The Journal of Hand Surgery (Asian-Pacific Volume)

Cubital tunnel syndrome is the second most common nerve compression syndrome seen in the upper limb. Paresthesia and weakness are the two most common presentations in the hand. If left untreated, compression can lead to irreversible nerve damage, resulting in a loss of function of the forearm and hand. Therefore, recognizing the various clinical presentations of cubital tunnel syndrome can lead to early detection and prevention of nerve damage. Conservative management is usually tried first and involves supporting the elbow using a splint. If this fails and symptoms do not improve, surgical management is indicated. There are 3 main surgical techniques used to relieve compression of the nerve. These are simple decompression, anterior transposition and medial epicondylectomy. Studies comparing the techniques have demonstrated particular advantages to using one or another. However, the overall technique of choice is based on both the clinical scenario and the surgeon’s digression. Following primary cubital tunnel surgery, recurrent symptoms can often occur due to a variety of pathological and non-pathological causes and revision surgery is usually warranted. This article provides a complete review of cubital tunnel syndrome.

Background: Avocados are increasingly being consumed due to the nutritional benefits they provide. Avocado related hand injuries reflect their increasing popularity. Most injuries occur in attempting to de-stone the fruit. This is a prospective cohort study reviewing hand injuries sustained from preparing the fruit.

Methods: Data was prospectively collected from three centres across United Kingdom (UK) over a 4-year period. The data was analysed for patient demographics, nature and zone of injury and management required.

Results: A total of 35 patients and 42 injuries were included in the study. The median age of patients presenting with these injuries was 33 years, with majority of injuries occurring in the 21–30 age group. Most (88%, n = 31) of patients were male. Majority (85%, n = 36) of injuries happened during the de-stoning of the fruit. All injuries occurred in the non-dominant hand, with 70%, (n = 30) of wounds being sustained in zone 3. All injuries required surgical management and needed between 1 to 6 follow up outpatient visits. Vital structures such as tendons, digital nerves, pulleys and joint capsule were frequently implicated and required exploration or repair.

Conclusions: Avocado related hand wounds are serious injuries with an associated morbidity. They frequently sustained by young patients. They usually require surgical management and may need numerous outpatient attendances. Caution and public education should be advocated on the preparation of avocados. This is the largest study to date that has reviewed the surgical management of avocado hand injuries.

Background: Leprous neuropathy is a significant, yet preventable, cause of disability worldwide. Decompressive surgery and oral steroids have been used along with Multi Drug Therapy (MDT) for treating leprous neuropathy with varied success as reported in literature.

Methods: We prospectively studied 16 peripheral nerves in 10 patients with leprous neuropathy of less than a year duration and not responding to steroid therapy in 3 weeks. The patients were divided into 2 groups: Group-A (decompressive nerve surgery was done within 12 weeks of onset of neurological deficit), and Group-B (nerve decompression was performed after 12 weeks from onset of neurological deficit). Post-operatively patients were assessed for regression of deformity, sensory, motor, vasomotor recovery and neuropathic pain.

Results: Median age of patients was 32 years (range; 18 years to 46 years). Mean motor score and mean grip strength was significantly better for group A patients at 2 years follow-up (p < 0.05). Mean sensory score improved significantly in both the groups (p < 0.05). Similarly, mean VAS score for neuropathic pain improved significantly in both the groups (p < 0.05). Recovery of autonomic function was observed in 3 nerves in group A and 1 in group B.

Conclusions: The cases who underwent nerve decompression surgery within 12 weeks had better functional outcomes, especially in terms of motor recovery, than those who were operated after that. Studies involving larger number of patients are required to draw firm conclusions.

Background: The treatment strategy for distal radius fractures accompanied by volar lunate facet fragment is controversial. In most cases, only the bone fragment size was discussed and a plate for distal placement is selected due to the accompanying volar lunate facet fragment regardless of the direction of bone fragment displacement. In this study, we divided distal radius fractures accompanied by volar lunate facet fragment into dorsal and volar displaced fractures, and treated these surgically based on different treatment strategies.

Methods: The subjects were 25 patients with distal radius fractures accompanied by volar lunate facet fragment treated by reduction and fixation using a volar locking plate (VLP) (male: 14, female: 11, mean age: 57.8 years old). A proximal VLP (PVLP) was selected for 13 dorsal displaced fractures and a distal VLP (DVLP) was selected for 12 volar displaced fractures. The range of motion, VAS, Q-DASH, and Mayo score were evaluated at 12 months after surgery, and compared.

Results: No significant difference due to the difference in the direction of displacement was noted in the range of motion, VAS, Q-DASH, or Mayo score at 12 months after surgery and there were no perioperative complications. In addition, no re-displacement of volar lunate facet fragment was noted after surgery in any patient and bone fusion was observed.

Conclusions: Reduction and fixation with a PVLP are possible even for dorsal displaced distal radius fractures accompanied by volar lunate facet fragment. For the volar displaced distal radius fractures, a favorable postoperative outcome is possible by applying a DVLP to the distal ulnar.

Background: Foreign bodies in the hand are common but easily and often missed in the initial evaluation of injury. Diagnosing retained foreign bodies is difficult due to radiolucent foreign bodies. Purpose of this study is to emphasize the need of consideration of foreign bodies in patients with chronic synovitis in hand.

Methods: Twenty-five patients who had retained foreign body in soft tissue of hand with chronic inflammation symptoms were included. Ultrasonography was conducted in all of the patients. Patient age, sex, localization of foreign body, duration of symptom, history of injury, follow up period, complication, and biopsy results were recorded and reviewed. Also, patients’ demographics and clinical results were retrospectively reviewed.

Results: Nine of the 25 patients diagnosed with a foreign body in the hand did not remember the initial presentation of injury. The average symptom duration (from injury to hospitalization) was 10.5 months (range 1–96 months). The middle finger and the proximal interphalangeal joint were the most common site of a retained foreign body (10 patients). All patients were diagnosed via ultrasonography and underwent surgery. Biopsy results showed mainly chronic inflammation, fibrosis, granuloma, and foreign bodies.

Conclusions: Patient with symptoms of cellulitis, osteomyelitis, and palpable mass in hand for over a month without a diagnosis should be suspected of retained FBs.

Background: The pins and rubbers traction system is widely used to treat unstable proximal interphalangeal (PIP) joint fracture-dislocations. However, dealing with rubber bands can be difficult due to its elasticity and weakness. The purpose of this study was to report the results of an alternative dynamic external fixator technique for unstable PIP joint injuries.

Methods: Thirteen patients with acute unstable PIP joint fracture-dislocation (n = 8), pilon fracture (n = 2), or comminuted shaft fractures of a middle phalanx with or without PIP joint extension (n = 3) were enrolled. The alternative fixator used a plastic syringe to maintain distraction force instead of the commonly used rubber bands. Four patients underwent combined open reduction due to unsatisfactory reduction by closed mean. The fixator was removed when there was radiographic evidence of healing.

Results: At 6 months after the operation, the mean active ROM of the injured PIP joint was 89° (range, 70–104°), and the mean Quick-DASH score was 9.78 (range, 0–40.9). The mean NRS of pain before fixator removal was 1 (range, 0–4). One patient had a pin tract infection and underwent debridement and fixator removal at 33 days postoperatively. There was no loss of reduction or implant failure in the study.

Conclusions: The results were comparable to other dynamic external fixation techniques used for unstable PIP joint fracture-dislocations. The main advantages of this technique were strength of the system, procedure simplicity, the compact design, and relatively low cost. In addition, this technique can also be used in pilon fractures and comminuted shaft fractures of a middle phalanx with or without PIP joint extension.

Background: To determine normative values for the QuickDASH questionnaire in the elderly Japanese population and their associated factors.

Methods: Three-hundred and eighty-one residents between 50 and 89 years of age were randomly selected from residents of a town in Japan. All participants completed a QuickDASH questionnaire. A multivariate analysis was performed to identify associated factors.

Results: Males and females aged 70–79 and 80–89 showed significantly higher QuickDASH scores than the 50–59 age groups. Females aged 50 to 59 showed significantly higher QuickDASH scores than males aged 50–59. Motion pain or tenderness at the shoulder and side pinch strength showed a significant effect on QuickDASH scores.

Conclusions: The mean QuickDASH score was 5.7. As an associated factor for the QuickDASH, aging, female, and shoulder disorders were confirmed.

Background: Ulnar shortening osteotomy (USO) is a well-established procedure for ulnar impaction syndrome. Various types of osteotomies have been described.

Methods: A retrospective cohort study was conducted to compare the results of transverse osteotomy (TO) fixed with a small fragment dynamic compression plate (Synthes, Pennsylvania, USA), to oblique osteotomy (OO) fixed with a procedure specific plate and instrumentation system (Acumed LLC, Oregon, USA). A total of 39 patients underwent TO and 62 patients underwent OO between 2007 and 2016. The main outcomes compared were rate of union, duration of radiological healing, implant removal rate and other complications.

Results: The two groups were comparable with regards to demographics, side operated and smoking status (p > 0.05). Amongst the TO group; 36 out of 39 patients (92.3%) achieved union, 3 patients (7.7%) developed non-union. Six out of the 36 healed TO (16.6%) required removal of hardware due to implant-related pain. No other complications were recorded amongst TO group needing surgical intervention. Amongst the OO group, 2 of the early cohort of 62 patients (3.2%) sustained acute failure of the metalwork due to technical error. One of the remaining 60 patients (1.6%) developed non-union giving an overall union rate of 95.2%. Two patients out of 59 healed OO (3.3%) required removal of hardware.

Conclusions: Although there were 2 early failures, there was a trend towards improved union rate with OO, but this did not reach statistical significance (p > 0.05). There was a significantly higher hardware removal rate recorded in TO group (p = 0.023). The OO showed shorter duration for radiological healing than TO (p < 0.05). USO performed with an OO and fixed with procedure specific plate has lower implant removal rate, a shorter duration for radiological healing and comparable union rate to TO fixed with DCP, but needs careful attention to detail.

Background: Pulvertaft Weave (PTW) is an established method of tenorrhapy in tendon transfers. Previous studies have suggested that a Side-to-Side (STS) tenorrhapy is easier to perform has the same advantages and has greater load to failure, ultimate load and stiffness compared to PTW. However, there is insufficient data comparing behaviour of STS and PTW during cyclical loading. The aim of this study is to compare these two methods in terms of creep after cyclic landing.

Methods: Fresh porcine flexor digitorum tendons were used. Ten tendon PTW and ten STS repairs were performed. Cross sectional diameter was measured. The tendon repairs were tested by applying tension up to 25N for 100 cycles, followed by tension up to 75N for 100 cycles, followed by loading to failure. Force-displacement data was used to determine the creep of the repaired tendon.

Results: All tendons survived 100 cycles of loading at 25N. After 1 cycle of loading, the mean cyclic creep in the PTW group was almost 3 mm larger than in the STS group (p = 0.046). After 100 cycles, the mean cyclic creep in the PTW group was 4.4 mm larger (p = 0.008). The cyclic creep rate was significantly larger in the PTW group (p < 0.001). All STS but only four PTW repairs survived after cyclic loading at 75N (p = 0.01). After 1 cycle and 100 cycles, mean creep of the surviving PTW samples was almost 7 mm (p = 0.006) and almost 9 mm (p = 0.004) larger than the STS group. The mean load to failure was four times larger in the STS group than the PTW group (p = 0.004).

Conclusions: STS repairs have a significantly smaller permanent elongation after cyclic loading at 25N and 75N, a significantly smaller cyclic creep rate, require a significantly larger load to fail. This implies that STS repairs are less likely to elongate after cyclic loading and can withstand greater loads. These properties can be valuable in allowing patients to commence mobilisation immediately after surgery.

Background: Management of Dupuytren Disease is variable, and influenced by multiple factors including location, extent of disease, surgical preference and familiarity with different treatment techniques. The objective of this study was to determine current Dupuytren Disease management trends in Australia.

Methods: A questionnaire was sent through The Australian Hand Surgery Society to all members. In addition to demographic data, indications and preferences for different management interventions were surveyed on location of disease, age and activity level of the patient.

Results: 99 (48%) of the Australian Hand Surgery Society members completed the survey. Respondents were primarily Orthopaedic (50%) or Plastic (49%) Surgeons, and most worked in private (99%) and public (71%) practice. Surgeon’s believed that Tubiana’s treatment goals to correct deformity was the most important (60%) and to shorten post-operative recovery (60%) was the least important. Only 42% of respondents perform needle aponeurotomy for Dupuytren Disease. In contrast 70% of respondents perform collagenase injections, with manipulation most commonly undertaken on the second day (46%) and skin tears (52%) the most common complication. Seventy-five percent of the respondents feel there is sufficient evidence to support the treatment of Dupuytren disease with collagenase injections. Ninety nine percent of all respondents perform fasciectomes for Dupuytren Disease, with Limited (without graft) (76%) the most routine performed.

Conclusions: Several procedural options for the treatment of Dupuytren Disease exist within Australia. This study shows current Australian practice trends and highlights the increasing use of collagenase.

Background: Several approaches to plate fixation of the proximal phalanx have been proposed, such as the dorsal extensor splitting approach and the lateral or dorso-lateral extensor sparing approach, which aims to minimise invasiveness to promote native extensor tendon glide. This study aimed to meta-analyse the outcomes of these two approaches.

Methods: A systematic review of electronic databases was undertaken, and the outcomes of comparative studies meta-analysed.

Results: Three studies were included for meta-analysis. Total active motion (TAM) was significantly greater in the extensor sparing group compared to the extensor splitting (Mean difference 8.52 degrees, 95%CI 0.8–16.36, p = 0.03).

Conclusions: This study demonstrates that there is preliminary evidence favouring the use of extensor sparing approaches when fixing proximal phalanxes – however, this result requires validation with randomised controlled trials.

Background: Severe flexion contractures of proximal interphalangeal joint of fingers can significantly impair hand function, typically after burn injury recovery. Extensive surgical release exposes deep vital structures, which subsequently requires significant skin coverage. The author presents the results of using bilateral side-finger flaps (wing flaps) and full-thickness skin graft for coverage of the defects.

Methods: Seven patients (8 fingers) with chronic severe flexion contractures of fingers resulting from burn injury were included.

Results: Mean flexion contracture and full flexion angles of the joints were improved from 84.4°/93.7° to 4.7°/92.5° at the last follow-up visit. No major complications were observed during the postoperative follow-up period (range, 6–16 months).

Conclusions: This alternative surgical technique can be successfully applied for the treatment of chronic severe flexion contractures of fingers. The advantages of this approach are the use of local flaps from injured digit, and that it can be performed as a one-session procedure.

Background: The purpose of this study was to report the results of metaphyseal and diaphyseal ulnar shortening osteotomies (USO) for the treatment of ulnar abutment syndrome (UAS).

Methods: From 2011 to 2016, we performed metaphyseal USO in 8 patients (8 wrists) and diaphyseal USO in 6 patients (7 wrists). The results were investigated in terms of bone union and cast immobilization, wrist and forearm range of motion (ROM). The mean follow-up duration was 29 months.

Results: All 14 patients had bone union. The mean duration of bone union in metaphyseal USO and diaphyseal USO were 3.5 months and 4.3 months and the duration of cast immobilization after surgery were 24.2 days and 29.2 days. The mean forearm ROM (degree) were 134.3 (pronation/supination: 66.7/67.6) and 169.3 (pronation/supination: 84.3/85.0) at 3 months after surgery and 173.4 (pronation/supination: 86.0/87.4) and 172.8 (pronation/supination: 87.1/85.7) at 6 months after surgery.

Conclusions: The results from this study suggest that metaphyseal osteotomies are an effective alternative to diaphyseal osteotomies for the treatment of ulnar abutment syndrome. Although metaphyseal osteotomies were associated with temporary decrease of pronation, this discrepancy resolved at 6 months postoperatively. Metaphyseal USO has the potential to promote primary bone union and appears to be an alternative treatment for UAS.

Background: Flexor tendon rupture is a major complication after volar locking plating for distal radius fracture (DRF). Few studies have investigated changes in the rate of postoperative flexor tendon rupture in patients with DRFs. The present study aimed to investigate the changes in the rate of postoperative flexor tendon rupture and to assess plate placement and reduction positions.

Methods: We retrospectively reviewed patients in whom more than 24 months had passed since DRF surgery. The patients were interviewed by telephone. Forty-nine patients (50 fractures; 2007–2009) from institution A were included in group 1 and 81 patients (84 fractures; 2013–2016) from institution B were included in group 2. The DRF surgery method was similar between the two groups. The rate of flexor tendon rupture, Soong classification grade, and radiological index (i.e., volar tilt [VT], radial inclination [RI], and ulnar variance [UV]) were statistically investigated in both groups.

Results: Patient epidemiology was not significantly different between the two groups. The flexor tendon rupture rates were 2% and 0% in groups 1 and 2, respectively, without a significant difference. With regard to the Soong grade, 44 fractures were grade 2 and 6 were grade 1 in group 1, whereas 18 were grade 2, 38 were grade 1, and 28 were grade 0 in group 2, with a significant difference (p < 0.05).

With regard to the radiological index, the mean VT values were 5° and 11° in groups 1 and 2, respectively, with a significant difference (p < 0.05). However, RI and UV showed no significant difference.

Conclusions: Plate placement and reduction positions, which are risk factors for flexor tendon ruptures after DRFs, have improved recently when compared with previous findings. With these changes, the rate of flexor tendon rupture is presumed to have decreased.

Background: The aim of this study was to investigate what should be considered when diagnosing and treating displaced extra-articular fractures based on plain radiographs.

Methods: We included 181 extra-articular distal radius fractures with marked displacement requiring surgery, which were diagnosed with posteroanterior (PA) + lateral (Lat) + oblique views (obl). We compared the plain radiographs with CT scans to determine whether the diagnosis was properly made. We described the types of articular involvement incidentally found on CT scans and how the articular involvement was treated. We tested the inter-observer and intra-observer reliability with three orthopedic surgeons.

Results: Forty-two (32%) out of 181 displaced extra-articular fractures diagnosed by plain radiographs had intra-articular involvement on CT scans. Dorso-ulnar intra-articular fragment was most commonly found. Thirty-three (78.6%) out of 42 intra-articular involvements required additional reduction and a dorsal approach was used in eight patients. Inter-observer and intra-observer reliability ranged from “substantial” to “almost perfect”.

Conclusions: When treating displaced extra-articular fractures requiring surgery, CT scans might be necessary to find intra-articular involvement and at least, an oblique view showing the dorso-ulnar corner of the articular surface should be added. Surgeons should consider that extra-articular fractures with marked displacement, which are diagnosed by plain radiographs alone, might have intra-articular involvement requiring additional reduction or fixation via a different incision.

A 49-year-old woman with rheumatoid arthritis who underwent replacement arthroplasty of second to fifth left metacarpophalangeal joints with silastic implant seven years ago presented with a complaint of mild pain and discomfort on the replaced joint of index finger. Ulnar deviation had relapsed, with severe swan neck deformities. Computed tomography examination demonstrated that the tip of the stem of the silicon implant penetrated the second metacarpal. We confirmed that finding surgically, and we performed a revision surgery successfully with autogenous bone grafting from distal radius. As the patient had undergone finger joint replacement surgery with silastic implant, nontraumatic perforation of the bone cortex by the implant could happen in a long-term process. On long-term follow up of silastic arthroplasty of finger joint, the possibility of nontraumatic perforation of the finger bone by the prosthesis should be considered, especially in the coexistence of severe finger deformities such as swan neck deformity.

As the brachial plexus traverses the costoclavicular space, it is susceptible to compression by pathologies affecting the clavicle. Clavicle nonunions with hypertrophic callus may cause a delayed onset of brachial plexus palsy. We present a rare case of a floating shoulder injury causing medial and posterior cord brachial plexus palsy two months after initial injury. After the diagnosis was established, the patient was treated successfully with expeditious brachial plexus decompression, callus excision, and rigid osteosynthesis, with healing of the clavicle nonunion and scapular fracture, and recovery of sensory and motor deficits.

There are only a few reports regarding snapping thumb caused by the pathology of the extensor tendon. We report a rare case of snapping thumb caused by a displaced non-union fragment from the trapezium in a 54-year-old man treated with the surgical resection. The intraoperative findings and the outcome are described.

We present a case of a 26-year-old right hand dominant male landscaper with a slow growing right ring finger subungual mass. MRI confirmed a 0.9 × 1.5 × 0.9 cm well circumscribed subungual mass believed to be consistent with a glomus tumor, although size and symptoms were not consistent with that diagnosis. The mass was completely excised and diagnosis of schwannoma was confirmed by H&E histology. A literature search was performed utilizing the term “subungual schwannoma.” Four case reports were found describing this diagnosis in the hand as well as a single case report describing it in the foot. In summary, this is a 26-year-old male who presents with a schwannoma in the unusual subungual location. Although rare, based on our case and the existing literature, subungual schwannomas should be included in the differential diagnosis of a slow growing subungual mass, particularly if symptoms and exam are inconsistent with more common etiologies.

We present the case of a severe and long-standing Dupuytren’s contracture where intraoperatively an ossified nodule was encountered within the diseased tissue. Histologically palmar fibromatosis in contact with cartilaginous tissue with central ossification could be confirmed, compatible with metaplasia. Our finding suggests that metaplastic activity inherent to longstanding, severely diseased Dupuytren’s tissue can lead to heterotopic ossification.

Tendon grafting is a key component of hand reconstructive procedures. Commercially produced tendon harvesters facilitate this grafting process but are not always available. We present an innovative technique that allows tendon harvest to be undertaken using equipment readily available in all hospitals. Only a scalpel blade and a plastic Yankauer suction tip are required. Two simple and rapid modifications are made to the suction tip using the blade prior to its use. The described tool has been conceived, refined and used successfully by the authors, without complications, and allows tendon harvest via the standard minimally invasive approach associated with a conventional harvester. Creating this improvised harvester is neither challenging nor time-consuming, and this cheap and effective substitute allows tendon grafts to be harvested using a minimal access approach in environments where a traditional harvester is not available, or not sterile.