Journal of Hand Surgery (European Volume) current issue

Frontispiece

Wed, 21 Oct 2009 01:11:14 PDT

New trends in arthroscopic management of type 1-B TFCC injuries with DRUJ instability

ATZEI, A. — Wed, 21 Oct 2009 01:11:15 PDT

Advances in radiocarpal and distal radioulnar joint (DRUJ) diagnostic arthroscopy permits a treatment-oriented classification of triangular fibrocartilage complex (TFCC) peripheral tears: 1) repairable distal tears; 2) repairable complete tears; 3) repairable proximal tears; 4) non-repairable tears; and 5) tears associated with DRUJ arthritis. Class 1 tears should be sutured; Class 2 and 3 are associated with DRUJ instability and require TFCC reattachment to the fovea; Class 4 tears need reconstruction using a tendon graft and Class 5 tears require an arthroplasty. Arthroscopic assisted TFCC foveal reattachment is possible through the direct foveal portal, a dedicated DRUJ working portal. Arthroscopic TFCC reconstruction using a tendon graft showed promising results.

Intra-articular distal ulnar fractures associated with distal radial fractures in older adults: early experience in fixation of the radius and leaving the ulna unfixed

NAMBA, J., FUJIWARA, T., MURASE, T., KYO, T., SATOH, I., TSUDA, T. — Wed, 21 Oct 2009 01:11:15 PDT

There is no clear consensus about the best management of intra-articular distal ulnar fractures associated with distal radial fractures in older adults. We describe a treatment wherein the distal radial fractures were securely fixed with a palmar plate, leaving the associated ulnar fractures unfixed. The wrists of 14 patients with a mean age of 74 years were reviewed at an average of 18 months after surgery. The results were excellent in 11 cases and good in three, according to the modified Gartland and Werley score. All fracture sites displayed union, and there was no instability of the distal radioulnar joint. A widening of the distal radioulnar joint space was present in one wrist. Angular deformity of the distal ulnar metaphysis was seen in five wrists. This treatment could be an alternative to open reduction with internal fixation for intra-articular distal ulnar fractures in older adults.

Computer tomography aided 3D analysis of the distal dorsal radius surface and the effects on volar plate osteosynthesis

PICHLER, W., WINDISCH, G., SCHAFFLER, G., RIENMULLER, R., GRECHENIG, W. — Wed, 21 Oct 2009 01:11:15 PDT

The aims of this study were to measure the size of Lister’s Tubercle, the extent of the extensor pollicis longus (EPL) groove and the dihedral angle of the distal dorsal radius. Computer tomography scans of 30 forearms were performed by using a 64-slice Siemens SOMATOM Sensation^® CT system (Resolution 0.6 mm). DICOM raw data were calculated to 3D by MIMICS^® software (Materialise, Leuven, Belgium). The size of Lister’s Tubercle varied from 1.4 to 6.6 mm (average 3.3 mm) in height radial to the tubercle, and from 5.6 to 18.6 mm (average 13.2 mm) in length. The depth of the EPL groove varied from 0.6 to 3.2 mm (average 1.6 mm). The height on the ulnar side, between the depth of the groove and the tip of the tubercle, varied from 2.2 to 5.8 mm (average 3.4 mm). The dihedral angle of the distal dorsal radius varied from 110° to 135° (average 123°). The variations in height of Lister’s Tubercle and in depth of the EPL groove are considerable. This needs to be taken into account when performing volar plating of distal radius fractures otherwise screws may inadvertently penetrate the dorsal cortex of the radius potentially leading to EPL rupture.

Long-term results of lunocapitate arthrodesis with scaphoid excision for SLAC and SNAC wrists

FERRERES, A., GARCIA-ELIAS, M., PLAZA, R. — Wed, 21 Oct 2009 01:11:15 PDT

When treating the degenerative arthritis that follows scapholunate instability or scaphoid pseudarthrosis, excision of the scaphoid must be combined with a stabilisation of the midcarpal joint. Two alternatives have been proposed for that purpose: fusing the lunate, triquetrum, capitate and hamate (four corner fusion), 4CF; or limiting the arthrodesis to the lunate and capitate, preserving or excising the triquetrum. Previous reports have attributed a high level of complications to lunocapitate arthrodesis, mainly in respect of nonunion. We have reviewed 17 patients who had been treated with a lunocapitate fusion, after an 8 to 12-year follow-up period, and found similar results compared with 4CF, even with a major degree of motion in ulnar-radial deviation. Recent work on the innervation of the radiotriquetral ligaments has given relevance to the preservation of lunotriquetral motion in maintaining proprioception. Also if the triquetrum is excised to gain more motion, the proprioceptive role of the radiotriquetral ligaments is compromised.

Four-corner bone arthrodesis with dorsal rectangular plate: series and personal technique

ESPINOZA, D. P., SCHERTENLEIB, P. — Wed, 21 Oct 2009 01:11:15 PDT

Controversy exists about the best method to achieve bone fusion in four-corner arthrodesis. Thirty-five patients who underwent this procedure by our technique were included in the study. Surgical indications were stage II–III SLAC wrist, stage II SNAC wrist and severe traumatic midcarpal joint injury. Mean follow-up was 4.6 years. Mean active flexion and extension were 34° and 30° respectively; grip strength recovery was 79%. Radiological consolidation was achieved in all cases. The mean DASH score was 23 and the postoperative pain improvement by visual analogue scale was statistically significant. Return to work was possible at 4 months for the average patient. Complications were a capitate fracture in one patient and the need for hardware removal in four cases. Four-corner bone wrist arthrodesis by dorsal rectangular plating achieves an acceptable preservation of range of motion with good pain relief, an excellent consolidation rate and minimal complications.

Effect of scaphoid and triquetrum excision after limited stabilisation on cadaver wrist movement

BAIN, G. I., SOOD, A., ASHWOOD, N., TURNER, P. C., FOGG, Q. A. — Wed, 21 Oct 2009 01:11:15 PDT

This study assessed the effect of excision of the scaphoid and triquetrum on the range of motion of the embalmed cadaver wrist joint after midcarpal stabilisation. The range of motion was measured in 12 cadaver wrists before and after stabilisation of the joints between the lunate, capitate, triquetrum and hamate. This was measured again following resection of the scaphoid and then the triquetrum. Scaphoid excision after four-corner stabilisation increased the radioulnar (RU) arc by 12° and the flexion–extension (F–E) arc by 10°. Subsequent excision of the triquetrum, to produce a three-corner stabilisation, further increased the RU arc by 7° and the F–E arc by 6°. Three-corner stabilisation with excision of scaphoid and triquetrum improved wrist motion in embalmed cadavers.

A prospective randomised trial of absorbable versus non-absorbable sutures for wound closure after fasciectomy for Dupuytren's contracture

HOWARD, K., SIMISON, A. J. M., MORRIS, A., BHALAIK, V. — Wed, 21 Oct 2009 01:11:15 PDT

After fasciectomy for Dupuytren’s contracture the wound has traditionally been closed with non-absorbable sutures. A prospective randomised study of 59 patients was undertaken to compare wound closure after fasciectomy with irradiated polyglactin 910 absorbable sutures and non-absorbable sutures. The outcomes studied were: time spent attending to the wound at the first postoperative visit; the patient’s pain score at that visit; and any complications. Wound care required significantly more time when non-absorbable sutures were used. There was no significant difference in pain scores or in complications between the two groups. We recommend the use of irradiated polyglactin 910 absorbable sutures for wound closure after fasciectomy as it saves time and resources without compromising wound healing.

Analysis of rewarming curves in Raynaud's phenomenon of various aetiologies

Wed, 21 Oct 2009 01:11:15 PDT

This study investigated whether a modified Cold Provocation Test could distinguish between 86 normal subjects and 31 patients with Raynaud’s phenomenon or 59 with hand arm vibration syndrome (HAVS). Of the HAVS subjects, 56 were seen for medical reports as they were involved in litigation. Their assessments were done in a different location but the same protocol was used. A standardised cold stress was used to reduce the finger temperature to 15°C or less without inducing reflex hyperaemia. This test had acceptable repeatability for subjects without HAVS with an intra-class correlation of 0.7. Baseline temperature, temperature rise in the first 30 seconds and the time taken to rewarm by 5°C were measured. Patients with Raynaud’s phenomenon and HAVS had cooler hands than controls. HAVS patients rewarmed most in the first 30 seconds. Patients with Raynaud’s phenomenon take longer to rewarm by 5°C than controls or those with HAVS (P<0.001). A baseline difference of >7.5°C between the temperature of the digit and that of the room is unlikely to occur in patients with Raynaud’s phenomenon or HAVS. A temperature gain of ≥2.2°C in the first 30 seconds on rewarming combined with a low baseline temperature strongly suggests HAVS. This modified cold provocation test may differentiate between patients with Raynaud’s phenomenon, HAVS and controls but this observation requires independent verification in subjects not involved in litigation and tested in the same facility.

Cost-effectiveness of MRI in managing suspected scaphoid fractures

HANSEN, T. B., PETERSEN, R. B., BARCKMAN, J., UHRE, P., LARSEN, K. — Wed, 21 Oct 2009 01:11:15 PDT

In a cost-effectiveness study, we compared a treatment algorithm using repeated radiological examination with an algorithm using subacute MRI in patients with clinical signs of scaphoid fracture but normal initial radiography. Twenty-seven patients were included in both groups, and MRI reduced the immobilisation time from 20 days (range, 6–54) to 4 days (range, 1–19) and sick leave from 27 days (1–92) to 11 days (0–28). Use of MRI increased hospital costs by 151 (P<0.05), but reduced non-hospital costs by 2869 (P<0.05), making MRI cost-effective in the treatment of suspected scaphoid fractures.

Undisplaced scaphoid waist fractures: is 4 weeks' immobilisation in a below-elbow cast sufficient if a week 4 CT scan suggests fracture union?

Wed, 21 Oct 2009 01:11:15 PDT

This prospective study investigated a cohort of 59 scaphoid waist fractures which were treated nonoperatively in a below-elbow plaster cast for 4 weeks and then underwent a Week 4 CT scan to assess displacement and progress to union. Forty-three were classed as undisplaced and 37 of these 43 were also classed as ‘united’. All the 37 undisplaced and ‘united’ fractures united with up to 8 weeks’ cast immobilisation, including 26 which were taken out of plaster at 4 weeks and mobilised. We conclude that scaphoid waist fractures which appear to be undisplaced and united on a week 4 CT scan will unite, and may not need to be immobilised in a plaster cast for more than 4 weeks. Such a treatment policy may reduce the period of disability and time off work associated with nonoperative treatment.

Treatment of nonunions of the distal phalanx with olecranon bone graft

OZCELIK, I. B., KABAKAS, F., MERSA, B., PURISA, H., SEZER, I., ERTURER, E. — Wed, 21 Oct 2009 01:11:15 PDT

Distal phalangeal fractures are the most common fractures of the hand but nonunions are unusual in the distal phalanx. Eleven patients were operated on for nonunions of the distal phalanx. The diagnosis of nonunion was made by the presence of the clinical (pain, deformity, instability) and radiological signs of nonunion more than 4 months after the initial injury. Three patients had developed infection and four of them had bone resorption after their initial treatments, which probably caused nonunion. Olecranon bone grafting combined with Kirschner wire fixation was done in all patients. The mean follow up was 7 months (range 5–18 months). There were no major complications at the donor or recipient sites. One patient had a haematoma formation at the donor site. There was complete radiological union of bone-grafted sites in all patients except one. There were no cases of pain, deformity, or instability after the treatment. The olecranon bone graft was found to be safe and easy to harvest. Its strong tubular structure replaced the distal phalanx successfully.

The effect of tissue culture on suture holding strength and degradation in canine tendon

OMAE, H., ZHAO, C., SUN, Y.-L., ZOBITZ, M. E., MORAN, S. L., AMADIO, P. C. — Wed, 21 Oct 2009 01:11:15 PDT

The purpose of this study was to assess tendon metabolism and suture pull-out strength after simple tendon suture in a tissue culture model. One hundred and twelve flexor digitorum profundus tendons from 28 dogs were cultured for 7, 14, or 21 days with or without a static tensile load. In both groups increased levels of matrix metalloproteinase (MMP) mRNA was noted. Suture pull-out strength did not decrease during tissue culture. While the presence of a static load had no effect on the pull-out strength, it did affect MMP mRNA expression. This tissue culture model could be useful in studying the effect of factors on the tendon-suture interface.

The optimum length of the Silfverskiold circumferential cross stitch

HIRPARA, K. M., SULLIVAN, P. J., O'NEILL, B., O'SULLIVAN, M. — Wed, 21 Oct 2009 01:11:15 PDT

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.

End-to-side nerve suture in traumatic injuries of brachial plexus: review of the literature and personal case series

BATTISTON, B., ARTIACO, S., CONFORTI, L. G., VASARIO, G., TOS, P. — Wed, 21 Oct 2009 01:11:15 PDT

We used end-to-side nerve coaptation combined with standard end-to-end neurotisations to treat 11 patients who presented with complete (six cases) or incomplete (five cases) traumatic brachial plexus injuries. All patients were available for functional evaluation at a minimum of 2 years postoperatively. In three patients with shoulder abduction recovery, electromyographical studies (EMG) showed a contribution from the end-to-side neurotisation. In the remaining cases end-to-side neurotisations were unsuccessful. Our study did not demonstrate a reliable role for end-to-side nerve suture in brachial plexus surgery. We believe that at present end-to-side suture must not be a substitute for standard reconstructive techniques in brachial plexus surgery. Occasionally termino-lateral nerve sutures may represent a support to standard reconstructive procedures especially in case of severe injuries when few undamaged donor nerves are available.

Age is an important predictor of short-term outcome in endoscopic carpal tunnel release

HANSEN, T. B., LARSEN, K. — Wed, 21 Oct 2009 01:11:15 PDT

Endoscopic carpal tunnel release is a minimally invasive technique that may reduce sick leave and facilitate postoperative rehabilitation and short-term outcome. The aim of this study was to investigate the influence of age as a predictor of short-term outcome in endoscopic carpal tunnel release. We did a prospective registration of patient satisfaction, symptoms and function before and 2-months after endoscopic carpal tunnel release in 101 consecutive patients aged 23–94 years and then submitted the data to multivariable logistic regression analysis. Patient age >65 years was a good predictor of a less favourable short-term outcome, and endoscopic carpal tunnel release may not be justified as a routine procedure in elderly patients.

Assessment of a diagnostic questionnaire and protocol for management of carpal tunnel syndrome

HEMS, T. E. J., MILLER, R., MASSRAF, A., GREEN, J. — Wed, 21 Oct 2009 01:11:15 PDT

One hundred and fifty-two patients with suspected carpal tunnel syndrome (CTS) completed a questionnaire, including questions about the location of paraesthesia, nocturnal pain, the effect of shaking the hand, relief by use of a wrist splint and impairment of manual dexterity. A score was derived from the symptom questionnaire and clinical signs including Tinel’s test, Phalen’s test, and altered sensation. Nerve conduction studies (NCS) were done in 91 cases in which the diagnosis of CTS was in doubt. A threshold questionnaire score was selected as indicating a diagnosis of CTS. Sixty-six patients were predicted to have CTS. When compared with the results of NCS this score had a specificity of 67% and sensitivity of 82%. Ninety-five patients underwent carpal tunnel release. A management model has been developed based on the questionnaire score for symptoms and signs.

Carpal tunnel syndrome in Indian patients: use of modified questionnaires for assessment

Wed, 21 Oct 2009 01:11:15 PDT

This study was conducted to assess the use of a modified carpal tunnel syndrome questionnaire (the Boston Carpal Tunnel Questionnaire, BCTQ) in an Indian patient population. Seventy-six Indian patients with carpal tunnel syndrome (CTS) were recruited to this prospective study. On a scale of one to five, the average score for the severity of symptoms was 2.09 (0.89). The average score for functional disability was 1.94 (0.74), which was lower than the average function score reported for Western CTS patients (Levine et al., 1993). The symptom severity and function disability scores were higher in patients with positive Tinel’s sign and Phalen’s test. The function disability score was moderately correlated with other clinical tests for CTS. The average modified BCTQ scores for Indian CTS patients was established through this study. This modified questionnaire might assist physicians in developing countries to assess disability from CTS, although socioeconomic and cultural differences will have to be taken into account when comparing assessments across different populations.

Reducing the economic impact of carpal tunnel surgery

MALLICK, A., CLARKE, M., WILSON, S., NEWEY, M. L. — Wed, 21 Oct 2009 01:11:15 PDT

A nurse-led carpal tunnel service was started in Leicester in 1999. Many developments in the service have been patient-driven. A large proportion of our patients are not salaried and many had expressed concerns about the amount of time taken off work after surgery. This therefore prompted us to encourage immediate hand function after surgery. Subsequently, in 494 patients studied prospectively, we have seen 93% of patients return to work by 2 weeks and 99% by 4 weeks. This has obvious benefits in terms of reducing loss of income. Furthermore there is potential for considerable economic savings.

The importance of hand anatomy in the accident and emergency department: assessment of hand anatomy knowledge in doctors in training

DICKSON, J. K., MORRIS, G., HERON, M. — Wed, 21 Oct 2009 01:11:15 PDT

Good anatomical knowledge is essential for the early recognition of severe or significant hand injuries in the Accident and Emergency (A&E) department, in particular nerve, vascular or tendon injuries. In 1992, Murphy and Olney assessed hand anatomy knowledge in junior doctors. We have repeated this study 16 years on. The 2008 cohort performed worse in response to every question asked and in some areas significantly so. We discuss the results in relation to the recognition of serious injuries and also with regards to anatomy teaching in medical schools and at postgraduate level.

Subungual glomus tumours of the hand: diagnosis and outcome of the transungual approach

LEE, I. J., PARK, D. H., PARK, M. C., PAE, N. S. — Wed, 21 Oct 2009 01:11:15 PDT

We report 17 patients with a subungual glomus tumour. All complained of pain and tenderness when touched, and nine patients experienced severe pain in the cold. A transungual approach with nail plate avulsion on one side was used in all cases. A surgical microscope was used to localise and dissect the tumour and to repair the nail bed and matrix. This method has produced good results, without local recurrence or postoperative nail plate deformity.

Necrotising fasciitis after corticosteroid injection for trigger finger: a severe complication from a 'safe' procedure

Yam, A., Teoh, L.-C., Yong, F.-C. — Wed, 21 Oct 2009 01:11:15 PDT

Trigger finger after partial flexor tendon laceration: two case reports and review of the literature

Haidar, R., Harfouche, B., Koudeih, M. — Wed, 21 Oct 2009 01:11:15 PDT

Non-infectious subcutaneous emphysema of the forearm in a 12-year-old schoolgirl

Raeven, P., Haagen, A. A. M., de Hoog, D. E. N. M. — Wed, 21 Oct 2009 01:11:15 PDT

Influence of elbow position and handle size on maximal grip strength

Li, K., Hewson, D. J., Hogrel, J.-Y. — Wed, 21 Oct 2009 01:11:15 PDT

Extensor pollicis longus tendon rupture after intramedullary nail fixation of a fracture of the radius

Nagura, I., Fujioka, H., Kokubu, T. — Wed, 21 Oct 2009 01:11:15 PDT

An unusual complication of distal radius plating

Thorpe, P., Brown, D. — Wed, 21 Oct 2009 01:11:15 PDT

The Pacinian corpuscle: a method of locating the digital nerve

Guha, A. R, McMurtrie, A., Singh, R. — Wed, 21 Oct 2009 01:11:15 PDT

Ultrasound for schwannoma in the upper extremity

Kuo, Y.-L., Chiu, H.-Y., Yao, W.-J., Shieh, S.-J. — Wed, 21 Oct 2009 01:11:15 PDT

Radial artery injury caused by a sclerosant injected into a palmar wrist ganglion

Jalul, M., Humphrey, A. R. — Wed, 21 Oct 2009 01:11:15 PDT

Basal cell carcinoma of the thumb

Tehrani, H., Iqbal, A. — Wed, 21 Oct 2009 01:11:15 PDT

Re: S. Umarji and M. Pickford. A novel technique for harvesting a split flexor carpi radialis (FCR) tendon graft. J Hand Surg Eur. 2008 33: 817-8

Wallis, K. L., Hoon Tay, P. — Wed, 21 Oct 2009 01:11:15 PDT

Re: Tripathi AK, Mee SN, Martin DL, Katsarma E. The 'transverse intraosseous loop technique' (TILT) to re-insert flexor tendons in zone 1. J Hand Surg Eur. 2009, 34: 85-9

Azzopardi, E. A., Iyer, S. — Wed, 21 Oct 2009 01:11:15 PDT

Re: Tripathi AK, Mee SN, Martin DL, Katsarma E. The 'transverse intraosseous loop technique' (TILT) to re-insert flexor tendons in zone 1. J Hand Surg Eur. 2009, 34: 85-9

Lyons, I.D.S., Iwuagwu, F. C. — Wed, 21 Oct 2009 01:11:15 PDT

Re: Capo JT, Accousti K, Jacob G, Tan V. The effect of rotational malalignment on X-rays of the wrist, J Hand Surg Eur. 2009, 34: 166-72

Mason, W. — Wed, 21 Oct 2009 01:11:15 PDT

So you think you have read this journal?

Wed, 21 Oct 2009 01:11:15 PDT