We present 20 patients, who had a four corner arthrodesis, from July 2006 to March 2008, using a dorsal circular plate, to treat scaphoid nonunion and scapholunate dissociation with advanced collapse (SNAC, SLAC). The surgical technique was a fusion restricted to the central area filled with one piece of cancellous bone graft taken from the excised scaphoid. Wrist motion, grip strength, and Disabilities of Arm Shoulder and Hand (DASH) score improved after surgery at a mean follow-up of 20.2 months. Fusion occurred in 19/20 patients. Two patients (10%) had persistent pain. The rest had a good clinical result. We found that four-corner fusion using a dorsal circular plate using the specific technical modifications was successful.

The aim of this study was to obtain a better understanding of the cause of the medial rotation contracture of the shoulder after obstetric brachial plexus lesions by studying the morphology of the shortened subscapularis muscle. Muscle biopsy specimens were harvested from 13 children with obstetric brachial plexus palsy who underwent corrective surgery for the rotation contracture. The majority of the subscapularis muscle biopsy samples had an essentially normal morphology and showed a predominance of type I myosin heavy chain isoform, while one biopsy showed signs of marked fibrosis and a predominance of type II myosin heavy chain isoform. The findings support the assumption that shortening of the subscapularis is caused primarily by the nerve injury, which weakens the antagonistic lateral rotators, but that direct injury to the muscle might be a contributory factor.

Nineteen patients with longstanding and permanent brachial plexus injuries underwent a three-staged surgical reconstruction. First, a sural nerve was grafted from the contralateral intact medial pectoral nerve to the paralyzed arm. One year later, a free gracilis muscle was transferred and neurotized by the grafted sural nerve. This procedure results in reanimation of elbow flexion. Finally, the biceps tendon was transferred to the finger flexors using a fascia bundle of tensor fascia lata muscle. Two of the gracilis muscle free transfers failed. In the remaining 17 patients, the overall result was evaluated as satisfactory in 11 patients and good in 6.

The technique of two simultaneous pedicled flaps to a single extremity has recently proven useful in the care of war-injured military personnel. We present two cases of combat-injured Marines who underwent upper extremity reconstruction using simultaneous pedicled flaps. These cases illustrate a simple and successful alternative to free tissue transfer in providing coverage to complex soft tissue defects of the hand and forearm. Good outcomes were obtained in circumstances where free tissue transfer was not indicated.

With C7-T1 brachial plexus injuries, finger motion is absent while shoulder, elbow and wrist function are largely preserved. Previously, we have reconstructed finger flexion by transferring the brachialis muscle to the flexor digitorum profundus and flexor pollicis longus; and we have restored extension of thumb and finger by transferring the motor nerve to the supinator to the posterior interosseous nerve, which is only feasible in fresh injuries. We describe the transfer of the supinator muscle to the extensor pollicis brevis to reanimate thumb extension in patients with long standing C7-T1 brachial plexus palsy.

Enchondromas are common in the hand but less frequent in the distal phalanges. Epidermal cysts are rare in the hand but when they occur can be difficult to differentiate from enchondromas both clinically and radiologically. Our review of seven distal phalangeal bone lesions treated over 7 years included four enchondromas and three epidermal cysts. The patients with epidermal cysts all had a history of previous penetrating trauma 5–8 years earlier. One patient with an enchondroma had a history of a penetrating injury. Patients presenting with distal phalangeal lesions and a history of previous penetrating injury appear more likely to have an epidermal cyst than an enchondroma. This is important as there may be a higher recurrence rate following curettage and bone grafting.

Displacement of the neurovascular bundle within a digit affected by Dupuytren’s disease can occur when disease superficial to the neurovascular bundle is connected to disease deep to it. Contraction of such cords results in spiralling of the neurovascular bundle, classically when a pretendinous cord connects with the lateral digital sheet and Grayson’s ligament via the oblique cord, but also in association with an isolated digital cord. We describe six cases in which cord formation and contraction resulted in a distal spiral, which may occur in isolation or in combination with a classical proximal spiral, creating a double spiral or corkscrew neurovascular bundle.

We compared the biomechanical strength of the 2.5 mm PushLock suture anchor with a traditional Bio-SutureTak suture anchor in repair of ulnar collateral ligament injuries. Iatrogenic ulnar collateral ligament injuries in 18 cadaveric thumbs were repaired and used to test for load to failure and cyclic loading. The average force required to generate a 2 mm gap was 7.7 N for the 2.5 mm PushLock and 6.3 N for the Bio-SutureTak (p = 0.04). The ultimate load to failure was 28.0 N for the 2.5 mm PushLock and 18.8 N for the Bio-SutureTak (p = 0.16). There were no statistical differences between the two suture anchors under cyclic loading. The 2.5 mm PushLock suture anchor provides significantly stronger resistance to 2 mm gap formation at the repair site and is less likely to fail at the suture–ligament interface. However, there was no difference in the load to failure between the two suture anchors.

We treated a prospective series of 18 patients (nine men and nine women) with a mean age of 35 years (range 15 to 57), with chronic predynamic or dynamic scapholunate instability by a dorsal intercarpal ligament capsulodesis using the modified Mayo technique. All the patients were assessed by the modified Mayo wrist score and DASH questionnaire. Wrist arthroscopy was done in all patients before open surgery in order to grade the scapholunate instability and correlate the findings with the radiographic and MRI results. At an average follow-up of 45 months (range 34 to 60) pain significantly diminished (P < 0.05) with improvement in the grip strength (P < 0.005) in all 18 cases. Wrist motion remained almost the same. The mean Mayo wrist score improved from 62 to 84 (P < 0.005).We recommend dorsal capsulodesis by using the dorsal intercarpal ligament flap for the treatment of scapholunate dissociation, when the ligament is still repairable.

Muscle fibres that cross the proposed line of incision of the flexor retinaculum at carpal tunnel decompression can be a source of confusion, particularly for the less experienced surgeon. We investigated how frequently muscle fibres crossed the line of incision on the palmar surface of the flexor retinaculum at carpal tunnel decompression in 143 hands, and dissected 103 cadaver hands to study the origin and insertion of these muscle fibres. The line of incision was defined as a longitudinal line between thenar and hypothenar eminences along the third web space, with the wrist in neutral radioulnar deviation and the fingers in extension. Muscle fibres crossing the line of incision were absent in 50% of the operated hands, 2–10 mm wide in 39% and more than 10 mm wide in 11%. In the cadaver hands the proportions were similar at 50%, 35% and 15%, respectively. The fibres were extensions of the thenar and hypothenar muscles and did not appear to represent a separate anomalous muscle.

Mechanical tension and contracture are two related facets of tissue biology. This study assessed the effect of ilomastat, a broad-spectrum matrix metalloprotease (MMP) inhibitor, on generation of tension by Dupuytren’s disease fibroblasts. Nodule and cord-derived fibroblasts were isolated from five patients with Dupuytren’s disease; flexor retinaculum acted as the control. A culture force monitor (CFM) provided an in vitro model of tissue organization to assess development of mechanical tension, lattice contraction and spatial remodelling by fibroblasts. Responses to ilomastat were compared to treatment with a control peptide. Nodule and cord-derived fibroblasts exhibited a two-fold increase in tension compared with flexor retinaculum. Ilomastat significantly inhibited development of tension by nodule and cord but not flexor retinaculum derived fibroblasts at 100 µM. These results imply that MMP activity mediates regulation of tensile strength by Dupuytren’s disease fibroblasts and may be an important therapeutic target in patients with Dupuytren’s disease.

Previous descriptions of the pattern of communication between the digital flexor tendon sheaths have been largely based on imaging studies. An anatomic study on 12 cadaveric hands was conducted using water soluble dye and directly observed patterns of communication between the digital flexor tendon sheaths and the radial and ulnar bursae. Four out of twelve specimens (33%) demonstrated a communication between the radial and ulnar bursae. The ulnar bursa communicated with the ring finger flexor sheath in two specimens, and the index finger flexor sheath in two specimens. One hand (8.3%) showed communication between the middle finger tendon sheath and radial bursa and between the index finger flexor tendon sheath and radial bursa. These findings show a considerable level of variation in communicating patterns between the synovial sheaths of the hand and wrist. Clinicians should be aware of the possibility of variations to the classical presentation of spread of infection through the digital flexor sheaths.

Narakas classified babies with obstetric palsy into four groups: upper Erb’s, extended Erb’s, total palsy, and total palsy with a Horner. Over the last 15 years, it was noted at our obstetric palsy clinic that good spontaneous recovery in newborns with extended Erb’s palsy (C5, C6, C7 injury) was more likely if they recovered active wrist extension against gravity before 2 months of age. A hypothesis was made that newborns with extended Erb’s palsy (Narakas Group II) may be subclassified into two groups according to this ‘early recovery of wrist extension.’ In a retrospective study of 581 cases with strict inclusion criteria, the hypothesis was found to be true: patients with extended Erb’s and ‘early recovery of wrist extension’ have significantly higher percentages of good spontaneous recovery of limb function than those with extended Erb’s and ‘no early recovery of wrist extension’ (P < 0.0001 by chi-squared test).

This study assessed the impact of changes made to address the inadequate upper-extremity education through preclinical medical school curriculum reform. After the administration of a new upper-extremity curriculum, which also increased the time devoted to three preclinical medical school courses from 7.25 to 21.25 hours, second-year medical students were evaluated for mastery of these concepts through a national validated objective examination, and attitude and skill through clinical confidence and subjective surveys. After implementation of the new upper-extremity curriculum, students had significantly greater confidence in their ability to perform a physical examination but not in identifying differential diagnoses of the upper-extremity. Students were more satisfied with the amount of time spent on the musculoskeletal system but their performance in the national examination did not change.

This study details our series of epidermoid cysts in the hand, characterising the incidence, clinical characteristics and recurrence rate after marginal excision. A historical cohort of 101 epidermoid cysts that were excised from a soft tissue or intraosseous location in the hand over a 27 year period were reviewed. The incidence of epidermoid cysts, patient age, sex, occupation, anatomic location, history of trauma, treatment complications and cyst recurrence rate were noted. Key findings of the study were as follows. Epidermoid cysts represented a significant portion of our relatively large series of hand tumours. The majority occurred in male patients, most often involving the soft tissues on the palmar aspect of the hand. Four percent were intraosseous epidermoid cysts. After excision with a marginal tumour margin we found that 11 cysts (11%) recurred.

Claims for negligence are increasing in medical practice. We analysed data provided by the UK NHS Litigation Authority (NHSLA) on all hand and wrist surgery from 1995–2001. The numbers of claims increased from 13 to 40, but the number being successfully defended also increased from 2 to 13 during this period. Claims were most commonly attributed to errors at surgery (56%) or in outpatient clinics (24%). Strikingly the claims are clustered to a few common conditions, particularly the treatment of carpal tunnel syndrome (22%) and wrist fractures (48%). There were no claims related to complex hand surgery. We recommend better training for ‘routine surgery’, better description of distal radius fracture parameters at each clinic visit and better training in emergency departments (ED).

Eighteen out of 18 rheumatoid patients (at one centre of a two-centre 30 patient study previously reported) with a mean age of 56 years, and 72/72 operated joints were randomized to Avanta/Sutter or Swanson MCP prostheses and followed for 5 years. Both ulnar deviation and extension lag were improved already at 6 weeks and remained improved at 5 years. The Avanta prosthesis had a better range of motion (ROM) than the Swanson. Six of nine patients with Avanta/Sutter implants had at least one implant fracture compared to 1/9 patients with the Swanson implant (P = 0.05) but fracture did not change the outcome subjectively. The ROM at 3 months correlated with the occurrence of an implant fracture at 5 years and a greater early ROM may be related to implant fracture. At 5 years patients remained satisfied and the deformities remained corrected.

Eighteen patients who underwent revision non-vascularized bone grafting and internal fixation after failed surgery for scaphoid nonunion were reviewed after a minimum of 8.2 years. Eleven of the nonunions were located in the middle and seven in the proximal third of the scaphoid. The mean interval between injury and the revision procedure was 6 years. Sixteen of the 18 nonunions healed, two after a third attempt. Three patients with healed nonunions and one patient with persistent nonunion required salvage procedures for progressive radiocarpal arthrosis. In the remaining 14 cases, the mean loss of wrist flexion/extension arc compared to the contralateral wrist was 36°. Mean reduction of grip strength and key pinch was 9.3 kg and 0.9 kg respectively. The QuickDASH score was 18 and a visual analogue pain score was 21/100 at follow-up. Wrist degeneration increased in all but one case during the observation period. Thirteen of 16 patients with union and one patient with a persisting nonunion experienced moderate symptoms.

The fatigue strength of three peripheral suture techniques for flexor tendon repair was compared by cyclic loading of repairs in a cotton dental roll tendon model. Thirty pairs of dental roll were sutured using only peripheral sutures with 6-0 polypropylene. An initial cyclic load of 5 N for 500 cycles was applied and increased by 5 N for an additional 500 cycles at each new load until rupture. The fatigue strength of an interlocking cross-stitch suture was 113% greater than a running suture and 36% greater than a standard cross-stitch suture. Interlocking the cross-stitch prevented shortening of the transverse portions under load and appears to be a useful technique for increasing the strength of the peripheral suture.

The purpose of this study was to determine if an association exists between scaphoid–trapezium–trapezoid arthritis and lunate morphology. Plain neutral posteroanterior radiographs were evaluated for 48 patients with STT arthritis and 96 patients from a control group. Lunate type was determined using capitate–triquetrum (C-T) distance. A type I lunate was defined as a C-T distance ≤2 mm. A type II lunate was defined as a C-T distance ≥4 mm. Lunate type was recorded and compared between those with STT arthritis and a control group. The groups were similar with regard to age, gender and handedness. Type II lunates were found in 83% of cases with STT arthritis and in 64% of controls. STT OA was associated with type II lunate wrists (P = 0.02; OR = 0.35; CI: 0.15–0.82). We postulate that variations in scaphoid motion secondary to lunate morphology may contribute to the development of STT OA.

We investigated the biomechanics of the radiocapitate joint after a proximal row carpectomy in six fresh-frozen cadaver wrists using super-low-pressure-sensitive film on a material testing system. The average pressure within the lunate fossa increased significantly from 23.2 to 136.4 N/cm² with a sharp decrease in the contact area from 2.08 to 0.30 cm² after a proximal row carpectomy. The cartilage of the proximal capitate had four sub-facets and therefore was not as smooth as the normal proximal lunate. We found that the wrist was overloaded after a proximal row carpectomy and the main cause was the anatomical mismatch of the radiocapitate articulation.

This study reviews the results of Surface Replacement Trapeziometacarpal (SR TMC, Avanta®, San Diego, CA) total joint arthroplasty. Fifty patients (62 joints) were included in the study. Forty-three patients (54 joints) were seen at final follow up. Seven patients (eight joints) were interviewed over the phone. Seven patients were revised to trapeziectomy and ligament reconstruction with tendon interposition, five for aseptic loosening and two for dislocation. At final follow up, the mean Quick DASH score was 30.4 and the Sollerman Score was 77.3. Radiological review of the surviving 55 joints showed subsidence of four trapezial components in asymptomatic patients. Cumulative survival rate was 91% at 3 years. Eighty-five percent of the patients were satisfied with the outcome of their treatment.

Ultrasonography can be used in the diagnosis of various neuropathies, including nerve injury. Nerves often involved in traumatic and iatrogenic injury are small cutaneous branches in the hand and wrist, which cannot be seen in detail using current ultrasound probes. This study explored the potential of high-resolution ultrasonography in seeing these nerve branches in the human. The VisualSonics Vevo 770 system with a 15–82.5 MHz probe was compared to a commonly used 5–12 MHz probe and ultrasound machine. The accuracy was validated by ultrasound guided dye injection into cadaver nerves, with subsequent anatomical dissection and verification. Results were confirmed in two healthy volunteers. The Vevo 770 system was able to accurately identify the small cutaneous nerves. It could also depict the median nerve and its fascicles in greater detail. This may be useful for clinical diagnosis, localisation and follow-up of neuropathies and nerve injuries.

Lacerated flexor digitorum profundus (FDP) tendons in zone 1 and distal zone 2 were reconstructed in 73 consecutive cases using the motion-stable Mantero technique during a 7-year period. Sixty-five (89%) of these patients were re-examined an average of 40 (26–82) months postoperatively. According to Moiemen and Elliot (2000) assessment by Strickland's original and modified criteria and in addition the Buck-Gramcko score showed excellent and good results of 54%, 72% and 91% respectively. In contrast, examination of the results measuring the range of movement of the distal interphalangeal (DIP) joint alone provided a more realistic assessment in DIP joint function after Mantero technique with excellent and good results of only 38%.

This study reports our treatment of divided flexor pollicis longus tendons by primary repair from January 2004 to September 2007. Fifty flexor pollicis longus repairs carried out using the Tang technique of three Tsuge sutures are reported in this study. A circumferential suture was not used routinely. Excellent or good results were observed in 78/82% of cases (White/Buck-Gramcko assessments, respectively). No patients ruptured repairs as a result of early active mobilisation. No patients developed postoperative infections with wound and tendon dehiscence. One patient developed Chronic Regional Pain Syndrome Type 1. We have found this repair of the flexor pollicis longus tendon to be safe for early active mobilisation and it is easier to perform than primary repair of this tendon using four strand Kessler-type core sutures and elaborate circumferential sutures, as reported previously.

Hyaloglide® is a hyaluronan-based gel based on a novel auto-crosslinked technology designed to reduce postsurgical adhesions. Its efficacy was assessed in a multicentred randomised controlled trial comparing the results of flexor tenolysis in zone 2 following failed flexor tendon repairs. In the control group a standard release was performed. In the treated group, Hyaloglide® was applied into the flexor sheath and around the site of tenolysis. Forty-five patients, 19 controls and 26 treated with Hyaloglide®, were enrolled in 13 centres. All the patients were evaluated at 30, 60, 90 and 180 days after surgery by testing Total Active Motion, Quick-DASH questionnaire and number of working days lost after surgery. Patients in the Hyaloglide® group had a statistically better recovery of finger motion at all time intervals and returned earlier to work and daily activities. The use of Hyaloglide® did not appear to increase the complication rate.

The aim of this retrospective study was to evaluate the functional results of grip reconstruction after metacarpal amputation with microvascular toe transfer or transfers. The Sollerman hand function test and modified Tamai score were determined. Additionally, secondary objective outcomes were measured. As subjective outcomes, the patients were asked about pain, satisfaction, sensibility and activities of daily living (ADL). Complications and secondary operations were also recorded. An average of 12 years 5 months (range 11–270 months) follow-up of 8 patients (11 transfers) is presented. Sollerman hand function test averaged 54, range 36–73. The modified Tamai score averaged 63, range 54–70. All except one patient were either satisfied or highly satisfied. Patients’ perception of function in terms of ADL was generally good (average 26 out of 44) with many activities causing no difficulty or only slight difficulty. The study showed that it is possible to reconstruct a reasonable grip using microvascular toe transfers.

Cold intolerance is a well-known phenomenon that develops in the first months after hand injury and generally does not decrease over time. In this study, we evaluated the prevalence and severity of cold intolerance after hand fracture in 129 patients using the Cold Intolerance Symptom Severity (CISS) questionnaire. Patients with nerve and/or vascular injuries were excluded. The response rate was 59%. The mean CISS score was 23. Pathological cold intolerance, defined as a CISS score over 30, was experienced by 38% of the patients. Cold intolerance is common after hand fractures and can be severely disabling in some patients.

We performed a retrospective clinical and radiological case control study on 22 rheumatoid wrists following radiolunate fusion via Shapiro staples with a mean follow-up of 5 years. Radiographs showed one early loosening through dorsal staple migration and four nonunions. Six wrists fused in mild ulnopalmar dislocation of the lunate. Primary intra-articular positioning of a staple was found in nine wrists, secondary intra-articular staple dislocation was found in two wrists. Dorsal staple dislocation was found in four fused arthrodeses. Osteolysis around the staples was found in all but two wrists. In contrast to unsatisfactory radiological results the clinical results were good or excellent in 18 patients. Good and excellent clinical results in the majority of the patients following radiolunate fusion does not depend on the fixation device. Nevertheless staple fixation of the radiolunate joint in the rheumatoid wrist is associated with a high rate of radiological complications.

The purpose of this study was to investigate the incidence and characteristics of trigger digits in patients with diabetes. A questionnaire about trigger digit was completed by 544 patients with diabetes. Ten percent of the patients had a history of trigger digits and 4% had multiple digit involvement. The risk was significantly higher in insulin-dependent patients. The average duration of diabetes was significantly longer in the multiple digit group. Independently, the medical records of 132 trigger digit patients who underwent surgery were reviewed. Twenty-seven patients had diabetes, and 62 patients had multiple digit involvement. Involvement of more than three digits was significantly related to co-existing diabetes. In patients with diabetes, the incidence of trigger digits was about four times higher than in the general population. Screening for diabetes may be warranted in patients with involvement of more than three digits.

This retrospective study investigates the radiological and the functional results as well as complications following locking palmar plating on the distal radius. Eighty-nine adult patients with a dorsally displaced distal radius fracture were treated using a locking palmar plate at our clinic over a period of 25 months. The radiological and functional results as well as the DASH score were recorded for 77 out of 89 patients in the routine final examinations conducted on average 12 months later. The radiological examinations showed a relevant shortening of the radius among five patients. A dorsal angulation of more than 20° as well as a radial inclination of less than 10° was observed in 11 patients. Most of the patients showed good to excellent functional and radiological results as well as good results on the DASH score. A3 fractures in elderly patients and the majority of C1 and C2 fractures can be safely treated with locking palmar plating.

We evaluated the clinical outcome of tendon reconstruction using tendon graft or tendon transfer and the parameters related to clinical outcome in 51 wrists of 46 patients with rheumatoid arthritis with finger extensor tendon ruptures. At a mean follow-up of 5.6 years, the mean metacarpophalangeal (MP) joint extension lag was 8° (range, 0–45) and the mean visual analogue satisfaction scale was 74 (range, 10–100). Clinical outcome did not differ significantly between tendon grafting and tendon transfer. The MP joint extension lag correlated with the patient’s satisfaction score, but the pulp-to-palm distance did not correlate with patient satisfaction. We conclude that both tendon grafting and tendon transfer are reliable reconstruction methods for ruptured finger extensor tendons in rheumatoid hands.

In this study, the effects of periosteal autograft and human amniotic membrane on tendon healing were compared. Forty-two New Zealand rabbits were divided into three groups. Flexor digitorum fibularis tendons were cut and repaired with a modified Kessler technique and circumferential sutures in all groups. Tendon repair alone was carried out in group 1, tendon repair and application of human amniotic membrane was done in group 2 and tendon repair and application of periosteal autograft was done in group 3. Biomechanical and histopathological examinations were done 2 and 6 weeks postoperatively. Biomechanical examination showed that group 3 was the strongest at weeks 2 and 6. Adhesion, inflammation and new bone formation showed no difference between groups at week 2. However, adhesion formation was found to be less in groups 2 and 3 than group 1 at week 6. The application of periosteal autograft might be useful in repair of tendon injuries.

Documented experience of treatment of digital nerve lesions with the termino-lateral (end-to-side) nerve suture is limited. Our clinical experience of this technique is detailed here alongside a systematic review of the previous literature. We performed, from 2002 to 2008, seven termino-lateral sutures with epineural window opening for digital nerve lesions. Functional outcome was analysed using the two-point discrimination test and the Semmes–Weinstein monofilament test. The results showed a sensory recovery of S3+ in six cases and S3 in one case. The mean distance found in the two-point discrimination test was 12.7 mm (range 8–18 mm). After a review of the literature, we were able to obtain homogeneous data from 17 additional patients operated by termino-lateral coaptation. The overall number of cases included in our review was 24. A sensory recovery was observed in 23 out of 24 patients. The functional results were S0 in one case, S3 in one case, S3+ in twenty cases and S4 in two cases. Excluding the one unfavourable case, the mean distance in the two-point discrimination test was 9.7 mm (range 3–18 mm). It can thus be concluded that the treatment of digital nerve lesions with termino-lateral suture showed encouraging results. Based on the results obtained in this current study we believe that in case of loss of substance, end-to-side nerve coaptation may be an alternative to biological and synthetic tubulisation when a digital nerve reconstruction by means of nerve autograft is declined by the patient.

Eighteen finger pulp defects were reconstructed using a homodigital dorsal middle phalangeal neurovascular island flap procedure based on a single neurovascular pedicle preserving the length of the finger. All flaps survived and achieved adequate functional and cosmetic results. The mean follow-up time was 22 months. The mean value of static two-point discrimination test of the healed flaps was 7 mm and the mean value of moving two-point discrimination test was 5 mm. Range of motion was considered satisfactory in all reconstructed fingers except one, in which a 20° extension deficit at the proximal interphalangeal joint was observed. This flap represents a useful alternative for reconstruction of the fingers with large pulp defects.

The wrist joint is loaded not only while applying a proximally directed load but also, less obviously, while carrying a handbag. Ulnar shortening reduces pressure and relieves pain in the ulnocarpal joint. The present study evaluated the pressure distribution in the wrist joints with ulnar shortening and lengthening when applying traction to the flexed fingers while the fingers were loaded and unloaded. The compressive forces in the loaded wrist were distributed with 67% across the radiocarpal joint and 33% across the ulnocarpal joint. Shortening the ulna by 3 mm increased load in the radius to 80%. Lengthening of the ulna by 1 mm increased its load to 55%. The load share of the distal radioulnar joint was constant even when the ulna was shortened 3–4 mm. It seems advisable to shorten the ulna by 3 mm, since the increased load in the related joints are constant within a range of -2 to -4 mm.

Thirty-five unstable dorsally displaced fractures of the distal radius in 34 patients (mean age 39) were studied; 28 fractures were intra-articular. All fractures had open reduction and fixation, through a dorsal approach, with mini-fragment plates placed between the first and second dorsal tendon compartments and deep to the fourth compartment. A congruous reduction of the articular surface was obtained in all cases. Twenty-four patients were available for follow-up (median 38 months). The Modified Mayo wrist score was excellent in 12 cases, good in four, and fair in eight. The median Patient Evaluation Measure score was 23.5. There were no cases of extensor tendon rupture. Radiographic assessment at follow-up showed a mean palmar angle of 6°. There was evidence of osteoarthritis in six patients who had had intra-articular fractures. Open reduction and plating gives satisfactory medium term results for treatment of displaced intra-articular fractures of the distal radius in young patients.

The objective of this study was to clarify the effect of repetitive compression on nerve physiology in an experimental rabbit model. We defined 80 mmHg as a compression force which caused temporary disturbance of nerve conduction and blood flow with a brief compression. The following compressions were applied for 30 minutes to rabbit sciatic nerves: continuous compression, low frequency release compression (1 second of release time every 30 seconds) and high frequency release compression (1 second of release time every 10 seconds). Compound nerve action potentials and nerve blood flow were evaluated from the start of compression until 30 minutes after release. Endoneurial microvascular permeability was evaluated with Evans Blue albumin. The repetitive compression groups showed delay in recovery of compound nerve action potentials and blood flow after release, with endoneurial oedema. These findings suggest that repetitive compression may increase the risk of breakdown of the blood nerve barrier.

We carried out a prospective randomised controlled clinical trial to compare the functional and radiological outcomes of casting with percutaneous pinning in treating extra-articular distal radial fracture in an elderly Chinese population. Sixty patients were randomly allocated by sealed envelopes to either a ‘Cast’ group (n = 30) or a ‘K-wire’ group (n = 30). All patients were available for final follow-up assessment. The radiological outcomes in terms of dorsal angulation, radial inclination and radial length were statistically significantly better in the K-wire group, whereas the Mayo wrist score and quality of life, healing rate, healing time, and complications were similar. The functional outcomes and quality of life were not affected by the treatments. Both treatments had a very low rate of complication and high healing rates.

The aetiology of Kienböck's disease is unknown. Ulnar variance and lunate shape are possible mechanical risk factors. This study assessed the trabecular structure in 29 cadaveric lunates using microCT and correlated this with ulnar variance and lunate shape on plain radiographs and with bone density assessed using conventional CT. The bony trabeculae within the lunate were shown to run almost perpendicular to the proximal and distal joint surfaces in the coronal plane; these trabeculae met the subchondral bone at an angle between 72–102°. In lunates whose proximal and distal articular surfaces are not parallel, the trabecular orientation may be less able to resist compressive forces and more susceptible to fracture.

Six cases of young children with thumb polydactyly in which the radial component was complicated by symphalangism are reported. Since the symphalangism was cartilaginous, plain X-rays showed an apparent joint space. However, its continuity was confirmed at surgery. Thumb polydactyly with symphalangism may be more common than previously expected.

The actions of the interossei and lumbricals are many and their loss causes significant impairment of hand function. Many procedures have been described to restore intrinsic function following ulnar nerve palsy. There are many biomechanical issues involved in tendon transfers, including choice of muscle–tendon unit, route, insertion site, tension and drag. The surgeon, therefore, should have a good understanding of biomechanical principles to ensure optimal results. In this article the principles of biomechanics are reviewed with specific reference to tendon transfers for intrinsic reconstruction in ulnar palsy, along with their practical implications.

Seventeen children with Erb's (C5/6 and C5/6/7 types) obstetric brachial plexus palsy who underwent low rotation humeral osteotomy to treat internal rotation contracture of the shoulder were recalled back to the clinic at a mean of 10 (range 8–14) years after surgery. Eight were male and nine female with mean age of 16 (range 13–20) years. The osteotomy procedure was done at a mean age of 6 (range 5–8) years. Preoperative, early postoperative, and late postoperative motor assessments were compared. There was no recurrence of the internal rotation posturing of the shoulder and there was maintenance of the improvements in elbow extension deficit and forearm rotation. The most surprising finding was a significant (P = 0.003) decrease in shoulder abduction on long-term follow-up (the mean shoulder abduction was 135 °, 146° and 109° measured pre-, early post- and late postoperatively, respectively). There was no correlation between changes in shoulder abduction and the radiological score of the shoulder.

Repairs have been performed on porcine flexor tendons and subjected to tensile stress measurements to determine the effects and mechanism of core suture purchase (the length of the suture bite). Eighty-four pig trotter flexor profundus tendons were divided and repaired using four lengths of core suture purchase (1.33, 1, 0.66 and 0.33 cm) using a double modified Kessler repair (four strands, two knots) with a peripheral epitendinous suture. Tendon purchase was achieved by either bilateral equal purchase lengths or with one tendon purchase at a fixed depth of 1 cm. A separate group of tendons were incubated in blood for 24 hours to simulate the wound environment prior to testing. Tensile tests demonstrated a progressive increase of repair strength with purchase length. With the exception of the 0.33 cm group, video analysis demonstrated the mode of failure as suture failure and not due to suture pullout. Therefore, the increase in breaking strength cannot be attributed to a better grip of the tendon ends, but to the mechanical characteristics of the suture polymer. The tendency for the incubated tendons to fail more consistently by pullout rather than suture failure, particularly in the shorter purchase lengths, emphasises the importance of studying tendon purchase in vivo. The significance of ex vivo mechanical testing should be considered with caution.

Dupuytren's disease has a high rate of recurrence after treatment. In this study we have assessed the usefulness of histological staging in the prediction of recurrence. We have also verified whether there is a correlation between histological staging and features of Dupuytren's diathesis. We studied 139 hands in 124 Caucasian patients treated between 1997 and 2004. There was a significant difference in the recurrence rate between the three histological types (P = 0.04). Histological staging was independent of features of Dupuytren's diathesis. This study confirms that histological staging is a reliable method for predicting recurrence. However, it should be used in association with clinical data to determine precisely the prognosis of patients suffering from Dupuytren's contracture.

Many surgical procedures have been described for the treatment of mucous cysts. We report a case series of a surgical technique that excises the cyst along with overlying skin and reconstructs the defect using a Wolfe graft harvested from the wrist crease. This technique can be applied to cysts in all locations, even those adjacent to the nail. The procedure has been performed on 51 mucous cysts with satisfactory results, a very low recurrence rate (4%) and negligible complications.

The results in 75 of 105 patients with Older type II/III (AO type A2.2, A3.1, A3.2) Colles’ fractures, treated with non-bridging external fixation are presented. The mean age was 67.8 years, and all patients were followed prospectively for 12 months with radiological and functional assessment. No statistically significant loss of radial length, angulation or inclination was seen between the postoperative reduction and the 1-year follow-up examination. The clinical results after 1 year were 66 (88%) excellent/good, nine (12%) fair and 0 (0%) poor according to the modified Gartland and Werley score. Mean visual analogue scale pain score after 1 year was 0.8. In three patients (4%), re-displacement of the fracture occurred and was treated with plating. Non-bridging external fixation offers a reliable method of maintaining radiological reduction of Older type II/III fractures of the distal radius and gives a good functional outcome after 1 year.

Three groups of six porcine deep flexor tendons were repaired with a locking loop modified Kessler core suture using 4-0 braided polyester. Silfverskiöld repairs were performed using 6-0 monofilament nylon taking bites 2, 4 and 6 mm from the cut end of the tendon. The repairs were tested to failure and record made of bulking, mode of failure, force to produce a 3 mm gap and the ultimate strength. Data were analysed using one-way ANOVA, with analysis of mode of failure using the Chi-squared test. The 4 mm repairs were significantly stronger than the 2 mm for all parameters but there was no difference between the 4 mm and 6 mm repairs. We feel that optimal repair strength is provided using bites 4 mm from the cut tendon ends. Taking bites further from the cut end has no significant benefits and carries the theoretical risk of increasing the work of flexion.

This cadaveric study evaluates the margin of safety and technical efficacy of mini open carpal tunnel release performed using Knifelight® (Stryker Instruments) through a transverse 1 cm wrist incision. A single investigator released 32 wrists in 17 cadavers. The wrists were then explored to assess the completeness of release and damage to vital structures including the superficial palmar arch, palmar cutaneous branch and recurrent branch of the median nerve. All the releases were complete and no injury to the median nerve and other structures were observed. The mean distance of the recurrent motor branch to the ligamentous divisions was 5.7 ± 2.4 mm, superficial palmar arch was 8.7 ± 3.1 mm and palmar cutaneous branch to the ligamentous division was 7.2 ± 2.4 mm. The mean length of the transverse carpal ligament was 29.3 ± 3.7 mm. Guyon's canal was preserved in all cases.

We retrospectively defined the rate and clinical features of tendon entrapment in 693 consecutive patients with 701 distal radius fractures treated in a single hospital. Eight extensor tendons and one flexor tendon were entrapped. All fractures with extensor tendon entrapment were palmarly displaced (Smith type) or epiphyseal. Flexor tendon entrapment was seen in dorsally angulated (Colles type) epiphyseal fracture. The rate of tendon entrapment in acute distal radius fractures was 1.3%. Extensor tendon entrapment in palmarly displaced fractures is more common.

This study compared the result of percutaneous release using a miniscalpel-needle and steroid injection in 93 trigger thumbs in 83 patients. The patients were randomly assigned to either miniscalpel-needle percutaneous release (group A) or steroid injection (group B). Visual analogue pain scales and patients’ satisfaction were evaluated at baseline, 1 and 12 months. One patient in group A and two patients in group B were lost to follow-up. Forty-four of the 46 trigger thumbs in group A and 12 of 47 trigger thumbs in group B had satisfactory results at 12 months. No digital nerve injury occurred in either group. Percutaneous release with a miniscalpel-needle had a higher success rate than steroid injection.

Assessment of hand strength is used in a wide range of clinical settings especially during treatment of diseases affecting the function of the hand. This investigation aimed to determine age- and gender-specific reference values for grip and pinch strength in a normal Swiss population with special regard to elderly and very elderly subjects as well as to different levels of occupational demand. Hand strength data were collected using a Jamar dynamometer and a pinch gauge with standard testing position, protocol and instructions. Analysis of the data from 1023 tested subjects between 18 and 96 years revealed a curvilinear relationship of grip and pinch strength to age, a correlation to height, weight and significant differences between occupational groups. Hand strength values differed significantly from those of other populations, confirming the thesis that applying normative data internationally is questionable. Age and gender specific reference values for grip and pinch strength are presented.

This is a case series of 14 hamate body fractures, in the coronal plane, with 12 patients having an associated metacarpal injury. Treatment was either conservative or operative and was decided according to the degree of fracture displacement and presence of carpometacarpal subluxation. Patient follow-up was 14.8 months on average, using DASH scores and postoperative radiographs to determine functional and anatomical outcomes. Undisplaced fractures were treated in a cast with good outcome. Postoperative radiographs of patients treated with Kirschner wires for displaced fractures showed incomplete reduction and the outcomes were less favourable. Rigid internal fixation gave excellent radiographic results, although these did not correlate with functional outcome in all patients.