An alternative method to reconstruct grade-3 hypoplastic thumb by hemi-metacarpal transfer.

We designed a new method using hemi-longitudinal second metacarpal bone to reconstruct grade-3 hypoplastic thumbs. Seven patients were treated in two stages. In the first stage, the second metacarpal was split longitudinally and transferred to reconstruct the first metacarpal. In the second stage, opponensplasty was performed by transferring the FDS tendon. Bone union was achieved in all cases. All patients could oppose to their middle finger at least. They managed to do daily activities such as writing, eating, using smartphones and so on. This is a useful procedure to preserve a 5-digit hand with good function in treating grade-3 hypoplastic thumbs, with no harm to the foot and no need for vascular anastomosis. LEVEL OF EVIDENCE: IV.

Anomaly originated flexor digitorum superficialis muscle of the small finger: A case report.

RATIONALE: We present a clinical case of flexor digitorum superficialis (FDS) muscle belly of the small finger originating from the palm of a patient undergoing carpal tunnel surgery with a literature review. PATIENTS CONCERN: A 28-year-old right-handed woman visited our hospital with a chief complaint of a continuous tingling sensation and weakness in the right hand, which began after the volar side of her wrist was crushed by a machine during work 2 weeks prior. The patient complained of a continuous tingling sensation in the thumb, index, and middle fingers. The patient had a positive result on Tinel test of the median nerve of the wrist. As electromyography and nerve conduction velocities showed signs of severe injury in the right median nerve, exploration and carpal tunnel release were planned. DIAGNOSIS: Carpal tunnel release was performed under regional anesthesia using the classical open approach. The median nerve in the distal forearm and distal portion of the flexor retinaculum appeared to be narrowed and compressed. An anomalous muscle originating from the flexor retinaculum is also observed. INTERVENTION: The FDS muscle of the small finger was excised at the flexor retinaculum and musculotendinous junction and sutured to the flexor digitorum profundus tendon. OUTCOME: At the 37-month follow-up, the patient did not experience any tingling sensation or weakness. She showed excellent range of motion of the right small finger. The grip strength was 20 kg on both the right and left sides. Quick disabilities of the arm, shoulder, and hand score was 2.3. CONCLUSION: Asymptomatic small finger FDS muscle anomalies can occur, as demonstrated in this case study. Thus, physicians should familiarize themselves with small finger FDS muscle anomalies during interactions with patients to facilitate future treatments of patient complaints related to the hand, as well as wrist laceration or trauma requiring hand exploration.

A Customised paediatric thumb web splint for management of adduction contracture of thumb.

The thumb web has a unique anatomy, the integrity of which is vital to both form and function of the hand. Thumb web space adduction contractures are a common consequence of hand burns and are a progressive disabling deformity and prevention or early intervention is advisable. This case describes the use of a customised removable web splint in children with scarring and gradual contracture of the first web space causing pain with movement and significant restriction in the hand function to maintain the thumb web expansion. This inexpensive and effective appliance can be safely applied to an injured hand, maintain web space following surgical release and allows movement at the first carpometacarpal joint and hence obtains a good functional outcome.

A minimally invasive technique for residual zigzag deformities of the thumb.

OBJECTIVE: This study aimed to introduce a minimally invasive technique in correcting residual zigzag deformities after early treatment of thumb duplication followed by fixation with a cemented frame. METHODS: Nineteen patients (14 males, 5 females; mean age, 12 years; age range, 8-14 years) with residual zigzag thumb deformities were treated with the minimally invasive technique from 2017 to 2019. The function and cosmesis of the thumbs were assessed using the Japanese Society for Surgery of the Hand. RESULTS: The mean period between the first and the second operations was 35 months (range, 12-84 months). There were Wassel types III (n=4), IV (n=13), and V (n=2) residual zigzag thumb deformities. Preoperatively, the mean alignment deformities of the interphalangeal and metacarpophalangeal joints were 23° (12-42°) and 18° (11-33°), respectively. The mean function and cosmesis of the thumbs were 12 points (range, 8-14 points). There were 1 fair and 18 poor scores. At the final follow-up (mean, 28 months; range, 24-33 months), the mean alignment deformities of the interphalangeal and metacarpophalangeal joints were 1° (0-4°) and 18° (0-4°), respectively. The mean function and cosmesis of the thumbs were 18 points (range, 16-20 points). There were 5 excellent results, 13 good results, and 1 fair result. CONCLUSION: Residual zigzag thumb deformities can be successfully corrected with the minimally invasive technique, resulting in good functional and cosmetic outcomes. The technique can be used as an alternative in selected cases. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Midterm Surgical Outcomes of Duplicated Thumbs According to New Classification.

BACKGROUND: Surgical outcomes of duplicated thumbs differ depending on the branching type. The authors developed a new classification system and report surgical outcomes with an average 10.2-year follow-up. METHODS: A total of 529 patients with 562 duplicated thumbs were reviewed. Surgical anatomies were compared with radiographs, and then a new classification system was developed based on branching level and bone shape observed on the radiograph: distal type (D-type), including Wassel types I and II; proximal type (P-type), including Wassel types Ⅲ and Ⅳ, and four subdivisions (Po, Pa, Pb, and Pc) according to bone structure; and metacarpal type (MC-type), including Wassel types V and VI. All hands were assessed using the Japanese Society for Surgery of the Hand evaluation form, and factors causing poor outcomes were analyzed. RESULTS: There were 25% D-type, 59% P-type, and 14% MC-type hands; 2% of hands were not classified. Overall, 351 hands (63%) were directly assessed when patients reached 5 years of age. Seventeen percent of hands had fair results. Good results were achieved in 90% of D- and Po-type hands. Pa-, Pb-, Pc-, and MC-type hands had lower Japanese Society for Surgery of the Hand scores than did D- or Po-type hands. Pa- and Pb-type hands tended to develop interphalangeal joint malalignment and instability, whereas Pc- and MC-type hands developed disorders in the metacarpophalangeal joint with growth. CONCLUSIONS: The authors' new classification system clarifies the potential pitfalls for each type of duplicated thumb. More than 90% of D- and Po-type hands obtained good results. Care should be taken with interphalangeal joint reconstruction for Pa- and Pb-type hands. Meticulous reconstruction of the metacarpophalangeal joint is essential for Pc- and MC-type hands. This analysis provides important information for surgeons and patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, IV.

Intraoperative Observation of the Proper Digital Nerves in Wassel-Flatt Type â £ Radial Polydactyly.

PURPOSE: The aim of the study was to present the intraoperative findings of the relevant digital nerves of the duplicated thumbs in an excision and reconstruction procedure for the Wassel-Flatt type Ⅳ radial polydactyly. METHODS: The study was conducted on patients with Wassel-Flatt type IV radial polydactyly who underwent excision and reconstruction between 2018 and 2021 at our institution. The ulnar digital nerve of the radial thumb and the radial digital nerve of the ulnar thumb were identified and traced intraoperatively. The level of the bifurcation of the nerves and abnormal findings were documented. RESULTS: A total of 123 hands in 119 patients were included in this study. In 114 hands, the bifurcation of the nerves was located within 1 cm of the metacarpophalangeal flexion crease. The radial digital nerve to the ulnar thumb was abnormally compressed in deep fascial tissue in 7 of these 114 hands. In 5 hands, the level of bifurcation was more than 1 cm proximal to the crease. No radial digital nerve to the ulnar thumb was identified in the remaining 4 hands. CONCLUSIONS: Although rare, abnormal nerve compression of the digital nerve may exist in duplicated thumbs of Wassel-Flatt type IV radial polydactyly. CLINICAL RELEVANCE: In an excision and reconstruction procedure, we suggest that the bifurcation of the nerves should be identified before the nerve to the radial thumb is excised to avoid injuring the nerve to the main ulnar thumb.

Volar Plating of Scaphoid Fractures: A Retrospective Case Series.

BACKGROUND: The purpose of this study was to evaluate the rate of union of scaphoid fractures managed with volar plating and assess postoperative complications. METHODS: Retrospective consecutive case series of 28 patients with scaphoid fractures, 9 acute and 19 chronic nonunions, undergoing surgical fixation with volar scaphoid plating by a single surgeon between 2013 and 2019. Patients were followed up for a minimum of 3 months with scaphoid bony union being confirmed on radiograph or computed tomography. Postoperative complications and need for plate removal were recorded. RESULTS: Overall union rate of 96% with all 19 chronic nonunions demonstrating radiological union and 1 of 9 acute fractures not uniting and requiring revision surgery. The only postoperative complication identified was symptomatic plate impingement which necessitated plate removal in 57% of cases. CONCLUSIONS: This case series demonstrates volar plating of scaphoid fractures can be used as an alternative technique to achieve union.

Performance Outcomes and Return to Sport Following Metacarpal Fractures in Major League Baseball Players.

BACKGROUND: Major League Baseball (MLB) players are at risk for metacarpal fractures; however, little is known regarding the impact of these injuries on future performance. The purpose of this study was to determine whether MLB players who sustain metacarpal fractures demonstrate decreased performance on return to competition in comparison to the performance of control-matched peers. METHODS: Data for MLB position players with metacarpal fractures incurred over 17 seasons were obtained from injury reports, press releases, and player profiles. Age, position, career experience, body mass index (BMI), injury mechanism, handedness, and treatment were recorded. Individual season statistics for the 2 seasons immediately before injury and the 2 seasons after injury were obtained. Controls matched by player position, age, BMI, career experience, and performance statistics were identified. A performance comparison of the cohorts was performed. RESULTS: Overall, 24 players met inclusion criteria. Eleven players with metacarpal fractures were treated with surgery (46%) and 13 (54%) were treated nonoperatively. Players treated nonoperatively missed significantly fewer games following injury compared with those treated operatively (35.5 vs 52.6 games, P = .04). There was no significant difference in postinjury performance when compared with preinjury performance among the fracture cohorts. Players with metacarpal fractures treated nonoperatively had a significant decline in their Wins Above Replacement (WAR) 2 seasons postinjury (1.37 point decline) in comparison to matched controls (0.84 point increase) (P = .02). There was no significant difference in WAR 1 or 2 seasons postinjury for players with metacarpal fractures treated operatively in comparison to the control cohort. CONCLUSIONS: Major League Baseball players sustaining metacarpal fractures can expect to return to their preinjury performance levels following both nonoperative and operative treatment. However, players treated nonoperatively may witness a decline in their performance compared with peers over the long term. Orthopedic surgeons treating professional athletes with metacarpal fractures should consider these outcomes when counseling their patients and making treatment recommendations.

Surgical Technique and Outcomes of Reconstruction for Blauth Type III Thumb Hypoplasia.

BACKGROUND: Historically, amputation and pollicization has been the recommended surgical treatment for Blauth type III hypoplastic thumbs. However, due to aesthetic objections or cultural preferences, some parents seek out alternative surgical options. The present study describes a nontraditional technique that preserves and augments the hypoplastic thumb. METHODS: Patient charts were retrospectively reviewed to identify patients with Blauth type III hypoplastic thumbs who underwent thumb reconstruction at our institution from 2008 to 2018. The reconstruction procedure involved toe phalanx transfer, staged tendon transfers, and lengthening as needed. Motion was assessed categorically as ability to flex, extend, or oppose the thumb. Functionality was assessed as ability to pinch and grasp with the surgical hand. Patient- or parent-reported improvement in thumb function was also recorded. RESULTS: Of the 13 patients, 100% could flex, extend, and oppose the thumb to some degree. Eleven patients (85%) had functional one-handed grasp, and 9 (69%) had a functional pinch. Eleven patients (85%) reported no functional limitations of the operative hand. Thirteen patients (100%) reported improvement in hand function after surgery as compared to pre-operatively. There were 2 minor complications (15%), both of which resolved after intervention. No patients experienced donor-site morbidity. CONCLUSIONS: Reconstruction of Blauth III thumbs is a nontraditional technique that allows for digit retention by salvaging the hypoplastic thumb. In the present study, the majority of patients had functional thumbs and all reported postoperative improvement. Overall, our results suggest that reconstruction is a viable surgical option for Blauth III hypoplastic thumbs.

Postoperative Immobilization of Scaphoid Fractures: A Comprehensive Review of the Literature.

The optimal protocol for postoperative immobilization following operative treatment of scaphoid fractures remains controversial. Reports of successful management with brief postoperative immobilization suggest that earlier restoration of function may be achieved by limiting the duration of immobilization. However, the risk of nonunion and its associated complications suggest that a more conservative approach with extended immobilization could optimize fracture healing. This paper presents a thorough review of the relevant literature and summarizes the myriad postoperative immobilization protocols and their reported outcomes. Postoperative immobilization protocols and reported outcomes for displaced, comminuted, and proximal pole fractures are discussed separately. The literature is reviewed following different operative techniques, including open reduction internal fixation and percutaneous screw fixation. Vigilant postoperative care of scaphoid fractures managed surgically is warranted to monitor for signs of nonunion while attempting to regain motion and strength to the injured wrist.

Index pollicization: an evolution of ideas and techniques from a paediatric orthopaedic institution.

Pollicization has been a very successful procedure in the treatment of specific types of hypoplastic thumb. Although much has remained the same since early descriptions of the procedure in the 1800s and 1900s, refinements over the years have made it safer and more predictable. Over the years at our institution we have studied, modified and refined our incisions to produce a new thumb that is aesthetically pleasing with excellent function. We present our technique for pollicization along with pearls and pitfalls we have discovered.

Satisfaction with hand appearance in children with index pollicization for thumb hypoplasia.

Although the primary aim of pollicization is to augment function, aesthetic improvement is an important secondary aim. Satisfaction with hand appearance in children with index pollicization for thumb hypoplasia was evaluated in 18 patients at an average of 7.5 years after surgery. Patients and their parents rated the appearance of their operated hand using a 10-point visual analogue scale (VAS). Four independent surgeons and 16 non-surgeon observers also rated the hands after reviewing standardized photographs of each child. The median patient-reported and parent-reported scores were 9 for both groups (IQR: 7-10) with a trend for children 12 years and older, to report lower satisfaction with appearance. The non-surgeon group assessments varied more for a given hand than the surgeons' assessments, though when scores were averaged within these groups for each hand, there was a high degree of correlation between the two groups. Surprisingly, the patient's own assessment showed a trend towards negative correlation when compared with the average rating of the non-surgeon assessors, suggesting that patients' own assessment of their hand's appearance is more affected by subjective factors than the objective physical outcome.

First dorsal interosseous muscle transfer to restore opposition of the new thumb after index pollicization: anatomical description of an original technique and case report.

Index pollicization in severe thumb hypoplasia or aplasia in children or for the reconstruction of a mutilated thumb in adults is a rare and technically demanding procedure. Weakness of the new thumb is routinely reported after index pollicization. An inappropriate position of the first dorsal interosseous muscle (FDIM) can partly explain this strength deficit. Here, we report an original anatomical study on FDIM transfer for reanimation of the new thumb's opposition function and its clinical application. An anatomical study was carried out on three upper limbs from fresh, non-embalmed adult cadavers. We demonstrated the feasibility of an FDIM transfer pedicled on the proper FDIM artery and the deep branch of the ulnar nerve. The proximal FDIM insertions were sutured to the lateral border of the flexor retinaculum to recreate the superficial thenar musculature. This procedure was performed on a 52-year-old man who was referred to us with swelling on his hand. We discovered a myxoid inflammatory fibroblastic sarcoma of the thumb that required proximal thumb amputation while preserving the base of the first metacarpal. To our knowledge, this is the first description of FDIM pedicled flap transfer during an index pollicization procedure among an adult population. However, in severe thumb hypoplasia or aplasia cases, this procedure is limited by the size and anatomical variations of the neurovascular structures among a population affected by radial longitudinal deficiency.

Bilateral Ulnar Deviation Supination Stress Test to Assess Dynamic Scapholunate Instability.

PURPOSE: We describe a new radiologic test to assess the integrity of the scapholunate ligament in dynamic scapholunate dysfunction. METHODS: A bilateral forearm-holding device was designed to perform a comparative radiographic assessment of the scapholunate joint gap during resisted isometric contraction of the extensor carpi ulnaris muscle with full supination of the forearm. The concept is based on the known scaphoid pronation effect of this muscle. Clinical data from 12 patients were collected retrospectively and used to analyze the patients' symptomatic and asymptomatic (contralateral) wrists with a newly developed test called the Bilateral Ulnar Deviation Supination (BUDS) test. A wrist arthroscopy was performed in all cases as a reference standard for the radiologic test. RESULTS: The test was positive in 7 patients, with a mean scapholunate joint gap of 4.8 mm. The mean differences in the scapholunate joint gaps between both wrists were 2.6 mm in BUDS-positive patients and 0.2 mm in BUDS-negative patients. A Geissler stage III or IV scapholunate ligament rupture was confirmed in all BUDS-positive patients; by contrast, BUDS-negative patients exhibited either no lesion or a Geissler stage I injury. CONCLUSIONS: The BUDS test is a new radiologic test based on proven biomechanical effects that is able to accurately assess dynamic scapholunate dysfunctions. The analysis carried out found a correlation between radiographic and arthroscopic findings. Further research is needed to confirm the validity and reliability of the test. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

The Impact of COVID-19 on the Choice of Treatment for Hand Fractures: A Single-Centre Concordance Study.

Background: Management of hand trauma has evolved to incorporate assessment, treatment and rehabilitation of patients in a 'one-stop' clinic on initial presentation. Our aim was to evaluate the effect of coronavirus disease 2019 (COVID-19) on the choice of treatment for hand fractures using inter-rater agreement between surgeons. Methods: All patients with hand fractures during the COVID-19 lockdown from March to May 2020 were included in the study. Two experienced hand surgeons blinded to management and outcomes independently reviewed radiographic images and relevant clinical history to provide their opinion on optimal treatment. Weighted kappa analysis was performed to determine concordance and inter-rater agreement between the two surgeons and actual management. Results: The study included 82 patients (62 men and 20 women) with a mean age of 40.3 (SD 19.7). The injuries occurred most often at home following an accident (34%) or a fall (28%). Fractures involved the metacarpals in 29 patients and the distal phalanx in 22 patients. Thirty-five patients underwent surgery, whereas 47 were managed conservatively. Overall agreement between actual management and consultant A and consultant B was moderate (κ = 0.55, p < 0.0001 and κ = 0.63, p < 0.0001, respectively). Subgroup analysis showed a weak agreement between actual management of metacarpal fractures and consultant A and consultant B (κ = 0.22, p = 0.29 and κ = 0.47, p = 0.02, respectively). Inter-rater agreement was substantial for management of metacarpal fractures (κ = 0.73, p < 0.0001), but weak for distal phalanx fractures (κ = 0.29, p = 0.03). Conclusion: Our study has shown that overall management of hand fractures remained optimised throughout the pandemic. However, a lack of concordance was observed in the management of metacarpals. Level of Evidence: Level IV (Therapeutic).

[Soft tissue balance technique by flexor pollicis longus tendon transfer for Wassel â £-D thumb duplication in children].

Objective: To investigate the effectiveness of soft tissue balance technique by flexor pollicis longus (FPL) tendon transfer for Wassel Ⅳ-D thumb duplication in children. Methods: A clinical data of 14 children with Wassel Ⅳ-D thumb duplication met the selection criteria between January 2017 and January 2021 was retrospectively analyzed. There were 5 boys and 9 girls with an average age of 21.6 months (range, 18-35 months). Ten cases were left hand deformity and 4 cases were right hand deformity. During operation, the radial thumb was excised, and the FPL tendon of the radial thumb was used to reconstruct the soft tissue balance of the ulnar thumb. Postoperative evaluation included the range of motion (ROM) of passive flexion and extension of the interphalangeal joint (IP) and metacarpophalangeal joint (MCP), the alignments of the IP and MCP, the percentage of the width of the nail plate and the circumference of the thumb at the level of the IP to contralateral thumb. Results: All operations were completed successfully, and all incisions healed by first intention. The children were followed up 12-36 months (mean, 21.7 months). At last follow-up, the ROM of passive flexion and the deviation of the IP, and the deviation of the MCP significantly improved when compared with those before operation (P<0.05); the ROM of passive extension of the IP and the ROM of passive flexion of the MCP did not significantly improve when compared with those before operation (P>0.05). The ROMs of passive extension of the MCP were 0° before and after operation. The width of the nail plate was 76.6%±4.1% of the unaffected side, and the circumference of the thumb at the level of the IP was 92.0%±9.1% of the unaffected side. Conclusion: The soft tissue balance technique by FPL tendon trasfer can effectively correct the alignment of the Wassel Ⅳ-D thumb duplication in children, and maintain the correction effect effectively, but further follow-up and comprehensive evaluation are needed to investigate the long-term effectiveness.