Journal of Hand Surgery (European Volume)

Previous reports have indicated that inflammatory mechanisms may be involved in the pathogenesis of Dupuytren’s disease and it has even been suggested that this condition is a T-cell mediated autoimmune disorder. We investigated peripheral blood lymphocyte subsets from 21 patients with Dupuytren’s disease and compared them with ten healthy blood donors. The Dupuytren’s patients had an increase in DR+ T-cells compared with healthy controls. Furthermore, patients with both palmar and plantar involvement had a higher percentage of DR+ T-cells than those with only the palm affected. The percentage of circulating CD5+ B-cells was lower in the Dupuytren’s patients compared with the control group; this feature was marginally significant for the whole group of Dupuytren’s patients but was strongest in the group of patients with both palmar and plantar involvement. These findings support previous suggestions that immunological mechanisms, involving activated T-cells and probably also B-cells, are involved in the pathogenesis of Dupuytren’s disease.

Giant cell tumours of tendon sheath vary from solitary nodules to a multinodular variety that exhibits local infiltration. Recent advances in molecular oncology have defined a gene, nm23, expressed in normal cells which is responsible for inhibiting infiltration. The aim of this study was to investigate the expression of nm23 in a series of 52 giant cell tumours using immunohistochemistry and to assess its prognostic potential, nm23 expression was absent in 21% of tumours and this was associated with a highly significant risk of local recurrence (P<0.0001). Multivariate analysis of outcome showed nm23 expression to be more reliable than other clinicopathological parameters for predicting outcome. This immunohistochemieal test for nm23 is easily performed on standard paraffin sections and is recommended as an accurate prognostic marker for giant cell tumours of tendon sheath.

The histopathological appearances of the tendon sheath and synovium from 23 patients treated surgically for de Quervain's disease are described and compared with 24 controls. The condition was not characterized by inflammation, but by thickening of the tendon sheath and most notably by the accumulation of mucopolysaccharide, an indicator of myxoid degeneration. These changes are pathognomonic of the condition and are not seen in control tendon sheaths. The term ‘stenosing tenovaginitis’ is a misnomer and we believe that de Quervain's disease is a result of intrinsic, degenerative mechanisms rather than extrinsic, inflammatory ones.

Thirty-nine patients with Kienböck’s disease underwent silicone replacement arthroplasty between 1979 and 1994. The patients were followed-up from 1 to 8 years (mean, 8 years). Sixteen prostheses (41%) have had to be removed, from 1 to 18 years postoperatively (mean, 5.6 years), 15 of them because of pain and silicone synovitis or cysts. It appears that silicone synovitis with cyst formation is an inevitable problem in the wrist after silicone replacement arthroplasty of the lunate, and this procedure is only a temporary solution for Kienböck’s disease.

The outcomes in 20 patients with advanced Kienböck's disease treated by proximal row carpectomy (seven patients) or limited wrist arthrodesis (13 patients) were reviewed retrospectivey. Postoperatively, the results were more satisfactory in terms of wrist pain, the range of wrist flexion–extension, and grip strength following limited wrist arthrodesis than after proximal row carpectomy, although the differences were not statistically significant. We recommend scaphotrapeziotrapezoid arthrodesis in selected patients with advanced Kienböck's disease who have a fragmented lunate.

The incidence of Kienböck's disease is known to be higher in cerebral palsy patients, but little has been written on treatment. We report a case of Kienböck's disease in a young man affected by cerebral palsy. A proximal row carpectomy was done, which relieved spasticity at the same time as treating the disease.

Three patients who continued to have distal radioulnar joint pain following Bowers' hemiresection interposition technique were treated by converting the resection arthroplasty into a Sauvé-Kapandji procedure. The resected 10 mm segment from the distal ulnar metaphysis was used as an interposition bone graft in the arthrodesis site, placed between the sigmoid notch of the radius and distal end of the ulna. After a minimum follow-up of 3 years, all three patients were satisfied with the procedure, were pain-free, and the preoperative range of wrist and forearm motion had increased. All three returned to their previous working activities.

Although the ulnar impaction syndrome occurs most commonly in the ulnar positive wrist, it can also occur in wrists with either ulnar negative or neutral variance. Dynamic increases in ulnar variance may accompany forceful grip and pronation, but diagnosis of the ulnar impaction syndrome can be difficult nonetheless. This report further substantiates the occurrence of this problem in wrists with neutral and negative variance, and provides a description of diagnostic findings and pathoanatomy.

We report the results of Brunelli’s abductor pollicis longus transfer for symptomatic instability of the trapeziometacarpal joint in 15 hands (14 patients) at a mean follow-up of 21 months.

Patients were assessed subjectively, and objectively by an independent observer. All but one of the patients were very satisfied with the result of the operation, including the six patients who had significant degeneration of the carpometacarpal joint surface preoperatively. Four patients said they had no pain and the mean pain score overall on a visual analogue scale was 1.2 (out of a maximum of 10). Overall the outcome was rated good or excellent in 11 of the 15 thumbs.

The radiological images of 30 normal wrists in varying degrees of radial and ulnar deviation were analysed by measuring parameters of flexion and translation of the scaphoid bone. Results demonstrated a linear relationship, indicating that movement is consistently either by flexion of the scaphoid, translation or more commonly a combination of the two. The significance of this is discussed. There did not appear to be any age or sex related differences.

Degenerative arthritis following scaphoid nonunion was studied in 28 patients (29 wrists) using X-ray computed tomography and three-dimensional computed tomography (3-DCT). Degenerative changes were observed in 18 wrists with plain radiography and 27 wrists with 3-DCT. 3-DCT imaging more readily revealed osteophyte formation in osteoarthritis than plain radiography. 3-DCT images showed degenerative changes in the distal fragment of the scaphoid earlier than plain radiography. We found three stages of osteophyte formation in the radioscaphoid joint using 3-DCT. In the first stage, a linear osteophyte formed along the most radial portion of the distal fragment of the scaphoid. In the second stage, the radial styloid became pointed. In the third stage, the osteophyte on the distal fragment enlarged and lay over the dorsum of the radioscaphoid joint and other intercarpal joints.

Three patients with painful malunions of the scaphoid and significant loss of active wrist extension were treated with an opening wedge multiplanar osteotomy that corrected flexion, ulnar deviation, and pronatory rotational malalignment of the distal fragment.

After a minimum follow-up of 4 years, all three patients were satisfied with the procedure and were pain-free. The preoperative range of wrist motion had improved, and they had returned to their preoperative occupations.

Twenty-four patients were treated with scapholunate ligament repair and dorsal capsulodesis for scapholunate dissociation. Seventeen patients were available for follow-up at an average of 30 months. The average interval between injury and surgery was 3 months. At final follow-up, no patients were pain-free. Average total wrist motion was 60% and grip strength 70% of the opposite normal side. The average preoperative scapholunate angle was 78° and was corrected to a normal 47° at surgery. The average final scapholunate angle was 72°, which was not significantly different from the preoperative value. The scapholunate gap likewise was not significantly changed postoperatively. Only two patients had an excellent or good outcome using a clinical grading system, and six out of 17 scored good or excellent using a radiographic grading system. In conclusion, repair of the scapholunate ligament with dorsal capsulodesis failed to provide consistent pain relief and maintain carpal alignment in patients with static scapholunate instability.

We present 19 ray lengthenings in 14 patients done with a small external fixator. In six cases the thumb was lengthened and in the other 13 cases, other digital rays. The most frequent reason for lengthening was an amputation sustained in a work accident.

All the lengthenings were done by an osteotomy and subsequent gradual distraction with a small external fixator. The mean lengthening achieved was 20 mm (range, 0–32). An iliac-crest graft was needed in nine cases, corrective osteotomy in five cases and a deepening of the web in the six cases of thumb lengthening. In five cases an additional technique was needed to achieve bony consolidation. We have analysed the functional results and the ability to perform activities of daily living and resume employment. Although most of the patients had multiples injuries, the results have been very favourable, achieving a very high level of patient satisfaction.

We present the case of an 18-year-old woman with a shortened right index finger. The digit was stabilized and lengthened a total of 18 mm by external fixation and iliac bone grafting. A distal interphalangeal fixed flexion deformity of 60° was corrected with external fixation and intermedullary wiring.

The application of a video-based motion analysis system for goniometry of finger joints during measurement of the fingertip motion area has been assessed. The results indicate that the motion analysis system is reliable for angular measurements of finger joints that are comparable with those obtained by conventional goniometer. The advantages of using the motion analysis system is that it can record and show the changes in angle of all finger joints continuously during finger motion.

We studied the initiation and sequence of digital joint motion during unrestricted flexion and extension using a 3-D motion analysis of all fingers moving simultaneously. Our results showed that motion started in a single joint in 83% of flexion and 80% of extension cycles. The DIP joint initiated flexion and extension in the index, middle, and ring fingers, but in the little finger, flexion started in the PIP joint, and extension in the MP joint. The two most frequent sequences of joint movement during flexion of the three radial fingers were DIP-PIP-MP and PIP-DIP-MP. The two most frequent sequences during extension of the three radial fingers were DIP-MP-PIP followed by DIP-MP/PIP. In the little finger, however, the most frequent sequences during flexion were PIP-DIP-MP followed by DIP-PIP-MP and during extension, DIP-MP/PIP followed by PIP/DIP-MP

The purpose of this study was to measure the amount of active flexion from a neutral position in normal thumb metacarpophalangeal and interphalangeal joints and compare the results with previously published reports. One hundred and nineteen subjects (238 thumbs) volunteered to have active flexion of the metacarpophalangeal (MP) and interphalangeal (IP) joints of the thumb measured with a computerized Greenleaf goniometer by a certified hand therapist. The mean MP flexion was 59° and IP flexion was 67°. The results of this study suggest that the accepted normal values of thumb flexion should be reconsidered, particularly as a guide for determining impairment.

We reviewed 20 cases of chronic dorsal fracture-dislocation of the proximal interphalangeal joint, with a mean follow-up period of 74 months. In patients without comminuted palmar fragments, open reduction and internal fixation or osteotomy of the malunited fragment provided good results. In treating patients with damaged articular cartilage or with comminuted palmar fragments by palmar plate arthroplasty, poor results were obtained because of secondary osteoarthritic changes.

We treated 22 patients with mallet finger fractures involving more than one-third of the articular surface by the extension-block K-wire technique. There were 18 men and four women with a mean age of 23 years (range, 14–34). The Wehbé and Schneider method was used to classify the fractures and the results were graded according to Crawford’s criteria. All the fractures united, with an average healing time of 5.6 weeks (range, 4–7). At a mean follow-up of 25 months (range, 18–48) 21 mallet finger fractures had an excellent or good result. One patient had a fair result with a lag to extension of 20°. We conclude that the extension-block K-wire technique is an effective method of treatment for displaced mallet finger fractures.

A purely rotational Salter-Harris type I fracture of the proximal phalanx of the middle finger is described. This injury presents diagnostic problems as the radiographs do not show the displacement. Accurate clinical examination is essential, in particular checking for rotation of the finger.

We report 49 patients with a wide variety of hand infections, which developed after injuries from St Peter’s fish (Tilapia zillii). Twenty-eight of 36 patients who had been operated on had non-cholera vibrio infections, all identified as Vibrio vulnificus. The course in these patients was characterized by rapid spread of the infection with progressive necrosis of the tendon sheath, subcutaneous tissues and the skin. Two of them required amputations but the others had satisfactory functional results. Thirteen other patients were managed nonoperatively with intravenous antibiotics and all of them recovered completely.

We report a case of non-tuberculous tenosynovitis of the wrist caused by Mycobacterium malmoense. The patient presented with a ganglion-like swelling on the flexor aspect of the wrist. The diagnosis was confirmed by fine needle aspiration biopsy. A satisfactory resolution was obtained by antibiotic therapy alone, indicating that radical synovectomy may not be necessary in all cases of M. malmoense infection.

We report a case of a profundus tendon sheath fibroma which initially presented as triggering on wrist movements but rapidly caused a flexor tenosynovitis limiting both finger and wrist movements. Surgical excision was curative.

A patient with bilateral intraarticular distal radial fractures associated with scapholunate dissociation and post-traumatic lunotriquetral fusion on one side is described.

A case of bilateral congenital aplasia of the carpal scaphoid bone is presented. In contrast to previously reported cases of congenital hypoplasia of the scaphoid, this case was not associated with hypoplasia or absence of thenar and forearm muscles, absence of the sesamoid bones of the thumb, abnormalities of the skeleton of the thumb ray or hypoplasia of the forearm bones.

Most arteriovenous malformations usually arise from pre-existing named vessels. We report an unusual variant of an arteriovenous malformation. An 18-year-old man presented with a painful swelling of the right forearm. Arteriograms suggested branches of the anterior interosseous artery were feeding the malformation. Operative findings however, revealed the presence of a persistent median artery, which was contributing branches to the swelling.