOR) at 5–6 weeks post-reduction. Bivariate analysis was applied to previously published instability factors along with VCI. A forward stepwise logistic regression was then used to identify instability factors that, as a group, are most predictive of outcome.

Results: Results of 112 patients were collected. Reduction was maintained in 62 patients (55.35%) at 5–6 weeks Biivariate analysis showed a statistically significant difference in volar cortical integrity between the 2 groups (80.6% MOR vs 59.2% LOR). Forward stepwise logistic regression analysis of subgroups revealed that post-reduction radial height and VCI were together statistically significant in the model. The presence of VCI, post-reduction radial height greater than or equal to ulnar neutral at the time of initial reduction resulted in a 67.8% successful MOR.

Conclusions: We were able to confirm the importance of volar cortical integrity as a predictor of successful maintenance of reduction in non-surgically managed distal radius fractures. When combined with post-reduction radial height greater than or equal to ulnar neutral at the time of initial reduction, it showed a 67.8% MOR with non-operative management in our data-set.

Background: Fingertip amputation injuries are common hand injuries amongst all ages. If occurring as a result of workplace accidents, these injuries has the potential to lead to significant socioeconomic costs. Non-surgical techniques can treat these injuries with the potential to alleviate the burden of these socioeconomic costs. The aim of our study is to describe an alternative, cost-effective device to manage fingertip amputation injuries, and to present our short-term outcomes with this treatment modality.

Methods: A retrospective study of patients with isolated fingertip amputation injuries who received treatment with semi-occlusive dressing and splint cap from 1 February 2018–21 December 2018 was conducted. The semi-occlusive dressing used was UrgoTul. The splint cap is a 3-dimensional thermoplastic splint to cover the semi-occlusive dressing of the injured finger.

Results: There were 28 patients and 31 digits. The average age was 39.9 ± 12.7 years. 89.3% were male, 75% were foreign workers, 96.4% were blue-collared workers, 40% had dominant hand injuries and 25.8% had nailbed involvement. The average duration of follow-up was 66 ± 37.4 days and the average duration of hospital leave was 6.5 ± 4 weeks. The splint cap was applied for an average of 18.1 ± 6.2 days. The total time for tissue regrowth was 27.5 ± 8.8 days. 14.8% had residual nail deformities and return of sensation took 31.5 ± 11 days. Grip strength was 82.5% of unaffected hand. The mean range of motion at the distal interphalangeal, proximal interphalangeal and metacarpophalangeal joint was 58.8 ± 21.3°, 86.9 ± 15.5°, 81.4 ± 6.0° respectively, and 63.9 ± 23.6° and 66.3 ± 17.3° at the interphalangeal and metacarpophalangeal joint of the thumb respectively. Cost analysis will be further elaborated in the paper.

Conclusions: Fingertip amputation injuries have a potential for regeneration through healing by secondary intention under semi-occlusive dressing conditions. The splint cap provides an easy to fashion, cost-efficient and comfortable addition to semi-occlusive dressings for fingertip injuries.

Background: Microvascular surgery is now an integral part of many surgical disciplines, and the success of these procedures relies on the technical skills of the surgeon. Although numerous training models and simulations have been developed, the living rat model is favoured for its high fidelity to clinical microsurgery. However, there are serious ethical concerns over the use of live models for training. The aim of this study was to demonstrate if effective skill acquisition was possible with a reduction in the number of live rats.

Methods: Two course structures were designed, that were implemented. Total training hours remained the same in both the courses, but the number of rats used was reduced from conventional five rats per participant to four in group A and to three in group B while increasing the training time spent on synthetic and ex-vivo models. We assessed the effectiveness of the courses by comparing the patency rates, the time taken per anastomosis and efficiency of the utilisation rate of rats.

Results: There were 30 participants in Group A and 28 participants in group B. We observed that group B was able to perform anastomosis in a significantly shorter time and with patency rates similar to group A in spite of a lesser number of rats used in the training.

Conclusions: we were able to conclusively demonstrate that it was possible to reduce live rat usage in microsurgical training without compromising on the quality of training.

Background: Steroid injection is a proven treatment for trigger digits. The time taken for resolution of triggering following an injection is a question often asked by patients and one that has not been adequately addressed in existing literature. The aim of this study was to determine the time taken for triggering to resolve after a single steroid injection in patients presenting for the first time with a trigger digit.

Methods: A prospective study was conducted in patients with first presentation of a grade II or grade III trigger digit(s) that received a steroid injection. Data with regards to age, gender, digit(s) involved, duration of symptoms, trigger grade, and presence of diabetes were collected. They were given a stamped addressed postcard with instructions to fill in the date that the triggering resolved and mail the postcard back to us. If the postcard was not received at three weeks, we contacted the patient by telephone to ask for the date of resolution of trigger.

Results: 56 patients with 66 trigger digits were included in the study. 52 out of 66 digits (79%) had resolution of the trigger at one month. The mean duration for resolution of trigger was 8.8 days (range 1–30 days).

Conclusions: Patients can be counselled that a steroid injection is effective in resolving the trigger in 79% of trigger digits presenting for the first time and that the mean time taken for resolution of triggering is 8.8 days. It is recommended to wait for at least one month before considering another injection or alternative treatments.

Background: The rotational malalignment in proximal phalanx fracture is unacceptable. Authors attempted to describe clinical and radiographic outcomes as well as complications after open reduction and internal fixation with screw only or plate for phalangeal fractures accompanied by rotational malalignment.

Methods: Authors conducted a retrospective review of 46 patients who had been treated between Jan. 2010 and Dec. 2016. The average follow-up period was 16.7 months. A total active motion (TAM), Disability of Arm, Shoulder and Hand score (DASH), and tip pinch power between thumb and fractured finger were measured at the final follow-up. Complications were investigated during the follow up. We assessed the amount of rotation by measuring angle between 3rd ray and fractured finger. The measurement was divided into two groups depending on rotation direction, divergent and convergent direction group.

Results: Twenty-eight cases were fixed with mini LCP plate, 12 cases with lag screws, and rest 6 cases with combined. All patients showed solid bony union on radiographs on average follow-up of 68 days (range, 41–157 days). Average TAM of the injured finger was 244 degrees and average DASH score was 4.9 at the last follow-up. Tip pinch power was 3.2 kg, which was not significantly different from that of the contralateral side at 3.4 kg (p = 0.21).

The preexisting rotational angle was significantly adjusted (overall, 11.1°). Depending on rotation direction, preoperative 21.7° to postoperative 12.1° in 27 patients of convergent group and preoperative −5.0° to postoperative 8.3° in 19 patients of divergent group were achieved.

Conclusions: The rotation from proximal phalanx fractures could be corrected with anatomic reduction by open reduction. Our results showed that open reduction and rigid internal fixation after physical examination for acute proximal phalanx fractures accompanied by rotational malalignment could achieve good clinical results.

Background: Pediatric supracondylar humerus fracture (PSHF) is one of the most common fractures of the elbow seen among boys aged between 5 and 7 years. The timing of surgical treatment for this type of fracture is still controversial. Thus, we aimed to investigate whether the timing of surgery for PSHFs affects the incidence of early postoperative complications and reduction of PSHFs.

Methods: We retrospectively reviewed the medical records of PSHF patients who underwent surgery at our hospital between January 2007 and March 2019. We classified patients who underwent surgery within 12 h and more than 12 h after the fracture as the early and delayed groups, respectively. The outcome measures compared between the two groups were the incidence of postoperative early complications such as neurological deficits, including iatrogenic ulnar nerve injury, vascular compromise, compartment syndrome, K-wire migration, and unplanned returns to the operating room. We also examined surgical time, reduction procedure, and perioperative radiographic parameters.

Results: There was no significant difference in the incidence of early complications between the early and delayed groups for either modified Gartland type II or type III fractures. There was also no significant difference in surgical time, reduction procedure, or perioperative radiographic parameters between the two groups.

Conclusions: Delayed surgery was not associated with an increased rate of postoperative early complications in either type II or type III fractures. The timing of surgery does not affect the difficulty or quality of reduction.

Closed reduction and fixation with elastic intramedullary nails is a popular technique to treat displaced pediatric forearm fractures and has yielded good functional results. Postoperative neurological symptoms can be due to neuropraxia and expectative treatment has been advised for 3 months until further investigation is necessary. We present a case of an 11-year-old boy that presented with median nerve palsy 2 months after a displaced forearm fracture treated with elastic intramedullary nails. Ultrasound and nerve conduction study confirmed the presence of a median nerve entrapped in the callus of the radial fracture. Surgical exploration demonstrated that the nerve was twisted around the intramedullary device. After neurolysis and surgical repair the patient finally recovered 2 years after the operation. This case highlights the possibility of median nerve entrapment after reduction with elastic intramedullary nails. Symptoms should be recognized early, and urgent surgical exploration is needed to prevent irreversible damage.

We describe a case of an adult patient presenting with cubital tunnel syndrome in the setting of previously undiagnosed macrodactyly. Early diagnosis and management of macrodactyly is important to help prevent symptoms associated with compromised peripheral nerves and reduce the likelihood of the permanent motor and sensory sequelae of prolonged nerve compression.

Flexor Digitorum Profundus avulsion injury associated with an enchondroma at the level of the distal phalanx is extremely rare. There have been few cases reported to date and most have been surgically managed using a screw and/or Bunnell pull-out wire technique with or without bone grafting. We describe the first case using a simple interosseus fixation technique for the reattachment of FDP tendon without bone grafting. The patient made an excellent post-operative recovery. This technique is a simple, effective, patient-friendly and internalised solution which, in addition, may prevent the need for bone grafting.

Although osteochondroma is a benign bone tumor often observed in daily practice, solitary osteochondroma of the bicipital tuberosity is rarely observed. Herein, we report a case of bilateral solitary osteochondroma of the bicipital tuberosity. A 76-year-old woman experienced crackling and painful clicking bilaterally in her proximal forearms during pronation-supination. X-ray imaging, computed tomography, and magnetic resonance imaging revealed that the symptom was caused by bilateral solitary osteochondroma of the bicipital tuberosity. Bone tumor resection was performed on both sides. After surgery, the symptoms improved. X-ray imaging performed 2 years after surgery revealed no tumor recurrence. When painful clicking occurs around the elbow joint, a solitary osteochondroma of the bicipital tuberosity should be suspected; this symptom should be examined, and the surgeon should consider surgery positively. Exposed subchondral bone may rub against, collide with, or impinge upon the ulna during forearm pronation-supination and induce pain.

Homunculus is a term used to refer to any representation of a miniature human being. In scientific fields, the word homunculus has been used to refer to any scale model of the human body that represents physiological, psychological, or other human functions. The hand is thought as a homunculus of the body in Hand Acupuncture Therapy, a type of alternative medicine in Korea. Hand acupuncture therapists believe stimulating the hand can improve bodily health. Although there is a need for scientific evidence regarding this concept, those that perform hand acupuncture seem to recognize the importance of hand in our body.