Journal of Hand Surgery (European Volume)

The double free-muscle transfer technique achieved a dramatic revolution in the treatment of total paralysis of the brachial plexus by providing universal prehensile function, although several requirements such as successful free-muscle transfers, stability of the proximal joints and prolonged postoperative rehabilitation are necessary for the success of this procedure. To obtain the best outcome of double free-muscle transfer, it is imperative to understand the key factors, viz. selection of the donor muscle, meticulous microsurgical technique, importance of proximal joint stability, selection of the kind of grip and postoperative rehabilitation. Double free-muscle transfer is not a simple microsurgical muscle transfer for finger movement, but a universal reconstructive procedure for total paralysis of the upper limb.

Joseph Swan was born in 1791 and appointed surgeon to Lincoln County Hospital in 1814. In addition to his clinical work, he carried out what were probably the first animal experiments on nerve injuries. These were mostly on rabbits, in which the sciatic nerves were partly or wholly divided, had a section excised, or were ligated. He found that regeneration could occur, even after neurectomy. He reported these results, together with his experience in human patients and the effects of neurectomy in a horse, in an essay of 1819, which won the Jacksonian Prize of the Royal College of Surgeons of England and is still preserved there. In 1827 he moved to London, where he devoted himself mainly to dissections of the nervous system and was active in the College. He retired to Filey in Yorkshire, where he died in 1874.

A prospective study was performed in 19 patients with trigger thumbs to define the anatomy of the A1 pulley of the thumb in this condition and to evaluate biomechanical parameters of the thumb after complete division of the A1 pulley. Pre- and postoperatively, flexion of the interphalangeal and metacarpophalangeal joints, key pinch strength and tip pinch strength were measured and compared with these measurements on the contralateral thumb. We identified three types of A1 pulley. The clinical data showed that there is no deficit with respect to motion and strength of the thumb after completely sectioning any of the three types of A1 pulley.

This study was undertaken to evaluate tourniquet tolerance in healthy people. An arm tourniquet was inflated to 100 mmHg above systolic blood pressure for 21 minutes. We measured pain and grip strength before, during and at various times after deflation. We tested 40 subjects (20 women and 20 men) with an average age of 38 (range 22–58) years. Eight individuals did not tolerate the tourniquet for this length of time and the test was stopped. Visual analogical scale had a globally linear increase during tourniquet application. We noted a sensation of well-being just after deflation, quickly replaced by pain in the tested limb due to limb reperfusion. We also noted a significant loss of strength in the tested limb, which completely recovered by 48 hours. We also observed a significant loss of strength in the contralateral hand, which also recovered by 48 hours. The possible reasons for these temporary losses of strength in both the ipsilateral and contralateral limbs are discussed.

Although Dupuytren’s disease of the thumb was first described in 1833, the literature on this subject is limited to a few anatomical and clinical studies. This study examined the pattern of cords of Dupuytren’s disease in 260 thumbs in 181 consecutive patients with evidence of disease relating to the thumb attending an out-patient clinic over a period of 36 months. Discrepancies in the literature are discussed in the light of the findings of this more detailed analysis and a simple but practical pictorial system for recording disease severity and detailing progression over time is presented.

This retrospective study aimed to evaluate the factors that influence the final outcome of treatment of purulent flexor tenosynovitis, viz. delay in treatment, severity of the condition, the infecting pathogen and the method of treatment. Of 41 patients with this condition treated by drainage and irrigation through two small incisions (16) and wide incision (25), 16 were treated after a delay. Continuous postoperative irrigation was applied in 26 patients. Re-operation was necessary in 11 patients. In most cases, Staphylococcus aureus was detected. The results were excellent in 32 cases and the mean Disabilities of the Arm, Shoulder and Hand score was 8.1. Irrigation through small incisions and continuous postoperative irrigation decreased the probability of an unfavourable outcome. Delayed treatment and infections with specific pathogens led to a worse outcome. Early diagnosis of purulent flexor tenosynovitis followed by drainage through small incisions and continuous postoperative irrigation appear, from this retrospective review, to lead to the best functional outcome.

A finite-element analysis model of the lunate was established using geometrical data obtained from cadaveric bones. The lunate cortex was modelled with triangular and quadrilateral elements and its intraosseous structure was represented either as a homogenous elastic structure or as an anisotropic network of cortical bone beams (trabeculae) with different orientations and thicknesses. Compressive loads applied to the metacarpus were distributed in the carpus against the fixed radius and ulna. The ulnar variance had a strong influence on the ratios radiolunate/ulnolunate total load and peak pressures. The distribution of internal stresses was markedly affected by the lunate uncovering index. The evolution of a simulated incomplete fracture was dramatically influenced by morphological parameters: with positive ulnar variance, the fracture did not progress, but in the presence of three associated conditions, negative ulnar variance, a high lunate uncovering index and angulated trabeculae, the fracture progressed and the proximal part of the lunate collapsed. This study supports the concept that some lunates are predisposed to Kienböck’s disease because their anatomy induces abnormal internal stresses, which allow an incomplete fracture to progress, under heavy loading conditions, and cause progressive collapse and localised trabecular osteonecrosis.

The association of trapeziectomy with ligamentoplasty is a simple treatment for osteoarthritis at the base of the thumb. Here we present the long-term results of a technique that creates a “hammock” under the first metacarpal bone using the Abductor Pollicis Longus tendon. This paper reports the results of treatment by this operation of 60 thumbs in 50 patients, including 13 men and 37 women of average age 60 (46–75) years. Thirty thumbs presented with severe pain and 30 with moderate pain. At final follow-up, 47 thumbs (78%) had experienced dramatic relief of pain following the procedure, 12 (20%) thumbs still had mild pain and one (2%) thumb had severe pain. No patients needed revision.

Twenty-five cases of crush injury to the hand resulting in the triad of multiple finger metacarpal fractures/dislocations of the fingers, a balloon hand appearance due to severe swelling and clinical evidence of acute median nerve dysfunction were retrospectively reviewed. All were men with a mean age of 33 (range 20–45) years. All injuries occurred following industrial or major car accidents. The fracture site included metacarpal head/neck fractures, metacarpal shaft fractures and carpometacarpal joint fracture–dislocations. All patients underwent fasciotomies, open carpal tunnel release and fixation of displaced fractures, followed by immediate mobilisation of the fingers. At a mean final follow-up of 7 (range 6–8) months, full recovery of median nerve function was seen in all patients. The final mean total active motion of the fingers was 243°, 230° and 250° in displaced distal, middle and proximal impact fractures, respectively. All patients were able to return back to work.

Twenty-two patients underwent surgery for 23 complex articular fractures of the distal radius of C.3 type, according to the AO classification. The surgical treatment consisted, in all cases, of a closed, or limited-open, reduction and external fixation. The functional and radiographic results were analysed at a mean follow-up of 40 months. This retrospective study confirms that satisfactory functional results where obtained in 12 out of the 15 wrists where all the intra and extra-articular parameters of the Fernandez’ criteria where respected. For those wrists where keeping with Fernandez’ criteria for intra-articular parameters and ulnar variance was not possible, four of eight had satisfactory results. As far as the acceptability criteria for radial inclination and dorsal tilt are concerned, the functional results seem to suggest that a little wider tolerance than proposed in the literature could be accepted.

This paper reports an isolated dorsal fracture–dislocation of the scaphoid at its waist with the proximal fragment dislocated dorsally. Such a fracture–dislocation is extremely rare. We believe the pathomechanics of this injury to have been a flexion and radial deviation with an axial force on the wrist.

This paper presents the medium-term follow-up results (34 and 40 months, respectively) of two cases of recurrent giant cell tumour of the head of the second metacarpal, treated by marginal excision and reconstruction with a vascularised toe joint transfer. Both patients had painless, stable joints with excellent ranges of motion at the metacarpophalangeal joint of 80° and 70°, respectively, no degenerative changes and no recurrence of the tumours.

This case report documents the first use of bone morphogenetic protein (BMP) as an adjuvant to revascularisation with a first dorsal metacarpal arterio-venous pedicle in the treatment of a patient with Stage III Kienbock’s disease. The patient had complete relief of her symptoms of wrist pain by 8 months postoperatively, when X-rays showed no further evidence of lunate collapse and an MRI scan demonstrated islands of revascularisation. It is impossible to prove unequivocably that BMP contributed to the result seen in this one patient, but this adjuvant concept is based on experimental evidence demonstrating that optimal bioengineering of vascularised bone is dependent on four factors – a structural matrix, progenitor cells, BMP and a vascular supply, and BMP may play a future role in promoting new bone formation in Kienbock’s disease.

In this prospective study, the plain X-rays and MRI scans of 60 patients with intraarticular distal radius fractures were examined in random order. MRI evaluation revealed that 27 of the 60 patients (45%) had triangular fibrocartilage lesions. No correlation was found between triangular fibrocartilage injury and the Melone classification system, the presence of an ulnar styloid fracture, comminution of the articular surface of the distal radius, >20° dorsal angulation of the distal radius or subluxation/dislocation of the distal radioulnar joint on the plain X-rays. When Frykman Type VI and VIII fractures were compared with all the other Frykman subtypes, a significant difference in the incidence of triangular fibrocartilage complex tears was observed. We conclude that triangular fibrocartilage injury should be considered with all distal radial fractures, especially the Frykman Types VI and VIII.

The purpose of this study was to determine whether a measurable decrease in isokinetic (dynamic) and isometric (static) hand strengths occurs in carpal tunnel syndrome (CTS) patients. Eighteen CTS patients and 20 healthy controls were included in the study. Isokinetic (eccentric and concentric) and isometric grip and pinch strengths were measured with a Biodex System 3 dynamometer (Biodex Medical System, Inc. New York). All strength measurements, except isometric and isokinetic (concentric/eccentric) three-point pinch and isokinetic (concentric) tip pinch, revealed statistically significant differences between CTS patients and controls. Measurable decrease in hand strengths may exist in CTS despite normal manual assessments. Although both isokinetic (dynamic) and isometric (static) dynamometers are capable of detecting this decrease, neither technique seems better than the other.

This randomised trial compared the results of carpal tunnel decompression using the TM Indiana Tome (Biomet, Warsaw, Indiana, USA) and a standard limited palmar open incision. Two hundred patients were randomly selected to have a carpal tunnel decompression with either the Indiana Tome or a limited palmar technique. They were assessed clinically for 3 months and using the Levine–Katz self-assessment evaluation for 7 years. After 7 years, there were 62 returned questionnaires from the open group and 53 from the Tome group. There were no significant differences in functional scores, pain, scar tenderness, pinch and grip strength at 3 months. There were two complications in the open group and nine in the Tome group, including one median nerve injury. There was both a higher rate of immediate complications, and more recurrences and persisting symptoms at 7 years in the Indiana Tome group.

The effectiveness of a collagen mesothelial tube for nerve bridging was investigated in an experimental model of repair of rat sciatic nerves. The right sciatic nerve was cut, the two stumps were reflected and a collagen mesothelial tube was placed in the gap. The rod was removed at 4 weeks after implantation. At this point, the “bridging” was performed with a 10-mm gap (Group M). Two control groups were similarly treated but one with a collagen tube (Group C) and the other with a silicone tube (Group S). Regeneration of the sciatic nerves was assessed using a sciatic function index, by measuring blood flow and by the number of regenerated axons at 4, 8 and 12 weeks after bridging. Group M showed significantly better results with respect to all three assessments. The collagen mesothelial tube used in our study appears to be a promising tool for bridging peripheral nerve defects.

Distal arterial occlusion in the hand threatens the viability of the digits and is difficult to treat. This study reports two cases in which fibrinolytic agents were used successfully to restore circulation in the digital arteries.

We present the outcome of treatment of eight chronic neglected dorsal fracture dislocations of the proximal interphalangeal joint treated with a single-stage ligamentous distraction using the Penning mini-external fixator and a closed reduction. The distraction correction and 2 to 3 mm over distraction was performed acutely at the time of operation in all eight cases at an average injury-to-surgery time of 6 weeks. Satisfactory results with an average range of motion of 79° were obtained at an average follow-up of 20 months. This technique is simple, effective and offers the advantage of being minimally invasive. We recommend this single-stage distraction correction technique for the treatment of chronic neglected dorsal dislocations of the proximal interphalangeal joint, which are no more than 10 weeks-old.

Many scaphoid fractures can be treated with percutaneous screw insertion, but fracture displacement usually necessitates open reduction. Two surgeons treated 20 consecutive patients with displaced fractures of the scaphoid using arthroscopic-assisted percutaneous screw fixation. Thirteen patients had dorsal (antegrade) and seven had palmar (retrograde) percutaneous screw insertion. At an average follow-up of 18 (range 6–48) months, all of the fractures were healed and there were no implant problems. The early results of arthroscopic-assisted percutaneous screw fixation of displaced fractures of the scaphoid suggest that union can be obtained and good to excellent function achieved predictably without the need for open exposure. Avoidance of an open exposure limits wrist ligament injury and may preserve blood supply. Further evaluation of this procedure is merited.

The aim of this study was to assess whether autonomic dysfunction associated with carpal tunnel syndrome (CTS) can be assessed quantitatively with a (modified) biro test of finger sweating. Twenty-six hands of 16 patients with CTS were compared with 30 hands of 15 normal subjects. A device was constructed to measure the angle from the horizontal at which a biro slips from the finger (the critical angle). In the control subjects, no significant difference was found in the critical angle between the little and index fingers in either hand. By comparison, in subjects with CTS, the critical angle was significantly lower in the index finger than in the little finger, the mean difference being 8.65°, indicating a quantifiable and significant difference of sweating of the median nerve-innervated index finger.

The final outcome of severe hand injuries is not solely determined by the residual functional impairment, but is also a function of non-functional criteria, including the sequelae of the accompanying psychological trauma. This paper reviews the literature with respect to the psychological impact of severe hand injuries, including the special impact of amputations, adaptation processes, adaptation stages, prognostic criteria and aesthetic issues influencing the final individual outcome, including present recommendations for promoting a positive outcome. Motivated and psychologically stable people are reported to do well irrespective of the severity of a hand injury. In patients who find it difficult to cope mentally, successful treatment strategies have been proposed. Their implementation is in a constant state of evolution and includes not only improved surgical techniques and advanced pharmacological pain management but also early psychotherapeutic input and involvement of patients in decision making for treatment.

In this study, the insertion time and histological effects of drilling and hammering K-wires into bone are described. The insertion time was measured while drilling or hammering K-wires into the femurs and tibias of ten rabbits. Four K-wires, inserted into one hind limb, were used for histological examination directly after insertion and four K-wires inserted into the contralateral hind limb were used for the same measurements 4 weeks later. The specimens were scored for presence, or absence, of osteocytes, fragmentation of the bone edges, haemorrhage, microfractures, cortical reaction and callus formation around the pin track. The insertion time needed for drilling in K-wires was significantly longer than that of hammering. Drilling also resulted in the disappearance of the osteocytes in almost all sections while hammering did not have this effect but did result in more microfractures. Hammering K-wires may be a superior technique because it prevents osteonecrosis and requires a shorter insertion time.

Sixteen observers measured eight anatomical parameters on digitalised images of six acute distal radial fractures using the Patient Archiving Communication System software and repeated the measurements at least 2 weeks later. Inter- and intraobserver reliability was calculated using intraclass correlation coefficients and tolerance limits. The highest interobserver agreement was demonstrated in the dorsal tilt (intraclass correlation coefficient 0.858; tolerance limit 14.2°). When compared with the results of a study looking at observer reliability in measurement of healed distal radial fractures, the reliability of computerised measurements is not significantly different from those achieved by manual techniques (dorsal tilt interobserver tolerance limits on computer system 16°, compared to 15° using ruler and protractor). These results suggest that the recommended radiological reduction limits for distal radius fractures of <10° change in palmar tilt, <2 mm radial shortening, <5° change in radial angle and a <1 to 2 mm articular step cannot be reliably measured.

Finger ring avulsion injuries can be functionally, cosmetically and emotionally devastating for the patient. This cadaveric study assessed a simple way to prevent ring avulsion injuries. Fresh cadaver fingers were used to test the incidence of avulsion injury with ordinary rings and when a single slot was cut in the ring. Intact rings mostly produced significant digital injuries, while the rings with slots did not.

This paper presents a rare case of trans-scaphoid, transcapitate, transtriquetral, perilunate fracture–dislocation of the right wrist as a result of a motorcycle accident. Open reduction and internal fixation of the scaphoid and capitate with one screw was performed and the lunotriquetral ligament was repaired using a suture anchor.

In order to perform motion-preserving procedures for wrist arthritis rather than total joint fusion, it is important to determine the integrity of specific areas of wrist cartilage. This is generally performed using a wrist arthroscope and by directly visualising the cartilage. Twenty patients with wrist pain were investigated over a 1-year period with both MRI and wrist arthroscopy. Kappa analysis was used to compare the two methods of cartilage assessment. There is only a fair correlation (K = 0.38) between the two methods. With only a fair correlation between arthroscopy and MRI, it cannot be concluded that the two methods are equivalent for assessing wrist cartilage and, as such, wrist arthroscopy still has an important role to play in the assessment of a painful degenerative wrist.