The Journal of Hand Surgery (Asian-Pacific Volume)

Metacarpals are unique bones that support the finger to aid hand function. Metacarpals are also the commonest bones to get fractured in the hand. Historically, most metacarpal fractures were managed conservatively. Due to increased patient expectations as well as advancements in diagnosis and osteosynthesis, various surgical options are now available for metacarpal fractures. The goal of operative management of metacarpal management is no longer limited to achieving clinical or radiological union. To restore hand function to a preinjury level, the surgeon must achieve adequate anatomical reduction and stable fixation with minimal soft tissue damage. Similar to tendon repair, to start early active motion should be the goal after metacarpal fracture fixation. Intraoperative consideration should also include minimizing soft tissue damage and avoiding tendon, ligament or capsular entrapment. The aim of this article is to explain the principles of surgical management, the different options available for metacarpal fractures, the techniques, pearls, advantages and disadvantages of each technique, so the surgeon can choose the ideal option to achieve the best result.

Background: Locking plate fixation is widely used in large long bone fixation and is now available for small “long” bones in the hand. Potential advantages of unicortical locked fixation are reduced risk of over-drilling and therefore reduced risk of damage to surrounding structures and reduced risk of irritation from proud screws. Furthermore, unicortical fixation may be used where bicortical fixation is technically impossible. Our aim was to compare fixation strength of unicortical locked plate fixation with bicortical non-locked fixation in a human cadaveric model, by assessing strength under cyclical loading conditions and load to failure (LTF).

Methods: 16 matched pairs of embalmed and refrigerated human cadaveric metacarpals were randomly allocated to either unicortical locked or bicortical non-locked plate and screw fixation. A transverse osteotomy was made. Fractures were stabilized with 2.0 mm self-tapping locking or cortical screws. Each metacarpal was then loaded with a 3-point cantilever testing using a 100 N cell on an Instron materials testing device, cyclically loading them at 1,000 repetitions of 30 N and 50 N. If there was no visible failure of the fixation from cyclical loading they were then loaded to failure with a 1 kN cell.

Results: There was a significant difference of average LTF between the bicortical non-locking and unicortical locking of 38.07–59.95 N (p < 0.01). However, both groups showed no statistically significant difference when comparing their performance under cyclical loading.

Conclusions: The authors regard unicortical locked fixation as a useful adjunct to standard plating technique.

Background: Previous reports on schwannomas of the upper extremities have mainly focused on proximal involvement. This study aimed to evaluate pre- and peri-operative findings in schwannomas of the distal upper extremities and assess the accuracy of diagnosis and surgical outcome.

Methods: We identified 24 patients with isolated tumors. Seven patients had schwannomas located in the forearm, eleven in the hand, and six in the digits. We collected the following data: preoperative clinical and magnetic resonance imaging findings, provisional diagnosis, surgical findings and procedures, tumor volume, and postoperative clinical findings. Data were compared between tumors of different locations.

Results: The mean age of our cohort at the time of surgery was 48.0 years and the mean follow-up period was 10.6 months. All patients with forearm schwannomas were diagnosed preoperatively by the presence of the Tinel-like sign and suggestive magnetic resonance imaging findings. In contrast, schwannomas in the hands and digits often lacked these diagnostic features; only five patients with hand schwannomas and one with digit schwannoma were correctly diagnosed. Microsurgical enucleation was the most common treatment. Ten patients reported newly acquired paresthesia after operation, which resolved within the follow-up period in nine patients. Three of the four patients with preoperative paresthesia and one patient who underwent enucleation with surgical loupes still had paresthesia at the final follow-up.

Conclusions: In schwannomas of the distal upper extremities, a more distal location is associated with a lower occurrence of the Tinel-like sign and fewer suggestive magnetic resonance imaging findings, resulting in lower diagnostic accuracy. However, intra-operative diagnosis is usually straightforward and microsurgical enucleation does not cause iatrogenic nerve deficit. When treating soft tissue tumors in the hand and digits that present without specific or suggestive findings, the possibility of schwannoma should be considered.

Background: Congenital hand differences (CHD) exhibit enormous diversity and heterogeneity. Surgeons and parents often have different concepts of severity, making things difficult during parental consultation. This study aims to align surgeon/parental views on the severity of the child’s CHD using a novel severity classification.

Methods: Parents of affected children were asked to score the severity of their child’s abnormality pre- and post-consultation using a subjective scale (1–4) without any explanation. Furthermore, parents were asked to rate their concerns about the future function and appearance of their child’s hand condition using a similar scale of 1–4. They were then asked to rate the severity of the CHD post-consultation and three months post-operatively following explanation of the 4-point scale, as follows: 1 = treatment possible to normal; 2 = treatment possible to near normal; 3 = treatment possible but always some hand differences; 4 = treatment not possible. The surgeon also independently scored all children using his perception of the scale.

Results: Forty-three children with a range of CHD were recruited into the sample. Linear weighted kappa analyses comparing inter-rater agreement showed no agreement between surgeon and parents during the initial scoring without any explanations. However, with explanations added, agreement rose significantly (kappa = 0.437 post-consultation and kappa = 0.706 three months post-op). No correlation was found between severity with both appearance and function (r = 0.277 and r = −0.184, respectively).

Conclusions: This study demonstrated that the use of a simple scoring system was able to improve parental understanding of the severity and prognosis of CHD. The system demonstrated a good correlation between surgeon and parents. Such a scoring system can be easily utilised in the outpatient department to manage expectations and reduce anxiety.

Background: Despite the movement of the thumb carpometacarpal joint has been studied, many unclarified points remain regarding the movement of this joint. The purpose of this study was to evaluate the in vivo kinematics of the thumb carpometacarpal joint during flexion and abduction using computed tomography images.

Methods: The subjects were 9 healthy males. Computed tomography images were obtained in 4 equally-divided positions from maximum extension to maximum flexion, and maximum adduction to maximum abduction of the thumb. A three-dimensional model was constructed from these images, and the models of each position were superimposed with reference to the trapezium. The amount of angular change around the bone axes of first metacarpal bone and rotation axes were evaluated.

Results: We found that the first metacarpal bone showed relatively simple behavior during abduction. However, during flexion, it exhibited a particular movement in which the amount of angular change of the metacarpal bone with respect to the trapezium rapidly increased with deep flexion.

Conclusions: These results suggest that the thumb carpometacarpal joint exhibits a special movement during flexion, especially deep flexion.

Background: Angle grinders are a handheld power tool used for grinding and polishing stone, metal, and concrete. Some people, however, use them with a circular saw blade attachment for cutting wood and consequently, suffer injuries. We aimed to investigate the underlying cause and mechanisms of injuries caused by cutting wood with an angle grinder.

Methods: We conducted a retrospective study using medical records from our trauma center and identified 15 patients treated for angle grinder injury between 2017 and 2018. Moreover, we contacted the National Consumer Affairs Center of Japan for further information about angle grinder injuries.

Results: Nine of the 15 patients used angle grinders improperly, of which only three patients were aware of the risk of injury. The details of the nine patients were as follows: the types of injuries: complete finger amputation (n = 2), partial finger amputation (n = 1), tendon injury with phalangeal fracture (n = 5), and tendon injury alone, (n = 1); the causes of accidents: kickback (n = 7) and glove entanglement (n = 2); and the accident situations: on-the-job (n = 5) and do-it-yourself (n = 4).

Conclusions: The primary cause of angle grinder injury caused by cutting wood was a lack of user knowledge that an angle grinder cannot be used as a cutting tool. Appropriate feedback from hand surgeons are necessary to urge manufacturers to take safety measures.

Background: The evaluation of pain catastrophizing, which is a negative emotion associated with pain, is useful for predicting pain after surgery and is also associated with upper extremity disability. Therefore, it is important to evaluate pain catastrophizing after surgery for upper limb musculoskeletal disorders. This study examined the appropriate time to evaluate pain catastrophizing after surgery for upper extremity motor disorders.

Methods: A total of 32 patients underwent surgery. Pain catastrophizing (Pain Catastrophizing Scale: PCS) and pain intensity (Numerical Rating Scale: NRS) were measured at the start of rehabilitation and 2, 4, and 8 weeks postoperatively. The subjective ability of the upper extremity was measured 8 weeks postoperatively using the Hand20 questionnaire. The variation in the postoperative PCS and NRS were investigated.

Results: The PCS and NRS values were significantly lower 2 weeks postoperatively than at the time rehabilitation started. Pain catastrophizing was a significant predictor of pain, with the greatest degree of prediction at 2 weeks. Pain catastrophizing was also a significant predictor of the Hand20 result at 8 weeks postoperatively.

Conclusions: Our data shows that pain catastrophizing should be evaluated 2 weeks postoperatively for the prediction of continuing pain.

Background: Stack splint is commonly used for mallet finger treatment but patients had a tendency to frequently remove it because of skin complications. We hypothesized that a comprehensively instructed splinting regime would increase patients’ compliance and lead to favorable outcomes with fewer skin complications. The aims of this study were to assess the patients’ compliance and to evaluate outcomes with that particular splinting regime.

Methods: Forty-six consecutive patients were enrolled in this prospective study. They were instructed to wear the Stack splint for 24 hours a day every day in the first six weeks and remove it once a day for 10 minutes to vent. They were told to support distal interphalangeal joint volarly both while wearing the splint and when it was removed. Free movement of proximal interphalangeal joint within the splint was checked after each application. Following whole-day regime for 6 weeks, night splinting continued for 2 more weeks. Range of motion, skin complications, patients’ compliance and satisfaction were assessed at last follow-up.

Results: There were 26 patients with a mean age of 39.8 and mean follow-up period of 6.7 months. No skin complications or proximal interphalangeal joint stiffness were reported. However, nine patients declared that they wore the splint ≤ 4 weeks, the compliance rate to our regime was 65.4% (17/26). In the 17 fully compliant patients, mean distal interphalangeal joint extension lag was 12.4 and nine of them (52.9%) were satisfied with the outcome.

Conclusions: Our both hypotheses failed; comprehensive instructions for the splinting regime did not improve patients’ compliance satisfactorily, nor did it lead to favorable outcomes. Although Stack splint has practical points, we no longer use it.

Background: Surgical fixation using intramedullary headless screws (IHS) is a relatively new technique for metacarpal fracture repair. However, there are very few studies investigating the outcomes of this procedure. We present the surgical and functional outcomes of a consecutive series of 30 metacarpal fractures treated by a single surgeon over a 2.5-year period using IHS.

Methods: We retrospectively reviewed the records of 30 metacarpal fractures in 27 patients who underwent IHS fixation from March 2016 to October 2018. There were 29 fractures of the metacarpal neck and 1 was to the metacarpal head. All fractures underwent the procedure by a single operating surgeon. Individual joint movements along with total active movement (TAM) was measured at postoperative follow-up appointments 4–8 weeks after surgery. Fracture healing was confirmed with plain radio-graphs. Patients were also recalled in March 2019 for their latest functional measurements. A QuickDASH (disabilities of the arm, shoulder and hand) questionnaire was used to assess for any residual functional disability.

Results: All fractures healed within acceptable radiological parameters with no mal-unions or rotational deformities. The average TAM at initial follow-up was 245°, which improved to 264° at the March 2019 review. All patients returned to work in an average of 6 weeks. The final functional QuickDASH score was an average of 2.9/100 (range 0–18.2). 2/27 patients required further surgery for stiffness before regaining excellent TAM. No patient required metalwork removal. There were no other complications.

Conclusions: Our findings suggest that IHS fixation is an effective alternative technique for the treatment of metacarpal fractures. It is a relatively simple procedure, which provides good stable fixation, allowing for early mobilisation. It has few complications and does not routinely require removal of the implant.

Background: Although postoperative outcomes of olecranon fractures are relatively favorable, postoperative stiffness of the elbow joint occurs occasionally. We aimed to identify negative prognostic factors for unfavorable outcomes following olecranon fractures.

Methods: We retrospectively reviewed the records of 100 patients with olecranon fractures and collected data on the conducted procedures, age, fracture condition, postoperative reduced position, and postoperative active range of motion (AROM) of the elbow joint. The primary outcome was the regaining of an AROM of > 130° flexion and < −30° extension of the elbow joint at the final follow-up. We performed multivariate logistic regression analysis to identify the negative prognostic factors.

Results: The mean follow-up period was 11 months. All patients regained an average AROM of 121 degrees. Eighty-one patients regained a favorable AROM of the elbow joint. On univariate logistic regression analysis, diabetes mellitus (OR, 8.2; 95%CI, 1.6–41.7), comminution of the fractured site (OR, 23.1; 95% CI, 13.2–165.0), and utilization of the tension band wiring (TBW) technique (OR, 7.5; 95% CI, 1.16–48.2) were significant factors in aggravating the final result of elbow AROM. On multivariate analysis, patients with diabetes mellitus (OR, 10.9; 95% CI, 2.83–41.9), comminuted fractures (OR, 11.4; 95% CI, 2.61–50.2), or undergoing the tension band wiring technique (TBW) (OR, 5.5; 95% CI, 1.35–50.2) showed reduced postoperative AROM of the elbow joint; postoperative malreduction of the articular surface was not a negative prognostic factor. Seven of 51 patients treated with TBW underwent revision surgery because of non-union or postoperative displacement.

Conclusions: TBW for olecranon fractures is a simple and cost-effective procedure; however, negative effects could develop when regaining sufficient postoperative AROM of the elbow joint. Therefore, rigid fixation without reoperation may lead to a favorable outcome. Postoperative malreduction does not always worsen the postoperative AROM of the elbow joint, at least not in the early postoperative period.

Background: Although extension block pinning for mallet fracture is popular, it occasionally results in poor outcome. We reviewed previous cases to elucidate the factors associated with poor outcome.

Methods: From 2012 to 2017, 50 mallet fingers in 50 patients were consecutively repaired by extension block pinning using modified Ishiguro method. Inserted Kirschner-wires (K-wires) were removed at 6 weeks, followed by night splinting in extension. For outcome evaluation, distal interphalangeal (DIP) joint motion was measured and classified as either good or poor. Poor outcome was defined as either > 10° of extension lag or < 40° of active flexion or the presence of DIP joint pain. Associations between outcome and age, affected finger, interval to operation, fragment size (in terms of joint surface and dorsal cortex ratios), and fixation angle were evaluated.

Results: 33 fingers (66%) had good outcome and 17 (34%) had poor outcome. Mean age was significantly greater in the poor (50.6 years) than in the good (40.1 years) outcome group (p < 0.05). The dorsal cortex ratio was also significantly larger in the poor than in the good outcome group (p = 0.006), but there was no significant difference between two groups in joint surface ratio. Affected finger, interval to surgery, and fixation angle also did not significantly differ between groups.

Conclusions: Fracture fragments with a long dorsal cortex and older age associated with poor outcome following extension block pinning for mallet finger. The dorsal cortex ratio should be evaluated pre-operatively to determine the appropriate treatment method.

Background: Treatment of the proximal ulnar stump with the Darrach or Sauvé-Kapandji (SK) procedure remains controversial. Ulnar wrist symptoms can result, and although many surgeons attribute these to ulnar stump instability, they can also be caused by radioulnar convergence or stump irritation. We present a novel surgical method for protecting the proximal ulnar stump and avoiding these complications.

Methods: Our cases were five men and five women (mean age 72.0 years, range, 34–89). Mean follow-up duration was 41.7 months (range, 6–101 months). Radiological findings were osteoarthritis in five, rheumatoid arthritis of distal radioulnar joint in three, and ulnocarpal abutment syndrome in two. Pronator quadratus (PQ) was released from its insertion on the radius and transferred dorsally to cover the proximal ulnar stump. Postoperative ulnar wrist symptoms such as ulnar stump tenderness, forearm range of motion, and grip strength were compared with contralateral values. Dynamic radioulnar impingement was evaluated by Lee and Scheker’s stress roentgenogram. Nine patients completed the Patient Rated Wrist Evaluation (PRWE) at final follow-up.

Results: No patients reported ulnar wrist pain or tenderness at the proximal ulnar stump. Postoperative forearm range of motion recovered almost to contralateral values in cases without preoperative forearm contracture. In the two cases with contracture, postoperative pronation and supination recovered to more than their preoperative range. Grip strength averaged 86.4% (range, 66.7–103%) of the contralateral value at final follow-up. Lees and Scheker’s stress roentgenogram revealed marked radioulnar impingement in one case, mild impingement in four cases and none in five, yet no patient complained of pain during the maneuver. The mean PRWE score was 34.7 points (range, 0–52.5 points).

Conclusions: Insertion-released PQ pedicle transfer is an effective treatment option for the proximal ulnar stump after the Darrach or SK procedure.

Background: Literature has limited evidence concerning the morphology of volar surface of distal radius. A mismatch between the plate-contour and contour of the actual volar bony surface can result in malreduction. The purpose of this study is to analyze the normal curvature morphology of volar surface of distal radius and related parameters that can help in designing of the volar plates for fixation of distal radial fractures.

Methods: We retrospectively analyzed CT scans of uninjured healthy distal radii performed during a one year period (2018–2019). The mediolateral extent of the pronator quadratus line, the mediolateral curve of the pronator quadratus line, the mediolateral surface angle between intermediate column and radial column of distal radius, the curvatures and locations of their vertices for radial and intermediate columns were measured.

Results: A total of 84 CT-based studies were analyzed. The mediolateral extent of the pronator quadratus line, the mediolateral curve of the pronator quadratus line, and the mediolateral surface angle between intermediate column and radial column of the distal radius were 24.27 mm, 144.8 degrees and 163.1 degrees, respectively. The mean volar curvatures of the radial and intermediate columns were 156.5 and 151.4 degrees, respectively and distances of their vertices from the pronator-quadratus line were 10.96 mm and 14.13 mm, respectively.

Conclusions: Considerable variations occur in curvature morphology of distal radial volar surface. A best fit rather than an anatomical fit can be considered during implant selection owing to these variations. Besides volar curvature of radial and ulnar columns, location of their vertices, mediolateral angulation and surface curvature between these columns at the level of watershed line should also be considered in plate selection. A combination of a few serial increments of the described parameters in the designs of volar fixation plates would be helpful for surgeons in the best implant selection.

Background: With the emergence of the COVID-19 pandemic, most health-care personnel and resources are redirected to prioritize care for seriously-ill COVID patients. This situation may poorly impact our capacity to care for critically injured patients. We need to devise a strategy to provide rational and essential care to hand trauma victims whilst the access to theatres and anaesthetic support is limited. Our center is a level 1 trauma center, where the pandemic preparedness required reorganization of the trauma services. We aim to summarise the clinical profile and management of these patients and highlight, how we modified our practice to optimize their care.

Methods: This is a single-centre retrospective observational study of all patients with hand injuries visiting the Department of Plastic Surgery from 22^nd March to 31^st May 2020. Patient characteristics, management details, and outcomes were analysed.

Results: A total of 102 hand injuries were encountered. Five patients were COVID-19 positive. The mean age was 28.9 ± 14.8 years and eighty-two (80.4%) were males. Thirty-one injuries involved fractures/dislocations, of which 23 (74.2%) were managed non-operatively. Seventy-five (73.5%) patients underwent wound wash or procedure under local anaesthetic and were discharged as soon as they were comfortable. Seventeen cases performed under brachial-plexus block, were discharged within 24 hours except four cases of finger replantation/ revascularisation and one flap cover which were discharged after monitoring for four days. At mean follow-up of 54.4 ± 21.8 days, the rates of early complication and loss to follow-up were 6.9% and 12.7% respectively.

Conclusions: Essential trauma care needs to continue keeping in mind, rational use of resources while ensuring safety of the patients and health-care professionals. We need to be flexible and dynamic in our approach, by utilising teleconsultation, non-operative management, and regional anaesthesia wherever feasible.

An exceptional case like our patient who was a 24-year-old man presented 6 weeks after type 4 Allen amputation to his right index finger where primary surgical stump closure was done, presented to us with the amputated distal part warm preserved. The reposition of distal amputated part using the authors described GRF (Graft Reposition on Flap) technique was done and followed. Good consolidation and bone graft union, good nail with near normal pulp and normal sensation with good functional outcome was achieved at the one-year final follow up.

Carpal tunnel syndrome (CTS) is the most common type of entrapment neuropathy. The majority of CTS cases are idiopathic and affect females between 40 and 60 years old. Conversely, this report describes two female patients in their mid-30’s diagnosed with CTS caused by a median artery in the carpal tunnel using ultrasonography. We visualized the median artery which emerged from the radial artery and common interosseous artery in the proximal forearm of each patient by magnetic resonance angiography (MRA) before surgery. After the vertical incision of the transverse carpal ligament, the anomalous vessel was encountered, which ran over the median nerve at the radial aspect, and a simple mini-open procedure was performed for carpal tunnel release. Postoperatively, the CTS symptoms were relieved in both patients. The purpose of this report is to describe the persistent median artery using MRA in two patients and to report on their postoperative mini-open carpal tunnel release outcomes.

Although distal radius fractures are common, wrist contracture caused by an extra-articular lesion after a distal radius fracture is seldom reported. We report a rare case of wrist contracture caused by adhesion of extensor carpi radialis brevis (ECRB) tendon after distal radius fracture. The patient was successfully treated with tenolysis of the ECRB tendon.

Chronic embedded-ring injury is a rare and uncommon presentation. This is also known as “chronic ring erosion” or “embedded ring syndrome” in the literature. Injury of this type has been associated with psychological impairment causing neglect of such injury. We herein describe a case of double embedded rings on the right ring finger in a 30-year-old healthy construction worker. A primary amputation at the metacarpophalangeal joint was performed in view of the chronicity of his condition and associated neurovascular damage. Early removal of ring is of paramount importance in any ring-associated injuries. However, fear of losing a digit has been the reason of delay in seeking medical treatment, which in turn ended up in dire consequences.

A new nerve transfer option of using viable fascicle of the ipsilateral middle trunk for suprascapular nerve reconstruction is presented. The procedure was used in two patients with upper brachial plexus injury involving loss of shoulder abduction and external rotation. Clinical evaluation and nerve conduction studies in both patients confirmed axonopathy of C5, C6 roots and C5 root, respectively. The proximal root stumps were unavailable for nerve grafting due to a very proximal root level scarring. The middle trunk fascicle was dissected on its superior surface and transferred to the non-functional suprascapular nerve. After 24 months follow up full abduction and external rotation could be achieved in both the patients. It is a simple and easy option for transfer to a suprascapular nerve in upper brachial plexus injuries. It lies next only to the upper trunk and does not require any additional dissection time. Donor deficit was not observed in our two patients.

In baseball players, a high degree of functional recovery is required for the treatment of fractures in the distal interphalangeal (DIP) joint, especially on the throwing side. While dynamic external fixation is a useful treatment option to restore the joint function, existing external fixators are too large for use on DIP joints. Three cases of DIP joint intra-articular comminuted fractures in baseball players treated using the new dynamic external finger fixator which we developed are reported. The external fixator was kept attached for four weeks. The patients returned to play baseball 7–8 weeks after surgery. The total arc of the DIP joint was 90–100% of the contralateral side. Follow-up radiographs demonstrated that joint congruity had been reacquired. This technique was adaptive in the treatment of comminuted intra-articular fractures of the DIP joint and resulted in a near-normal range of joint motion and remodeling of the joint surface.

Congenital radioulnar synostosis with posterior dislocation of the radial head remains challenging to treat. We describe a three-step treatment method that combines radial shaft osteotomy with a custom-made device, ulnar shaft osteotomy, and local adipofascial flap elevation procedures. For posterior radial head dislocation treatment, osteotomy near the proximal radius cannot recover physiological rotation of the radial head. Thus, we chose a precise radial shaft osteotomy with a custom-made device according to preoperative planning based on three-dimensional evaluation of the bone deformation. Performing radial shaft osteotomy alone, however, may not be enough to achieve sufficient supination range of motion. We, therefore, also performed ulnar shaft osteotomy. Finally, we elevated the local adipofascial flap to prevent re-adhesion. In three patients, the range of motion of the elbow improved postoperatively. In conclusion, our three-step method does not require a microsurgical technique and is easy to perform.

Most procedures that require exposure of the wrist joint requires us to go through the third and fourth compartment. This is followed by dividing the septum between the 3rd and 4th compartments and retracting the EDC tendons ulnarwards. This can be done by various techniques. Using a form of self-retaining retractor is cumbersome and has to be repeatedly repositioned as the tendons keep slipping out. We describe a novel method to maintain this retraction throughout any wrist procedure.

Coronavirus disease-19 has affected million of people worldwide, constituting the biggest social, economic, and health crisis since World War 2. During this pandemic, the hospitals have become hot zones for the treatment of patients. Therefore, it is important to take the appropriate protective measures and ensure the physician’s health and, especially, those who work in the intensive care units and in operating rooms. In this letter, we are trying to make a discussion regarding the measures that should be considered by the healthcare workers who are facing this invisible enemy during their effort to provide their services in the surgery rooms.