Hand (Hand)

Publications in this journal

• Article: Clinical diagnosis and wide-awake surgical treatment of proximal median nerve entrapment at the elbow: a prospective study

  Elisabet Hagert
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  ABSTRACT: Background Proximal median nerve entrapment (PMNE, or pronator syndrome) at the elbow has traditionally been considered an elusive and rare diagnosis, as it is seldom detectable using electrophysiological techniques. In this paper, the clinical manifestations, physical diagnosis, surgical technique, and results of surgical treatment of PMNE are presented, with accompanying instructional video. Patients/Methods During 2011, 44 patients with PMNE were surgically released and followed prospectively, 22 women/22 men, mean age 48.8 (range 25–66). The patients were equally distributed between right/left hands (23/21) and the dominant hand was treated in 56 % of cases. The diagnosis was based on: (1) weakness in median innervated muscles distal to the lacertus fibrosus; (2) pain upon pressure over the median nerve at the level of the lacertus fibrosus; and (3) positive scratch collapse test. A minimally invasive surgical treatment using only local anesthesia with lidocaine–epinephrine and no tourniquet was used, and direct perioperative return of strength in median innervated muscles was seen in all subjects. Results The average preoperative quick DASH was 35.4 (range 6.8–77.2); work DASH, 44.3 (6.25–100); and activity DASH, 61.6 (12.5–100). There were 71.1 % patients who completed the 6-month follow-up, and the average postoperative quick DASH was 12.7 (range 0–43.1), which is a statistically significant reduction (p<0.0001; Student’s paired t test). Similarly, the work and activity DASH was significantly reduced (p<0.001) to 12.5 (0–75) and 6.25 (0–50), respectively. Conclusions PMNE at the level of the lacertus fibrosus should be called lacertus tunnel syndrome to distinguish it from other levels of median nerve entrapment. It is a clinical diagnosis based on three distinct clinical findings: weakness, pain over point of compression, and positive scratch collapse test. Surgical release in local anesthesia allows for a safe, ambulatory, and cost-efficient procedure with low morbidity. Keywords Entrapment . Median nerve . Pronator syndrome . Surgery .Wide-awake
  Hand 01/2013; 8(1):41-46.
• Article: Minimally invasive technique for release of Dupuytren’s contracture: segmental fasciectomy through multiple transverse incisions

  Eon Kyu Shin, Neil Ford Jones
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  ABSTRACT: BackgroundA multitude of operative approaches have been described for treatment of Dupuytren’s contracture. A less-invasive technique of segmental fasciectomies performed through multiple small transverse incisions is presented. MethodsSeventy-three digits in 37 patients were treated with segmental fasciectomies. The results of 34 digits in 14 patients are described with subsequent follow-up longer than 2years. ResultsMetacarpophalangeal joint extension improved from a mean of 32.5° to 2.2°, while proximal interphalangeal joint extension improved from 22.9° to 4.1°. Patients subjectively rated their surgical outcomes as excellent or good in 91.2% of cases. No recurrence of the disease was noted, though extension of the disease to adjacent digits was observed in three patients. ConclusionsThough this approach is technically demanding and requires the help of a skilled assistant, this preliminary study supports our contention that this less-extensive procedure allows excellent correction of contractures; results in mild postoperative pain; and permits a rapid return of finger flexion with satisfactory long-term results so far at 2-years follow-up. KeywordsDupuytren’s contracture–Fibromatosis–Segmental fasciectomy–Transverse incision
  Hand 04/2012; 6(3):256-259.
• Article: Agreement between Initial Classification and Subsequent Reclassification of Fractures of the Distal Radius in a Prospective Cohort Study

  Roderick H. van Leerdam, J. Sebastiaan Souer, Anneluuk L. C. Lindenhovius, David C. Ring
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  ABSTRACT: We tested the hypothesis that the original surgeon-investigator classification of a fracture of the distal radius in a prospective cohort study would have moderate agreement with the final classification by the team performing final analysis of the data. The initial post-injury radiographs of 621 patients with distal radius fractures from a multicenter international prospective cohort study were classified according to the Comprehensive Classification of Fractures, first by the treating surgeon-investigator and then by a research team analyzing the data. Correspondence between original and revised classification was evaluated using the Kappa statistic at the type, group and subgroup levels. The agreement between initial and revised classifications decreased from Type (moderate; Κ type = 0.60), to Group (moderate; Κ group = 0.41), to Subgroup (fair; Κ subgroup = 0.33) classifications (all p < 0.05). There was only moderate agreement in the classification of fractures of the distal radius between surgeon-investigators and final evaluators in a prospective multicenter cohort study. Such variations might influence interpretation and comparability of the data. The lack of a reference standard for classification complicates efforts to lessen variability and improve consensus. KeywordsDistal radius fractured-Prospective cohort-Classification-Agreement
  Hand 04/2012; 5(1):68-71.
• Article: Isolated Symmetrical Brachymetacarpia of the Thumb—Case Report

  S. S. Suresh, Raju Abraham, Pullanikattil Ravi
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  ABSTRACT: The authors report a case of isolated symmetrical metacarpia of the first metacarpal in a 33-year-old serving soldier. The patient was totally unaware of the deformity, which was found incidentally while radiographs were done for the wrist to rule out scaphoid fracture. To the best of our knowledge, there have been no similar reports in the English literature before.
  Hand 04/2012; 4(4):424-426.
• Article: Sarcoidosis Presenting as a Proximal Phalangeal Bony Swelling—a Case and Review of the Literature

  Andrew D. Duckworth, Adam T. Hill, Ian Beggs, James T. Patton, Donald M. Salter, Daniel E. Porter
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  ABSTRACT: We report a case of a 27-year-old man who presented with a progressive painful swelling at the base of his left index finger, with radiographs and a computed tomography scan revealing a lytic lesion of the proximal phalanx. Following further investigation, the patient underwent a bone biopsy that revealed a florid noncaseating granulomatous chronic inflammatory infiltrate, compatible with sarcoidosis. Osseous sarcoidosis of the hand is uncommon and, in the absence of significant systemic disease, is rarely the primary presenting feature. Early diagnosis and treatment of such undetermined bone pathology, via referral to a regional musculoskeletal tumor service, can prevent significant future complications. KeywordsCaseating granuloma-Osseous sarcoidosis-Phalanx-Sarcoidosis
  Hand 04/2012; 5(1):90-94.
• Article: Flexor Tenorrhaphy Tensile Strength: Reduction by Cyclic Loading

  C. E. R. Gibbons, D. Thompson, M. J. Sandow
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  ABSTRACT: The integrity of the repair is critical to maintain coaptation of the severed flexor tendon end until healing has advanced sufficiently. In our hospital, we use a modified Savage repair (four-strand Adelaide technique) using 3–0 Ethibond (Ethicon, Somerville, NJ, USA) for acute flexor tenorrhaphy and an active postrepair mobilization protocol. To explain the apparent differences between the theoretical and actual repair strength of a multistrand repair in a single tension test and the reduced strength of a repair subjected to cyclic loading, we compared single and cyclical tensile loading with different suture in vitro configurations of 3–0 Ethibond (Ethicon, Somerville, NJ, USA; one, two, and four strands) and an ex vivo four-strand repair of freshly divided porcine tendon to calculate the ultimate tensile strength (UTS). Mechanical testing was repeated 15 times with both single tensile and cyclical loading for each suture configuration and porcine repair. In the in vitro model, the presence of a knot in a single strand reduced the UTS by 50%. The stiffness of a knotted strand was substantially less than the unknotted strand but became identical after cyclical loading. There was no statistical significance of the UTS between single and cyclical loading with different numbers of strands in this model. In the ex vivo four-strand porcine repair model, there was a significant reduction in UTS with cyclical loading, which equated to the number of strands times the strength of the knotted strand. This discrepancy can be explained by the change in stiffness of the knotted strand after cyclical loading and has important implications for previous studies of suture tendon repair using single tensile loading where the UTS may have been overestimated. We believe that cyclical loading is more representative of physiological loading after acute flexor tendon repair and should be the testing model of choice in suture tenorrhaphy studies.
  Hand 04/2012; 4(2):113-118.
• Article: Modification of Blood Vessel Diameter Following Perivascular Application of Botulinum Toxin-A

  Peter B. Arnold, Chris A. Campbell, George Rodeheaver, Wyndell Merritt, Raymond F. Morgan, David B. Drake
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  ABSTRACT: The purpose of this study was to demonstrate that perivascularly applied botulinum toxin-A (BTX) increases the diameter of treated blood vessels in a rat femoral vessel exposure model. Six adult Sprague–Dawley rats were used and bilateral femoral artery and vein exposures were performed. Five units of BTX were applied to the experimental side and an equal volume of sterile saline was applied to the control side. Digital images of the vessels were obtained at the following time points: pretreatment, immediately posttreatment, and postoperative days (POD) 1, 14, and 28. Vessel diameters were equivalent at baseline and immediately following application of BTX and saline. The BTX artery was significantly larger than the control artery on POD1 and 14. The BTX treated artery was significantly larger than all other vessels on POD14 (p < 0.05) as well as all prior time points (p < 0.01). Direct perivascular application of BTX increases the diameter of rat femoral vessels as early as POD1. The affect is most robust on POD14 where the artery was significantly larger than all other vessels at all time points. It is likely that the increased diameter of blood vessels results in an increased blood flow across the area of dilation. Such an increase in flow may serve to improve end-organ perfusion in microvascular procedures.
  Hand 04/2012; 4(3):302-307.
• Article: End-of-Skin Grafts in Syndactyly Release: Description of a New Flap for Web Space Resurfacing and Primary Closure of Finger Defects

  Ramesh Kumar Sharma, Puneet Tuli, Surinder Singh Makkar, Atul Parashar
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  ABSTRACT: Treatment of syndactyly necessitates creation of neo-web space and separation of fingers. Traditionally, this has been done by use of flaps taken from the dorsum; the resultant raw areas thus created have been managed by use of skin grafts. The classical teaching has been that the separated fingers will need skin graft as primary closure is not possible. The skin grafts have a tendency to contract and lead to finger flexion contractures and “creep” of the web space. We describe a flap based upon subcutaneous tissue in the web that is moved in a V–Y fashion to resurface the neo-web. The flap donor site can easily be closed primarily. The fingers are then separated; the subcutaneous fat is carefully removed from the finger flaps under magnification to allow primary closure of the finger defects. It has been possible to primarily close the donor site and fingers in all the patients. The procedure has been used in seven patients with 14 web releases. The age varied between 10months to 3years. The V–Y advancement flap based upon the subcutaneous pedicle in the region of the web allows adequate creation of a new web space. The careful de-fattening of skin flaps allows the separated fingers to be closed primarily.
  Hand 04/2012; 4(1):29-34.
• Article: Outcome of Boxer’s Fractures Treated by a Soft Wrap and Buddy Taping: A Prospective Study

  Jan van Aaken, Stephan Kämpfen, Martin Berli, Daniel Fritschy, Dominique Della Santa, Cesare Fusetti
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  ABSTRACT: IntroductionThe ideal treatment for a boxer’s fracture remains controversial, particularly the degree of volar dislocation considered acceptable for nonoperative treatment. Patients and MethodsFrom December 2003 to December 2004, 25 patients who sustained a subcapital metacarpal fracture of the little finger with volar angulation between 30 to 75° were prospectively enrolled in the study. All patients were treated with a circular self-adherent wrap covering metacarpal bones II–V and buddy taping of the ring and little fingers for a period of 3weeks while allowing immediate free range of motion. ResultsFinal evaluation at a mean of 5months revealed all patients to be satisfied without subjective functional impairment. All fractures healed, and the angulation of the fracture remained unchanged, but moderate shortening was observed. Active flexion of the metacarpophalangeal (MCP) joint was significantly lower on the fracture side, but as the median degree of MCP flexion was the same, this statistical difference was without clinical relevance. There was no loss in grip strength. A subjective long-term evaluation was performed by phone; at a median of 3years, a QuickDash score gave a median of 0 point. ConclusionTreating a boxer’s fracture with angulation of up to 75° by soft wrap and buddy taping resulted in satisfied patients and good clinical results.
  Hand 04/2012; 2(4):212-217.
• Article: Parsonage–Turner Syndrome—Case Report and Literature Review

  A. J. Hussey, C. P. O’Brien, P. J. Regan
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  ABSTRACT: Parsonage–Turner syndrome is the term used to describe a neuritis involving the brachial plexus. It may present with symptoms of an isolated peripheral nerve lesion, although the pathology is thought to lie more proximally. A case describing an isolated anterior interosseus nerve palsy due to an acute brachial neuritis is presented where the electromyographic findings confirmed the diagnosis, but also demonstrated the coexistence of a dual pathology in the form of a cervical radiculopathy. The literature is reviewed regarding etiology, treatment, and prognosis.
  Hand 04/2012; 2(4):218-221.
• Article: Characteristics of sleep disturbance in patients with carpal tunnel syndrome.

  Jay N Patel, Steven J McCabe, John Myers
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  ABSTRACT: Sleep disturbance is common in carpal tunnel syndrome (CTS), and we hypothesize that it has an important impact on the quality of life of CTS patients. The characteristic of sleep problems associated with CTS has not been evaluated. We performed a case-control study to measure the association between a variety of sleep disturbances and CTS. Sixty-two cases with clinically diagnosed CTS and a probable or classic hand diagram were compared to 138 primary care patients without CTS. In addition to demographic features, we collected the nature of sleep disturbance experienced by the patients from a categorical list and the nature, impact, and severity of sleep disturbance using the Insomnia Severity Index. Patients with CTS complained of significantly more severe problems with sleep than the control population and had multiple sleep complaints compared to the control group. Sixty-three of the 138 control patients indicated that they had one cause of sleeping disturbance with no control patient choosing more than one. In contrast, in CTS patients, 44 of 63 patients indicated they had two or more causes of sleep disturbance. The Insomnia Severity Index was significantly higher in CTS patients and the impact of sleep disturbance on quality of life was higher in the cases. Sleep disturbance in CTS patients is characterized by a broad array of physical symptoms that have a significant impact on quality of life.
  Hand 03/2012; 7(1):55-8.
• Article: Long-term outcomes of proximal row carpectomy: a minimum of 15-year follow-up.

  Mir H Ali, Marco Rizzo, Alexander Y Shin, Steven L Moran
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  ABSTRACT: Proximal row carpectomy (PRC) is a popular procedure for the treatment of wrist arthritis; however, the long-term clinical outcomes of this procedure are not well-characterized. The purpose of this study was to evaluate long-term results with PRC and to identify factors that may improve clinical outcomes. A retrospective study was performed on all patients who underwent proximal row carpectomy between January 1967 and January 1992. Medical records and available radiographs were reviewed. The Disabilities of the Arm, Shoulder and Hand, and Patient Rated Wrist Exam, as well as hand motion diagrams were sent to all surviving patients. The contralateral extremity was used as a control. Data was analyzed using multivariant analysis and a Student's test. Eighty-one patients underwent PRC. Average age at the time of surgery was 41 years. Average follow-up was 19.8 years. Sixty-one patients responded to the questionnaires. On final follow-up, wrist motion and grip strength were not significantly different from preoperative values. Radiographic follow-up beyond 2 years revealed joint narrowing and arthritic changes within the radiocapitate joint. Forty-six patients (74%) were not satisfied with the results of their surgery due to persistent pain or inability to return to previous occupational activities. Fifty-two patients required daily pain medication for wrist pain. Twelve patients had undergone a wrist arthrodesis. Post-operative motion and grip strength values following PRC appear to remain stable over time. Surgical failure rates with conversion to wrist fusion occurred early within the post-operative follow-up. Many patients continued to complain of pain requiring daily medication and were unable to return to manual labor type jobs. The results of this study suggest that long-term patient satisfaction following PRC can be poor and the surgeon may wish to consider alternative treatment options for younger patients and those with high-demand jobs.
  Hand 03/2012; 7(1):72-8.
• Article: Bilateral V-Y rotation advancement flap for fingertip amputations.

  Nezih Sungur, Yüksel Kankaya, Kaya Yıldız, Utku Can Dölen, Uğur Koçer
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  ABSTRACT: Fingertip amputation is the most common type of injury in the upper limb. Goals in fingertip amputation reconstruction are covering the defect, establishing maximum tactile gnosis, keeping the length of the finger, protecting the joint function, acquiring a well-padded pulp tissue, providing a bed for growing nail, obtaining a satisfactory cosmetic appearance and allowing the patient to return to work as soon as possible. Adjacent skin and soft tissue are the best covers for fingertip injuries. However, local homodigital flaps lack enough tissue to cover the defect. To solve this problem, we used V-Y rotation advancement flap bilaterally in fingertip amputations which meets all the reconstruction goals. Rotation besides advancement makes this flap more mobile and easier to cover larger defects in all amputation planes. Between 2007 and 2009, we performed bilateral V-Y rotation advancement flap on seven male patients' pulpa (average age, 37.6 years) whose fingertips were not replantable. Fourteen flaps were made on 7 fingers. There was neither total nor partial flap loss. Patients had neither cold intolerance nor scar hypersensitivity. Stiffness of the PIP joint did not occur. No obvious hooked nail occurred in patients who have remaining nail matrix. Because flaps contain neurovascular bundle, there was no difference in sensation and perfusion between the finger's pre-operative and post-operative status. The result was satisfactory with painless pinching. In addition to the various and versatile fingertip reconstruction methods, we want to present V-Y rotation advancement flap as a quick, reliable and aesthetic method.
  Hand 03/2012; 7(1):79-85.
• Article: A systematic review of peer review for scientific manuscripts.

  Bradley P Larson, Kevin C Chung
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  ABSTRACT: The usefulness of peer review has been expressed as a method to improve the quality of published work. However, there has been a lack of systematic reviews to date to highlight the essential themes of the peer-review process. We performed a search of the English language literature published prior to October 2011 using PubMed to identify articles regarding peer review. Inclusion and exclusion criteria were developed a priori. Data were extracted and then analyzed for the prevalence of peer-review themes contained within the literature. Of the 941 articles found during our original literature search, 37 were selected for review. The majority were commentary/editorial articles. The themes in our search included the structure and process of the peer-review system, the criteria for papers, ethics, and the different forms of the peer-review process. The criteria for submission will vary, but our systematic review provides a comprehensive overview of what reviewers expect from authors. Our systematic review also highlighted ethical considerations for both authors and reviewers during the peer-review process. Although the topic of peer review is expansive and its process may vary from journal to journal, the understanding of the themes outlined in this paper will help authors recognize how to write a more successful paper. Also, more research must be carried out to establish the efficacy of the different styles of peer review, and it would be presumptuous to draw conclusions until further research is established.
  Hand 03/2012; 7(1):37-44.
• Article: Cancellous bone graft and Kirschner wire fixation as a treatment for cavitary-type scaphoid nonunions exhibiting DISI.

  Stuart G Kirkham, Michael J Millar
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  ABSTRACT: Cavitary-type scaphoid non-unions represent one of the most difficult treatment challenges amongst all scaphoid non-unions as they exhibit bone loss, scaphoid shortening, flexion ('humpback') deformity and dorsal intercalated segmental instability (DISI), creating altered carpal mechanics which may proceed to the degenerative changes of scapholunate advanced collapse of the wrist. Our technique and its rationale are presented in the largest-to-date series on cavitary scaphoid non-unions exhibiting DISI. Our technique for treatment of these cavitary non-unions is presented through a series of 27 patients. Union was achieved in (26/27) 96% of cases, with no complications. Carpal mechanics was restored, with an average carpal height index of 1.52 ± 0.06, and an average scapholunate angle was 46 ± 9°. Average follow-up was 2.2 years. In this subset of patients, we believe this technique is less technically demanding than the use of either cortico-cancellous grafts or various compression screws. Our success equals or betters that of other published techniques, with all patients enjoying a full return to work, even in occupations demanding heavy labour. We believe that scaphoid union, coupled with the often difficult restoration of carpal height and intra-carpal angles, has produced very good functional outcomes in the management of these challenging cases.
  Hand 03/2012; 7(1):86-93.
• Article: A blinded placebo-controlled randomized trial on the use of astaxanthin as an adjunct to splinting in the treatment of carpal tunnel syndrome.

  Joy C Macdermid, Joshua I Vincent, Bing S Gan, Ruby Grewal
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  ABSTRACT: Nutritional supplementation is a potential adjunct in the conservative management of carpal tunnel syndrome (CTS). This study investigated whether astaxanthin (a beta-carotenoid) increased the effectiveness of splinting in managing CTS. This is a triple-blinded randomized controlled trial where 63 patients with electrodiagnostically confirmed CTS were randomly allocated into either the experimental group ( = 32) (astaxanthin-4-mg capsules + splinting) or the control group ( = 31) (placebo + splinting). Medications were taken for 9 weeks followed by a 3-week washout. The primary outcome measure was the Symptom Severity Scale (SSS). Secondary outcome measures in the study included physical impairments, disability, and health status measures. Electrodiagnostic testing was performed before entry into the study and again at 12 weeks. All other outcomes were measured at baseline, 6, and 12 weeks. There was a reduction in symptoms as measured by the SSS over the course of treatment in both groups ( = 0.002), but no differences between the groups ( = 0.18). The Disability of Arm, Shoulder and Hand questionnaire and the Short Form 36-item Health Survey showed no effects over time or between treatment groups. The baseline difference between the groups in the level of total cholesterol and low-density lipoproteins remained constant over the course of the study. Impairment measures demonstrated no significant changes in grip, dexterity, or sensation. At present, the role for astaxanthin as an adjunct in conservative management of CTS has not been established.
  Hand 03/2012; 7(1):1-9.
• Article: Cold intolerance after brachial plexus nerve injury.

  Christine B Novak, Dimitri J Anastakis, Dorcas E Beaton, Susan E Mackinnon, Joel Katz
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  ABSTRACT: The purpose of this study was to evaluate cold intolerance symptoms in patients with brachial plexus nerve injury. We hypothesized that higher levels of cold intolerance would be associated with more pain, greater disability, and unemployment. Following research ethics board approval and patient consent, we included English-speaking adults more than 6 months following brachial plexus nerve injury. Patient questionnaires included Cold Intolerance Severity Scale (CISS), McGill Pain Questionnaire, SF-36, DASH, pain catastrophizing scale, and Post-traumatic Stress Disorder Checklist. Statistical analyses evaluated the relationships among the questionnaires and the independent variables. Multivariable linear regression evaluated the factors associated with the CISS. There were 61 patients, 20 women and 41 men (mean age 40 ± 17 years). The mean questionnaire scores indicated high scores in the CISS, DASH, and pain intensity. The CISS was significantly higher in women. The final regression model with CISS as the dependent variable included the following independent variables: McGill pain rating index, DASH score, and time since injury. Neither pain catastrophizing nor post-traumatic stress scores were retained in the final model. Patients with brachial plexus nerve injury reported substantial cold intolerance which was associated with the McGill pain rating index, upper extremity disability, and time since injury.
  Hand 03/2012; 7(1):66-71.
• Article: Locking of the ring finger at proximal interphalangeal joint due to a sesamoid bone: a case report.

  Yasuhiro Seki, Yuko Hoshino, Hiroshi Kuroda
  Hand 03/2012; 7(1):119-20.