Showing papers in "Journal of Hand Surgery (European Volume) in 1978"

Open reduction of carpal dislocations: indications and operative techniques.

Abstract: Based on their personal experience with 49 carpal dislocations in 46 patients, the authors suggest the following in the management of the acute injury: (1) Dorsal trans-scaphoid perilunate dislocation. After closed reduction, if the scaphoid is not anatomically reduced, primary open reduction and internal fixation with Kirschner wires is advised. A volar (Russe-type) approach gives adequate exposure, and bone grafting probably is not necessary. Satisfactory results can be achieved if the operation is done anytime within 2 weeks of injury. (2) Dorsal perilunate and volar lunate dislocation. Since cineradiographic studies show clearly that the lunate dislocation is usually the end stage of a perilunate dislocation, these injuries are treated identically after the initial closed reduction. Indications for open reduction are rotary subluxation of the scaphoid or lunate instability (dorsiflexion instability or volar subluxation). A dorsal approach is adequate for scaphoid subluxation alone, but combined dorsal plus volar approaches should be used for volar subluxation of the lunate with rotary subluxation of the scaphoid. Best results are achieved with open reduction as soon after the injury as possible. Factors in this series which were associated with poorer results were volar dislocation of the proximal pole of the scaphoid with the lunate, severely comminuted radial styloid fractures, extensive osteochondral fractures of the carpal bones, and late open reduction of rotary scaphoid subluxation.

Complications of surgical release for carpal tunnel syndrome

Abstract: Review of a series of 186 operative cases of carpal tunnel release revealed 34 complications in 22 patients, for an incidence of 12%. Complications were grouped into seven categories: (1) inadequate section of the transverse carpal ligament (associated with both transverse and curved incisions), (2) symptoms related to damage to the palmar cutaneous branch of the median nerve, (3) reflex sympathetic dystrophy, (4) unsightly hypertrophic scar due to inappropriate incision, (5) damage to the superficial palmar arch following blind sectioning of the transverse carpal ligament, (6) bowstringing of the flexor tendons after excision of the transverse carpal ligament, and (7) adherence of the flexor tendons following excision of the mesotenon. Except for four of the complications, two each of bowstringing and reflex sympathetic dystrophy which occurred in our own practice, all of the complications were seen in patients referred for care. Most complications can be prevented by proper operative technique.

The moving two-point discrimination test: Clinical evaluation of the quickly adapting fiber/receptor system

Abstract: As the Weber test evaluates the slowly adapting fiber-receptor system (constant touch), the "moving two-point discrimination test" evaluates the innervation density of the quickly adapting fiber-receptor system which mediates the perception of touch stimuli moving across the hand. Results with this test in 39 hands used as controls and in 63 patients with nerve injuries show it to be a simple, quick, and valid diagnostic tool in nerve compression syndromes and nerve lacerations and an accurate prognosticator and monitor during sensory reeducation following nerve repair.

Von Frey's method of measuring pressure sensibility in the hand: An engineering analysis of the Weinstein-Semmes pressure aesthesiometer

Abstract: The development of microsurgical techniques has generated a resurgence of interest in estimating local pressure sensibility as a measure of sensory improvement. Because our experience with Weinstein's modification of Von Frey's probes yielded variable and poorly understood results, we measured two sets of probes and examined them in the light of the engineering principles on which their behavior is based. The mechanical behavior of the nylon monofilaments can be described as buckling with one end built in and the other end pinned. The probes are relatively uniform and consistent. However, no loss in sensitivity would accompany division of the set into two or three equivalent sets. Variations in the buckling stress as high as a factor of eight are difficult to avoid. Gross errors arise from careless application, variations in the elastic modulus due to changes in temperature and humidity, and variations in the attachment of fibers to handles and differences in the ends of the filaments. Interpreting results for this instrument requires an understanding of the factors which can influence those results. The probes are simple to use but easy to misinterpret.

Experimental intrinsic healing of flexor tendons based upon synovial fluid nutrition.

Abstract: The healing process of totally cut and subsequently re sutured rabbit flexor tendons kept isolated in the knee joint cavity and free in the synovial fluid was studied by histological and ultrastructural techniques. This experimental model represents a "tissue culture in situ," where the tendon is nourished by diffusion from the synovial fluid only and where no adhesions are formed. Under these conditions there is a proliferation of tendon cells and deposition of collagen resulting in bridging of the suture line. On the basis of these findings, it is assumed that the tendon cells possess an intrinsic potential of repair, provided they obtain a sufficient nutritional supply. In the present experimental model, this nutrition was provided by way of diffusional pathways from the synovial fluid.

Treatment of trapeziometacarpal arthritis: Results of resection arthroplasty

Abstract: Ninety-one thumbs with symptomatic trapeziometacarpal arthritis were studied and classified by the severity of trapeziometacarpal arthritis, as seen on the roentgenogram. Thirty-five patients with mild changes had satisfactory relief of pain after treatment with anti-inflammatory drugs and a C-splint. Operation, consisting of resection of the trapezium and shortening by 1.5 cm of the abductor pollicis longus tendon was performed on 16 thumbs. In six patients a rolled palmaris longus tendon was inserted between the metacarpal base and the scaphoid. All patients had relief of pain, improvement of pinch and grip strength, and an increased range of thumb pronation after operation. There was no difference in the results of those patients treated with or without tendon interposition. Trapezial resection was found to be an effective means of treating patients with symptomatic trapeziometacarpal arthritis who failed to improve with conservative care.

Management of post-traumatic instability of the wrist secondary to ligament rupture.

Abstract: A retrospective review of 55 patients with post-traumatic radioscapholunate ligament disruption suggests that rupture of this ligament can be treated successfully if certain guidelines are followed. If the rupture is seen within 4 weeks, an anatomic reduction maintained in plaster for 8 weeks leads to good results. Ligament ruptures that cannot be held in reduction or that are diagnosed after 4 weeks do poorly with immobilization only. Results after ligament reconstruction have ranged from good to fair but appear to have been sufficiently successful to warrant continued trial rather than resort to arthrodesis, proximal row carpectomy, or similar reconstructive procedures. Patients with degenerative joint disease associated with radioscapholunate rupture are not candidates for ligament reconstruction. Radial styloidectomy or some variety of wrist arthrodesis or wrist arthoplasty should be considered in these instances.

Intraosseous wiring of the digital skeleton

Abstract: One hundred cases of osteosynthesis done by the use of intraosseous wiring are presented. Two techniques of wiring are described, one used in transverse fractures and arthrodeses in which an additional Kirschner wire is employed, the other in which No. 0 monofilament wire can be placed perpendicular to the line of osteosynthesis. Forty-seven fractures were treated and there was union in all cases; 53 arthrodeses were performed, with failure in five, due, it is believed, to a failure to observe the essential elements of the technique, namely the need to obtain congruous bone ends and to maintain all internal fixation until there is clinical evidence of union. Overall, 83.2% of the maximum attainable total active range of motion was achieved in the 100 cases.

An experimental approach to the mechanism of scaphoid waist fractures

Abstract: Fractures through the waist of the scaphoid were produced experimentally by application of static loads to fresh cadaver specimens. Fractures occurred only when the wrist was in 95° to 100° of dorsiflexion and when the radial portion of the palm received the major part of the load. Definition of these loading conditions allowed us to perform a mathematical analysis of the forces about the scaphoid. The analysis showed that the palmar capsular structures supporting the scaphoid waist were lax when fractures occurred and that the articular surface between the radius and scaphoid bore compressive loads four times greater than the load applied to the palm. This placed the proximal pole of the scaphoid in a vise between the radius and capitate. Fractures predictably occurred at the edge of the vise where the waist of the scaphoid was unsupported. Fractures of the waist of the scaphoid occur as a result of bending loads applied over the distal pole of the scaphoid which is unsupported by the palmar capsule. If these fractures occur while the radial palmar capsule is lax, then tension in this structure should cause malposition of the bony fragments. From this study it appears that the best anatomic reduction of most scaphoid fractures will be obtained when the wrist is placed in such a position that there is laxity in the radial-palmar capsular ligaments, i.e., the wrist in slight palmar flexion and slight radial deviation.

Technical problems with ulnar nerve transposition at the elbow: findings and results of reoperation.

Abstract: Ten patients who had persistent or recurrent paresthesias, muscular weakness, or sensory loss following transposition of the ulnar nerve at the elbow were explored. Operative findings included compression of the nerve at the intermuscular septum or at the entrance to the cubital tunnel, dense scarring after intramuscular transposition, and constriction by fascial slings. The average interval from the previous operation to re-exploration was 13 months. All patients were improved following neurolysis and submuscular transposition. Recovery was incomplete in nine patients. The average follow-up was 14.5 months.

Free muscle transplantation to provide active finger flexion.

Abstract: Free muscle transplantation is a procedure which involves the transfer of a skeletal muscle from one location in the body to another. Viability is maintained by microvascular anastomoses of the muscle's artery and vein to a suitable artery and vein in the recipient site. Voluntary muscle contraction is obtained by suturing of the muscle's motor nerve to an appropriate motor nerve in the recipient site. Two cases are presented: one using the gracilis and the other using the pectoralis major muscle. The indication for each transplantation was the traumatic loss of long flexor musculature to the digits. In both cases transplanted muscles survived and are functioning well. Excellent grip strength and nearly a full range of finger movement were provided by the transplanted muscle.

Scaphotrapezial trapezoidal arthrosis

Abstract: Scaphotrapezial trapezoidal degenerative arthritis as an isolated entity or as a preponderant part of a pantrapezial degenerative process was seen in 49 hands of 34 patients. Pain and weakness were the primary complaints. Point tenderness was present in all but two hands. Significant loss of grasp and pinch strength was noted in 18 hands, and loss of wrist motion occurred in 16 hands. Roentgenographic findings included narrowing of the scaphotrapezial trapezoidal joint space, subarticular cortical sclerosis, and cyst formation. A dorsiflexed position of the scaphoid, with a scapholunate angle of less than 45°, was noted in 38 of the 45 hands. Late collapse of the intercarpal joint with dorsiflexion instability of the lunate also was noted. Twenty-nine hands were treated conservatively by protective splints, corticosteroid injections, and avoidance of exacerbating activities. Surgical treatments consisted of fibrous arthroplasty (four), silicone interposition arthroplasty (six), trapezial replacement arthroplasty (three), arthrodesis (five), joint debridement (one), and trapezial excision (one). Late results were more encouraging than were early results and were moderately satisfactory for each method. Improvement in grasp and pinch strength was most predictable for arthrodesis, although wrist motion was diminished.

Digital sensibility following replantation

Abstract: The amputated digit serves as an excellent model for the examination of digital nerve repair. When amputation is complete, there is no question of cross-over or anomalous innervation. The sensibility of 35 replanted digits in 29 patients was evaluated. Sensory return was related most closely to restored digital vascularity, as measured by Allen test, pulse volume flow, and Doppler. Level of amputation, mechanism of injury, and age of patient also affected ultimate sensation. All patients experienced cold intolerance and some were considerably disabled because of it. The severity of cold intolerance with pain and requiring prolonged rewarming was directly proportional to digital vascularity. When one digital artery thrombosed, ipsilateral digital sensation was not diminished as long as flow through the contralateral vessel was adequate. Two-point discrimation in our series was not as good as that reported for digital nerve repair in the nonamputated digit. Establishing and maintaining adequate digital flow at the time of replantation is essential to obtain good digital sensibility and to avoid symptoms of cold intolerance.

Digital pulley reconstruction employing the always present rim of the previous pulley.

Abstract: Several methods have been proposed for pulley reconstruction. Cleveland! described the use of a fascia lata graft sutured to either side of the fibrous sheath. Bunnell used a free tendon graft encircling both the flexor and extensor tendons or one slip of the superficialis tendon sutured to the opposite side of the phalanx. 2 Weckesseil passed a tendon graft through a drill hole in the phalanx and encircled the flexor tendon. Wray and Weeks4 reported the use of silicone rubber and Dacron arterial grafts as synthetic substitutes for the fibrous pulley system. Because the methods described do not duplicate the size or number of the original pulleys and require prolonged immobilization of the graft before motion is permitted, a technique of pulley reconstruction as employed by Andreas Weilby5 of Denmark is described. It appears to be strong and allows immediate motion.

The spiral oblique retinacular ligament (SORL).

Abstract: A procedure is described for reconstruction of the oblique retinacular ligament using a small tendon graft in a spiral fashion to act as a dynamic tenodesis to restore distal interphalangeal extension and to restrain proximal interphalangeal hyperextension. The method has been uniformly successful in the treatment of post-traumatic "swan-neck" or "mallet" deformity. Although the concept is simple, the procedure demands thorough understanding of digital anatomy for successful completion.

Anatomic dissections relating the posterior interosseous nerve to the carpus, and the etiology of dorsal wrist ganglion pain

Abstract: Prompted by the finding of a neuroma, which clinically simulated a recurrent ganglion, we dissected the terminal branches of the posterior interosseous nerve. A constant relationship between these terminal branches and the scapholunate ligament was demonstrated. Since most, if not all, dorsal wrist ganglions arise from the scapholunate ligament, we suggest that the aching wrist pain associated with a dorsal wrist ganglion may be due to a compression neuropathy of the posterior interosseous nerve.

Pathogenesis of Dupuytren's contracture: a correlative clinical-pathological study.

Abstract: The tissue from 38 patients with Dupuytren's contracture was submitted for light and electron microscopy. The clinical and pathological data were correlated so that three stages of disease were recognized: early, active, and advanced. The cell of early disease was the perivascular fibroblast; whereas, the cell of active disease was the myofibroblast. Because the myofibroblasts have cell-to-cell and cell-to-stroma attachments, the collagen not only becomes oriented as it is formed, but it also is subjected to a contractile force.

Assessing ulnar instability of the metacarpophalangeal joint of the thumb.

Abstract: Seven hundred and fifty normal thumbs were examined to determine the normal range of radioulnar mobility of the metacarpophalangeal joint with the joint in full extension, 15 degrees of flexion, and full flexion. Full flexion was the position of greatest stability. Twenty-five adult unembalmed cadaver thumbs were examined to determine the optimal position for testing the metacarpophalangeal joint for ulnar collateral ligament stability. When radial stress was applied to the metacarpophalangeal joint of 20 specimens after cutting the adductor aponeurosis and capsule, minimal ulnar instability was found. However, further sectioning of the ulnar collateral ligament revealed marked ulnar instability most significantly when the thumbs were examined in full metacarpophalangeal flexion. Finally, division of the adductor aponeurosis, dorsal capsule, ulnar collateral ligament, accessory collateral ligament, and volar plate resulted in complete instability of the metacarpophalangeal joint in all positions tested.

A clinical study of forces generated by the intrinsic muscles of the index finger and the extrinsic flexor and extensor muscles of the hand

Abstract: A study of the forces generated by the intrinsic muscles of the index finger and coordinating muscles of the hand found that the intrinsic muscles of the index finger contributed combined forces equivalent to approximately 80% of those generated by the flexor profundus and superficialis, and to 73% of the moment for the motion of metacarpopalangeal flexion with simultaneous interphalangeal joint extension. No current tendon transfer operation can correct this deficit, though several supply sufficient force at the metacarpophalangeal joint to counterbalance the extrinsic extensors.

Treatment of mallet finger due to intra-articular fracture of the distal phalanx

Abstract: When a mallet finger deformity results from an intra-articular fracture of the distal phalanx comprising more than one third of the articular surface, an accurate reduction of this fracture is necessary to prevent secondary degenerative arthritis. A technique for open reduction is described in which the distal interphalangeal joint is exposed by dividing the extensor tendon and permitting a precise reduction of the fracture fragment. Elective division of the extensor tendon had not compromised the results.

Recovery of function in free muscle transplants using microneurovascular anastomoses

Abstract: Using the rectus femoris muscle of the rabbit, the functional capabilities of the normal and replanted muscle were studied after tenotomy, simple neurovascular repair, and orthotopic and heterotopic transplantation. Tenotomy alone altered the function more than did neurovascular repair, and although a muscle survived after replantation, it never achieved the functional capability of the normal muscle, maximum working capacity being only one fourth of the normal.

Closed tendon sheath irrigation for pyogenic flexor tenosynovitis

Abstract: Twenty patients with pyogenic flexor tenosynovitis were treated by through-and-through saline irrigation using an indwelling catheter and small Penrose drain The treatment lasted for 48 hours All patients were discharged from the hospital within 4 days Eighteen patients had regained complete active and passive motion by 1 week after operation One patient had a slight residual flexor tendon adherence and one gained motion after operation This technique provides rapid, complete return of function with minimal inconvenience to the patient

Metastatic tumors of the hand: A report of six cases

Abstract: Six metastatic tumors of the hand of mammary, renal, pulmonary, colonic, and humeral origins are described. The areas involved were the distal phalanges, the metacarpal bones, a carpal bone, the nail bed, and the soft tissue of the dorsum of the hand. All six patients died within a few months after the metastatic lesions were diagnosed correctly. Metastases to the bone can cause destruction, pain, and swelling and may be misdiagnosed before operation as osteomyelitis. Metastases to the soft tissues tend to be asymptomatic and can closely mimic benign soft tissue tumors.

Unstable fracture dislocations of the proximal interphalangeal joint of the fingers: A preliminary report of a new treatment technique

Abstract: A linkage of Kirschner wires activated by a single rubber band creates a force couple across a fracture-dislocated proximal interphalangeal joint. The method dynamically achieves concentric joint reduction, which is maintained through a full active range-of-joint flexion and extension. Two case reports accompany a description of the technique.

Tendon transfers for radial nerve palsy: Use of superficialis tendons for digital extension

Abstract: Since 1959, 22 patients have had wrist extension restored by transfer of the pronator teres to the extensor carpi radialis longus and brevis, common finger extension by transfer of the superficialis of the long finger, independent thumb and index finger extension by transfer of the superficialis of the ring finger, and abduction of the thumb by transfer of the flexor carpi radialis at the wrist joint level. Twenty-one of 22 patients have been evaluated from 8 months to 15 years after operation, with an average follow-up of 4.5 years. By our new system of evaluation, there were 10 excellent results, six good results, five fair results, and all patients improved. Sixteen patients obtained full, independent thumb-index finger extension, three had fair function, and two obtained thumb-index extension by tenodesis of the transfer. This procedure allows full metacarpophalangeal extension independent of wrist position, provides thumb-index finger extension independent of the ulnar three digits, and maintains the dorsal-radial-to-volar-ulnar plane of functional motion of the wrist by retaining the flexor carpi ulnaris.

Polydactyly and the triphalangeal thumb

Abstract: Polydactyly associated with triphalangeal thumb is not rare, as among the records of 1,269 patients with congenital deformation of the upper extremity at the University of Iowa there were 21 patients with 32 hands with such involvement. More detailed classification based on Wassel's work was made. Treatment should be early, with removal of the radial digit if equal in size, excision of all accessory parts including delta bone when present, reconstruction of joint ligaments or joint fusion and osteotomy for correction of deviations. Care should be taken to avoid leaving a narrow first web space.

Abductor digiti minimi opponensplasty in congenital radial dysplasia.

Abstract: Satisfactory results were obtained in 20 of 21 abductor digiti minimi opponensplasties performed in children with congenital radial dysplasia. A modified technique left the muscle attached to the pisiform and did not require complete dissection of the neurovascular structures. An adequate subcutaneous tunnel was made to accept the transferred muscle and laxity of the ulnar collateral ligament of the metacarpal-phalangeal joint of the thumb, a consistent finding in patients with isolated aplasia of the abductor pollicis brevis and opponens pollicis muscles, was repaired by imbrication and suture of one of the tendinous slips to the ulnar capsule.

Nutrient pathways to flexor tendons of chickens using tritiated praline

Abstract: The nutrient pathway to the flexor tendons within the digital flexor sheath of adult chickens was investigated using tritiated proline. There was no difference in the uptake of the radioactive tracer by free segment tendons (detached from blood vessels) and the intact tendon lying in synovium. The uptake of tracer by tendons isolated from the synovium (but with unaltered vascular attachments) was significantly less than by the intact tendons. Radioactive tracer not only diffused across the synovium into the tendon, but along the course of the tendon itself. There was no difference in the uptake of radioactive tracer by 2-week-old tendon grafts with and without adhesions.

Nutrient pathways to flexor tendons using hydrogen washout technique

Abstract: The nutrient pathways of the flexor tendons within the flexor sheath were studied using the hydrogen washout technique. Hydrogen uptake and decay of a free segment of flexor tendon detached from its blood supply were not significantly different from an intact tendon lying in the synovial bed. There was no hydrogen uptake by flexor tendons which were mechanically separated from the synovial bed, even though muscular, periosteal and vincular attachments were intact. We concluded from this study that the synovium of the flexor tendon was a significant nutrient pathway for the flexor tendon and that the blood vessels did not appear to play a significant role in the nourishment of the flexor tendon.

Temperature monitoring in digital replantation

Abstract: Postoperative monitoring of replanted and revascularized digits with skin temperature probes was performed on the 20 patients admitted to the Duke University Medical Center Orthopaedic Replantation Service from April to July, 1977. Using multiple probes, temperatures were recorded for the replanted digit, a control digit on the same hand, and the dressing which represented the ambient temperature. In addition, the following simultaneous clinical inspections were performed on the digits: capillary refill, skin color, turgor, audibility of arterial Doppler tones, and amplitude of pulp pressure tracing. Temperatures of the replanted digits were in the range of 26.0° to 35.0° C. Control temperatures remained relatively stable, in the range of 33.0° to 35.0° C. From the authors' experience the patterns of temperature change which signaled changes in perfusion of the replanted digit and possible poor prognosis were (1) the temperature of the replanted digit dropping more than 2.5° C while the control temperature stayed constant; (2) the temperature of the replanted digit dropping below 30.0° C for longer than 1 hour; and (3) the control temperature dropping below 30.0° C with no correctable cause found.