Showing papers in "Journal of Hand Surgery (European Volume) in 1989"
TL;DR: Based on anatomic and biomechanical studies and review of the clinical experience of the past 10 years, a classification of injuries to the triangular fibrocartilage complex is presented.
Abstract: Based on anatomic and biomechanical studies and review of our clinical experience of the past 10 years, a classification of injuries to the triangular fibrocartilage complex is presented. This classification is based on the clinical examination, routine x-ray films, wrist arthrograms, wrist arthroscopy, and wrist arthrotomy. The classification recognizes both traumatic and degenerative lesions. Traumatic lesions are classified according to their location. Degenerative lesions are classified by the location and severity of degenerative changes of the triangular fibrocartilage complex, ulnar head, ulnocarpal bones and lunotriquetral ligament.
969 citations
TL;DR: It is suggested that an internal neurolysis, combined with an anterior submuscular transposition, may be the best approach when the ulnar nerve is severely compressed.
Abstract: A review of 50 published reports between 1898 and 1988, comprising more than 2000 patients treated for ulnar nerve compression at the elbow, demonstrated that little more than personal bias is available for guidance in selecting treatment. To provide uniform data, the degree of nerve compression of the patients from these articles was staged using a sensory plus motor classification based on contemporary concepts of the pathophysiology of chronic nerve compression. The results of these studies are reinterpreted in light of this staging system. This analysis suggests that for a minimal degree of compression, excellent results can be achieved in 50% of the patients by nonoperative techniques and in almost 100% of patients by any of five surgical techniques. For a moderate degree of compression, the anterior submuscular technique yields the most excellent results with the fewest recurrences. For a severe degree of compression, the anterior intramuscular transposition yielded the fewest excellent and the most recurrent results. This review suggests that an internal neurolysis, combined with an anterior submuscular transposition, may be the best approach when the ulnar nerve is severely compressed.
359 citations
TL;DR: In a prospective study, 114 patients with 138 zone 2 flexor tendon injuries were treated over a three-year period and the active range of motion recovered was graded excellent or good in 77% of digits, fair in 14% and poor in 9%.
Abstract: In a prospective study, 114 patients with 138 zone 2 flexor tendon injuries were treated over a three-year period. Early active mobilisation of the injured fingers was commenced within 48 hours of surgery. 98 patients (86%) were reviewed at least six months after operation. Using the grading system recommended by the American Society for Surgery of the Hand, the active range of motion recovered was graded excellent or good in 77% of digits, fair in 14% and poor in 9%. Dehisence of the repair occurred in 11 digits (9.4%) and in these an immediate re-repair followed by a similar programme of early active mobilisation resulted in an excellent or good outcome in seven digits.
349 citations
TL;DR: The interosseous membrane of the forearm of 12 fresh cadaver specimens was studied anatomically and mechanically to better understand its role in stabilization of the radius after radial head excision.
Abstract: The interosseous membrane of the forearm of 12 fresh cadaver specimens was studied anatomically and mechanically to better understand its role in stabilization of the radius after radial head excision. A central band of ligamentous tissue, approximately twice the thickness of the membrane on either side was identified in all specimens. Mechanical studies determined the relative contribution to longitudinal stiffness of the forearm. The central band was responsible for 71% of the longitudinal stiffness of the interosseous membrane after radial head excision. The contribution of the triangular fibrocartilage complex was 8%. Silicone radial head implants were much less stiff than the intact interosseous membrane. Injury to the central band of the interosseous membrane may be crucial to the development of proximal migration of the radius after radial head excision.
309 citations
TL;DR: A "six strand" method of tendon repair has been used to treat 36 fingers with flexor tendon lacerations, and 81% of all the fingers were rated excellent or good.
Abstract: A "six strand" method of tendon repair has been used to treat 36 fingers with flexor tendon lacerations. Following surgery, active mobilisation in a protective splint was begun immediately. 63% of lacerations were in zone 2 and 27% in zone 1. 69% and 100% respectively achieved an excellent or good result using Buck-Gramcko's assessment method. 81% of all the fingers were rated excellent or good.
247 citations
TL;DR: Over a two-year-period, 34 adult patients who had suffered zone two flexor tendon injuries to 38 fingers were managed post-operatively by a regime of early active mobilisation, compared favourably with other more cumbersome methods.
Abstract: Over a two-year-period, 34 adult patients who had suffered zone two flexor tendon injuries to 38 fingers (70 tendons) were managed post-operatively by a regime of early active mobilisation. The results of this technique, assessed by the Strickland criteria after a mean follow-up period of 10.2 months, compared favourably with other more cumbersome methods.
228 citations
TL;DR: An enhancement of the Functional neuromuscular stimulation of the upper extremity technique is reported to include surgical implantation of a multichannel receiver-stimulator, sensory feedback stimulation, and tendon transfers.
Abstract: Functional neuromuscular stimulation of the upper extremity provides manipulative capacity to persons with high level tetraplegia who have insufficient voluntary muscles available for tendon transfer surgery. We report an enhancement of the technique to include surgical implantation of a multichannel receiver-stimulator, sensory feedback stimulation, and tendon transfers. Tendon transfers were done with spastic, rather than voluntary motors employing standard surgical techniques. The system described has been operational for more than 1½ years.
211 citations
TL;DR: The pressures were found to be significantly elevated in the immediate post-exercise period in the patients with carpal tunnel syndrome, and they demonstrated a prolonged recovery time to reach the resting pressure when compared with the normal control subjects.
Abstract: Twenty-two patients with carpal tunnel syndrome scheduled to have a carpal tunnel release, and six volunteer control subjects had carpal tunnel pressures measured with their wrist in neutral position, maximum flexion, and maximum extension. The wrist was then repetitively flexed and extended to maximum position at a rate of 30 full cycles per minute for 1 minute. Pressures were then continually monitored and recorded at 30-second intervals. The pressures were found to be significantly elevated in the immediate post-exercise period in the patients with carpal tunnel syndrome, and they demonstrated a prolonged recovery time to reach the resting pressure when compared with the normal control subjects. This property of prolonged recovery time in patients with carpal tunnel syndrome suggests a possible cause for carpal tunnel syndrome in the occupational setting.
195 citations
TL;DR: This study shows that the clinician may choose whichever technique he prefers when measuring ulnar variance, although the method of perpendiculars was most reliable for both interobserver and intraobserver reliability.
Abstract: This study compared three commonly used methods of measuring ulnar variance. The comparison included the project- a-line technique (A), the method of concentric circles (B), and the method of perpendiculars (C). Specific features studied were variations in results generated by each technique as well as the interobserver and intraobserver reliability for each technique. The only significant difference among techniques was between techniques A and B (p = 0.0224), where mean A values were more positive than mean B values. Observers were found to differ significantly (p = 0.0092) independent of technique. All methods studied were highly reliable, although the method of perpendiculars was most reliable for both interobserver (reliability = 0.9801) and intraobserver (reliability = 0.9719) reliability. This study shows that the clinician may choose whichever technique he prefers when measuring ulnar variance.
193 citations
TL;DR: One hundred seventy-nine patients with root avulsion brachial plexus injuries were treated with direct nerve crossing with the intercostal nerve and 159 cases were followed more than 1 1/2 years after the operation.
Abstract: One hundred seventy-nine patients with root avulsion brachial plexus injuries were treated with direct nerve crossing with the intercostal nerve and 159 cases were followed more than 1 1/2 years after the operation. When suture was done to the musculocutaneous nerve, 90% of 10 children who had operation within 7 months of injury and 81.8% of 110 adults, younger than 40 years with operation within 6 months of injury regained grade 3 or 4 elbow flexion power. This direct method seems to produce better results than those of nerve crossing, which uses intermediary nerve grafts.
191 citations
TL;DR: Anterior intramuscular transposition is a seldom considered alternative to other surgical methods in management of cubital tunnel syndrome and places the ulnar nerve anteriorly within the flexor-pronator mass removes it from a vulnerable subcutaneous position without extensive dissection.
Abstract: Anterior intramuscular transposition is a seldom considered alternative to other surgical methods in management of cubital tunnel syndrome. Placement of the ulnar nerve anteriorly within the flexor-pronator mass removes it from a vulnerable subcutaneous position without extensive dissection. Of 52 sequential procedures, 45 extremities in 40 persons were available for follow-up (mean, 28 months after operation). By use of a 12-point scale of objective and subjective parameters, there were 87% good or excellent results; 4% were graded fair, and 9% were graded poor. Age, duration of symptoms, and conduction velocity were not of prognostic value. Although 69% of patients had other compressive neuropathy or tendinitis, this did not adversely affect results. Those with changes seen by electromyogram or work-related compensable injury had a poorer prognosis.
TL;DR: The tenodesis is a reliable, reproducible salvage procedure for stabilizing the degenerated distal radioulnar joint and for salvaging the symptomatic unstable ulna after excessive distal ulna resection.
Abstract: A procedure for stabilizing the distal ulna using the extensor carpi ulnaris and flexor carpi ulnaris is described. Seven patients who had sustained posttraumatic distal ulnar dorsal instability and articular degeneration and one patient with instability caused by rheumatoid arthritis were operated on. All eight obtained stable ulnae with mean motion of 62 degrees of supination and 86 degrees of pronation (mean increase of 32 degrees of supination and 43 degrees of pronation). Follow-up averaged 28 months (range, 18 to 63 months). The tenodesis, using a weave of a distally-based slip of flexor carpi ulnaris and a proximally-based slip of extensor carpi ulnaris combined with a Darrach procedure, is a reliable, reproducible salvage procedure for stabilizing the degenerated distal radioulnar joint and for salvaging the symptomatic unstable ulna after excessive distal ulna resection.
TL;DR: It is believed that division of the transverse carpal ligament restores median nerve function by increasing the volume of the carpal canal by an anterior displacement of the newly formed transverseCarpal canal ligament and not from a widening of the bony carpal arch.
Abstract: We describe the morphologic changes that follow division of the transverse carpal ligament in patients with carpal tunnel syndrome. Fifteen hands in 12 patients with carpal tunnel syndrome were studied with magnetic resonance imaging before operation and for 6 weeks after operation. Eight hands were studied at 8 months after operation. Carpal arch width, anterior displacement of the carpal canal contents, and carpal canal volume were measured by use of multiplanar reformation and three-dimensional reconstruction of magnetic resonance images. There was a 24.2 +/- 11.6% increase in carpal canal volume 6 weeks after carpal tunnel release (p less than 0.001). This difference persisted at 8-month follow-up. There was an anterior displacement of carpal canal contents 3.5 +/- 1.9 mm from its original position 6 weeks after operation (p less than 0.001). This palmar displacement persisted at the 8-month follow-up. There was no statistically significant increase in carpal arch width 8 months after carpal tunnel release. We believe that division of the transverse carpal ligament restores median nerve function by increasing the volume of the carpal canal. This volumetric increase results from an anterior displacement of the newly formed transverse carpal ligament and not from a widening of the bony carpal arch.
TL;DR: The anatomy of 55 cadaver digits was studied, both statistically and with simulated active motion using weights attached to the flexor tendons, and showed two types of bowstringing that affected the relationship of tendon excursion to joint motion.
Abstract: The anatomy of 55 cadaver digits was studied, both statistically and with simulated active motion using weights attached to the flexor tendons. The modified description of Doyle and Blythe accurately described the anatomy observed. Serial pulley sectioning showed two types of bowstringing, both of which affected the relationship of tendon excursion to joint motion. The most constant, resulting in 15% loss of motion for a fixed tendon excursion, occurred over the concave surfaces of the proximal and middle phalanges. Bowstringing at the proximal interphalangeal joint was present only after 30 degrees of flexion had occurred, because of the convexity of the phalangeal condyles.
TL;DR: A biomechanical study in vitro has evaluated a new modification of the core and peripheral suture technique for flexor tendon repair involving a 'Halsted' horizontal mattress technique for the peripheral stitch.
Abstract: A biomechanical study in vitro has evaluated a new modification of the core and peripheral suture technique for flexor tendon repair. Groups of repairs were conducted in cadaver tendons, using a core suture alone, a core suture with a simple running surface suture and a new modification involving a 'Halsted' horizontal mattress technique for the peripheral stitch. The Halsted modification increased the load at which a visible gap formed by 93%, the load at which a 2 mm gap formed by 77%, and the maximum strength by 89%. This increase was due to the technique; it did not depend on the suture material used. The bulk of the tendon repair was not significantly greater with the Halsted modification.
TL;DR: The experience with the management of 93 consecutive patients with 108 trigger digits initially treated by triamcinolone acetonide injections into the flexor tendon sheath concludes that two distinct clinical types of trigger digits exist--nodular and diffuse.
Abstract: This article reports our experience with the management of 93 consecutive patients with 108 trigger digits initially treated by triamcinolone acetonide injections into the flexor tendon sheath. It appears that two distinct clinical types of trigger digits exist—nodular and diffuse. Ninety—three percent (63/68) success was obtained in the nodular type compared with 48% (10/33) in the diffuse type ( p
TL;DR: Observations suggest that algodystrophy of the hand is a more common complication of Colles' fracture than is generally realised.
Abstract: The prevalence of algodystrophy in the hand was determined at nine weeks and six months following Colles' fracture. At nine weeks, 27 of 109 patients showed signs of algodystrophy, all of whom demonstrated more than one feature of the disorder. Thereafter, no unaffected patient developed the disorder. At six months, 62% of the previously affected patients showed some residual abnormalities. In 66% of these, there was evidence of continuing vasomotor instability or swelling, suggesting that the syndrome was still active. These observations suggest that algodystrophy of the hand is a more common complication of Colles' fracture than is generally realised.
TL;DR: Among 1140 patients treated for any type of carpal fracture, dislocation, or subluxation, 16 patients seen with a traumatic axial disruption of both the carpus and metacarpus were identified, and prognosis was determined more by the associated soft tissue injuries than by the carpal derangement itself.
Abstract: Among 1140 patients treated in the last 16 years for any type of carpal fracture, dislocation, or subluxation, 16 (1.4%) patients seen with a traumatic axial disruption of both the carpus and metacarpus were identified. Most of these were crush or blast injuries. According to the direction of instability, the cases were classified into three groups: axial-ulnar disruptions (4 patients), axial-radial disruptions (11 patients), and combined axial-radial-ulnar disruption (1 patient). Treatment consisted of open reduction and percutaneous Kirschner-wire fixation in most cases. The results were less optimistic than suggested in the literature. An average follow-up of 61 months showed that prognosis was determined more by the associated soft tissue injuries than by the carpal derangement itself. Early management of both the skeletal and soft tissue components of the injury seems most effective.
TL;DR: Retrospective analysis of 48 medial epicondylectomy procedures in 46 patients demonstrated that symptomatic and objective improvement was usual and Medial epicondYlectomy is a safe and predictable procedure for the treatment of symptomatic cubital tunnel syndrome.
Abstract: Retrospective analysis of 48 medial epicondylectomy procedures in 46 patients demonstrated that symptomatic and objective improvement was usual. Most patients experienced improvement of symptoms (98%) and moving two-point discrimination (87%), and many demonstrated improved motor strength (54%). By use of the McGowan scheme for grading ulnar neuropathy, 92% of the patients with grade I neuropathy had a return to normal function. Subdividing patients with grade II neuropathy into grade IIA and IIB on the basis of the extent of motor compromise was useful in predicting postoperative outcome. Forty-five percent of the patients with grade IIA neuropathy had a return to normal ulnar nerve function and only 11% (one patient) in the IIB group had a full recovery. In the group with grade III neuropathy, one patient had improvement to grade II level and the other five remained grade III. No patient in this study demonstrated deterioration of his McGown grade. Medial epicondylectomy is a safe and predictable procedure for the treatment of symptomatic cubital tunnel syndrome.
TL;DR: It is concluded that intrasynovial injection of a steroid compound is the appropriate initial treatment for trigger fingers and thumbs.
Abstract: One hundred eight trigger fingers and thumbs in 74 consecutive patients were treated by injections of triamcinalone and followed for an average of 3 1/2 years. Minimum follow-up was 1 year. Eighty four percent of trigger fingers and 92% of trigger thumbs were cured with a single injection, and a repeat injection for treatment of recurrent symptoms raised these figures to 91% and 97%, respectively. All injections were done by one physician. There were no complications. We conclude that intrasynovial injection of a steroid compound is the appropriate initial treatment for trigger fingers and thumbs.
TL;DR: Hyaluronic acid had a beneficial effect on both the repair site and synovial sheath by decreasing the peripheral inflammatory response and promoting a contact healing process via epitenon and endotenon cell involvement in the repair process.
Abstract: This study assesses the effect of a preparation of hyaluronan (hyaluronic acid) applied topically at the time of flexor tendon repair in a well-established model. The hypothesis is that hyaluronic acid applied topically at the time of flexor tendon repair will decrease adhesions, and will improve clinically the gliding function of the repaired flexor tendon. After transect ion and repair of the second and fifth flexor tendons of the left forepaw of four mongrel dogs, the second flexor tendon was treated with hyaluronic acid of molecular weight 3.6 x 10 6 daltons applied topically between the synovial sheath and the repair site. The left forepaws were completely immobilized for 5 weeks to optimize the formation of adhesion ingrowth. After death, the repaired tendons and sheaths were removed en bloc, fixed, and dissected. Gross inspection and histologic evaluation of all tendons showed that the quality and quantity of adhesions from the wound repair to the synovial sheath appeared to have been consistently affected by hyaluronan. Hyaluronic acid had a beneficial effect on both the repair site and synovial sheath by decreasing the peripheral inflammatory response and promoting a contact healing process via epitenon and endotenon cell involvement in the repair process.
TL;DR: The scaphoid was shown to lose its role in the adaptative mechanism that allows preservation of articular congruency to the always changing space between the distal carpal row and the radius, and increased sliding motion of the lunate on the radius was found.
Abstract: Two limited intercarpal fusions, scapho-trapezial-trapezoidal and scapho-capitate, were simulated in six fresh human cadaver wrists by means of two Herbert screws. By use of a biplanar radiographic measurement system, the relative kinematic behavior of selected carpal bones, before and after the simulated limited fusions could be analyzed. Both scapho-trapezialtrapezoidal and scapho-capitate fusions produced a similar reduction in global range of motion and comparable effects on the relative intracarpal motion. In both fusions, a significant reduction in relative motion at the lunocapitate joint was recorded. The scaphoid, being fused to the distal carpal row, was shown to lose its role in the adaptative mechanism that allows preservation of articular congruency to the always changing space between the distal carpal row and the radius. After both types of fusion, increased sliding motion of the lunate on the radius was found. These kinematic changes are likely to enhance shear stresses on the lunate and tension on the surrounding ligaments, potentially diminishing long-term functional results.
TL;DR: Stainless steel and monofilament polyglyconate appeared to be the most suitable in that they had high tensile strengths, both knotted and unknotted, and had good knot-holding security.
Abstract: The following suture materials have been evaluated for their suitability for use in flexor tendon repairs: 4/0 gauge monofilament and multifilament stainless steel, mono-filament nylon, monofilament polypropylene, monofilament polybutestor, braided polyester, braided polyglycolic acid and a monofilament polyglyconate. These were investigated for their tensile strength (both knotted and unknotted), their extension to failure and knot-holding properties. Stainless steel and monofilament polyglyconate appeared to be the most suitable in that they had high tensile strengths, both knotted and unknotted, and had good knot-holding security. The only disadvantages are that stainless steel is difficult to use and monofilament polyglyconate is absorbable. Polypropylene and braided polyester, although having lower tensile strengths, are reasonable alternatives.
TL;DR: This study evaluates the time required for grip and pinch strength to return to preoperative levels after carpal tunnel release, finding data should prove useful in predicting when patients may be able toreturn to their previous level of occupational-related activity.
Abstract: This study evaluates the time required for grip and pinch strength to return to preoperative levels after carpal tunnel release. Grip strength was 28% of preoperative level at 3 weeks; 73% by 6 weeks, and returned to the preoperative level by 3 months. At 6 months grip strength was found to increase to 116%. Pinch strength returned sooner being 74% of preoperative level at 3 weeks and 96% by 6 weeks. By 3 months an increase to 108% was seen and at 6 months an increase to 126% of preoperative levels was found. This data should prove useful in predicting when patients may be able to return to their previous level of occupational-related activity.
TL;DR: A dynamic splinting program opposite to the one that is used for flexor tendon repair is used, with an outrigger splint holding the fingers in extension and allowing full active flexion, and all patients recovered full flexion.
Abstract: Extensor tendon injuries are traditionally splinted with no motion for 3 to 4 weeks after repair. This may result in limitation of flexion because of extensor tenodesis at the site of repair. To prevent this, we used a dynamic splinting program opposite to the one that is used for flexor tendon repair, with an outrigger splint holding the fingers in extension and allowing full active flexion. Fifty-two patients who had extensor tendon repairs in the area from the wrist to the middle of the proximal phalanx were treated. Motion was begun 2 to 5 days after repair and was continued for approximately 5 weeks. No tendon ruptures occurred, and all patients recovered full flexion.
TL;DR: Treatment consisted of unrestricted exercises without any splintage or attempts at reduction, irrespective of the degree of angulation of the fractures, although 14% of patients noted minor cosmetic deformity.
Abstract: Sixty two patients with fractures of the neck of the little finger metacarpal have been studied. Treatment consisted of unrestricted exercises without any splintage or attempts at reduction, irrespective of the degree of angulation of the fractures. Patients were reviewed at one or two-weekly intervals until movement had recovered and return to work was possible. One year after injury, patients were recalled for examination. Recovery was rapid with no long-term functional restriction, although 14% of patients noted minor cosmetic deformity.
TL;DR: Clinical postarthrodesis wrist motion is a combination of intercarpal and radiocarpal mechanics, with energy in the flexion and extension arc dissipated through the scapho-lunate interface.
Abstract: The effect of scapho-trapezio-trapezoid arthrodesis on wrist kinematics was studied in 25 patients with chronic static scapho-lunate instability and in 16 patients with dynamic instability, with follow-up ranging from 24 to 101 months (average, 56 months). Postoperative planar and cine-radiographic examination in patients returning to heavy labor reveal an absence of carpal shift-influence of the scaphoid proximal pole on the lunato-triquetral unit in ulnar deviation. Scapho-lunate diastasis present before operation persists in ulnar deviation as the STT fusion mass, capitate, and hamate rotate with the hand into ulnar deviation; the lunato-triquetral unit is not physiologically "pulled" radially into the lunate fossa of the radius. Triquetro-hamate mechanics remain normal as active engagement along the helicoidal triquetro-hamate interface initiates proximal row dorsiflexion. Clinical postarthrodesis wrist motion is a combination of intercarpal and radiocarpal mechanics, with energy in the flexion and extension arc dissipated through the scapho-lunate interface. The paucity of arthritic changes after up to 101 months after surgery is based on the kinematic changes presented in these data.
TL;DR: The flexor tendon sheath in the fingers is a synovial-lined, fibroosseous tunnel with segmental condensations of fibrous tissue, and fibrous bands or pulleys are: the palmar aponeurosis pulley, five annular pulleys, and three cruciform pulleys.
Abstract: The flexor tendon sheath in the fingers is a synovial-lined, fibroosseous tunnel with segmental condensations of fibrous tissue. These fibrous bands or pulleys are: (1) the palmar aponeurosis pulley (formed by the transverse fibers of the palmar aponeurosis), (2) five annular pulleys, and (3) three cruciform pulleys. The second and fourth annular pulleys are the largest, thickest, and most constant in form and incidence. The first, third, and fifth annular pulleys are less constant in shape and incidence as are the cruciform pulleys. No other pulleys have been identified in this study.
TL;DR: Digital sensibility and joint motion after replantation were better in these patients who had sharp amputations and on whom repairs were carried out in zone III, and return of intrinsic muscle function after hand replantations was poor; however, patient satisfaction with the procedures remained high.
Abstract: During the past 4 years we performed 261 replantations and revascularizations on amputated digits and hands in 153 patients. The overall survival rate was 82%. Clean-cut proximal level amputations and hypothermically preserved amputation parts had the highest survival rate. A higher survival rate and more satisfactory results with accelerated return of sensory function correlated with repair of both digital arteries and two veins rather than only one. All patients experienced intolerance to cold, but this was more troublesome in patients with digital replantation in whom only a single artery was repaired. Digital sensibility and joint motion after replantation were better in these patients who had sharp amputations and on whom repairs were carried out in zone III. Return of intrinsic muscle function after hand replantation was poor; however, patient satisfaction with the procedures remained high.