Journal of Hand Surgery (European Volume)

Clunking of the wrist is often the result of a combined radiocarpal and midcarpal ligament insufficiency, coupled with inadequate neuromuscular coordination. When symptomatic, these wrists may benefit from splinting, isometric exercising of specific muscles and advice on activity modification. Failing this, different surgical strategies have been proposed, depending on the location of dysfunction. When the clunking derives from an isolated injury of one joint, reconstruction of its inadequate ligaments may be an effective solution. However, soft tissue procedures tend to fail when clunking results from multilevel instability. In these cases, partial carpal arthrodesis is an alternative. Although effective in eliminating the clunking, midcarpal fusion is associated with alteration of the so-called “dart-throwing” motion, the most common rotation in daily activities, and hence is not recommended. Radiolunate fusion, by contrast, appears to be a less morbid alternative, with the benefit of eliminating the painful clunking while preserving a good range of dart-throwing motion.

Swan neck deformity is a progressive and disabling condition that commonly affects rheumatoid arthritic hands. During a 4-year period, 101 fingers in 43 patients had this deformity corrected using a new procedure combining the distally based extensor lateral band technique described by Littler and the flexor digitorum superficialis (FDS)-palmar plate pulley introduced by Zancolli. The ranges of motion of the metacarpophalangeal, proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints were assessed pre-operatively and 12 months after surgery. An average PIP joint hyperextension of −13.3° was converted to +13.4°. The ranges of motion of the proximal and DIP joints were significantly different (Student’s t-test). No patient suffered recurrence of the deformity during an average follow-up of 20 months. This new technique improves some unappealing aspects of previous techniques and provides a stable and reliable correction of swan neck deformity.

This paper reports our experience with temporary ectopic digital implantation. Four patients suffered 12 digital amputations with large defect over the proximal stumps. Only 8 digits were suitable for microsurgical salvage but the local conditions made direct replantation impossible. In our first patient, the two digits were ectopically implanted onto the foot, while in the second patient the four amputated digits were implanted onto the opposite forearm. After stump reconstruction, the digits were microsurgically transferred to the hand, restoring a functional pinch. One digit suffered a venous congestion and necrosis in the ectopic site caused by a haematoma and another experienced a no-reflow phenomenon. In conclusion, temporary ectopic implantation remains a procedure that can be used to salvage amputated digits.

Conservative management of spiral/long oblique fractures of the shaft of the metacarpal almost always results in shortening and hence these fractures have the reputation of ending up with an extension lag and reduced grip strength. In a prospective study, 42 patients with 54 fractures were treated with a palmar wrist splint and immediate mobilisation of all finger joints. All fractures united. Extension lag of fractured fingers was initially seen in all fingers, but eventually recovered. Grip strength progressively increased to reach a mean of 94% of the contralateral hand by 1 year after injury.

A literature review of metacarpal fracture fixation techniques revealed that the use of a combination of interosseous and cerclage dental loop wires has not been previously described. In this report, we review the results of 24 patients with long oblique/spiral metacarpal shaft fractures of the fingers treated by this combined technique of internal fixation, followed by immediate postoperative finger mobilisation in a wrist splint.

The study included 20 men and four women with a mean age of 32 (range 20–48) years. After a mean follow-up of 10 weeks, 23 patients had regained full range of motion of the fingers. Complications included one case of CRPS Type 1 resulting in mild stiffness and all four women complained of the hyperpigmentation of the dorsal hand scars. The advantages of dental wire fixation were discussed and compared to those of lag screws.

The outcomes of 218 little finger metacarpal shaft and neck fractures that had been treated non-operatively, with no attempt at fracture reduction, were compared with those of 44 that had been treated operatively with fracture reduction and fixation (plates or K-wires). Outcome measures included the grip strength of the little finger and the DASH score. Fracture malunion was assessed by clinical measurement of little finger ray shortening and measurement of palmar angulation on the initial radiographs. The severity of palmar angular deformity did not affect the outcome of the 105 metacarpal neck or 113 metacarpal shaft fractures that had been treated non-operatively. There were no differences between the outcomes of the 18 metacarpal neck fractures treated operatively and the 105 treated non-operatively. The DASH score (P = 0.001) and aesthetic outcome (P = 0.013) were significantly better for the 113 metacarpal shaft fractures treated non-operatively than for the 26 treated operatively.

Closed multiple metacarpal fractures are uncommon. They are usually associated with significant soft tissue swelling. Early stable fixation and functional rehabilitation optimises outcome. We present a review of 19 patients with 43 metacarpal fractures treated by early open reduction and internal fixation with 2 mm plates. Eighteen patients recovered a full range of motion, while one patient was lost to follow-up. Implant removal on account of extensor irritation was required in only two metacarpals in two patients. Plating of multiple closed metacarpal fractures is a safe, reliable and consistently reproducible treatment method.

The development of digital oedema, adhesion formation, and resistance to digital motion at days 0, 3, 5, 7, 9 and 14 after primary flexor tendon repairs using 102 long toes of 51 Leghorn chickens was studied. Oedema presented as tissue swelling from days 3 to 7, which peaked at day 3. After day 7, oedema was manifest as hardening of subcutaneous tissue. The degree of digital swelling correlated with the resistance to tendon motion between days 3 and 7. At day 9, granulation tissues were observed around the tendon and loose adhesions were observed at day 14. Resistance to digital motion increased significantly from day 0 to day 3, but did not increase between days 3 and 9. The early postoperative changes appear to have three stages: initial (days 0–3, increasing resistance with development of oedema), delayed (days 4–7, higher resistance with continuing oedema) and late (after day 7–9, hardening of subcutaneous tissue with development of adhesions).

This study presents a retrospective evaluation of patients managed with single-stage repair following complex extensor tendon injuries. Over a 2-year period, 21 extensor tendons were reconstructed in 18 patients with complex hand injuries in zones V–VII. All eight patients needed soft tissue cover. Active mobilisation was started in the first week.

Total active motion (TAM) at 4 weeks was a mean of 159° (SD 21.57) and at 6 weeks it was 202.6° (SD 13.26). Average TAM at 8 weeks was 223.8° (SD 16.46) and 249.5° (SD 14.38) at 12 weeks. Grip strength at 12 weeks and 6 months was around 75% and 90% of the contralateral normal hand in most of the patients.

Single-stage reconstruction of complex extensor tendon injuries seems to reduce morbidity in terms of hospitalisation, and reduced cost of treatment. It also helps to achieve better functional outcome in the early postoperative period.

The objective of this study was to measure the “preparation time” that is the speed of information processing in the brain, and discuss the relevance of this parameter in the restoration of hand function following flexor tendon repair. The preparation time of 48 healthy adult participants was measured twice at a 6-week interval and compared with that of 12 patients after flexor tendon repair. There was no difference between the left and right hands of the healthy participants. The correlation between repeated measurements was high, although healthy participants performed 2.6% faster 6 weeks after the first measurement. After 6 weeks of immobilisation, patients showed a significant deterioration with respect to the speed of information processing by the brain on both the injured and uninjured sides compared with healthy participants, who had improved between the first and the second measurements. The results indicate that a period of lack of normal use of the hand leads to a change in cerebral control of hand movements.

A new test to evaluate the ability of the distal radioulnar joint to sustain transverse loads while the forearm rotates from pronation to supination is described. Both arms were tested in 100 normal volunteers. The average weight-bearing capability of the normal unsupported forearm was 5.07 kg, equating to a force of 49.8 N. The test may be useful in the assessment of pathological conditions involving weakness of the forearm rotator muscles, with or without joint incongruity, as well as being an indirect way to assess the load-bearing capacity of radioulnar implants.

Previously published reports have shown good results after proximal row carpectomy in all cases that had a postoperative immobilisation period from 1 to 4 weeks. Immobilisation is thought to be necessary because of the risk of postoperative subluxation of the carpus and for pain relief. There is, however, no evidence of its value. The results in 13 patients who underwent proximal row carpectomy without postoperative immobilisation were compared with those in 25 patients who underwent proximal row carpectomy with postoperative immobilisation for 4 weeks. After a mean follow-up period of 27 months, no significant differences were found for pain, range of motion or return to work between the two groups. We conclude that postoperative immobilisation is not necessary after proximal row carpectomy.

This study evaluated the effectiveness of a patient-oriented, hand rehabilitation programme compared to a standard programme regarding functional outcomes, return to work, patient satisfaction and costs. Patients were recruited in two consecutive cohorts. One cohort received the standard treatment programme (n = 75) and the other a programme based on principles of patient orientation (n = 75). Data were collected at the beginning and end of rehabilitation and 6 months after discharge. Clinical variables included range of motion, grip and pinch strength. Self-reported measures included pain, upper extremity functioning, health status, satisfaction and job situation. Analysis of variance for repeated measurements was used to calculate the main effects. The patient-oriented group showed more favourable results with respect to DASH scores (P <.05), pain (P <.001) and patient satisfaction (P <.0001). More patients returned to their former jobs and time off sick was reduced. We concluded that the patient-oriented approach was more effective and cost-saving.

The treatment of severe Dupuytren’s disease of the little finger is controversial: several techniques have been described with variable reported results and postoperative complications. This paper reviews 98 cases that underwent surgery between 2001 and 2006 using the Jacobsen flap procedure, a modification of the McCash technique. We found this technique relatively simple and it allowed significant correction of the contracture, with a low rate of complication. We believe this is an excellent alternative to dermofasciectomy or amputation.

Dupuytren’s disease is characterised by nodular fibroblastic proliferation of the palmar fascia leading to contracture of the hand. Transforming growth factor beta (TGF-β) is thought to play a role in its pathogenesis. We performed a cDNA microarray analysis of Dupuytren’s diseased cord tissue with an emphasis on TGF-β isoforms. Normal-appearing transverse ligament of the palmar fascia from adjacent to the diseased cord and palmar fascia from patients undergoing carpal tunnel release were used as controls. TGF-β gene expression was confirmed by quantitative real-time polymerase chain reaction. Over 20 unique genes were found to be significantly up-regulated, including several previously reported genes. A dominant increase in TGF-β2 expression was seen in the cord tissue, whereas TGF-β1 and TGF-β3 were found not to be significantly up-regulated. Quantitative real-time polymerase chain reaction confirmed these findings. This gene expression profile allows for further experiments that may eventually lead to gene therapy to block the development and progression of Dupuytren’s disease clinically.

Percutaneous screw fixation of undisplaced fractures of the scaphoid waist has gained popularity but remains technically demanding. This study describes a transtrapezial modification of the volar percutaneous technique and reports the results in 41 patients. The patients were evaluated at a mean of 36 months (range 14–68 months) after surgery. All fractures healed within 10 weeks (mean 6.4 weeks). Functional ranges of wrist motion and grip strength were achieved in all patients. Radiographs showed accurate central placement of the screw in all patients and no degenerative changes were seen at the scaphotrapezial joint. In three patients, the screw was removed because it was prominent at the scaphotrapezial joint.

This paper presents a longitudinal study of the effect of ageing on ulnar variance. Between 1976 and 1985, ulnar variance in 1000 normal adult subjects was measured using the Palmer method. In 1995 to 2002, 17 to 22 years later, the ulnar variance was measured again in 864 of them. They were stratified into three age groups: Group I consisted of 351 subjects of young age (20–39 year-old), Group II of 318 subjects of middle age (40–59 year-old) and group III of 195 subjects of old age (60 year-old or older). The means of the initial and the final ulnar variance of the whole series and the three groups were compared by the paired Student’s t-test. There were no significant differences between the initial and final ulnar variances in all three age groups and in the whole series. In normal subjects without diseases or injuries affecting the wrist, ageing does not affect the ulnar variance.

A case of severe degloving injury to the left hand with complete destruction of the extensor apparatus of the thumb and exposure of the IP joint is presented. The damaged area was resurfaced with the use of the Integra® template and the abductor pollicis longus tendon, lengthened with a tendon graft provided by the extensor indicis, and used to restore thumb extension. The transfer was performed through a prefabricated sheath under the Integra® resurfaced area in a two-staged procedure. The final result was functional and aesthetically satisfying.

We report a case of giant cell tumour (GCT) of the hamate treated by acrylic cementation. It has not recurred 3 years after surgery, and no functional impairment has been observed. We have reviewed previously reported cases of GCTs in the hamate and discuss the best management to prevent recurrence while maintaining function.

We report a case of scaphotrapezial arthritis that developed in a patient with Marfan’s syndrome many years after a carpometacarpal fusion, which placed the thumb metacarpal in adduction. This problem was effectively treated with an abduction/opposition osteotomy, which both increased the patient’s first web space and improved her arthritic symptoms.