High-pressure injection injuries to the hand are uncommon soft tissue traumas of the hand which are frequently underestimated. They are, however, not uncommon among workers in industry using paint, automotive grease, solvents and diesel oil. The prognostic factors are the type, amount and temperature of the material and the pressure of injection. The results of 14 surgically treated high-pressure injection injuries of the hand with a minimum of two years follow-up are reported. Ten cases required soft tissue debridement and foreign body removal. Six required reconstructive microsurgical procedures and one underwent digital tip amputation, which followed major and devastating soft tissue problems. In the present study, we describe the mechanism of the soft tissue damage and the principles of treatment. This study confirms the fact that high-pressure injection injury to the hand is a significant problem, which can easily lead to serious sequelae and, even, amputation.
This study evaluated the flexor digitorum profundus quadriga effect by mimicking stiffness of one finger and observing its effect on the strengths of the other three fingers of the same hand. Thermoplastic wedges were used to simulate mild, moderate and severe stiffness of each finger and the individual strengths of each finger during power grip were measured using a digit-grip (TM) dynamometer in ten healthy adult volunteers. Middle, ring, and little fingers strength diminished significantly (P < 0.05) when each of the other fingers, including the index, was stiffened. Index finger strength was largely unaffected by simulated stiffness of the other fingers. The degree of simulated stiffness influenced the strength of the other fingers, but there was considerable intersubject variability, suggesting that the significance of the quadriga effect varies between individuals. An anatomical basis for our findings is suggested.
First carpometacarpal joint arthritis is a common condition encountered by hand surgeons. Traditionally, surgical approaches have included arthrodesis, trapeziectomy or reconstructive arthroplasty techniques. Previously, we described a technique for arthroscopic debridement and interposition arthroplasty of the first carpometacarpal joint. Patients with Eaton stages II and III symptomatic first carpometacarpal joint arthritis recalcitrant to >6 months of non-operative therapy underwent arthroscopic debridement of the first carpometacarpal joint with interposition of an acellular dermal matrix allograft (GRAFTJACKET™). In this paper, we describe outcomes following this procedure. Postoperatively, all patients reported symptomatic relief and 94% stated that they were partially, or completely, satisfied. More than 70% of patients reported no to mild difficulty in performing activities of daily living (average grip strength = 18.5 kg, pinch strength = 3.9 kg). Complications were minimal. Outcomes from this study compare favourably to those of other series, demonstrating that this technique is a viable option for treatment of Eaton stages II and III first carpometacarpal arthritis.
This study investigated the effect on the power and function of the hand of loss of finger(s) extension, number of fingers involved and the patient's age in Dupuytren's disease and the influence of improvement of finger extension and the patient's age on these variables after surgery. Median values at presentation included total loss of extension 80 degrees, total grip strength 41 kg and DASH score 54. Twelve months postoperatively, the median value of total loss of extension decreased to 10 degrees and the DASH score to 32 (both significant improvements). Grip strength decreased slightly to 40 kg. The severity of the contracture had no significant effect on function but had a significant negative effect on power. The number of fingers involved affected neither function nor power. The age of the patient did not influence function of the hand. However, older patients experienced less functional benefit from surgery. The improvement of finger extension following surgery had significant beneficial effect on function, but no effect on power.
This prospective study was performed to evaluate the clinical and radiological results of radiocarpal joint arthrodesis in the treatment of unstable Simmen group III and Larsen grade II or III rheumatoid wrists. Radiolunate arthrodesis was performed in 16 wrists and radioscapholunate arthrodesis in 7 wrists in 20 patients. When they were evaluated at a mean of 5.8 (range 3.5-9.8) years later, flexion was 29 degrees and extension 34 degrees , representing 67% and 92% of the preoperative values, respectively. Patient satisfaction was excellent, or good, for 20 wrists and satisfactory for 1 wrist. In two patients with poor satisfaction, arthritis progressed to the midcarpal joint and necessitated total arthrodesis of the wrist. Radiolunate joint arthrodesis, with inclusion of the scaphoid in the fusion if necessary, is a useful operation in the treatment of this degree of wrist disease as it produces a functional and pain-free wrist at the same time as preserving much of the mobility and bone stock.
Dislocations of the carpometacarpal joints of the ring and little fingers are common and are frequently missed at presentation. We describe a radiographic observation which assists in the confirmation of the diagnosis.
This paper reports the case of a 26-year-old Caucasian male with an aggressive digital papillary adenocarcinoma of his right index finger. Aggressive digital papillary adenocarcinoma is a rare tumour arising from sweat glands which occurs characteristically on the hands, fingers and toes. It has a high rate of local recurrence and can metastasise, occasionally resulting in mortality.
Painful neuromas following injury to the radial side of the wrist can be treated by relocation away from the zone of injury and implantation into muscle. Relocation to the brachialis muscle is useful for isolated neuromas of the lateral antebrachial cutaneous nerve and involves a shorter dissection than relocation to the brachioradialis. It is also useful in patients undergoing multiple procedures to avoid disturbing previous relocations to the brachioradialis. This paper describes the successful relocation of painful neuromas of the lateral antebrachial cutaneous nerve to the brachialis muscle in seven patients.
Forearm-based Bier’s block has been advocated as a useful anaesthesic technique in hand surgery. However, there is limited data comparing forearm blocks with the conventional Bier’s block. We conducted a randomised controlled trial ( n = 30) comparing the two techniques of anaesthesia for manipulation and reduction of closed distal radius fractures in an emergency room setting. Pain scores measured using the Visual Analogue Scale during the procedure were used as the primary outcome assessment. There was no significant difference in pain scores between the forearm and conventional Bier’s block (mean VAS 18.4 SD 22.10 versus 33.7 SD 29.6). No major complications were observed in either group. The forearm-based Bier block is an effective alternative to the conventional block.
This study investigated the relationship between socioeconomic deprivation and the incidence, patterns of injury, process of care and outcome of hand trauma using data collected prospectively on 1,234 injuries presented during six months. The Index of Multiple Deprivation 2004 was derived from census data and postcodes. Socioeconomic deprivation is significantly associated with hand trauma. The odds ratio for suffering hand injuries in the most deprived quintile is 1.6 (SE 0.09 95% CI 1.45, 1.83) compared to the least deprived quintile. This is most marked among older children and adults. Fractures, sprains and ligament injuries showed the strongest association with the degree of deprivation. Injuries related to sport were not associated with deprivation. Surgical time utilised is greater in more deprived patients and their self reported physical outcome is worse. Hand surgery units working in areas of high socioeconomic deprivation will have higher trauma workloads and unit costs. Social deprivation may also influence physical outcomes.
The internal consistency and validity of the Patient Evaluation Measure (PEM) was investigated in the setting of the distal radius fracture by assessing 200 patients 6 to 42 years after injury using the PEM and DASH questionnaires and objective measures of outcome. The PEM was completed separately for both the injured and uninjured wrist. We found highly significant correlations between the PEM and objective measures and, also, between the PEM and DASH scores. We also calculated a comparative PEM score by subtracting the score of the uninjured wrist from that of the injured side, to eliminate the effect of co-existing disease. This score was more strongly correlated with outcome than the PEM alone. We suggest that the PEM is a valid method of assessing distal radial fracture outcome. It may, also, be used to reduce the effect of symptoms from coexisting bilaterally represented pathologies.
Transfer of the abductor pollicis longus tendon to restore index abduction was performed simultaneously with ulnar nerve decompression in severe cases of cubital tunnel syndrome. Eighteen elbows in 18 patients were evaluated with an average follow-up period of 46 (range 12–120) months. The status of the ulnar nerve palsy was evaluated by the Yasutake’s scoring method. The mean score improved from 48 points pre-operatively to 78 points at final follow-up (maximum score 100 points). Pinch strength improved from 39% of the opposite side pre-operatively to 81% finally and it reached a plateau one year postoperatively. Despite this improvement in pinch strength, atrophy of the interosseous muscle did not disappear in nine of 12 patients with a follow-up of more than two years. All patients were satisfied with the results of increased strength and stability in pinching ability. No complications occurred.
A cohort of 119 patients with carpal tunnel syndrome completed the questionnaire of the Dutch version of the DASH score pre-operatively and one year postoperatively. The mean DASH score decreased from 38.2 to 22.0. There was a significant correlation with the Boston carpal tunnel outcome score (r=0.78). With an effect size of 0.87 and a standardized mean response of 0.69, the Dutch version of the DASH is highly responsive for the evaluation of the outcome of surgery for carpal tunnel syndrome.
This case reports another cause of delayed rupture of the extensor pollicis longus tendon in children following radial fracture management, due to attrition over a protruding nail end after elastic stable intramedullary nailing using the technique recommended to allow nail removal.
This study describes the predictors for cold intolerance and the relationship to sensory recovery after median and ulnar nerve injuries. The study population consisted of 107 patients 2 to 10 years after median, ulnar or combined median and ulnar nerve injuries. Patients were asked to fill out the Cold Intolerance Severity Score (CISS) questionnaire and sensory recovery was measured using Semmes–Weinstein monofilaments. Fifty-six percent of the patients with a single nerve injury and 70% with a combined nerve injury suffered abnormal cold intolerance. Patients with no return of sensation had dramatically higher CISS-scores than patients with normal sensory recovery. Females had higher CISS scores post-injury than males. Cold intolerance did not diminish over the years. Patients with higher CISS scores needed more time to return to their work. Age, additional arterial injury, site or type of the injury and dominance of the hand were not found to have a significant influence on cold intolerance.
Primary giant cell tumours involving digital bones of the hand are rare lesions which are generally diagnosed at an advanced stage. Accurate diagnosis requires clinical evaluation, imaging studies and histopathological assessment. Conservative treatment by digit-sparing surgery is associated with high recurrence rates. In a ten year retrospective review, this study identified only four cases. Three cases involved a phalanx and were treated by distal amputation of the involved digit. None recurred. One involved the metacarpal and recurred twice following repeated curettage and bone grafting. No further recurrence has been detected after resection and replacement with a non-vascularised fibular graft and Silastic implant replacement of the metacarpophalangeal joint. Our small series of cases supports a policy of aggressive primary surgery, including amputation or en bloc resection and reconstruction.
Trigger wrist is a relatively rare phenomenon. The pathological entities to which the term trigger wrist is applied are not well defined in the literature. We present three cases of trigger wrist as a result of flexor tendon pathology, review the literature and discuss the use of the term "trigger wrist".
The cross-finger flap has been used successfully for decades. Traditionally, the flap is elevated in the plane lying superficial to the extensor tendon. This damages the delicate subcutaneous tissues, which are important for the lengthening capacity of the skin of the dorsum of the fingers during flexion and extension. In this report, we present a modification of elevation of the cross-finger flap in a plane superficial to the dorsal veins of the fingers. This modification prevents donor finger complications such as poor graft take, extensor tendon adhesion to the graft and reduced range of finger joint movement and contour deformities. We have used this technique in six digits in four patients with successful results.
We measured the alignment of the nails in the hands of 100 normal adults with the interphalangeal joints extended and the metacarpophalangeal (MCP) joints at 0 degrees and 90 degrees. All fingers were naturally supinated (i.e. rotated towards the thumb), the index and little being the most supinated. When examining individual hands in MCP joint extension, only 17% of hands had all nails parallel. With the MCP joints flexed, this improved to 56%. If the little finger was excluded, this improved to 78%. When comparing matching fingers from the two hands, 76% of little, 83% of ring, 77% of middle and 80% of index fingers matched. Thumbnails were assessed in extension and found to match the other side in 95% of individuals. This study identifies that examination of the injured hand alone with all joints extended is an unreliable method of assessing malrotation following fracture, especially in the little finger. Comparing matching fingers in the two hands is more reliable, but there is still substantial variation in approximately 20% of normal individuals.
