Journal of Hand Surgery (European Volume)

A kinematic study was performed to examine the influence of elbow position on the range of supination and pronation of the forearm. The ranges of supination and pronation were measured in 50 volunteers (25 men and 25 women) using a custom-designed jig which constrained unwanted and confounding movements of the limb. Measurements were taken with the elbow in full extension, 45° flexion, 90° flexion and full flexion. The data showed a reciprocal relationship between the range of supination and the range of pronation of the forearm which depended on the degree of elbow flexion. As the elbow is flexed, the maximum angle of supination increases while the maximum angle of pronation decreases (p<0.001). The converse is true as the elbow is extended (p<0.001).

The Patient Evaluation Measure (PEM), The Michigan Hand Outcome Questionnaire (MHQ) and the Disabilities of the Arm, Shoulder and Hand (DASH) score were assessed independent of their originators for reliability, construct and criterion validity and acceptability, using an ease of use questionnaire. These were administered in random order to 100 patients with different hand and wrist disorders and with different impairments of movement, pain, sensation and strength. The internal consistency of all three questionnaires was very high suggesting redundancy in the questions. All questionnaires were reproducible and valid for finger and wrist disorders, but less for nerve disorders. All had poor construct validity. The PEM was the easiest to understand and complete, taking the least time. Correlation between the scales is high and conversion equations were calculated. All three are reliable and reproducible patient completed questionnaires, but the PEM is the easiest to use. The validity of all is suspected for nerve disorders.

This paper reports a long-term follow-up measuring pain, range of motion and weight-bearing ability, following implantation of a total distal radioulnar joint prosthesis. This prosthesis differs from excision arthroplasties and ulnar head replacements by replacing all three components of the distal radioulnar joint, viz. the sigmoid notch, the ulnar head and the triangular fibrocartilage. The design allows longitudinal migration of the radius throughout pronation and supination, as well as load bearing of the wrist. Thirty-one patients receiving the prosthesis returned or were interviewed by telephone at a mean of 5.9 (range 4–9) years. Pronation increased from a mean of 65.5° (range 5–90°) to 74° (range 20–90°) and supination from 53° (range 5–90°) to 70° (range 20–90°) while greatly diminishing and/or eliminating pain. Grip increased from a mean of 10 kg (22 lbs) to 24 kg (52 lbs). Weight bearing was restored or increased in 29 of 31 patients.

We present a case of acquired syndactyly secondary to keloid formation in a previously normal web space following release of syndactyly in the adjacent web space.

In the present study, we illustrate the use of an electrophysiological classification as a guide to the treatment of carpal tunnel syndrome (CTS). A total of 113 CTS patients were assessed with symptom severity scores, hand functional scores and electrophysiological studies. By setting criteria of electrophysiological tests, 179 hands in 113 patients were classified into mild, moderate and severe degrees of CTS. Of these, the 41 hands with severe CTS were referred for surgery. The 58 hands with moderate CTS and 80 hands with mild CTS received conservative treatment. The improvement ratios in the severe group were greater than that in the moderate and mild groups, both at 6 months and at 1 year. Eighteen hands with moderate or mild CTS returned to normal electrophysiology with the conservative treatments. No patient recovered to normal electrophysiology in the severe group. This electrophysiological classification is objective and it may serve as a useful guide for non-surgical and surgical treatment of CTS.

This paper presents a retrospective series of 20 LPM semi-constrained ceramic coated cobalt chrome proximal interphalangeal joint arthroplasties performed consecutively in 12 patients for arthritis of the proximal interphalangeal joint by a single surgeon between 2000 and 2004. Eleven were performed for osteoarthritis, four for post-traumatic arthritis and five for rheumatoid arthritis. Although 12 joints had an improvement in pain and an increased functional arc of movement, six joints required revision surgery for implant failure at an average of 19 months, with clinical signs of increasing pain, deteriorating motion and radiological signs of implant loosening and subsidence. This rate of revision is higher than in published series for other PIP joint implants and, therefore, close surveillance of all patients with this prosthesis currently in situ is recommended. Use of the prosthesis has ceased in this unit.

A 39 year-old farmer sustained a closed rupture of the left brachial artery, which was successfully managed by emergency vein graft repair of the artery. Adjacent nerve trunks were seen to be intact, but stretched. Burning pain in the distribution of the ulnar nerve started at day seven postoperatively, and worsened over the ensuing years. There was no response to membrane stabilising drugs, amitryptiline, nor to regional sympatholytic or local anaesthetic blocks. Neurolysis of the ulnar nerve, which was densely adherent to the dilated vein graft, abolished his pain.

Two clinical forms of ulnar polydactyly are recognised in the literature, viz the African and the Caucasian forms. The current study investigated the clinical and radiological features of ulnar polydactyly in 94 Saudi patients. The incidence of ulnar polydactyly was one in 1000 live births. There were 41 males and 53 females. Positive family history, syndromal cases, associated hand anomalies, polydactyly of the little toe and systemic abnormalities were seen in 11%, 6%, 5%, 29% and 23% of cases, respectively. There were 50 unilateral (53%) and 44 bilateral cases (47%). In unilateral cases, the left hand was more commonly affected. Using a modified Rayan–Frey classification, the majority of cases were classified as Type II (pedunculated polydactyly, 52 (55%) cases) and Type III (a functioning and articulating extra digit without complete duplication of the metacarpal, 29 (31%) cases). It was concluded that the Saudi clinical presentation of ulnar polydactyly is somewhat different epidemiologically and lies between the African and Caucasian forms.

This paper reports the results of fixation of intraarticular fractures of the distal radius using the TriMed fragment-specific fixation system by surgeons early in their experience with the system. A consecutive series of 22 AO types C2 and C3 fractures in 21 patients were internally fixed with the system. Restoration of articular congruity to less than 2 mm was possible in 20 fractures. At a minimum of 6 months follow-up, mean volar and radial inclination were 8° and 25°, respectively, with no loss of reduction. The patients had a mean of 50° flexion, 63° extension and a pronation–supination arc of 149°. The mean subjective Patient Rated Wrist Score was 20. Our complication rate was comparable to other published series despite long operating times. Therefore, we commend the system as a powerful tool to treat these difficult fractures but acknowledge the significant learning curve.

The aim of this retrospective study was to assess objective and subjective aspects of the long-term results of finger replantations and revascularisations. Forty patients with 59 successfully replanted or revascularised fingers, who had a mean age of 38 years, were followed-up over an average of 3.5 years. The assessment included: the profile of the blood flow in the digital arteries of replanted fingers with Doppler ultrasound, active range of motion, total grip strength, pinch grip, static two-point discrimination test and Semmes–Weinstein monofilament testing. The dexterity of the hand was evaluated subjectively with the Carlsson’s questionnaire and cold intolerance with a modified McCabe’s questionnaire. Statistical analysis was performed and a statistically significant correlation was found between the Carlsson’s functional score, active range of motion and total grip strength. In 28 fingers (74%), blood flow in the digital arteries showed an undisturbed profile, while ten fingers showed mild stenosis or impaired microcirculation.

Twenty digits in 15 patients with dorsal combined tissue loss were treated by radical debridement, primary non-vascularised iliac crest bone graft and immediate lower abdominal flap cover between 1996 and 2006. The average length of the bone grafts was 3.3 (range 2.5–5) cm. No extensor tendon reconstruction was carried out. The flaps were divided at 3 weeks without delay. Permissible thinning of the flap was done at the time of division of flaps. No secondary procedure was done. All patients were retrospectively reviewed and X-rays obtained. Radiological union was achieved in 18 of 20 digits. One bone graft was removed because of infection. One bridging bone graft united with the distal phalanx but had a painless non-union with the proximal phalanx. There were no flap complications. Bone graft length resorptions of 20% and 15% occurred in two terminal bone grafts. We recommend this protocol as a solution to this challenging problem.

Although most distal phalangeal fractures can be treated conservatively, there exists a subset of patients who are liable to develop symptomatic non-union, manifesting as pain and/or instability, and who may benefit from early fracture fixation. This group of patients includes those with displaced or comminuted fractures of the shaft or neck and those with oblique fractures prone to displacement. This paper reviews the use of a cortical miniscrew for fixation of fracture non-union in these patients and shows that this is an effective treatment modality with minimal morbidity. Fourteen patients with fractures of the shaft or neck of the distal phalanx complicated by symptomatic non-union were treated by open reduction and interfragmentary screw fixation. All of the fractures united at a mean of 4.2 months and all patients regained normal function of the finger.