Anatomy of the Volar Retinacular Elements of the Hand: A Unified Nomenclature.

Many investigators have described the anatomy of the volar retinacular structures of the hand over the last 60 years. As a result, multiple terms have been assigned to 1 anatomical structure and 1 name designated to more than 1 structure. Our purpose is to review the detailed anatomy and key components of the volar retinacular elements of the hand, their etymology, and their most recent descriptions. The objective also is to organize these structures into systems, which can be helpful for learners to assimilate into a practical anatomical guide. Lastly, the goal is to create a common nomenclature for identifying the volar retinacular structures of the hand in order to facilitate clear communication about them across languages.

Efficacy of Dorsoradial Capsulodesis for Trapeziometacarpal Joint Instability: A Cadaver Study.

PURPOSE: To test the biomechanical properties of the dorsoradial capsulodesis procedure. METHODS: Six cadaveric hands were used. After exposing the trapeziometacarpal (TMC) joint, we placed Kirschner wires in the distal radius and thumb metacarpal. The rotation shear test was then performed to test the joint axial laxity, and angular measurements using Kirschner wires as reference points were documented. The dorsoradial (DR) ligament and capsule were released, followed by the intermetacarpal (IM) ligament; angular measurements were obtained. Finally, the DR capsulodesis procedure was performed, and final measurements were obtained. Comparisons were made among the various stages of ligament integrity to determine the amount of stability provided by DR capsulodesis. RESULTS: All cadavers demonstrated axial laxity with transection of the DR ligament; an increase in stability was obtained after DR capsulodesis. Transection of the capsule and IM ligament caused increased laxity relative to the native joint (median, 24° and 35°, respectively, on rotational testing). After we performed DR capsulodesis, rotational stability improved by a median of 41° compared with DR ligament transection, 49° compared with DR and IM ligament transection, and 18° relative to the native joint. CONCLUSIONS: Dorsoradial capsulodesis restores rotational stability for TMC joint after division of the DR and IM ligaments. The stability achieved was statistically significant compared with both an intact native TMC joint and induced laxity of the TMC joint. CLINICAL RELEVANCE: The DR capsulodesis procedure may improve rotational stability to the TMC joint.

Surgical Treatment for Recurrent Dupuytren Disease.

BACKGROUND: Revision procedures for recurrent Dupuytren disease (DD) can be difficult and carry a high risk of complications. Our goal was to describe surgical strategies used for cases of recurrence and report on their outcomes. METHODS: We reviewed 1 surgeon's operative cases for recurrent DD performed at 1 institution. Prior procedures included collagenase injection, percutaneous needle fasciotomy, or open surgical fasciectomy in the same digit or area of the hand. RESULTS: From January 1981 to December 2020, 54 procedures were performed on 33 patients for recurrent DD. Most patients were men (82%), had bilateral involvement (64%) and family history (52%), and some had ectopic disease in their feet (24%). The small finger was involved in 76% of the cases, and the proximal interphalangeal (PIP) joint was involved in 83% of these digits. The procedures included 38 partial fasciectomies (72%), 12 dermofasciectomies (23%), 3 radical fasciectomies (6%), 1 of each needle fasciotomy, ray amputation, and PIP joint arthrodesis (2%). Twenty-three patients (43%) required full thickness skin grafts with an average area of 7.1 cm2 (range: 1-20 cm2). CONCLUSIONS: This study highlights the complexity of recurrent DD case management and found the treatment required for 95% of patients in this series was open partial fasciectomy with or without demofasciectomy. Full thickness skin grafting was necessary in nearly half of the cases.

Dorsoradial Capsulodesis for Stage I Trapeziometacarpal Joint Arthrosis.

BACKGROUND: Thumb trapeziometacarpal (TM) joint arthrosis is a common cause of thumb pain, which adversely affects hand function. Early arthrosis is characterized by capsular laxity, painful pinch and grip, and physical findings of joint tenderness and laxity. Dorsoradial capsulodesis (DRC) is a surgical technique used to stabilize the TM joint and treat early-stage arthrosis. We aim to evaluate the clinical outcomes of DRC for treating trapeziometacarpal instability in early-stage disease. METHODS: Between 2003 and 2019, 23 patients underwent DRC. Patients with stage I TM arthritis and more than 6-month postoperative follow-up were included. Pain and disability scores were calculated along with physical examination and radiographic evaluation at the final follow-up. RESULTS: At mean postoperative follow-up of 43.5 months, 13 patients with a mean age of 39.1 years were examined. The mean Disabilities of the Arm, Shoulder, and Hand score was 5.7, and visual analog pain score was 0.5. Patients had no significant difference in strength or range of motion in the ipsilateral versus contralateral hand. Follow-up radiographs did not demonstrate arthritic changes. CONCLUSIONS: Dorsoradial capsulodesis is a technically simple and reasonable option for stabilizing the TM joint in patients with early-stage arthrosis. This intervention showed no midterm progression to advanced arthritis in this cohort.

Thrombosis of digital arteries associated with tamoxifen use: case report.

Arterial thrombosis in the upper extremity occurs often at the wrist. We report a unique case of thrombosis that involved multiple digital arteries, without radial or ulnar artery involvement, which developed only after using tamoxifen despite chronic occupational blunt percussive hand use. Revascularization was achieved after thrombectomy. Multiple digital arterial thromboses may complicate the use of tamoxifen.

Astley Cooper: his life and surgical contributions.

Sir Astley Paston Cooper (1768-1841) was a successful and influential British surgeon during the early decades of the 19th century. He was a dedicated anatomist, an accomplished researcher, an inspiring teacher, and a skillful surgeon. Cooper published about the cause and treatment of Dupuytren's disease 10 years before Dupuytren. His contributions were widespread and substantially advanced the understanding and treatment of breast disease, vascular aneurysms, and abdominal wall hernias, along with orthopedic, otologic, and hand surgery. His contributions to surgical science have endured and are being used today.

Shoulder and upper arm muscle architecture.

PURPOSE: To examine the architecture of the shoulder and upper arm muscles and generate data that could serve as a guide for comparison, compatibility, and relative performance among these muscles for use in transfer. METHOD: Eleven shoulder and arm muscles were dissected bilaterally in 5 fresh cadavers. Of these 110 potentially available muscles, 107 were suitable for evaluation and were grouped according to similarities in architecture. Resting muscle length, required excursion, muscle fiber length, pennation angle, and mass were determined. Physiologic cross-sectional area (PCSA) was then calculated from these parameters using a standard formula. RESULTS: Based on the gross appearance of muscle fiber orientation, the 11 muscles were subdivided into 3 groups. Required excursion was found to be less than fiber length in all muscles except for the teres major and middle deltoid with abduction. The middle deltoid muscle was found to have a short fiber length, complex multipennate structure, and high PCSA. Comparison showed the biceps and posterior deltoid to have fiber lengths greater than any portion of the triceps; however, neither demonstrated architectural features that would generate the force (represented by PCSA) determined for the combined triceps. CONCLUSIONS: Data presented in this study offer the opportunity for direct comparison of architectural features of select shoulder and arm musculature.

Congenital Thumb-Index Web Space Deficiency.

Background: There are several congenital hand differences that cause thumb-index (TI) web space deficiency. There is a knowledge gap in the literature about the hand differences that are associated with TI web space deficiency. We aimed to identify these congenital differences and the various specific reconstructive surgical procedures that are used for these conditions. Methods: We conducted a retrospective chart review of children treated operatively over a period of 30 years for congenital TI web space deficiency by the senior author (G.M.R.). We gathered data on demographics and associated congenital hand differences and compiled a list of all surgical procedures performed for the web space and the ipsilateral upper extremity. Results: We included 71 patients (77 hands) with 12 congenital hand differences (62 developmental and 9 spastic). The total number of upper extremity operations, (ie), anesthetics performed for these patients was 186, averaging 2.6 settings and 7.5 procedures for each patient. Cutaneous reconstructive procedures included first dorsal metacarpal artery pedicle flaps (49 patients), 4-flap Z-plasties (15), and transposition flaps (13). In addition, 16 different thumb reconstructive procedures were necessary. Ten patients required revision of their TI web space procedures for recurrence. Conclusions: The prevalence of TI web space deficiency is underappreciated. These patients often have multiple musculoskeletal anomalies of the hand and upper extremity that should be ruled out and require surgical treatment to optimize hand function. Consideration should be given to performing more than one procedure in one setting when possible.

Dorsal pads versus nodules in normal population and Dupuytren's disease patients.

PURPOSE: There is ambiguity about using the term "knuckle pads" in Dupuytren's disease (DD). Clear definitions of dorsal knuckle pads and nodules are lacking and the prevalence of these 2 entities has not been determined. We sought to define these terms and investigate the distribution and frequency of dorsal knuckle pads and dorsal nodules in the normal volunteers and in DD patients. METHODS: We assessed 50 consecutive study patients with DD and a convenience sample group of 50 control patients without DD for dorsal cutaneous pads (DCP) (ie, thickening, sclerosis, and loss of skin elasticity) and dorsal Dupuytren's nodules (DDN) (ie, solid tumor-like masses over the digital joints). Demographic information was collected for both groups, including the extent of the disease in DD patients. We examined both groups for the presence of dorsal lesions and their characteristics, and the DD patients for other local and ectopic Dupuytren's lesions and for the level of diathesis. RESULTS: None of the control patients had DDN, whereas 9 DD patients had DDN (p = .002). Nine control patients had DCP, whereas 11 DD patients had DCP (p = .803) Among the 9 control patients with DCP, pads were predominantly over the proximal interphalangeal joints and tended to occur in men with physically demanding occupations, and in the dominant hand. The index and long fingers were most frequently affected. Six patients had only DCP, 4 had only DDN, and 5 had both DDN and DCP. In the control and study groups, the DCP characteristics and patients' demographic data were comparable. Patients with DDN were white men with physically undemanding occupations and had lesions over the proximal interphalangeal joints, most frequently in the index finger, with an average size of 6 mm. Neither DCP nor DDN were encountered in the thumb. CONCLUSIONS: Future studies should clearly distinguish between DCP and DDN. Although DDN are pathognomonic of DD, DCP demonstrates similar prevalence in normal and DD populations.

Genome-wide association scan of Dupuytren's disease.

PURPOSE: Dupuytren's disease (DD) has a strong genetic component that is suggested by population studies and family clustering. Genetic studies have yet to identify the gene(s) involved in DD. The purpose of this study was to identify regions of the entire genome (chromosomes 1-23) associated with the disease by performing a genome-wide association scan on DD patients and controls. METHODS: We isolated genomic DNA from saliva collected from 40 unrelated DD patients and 40 unaffected controls. We conducted the genotyping using CytoSNP-Infinium HD Ultra genotyping assay on the Illumina platform. Using both log regression and mapping by admixture linkage disequilibrium analysis methods, we analyzed the single nucleotide polymorphism genotyping data. RESULTS: Single nucleotide polymorphism analysis revealed a significant association in regions for chromosomes 1, 3 through 6, 11, 16, 17, and 23. Mapping by admixture linkage disequilibrium analysis showed ancestry-associated regions in chromosomes 2, 6, 8, 11, 16, and 20, which may harbor DD susceptibility genes. Both analysis methods revealed loci association in chromosomes 6, 11, and 16. CONCLUSIONS: Our data suggest that chromosomes 6, 11, and 16 may contain the genes for DD and that multiple genes may be involved in DD. Future genetic studies on DD should focus on these areas of the genome.

Closing wedge osteotomy of abnormal middle phalanx for clinodactyly.

PURPOSE: To report a series of clinodactyly patients to report clinical and radiographic outcomes after closing wedge osteotomy and K-wire fixation of abnormal middle phalanges. METHODS: Twenty-five fingers from 17 patients were included in the study. All patients had more than 25 degrees of angulation and were treated with closing wedge osteotomy. Subjective and objective data with radiographic assessment were compared preoperatively and postoperatively. RESULTS: Male gender was predominant in our series (14 of the total 17 patients). Family history was positive for clinodactyly in 4 patients. The appearance of all fingers improved after surgery. Angular deformity was corrected on average from 33 degrees preoperatively to 9 degrees postoperatively. Analysis of radiographs showed deformity correction from 29 degrees preoperatively to 5 degrees postoperatively. Preoperative and postoperative arc of motion measurements were available for 10 patients. Distal interphalangeal joint arc of motion decreased from 84 degrees prior to surgery to 81 degrees after surgery, whereas proximal interphalangeal joint arc of motion was unchanged. CONCLUSIONS: Closing wedge osteotomy of the abnormal middle phalanx for clinodactyly has provided our patients with adequate correction of the deformity, improved hand function, and has provided high satisfaction for parents. This treatment is recommended for moderate (15 degrees to 30 degrees ) and severe (>30 degrees ) deformities.

Distal Radius Fracture Fixation Devices and Their Radiographs.

Background: Distal radius fractures are among the most common fractures encountered in orthopedic practices. If treated operatively, most implants are retained after the fracture heals unless there is hardware failure, limitation of wrist motion, pain, infection, tendon rupture, or tenosynovitis. Complications have been reported during hardware removal, including not knowing the exact implant prior to its removal. If a patient presents for plate removal to a surgeon who did not perform the initial fracture fixation, having a preoperative visual aid can help the treating surgeon choose the right instruments for their removal. Methods: To identify many of the available distal radius fixation devices, we searched the Internet and contacted local industry representatives. We also approached industry personnel at the commercial exhibit of a national hand society meeting to provide us with implants they manufacture. The implants were placed on the volar and dorsal aspects of sawbone models of the distal radius and in one case the radial styloid, using the screws, screwdrivers and accessories in the standard implant set and then posteroanterior and lateral x-rays of the implants were obtained. We created an atlas and a list of the screwdriver(s) used for each. Results: We obtained radiographs and photographs for 28 implants that were manufactured by 14 different companies. Two companies sent us radiographs and photographs placed on either a sawbone or cadaveric model. We found that 7 of the implants were outliers and could be identified easily on the x-rays, whereas 21 implants had similar design of shaft and distal components. Conclusions: To aid the orthopedic surgeon in their removal, we compiled a comprehensive list of most distal radius fixation devices on the market including plates and their corresponding screws and screwdrivers. The goal was to help the surgeon when removing the plate to identify the implant on radiographs.

Amniotic Constriction Bands: Secondary Deformities and Their Treatments.

BACKGROUND: The purpose of this study was to report the surgical treatment experience of patients with amniotic constriction bands (ACB) over a 35-year interval and detail consequential limb deformities with emphasis on hands and upper extremities, along with the nature and frequency of their surgical treatment methods. METHODS: Fifty-one patients were identified; 26 were males and 25 females. The total number of deformities was listed. The total number of operations, individual procedures, and operations plus procedures that were done for each patient and their frequency were recorded. RESULTS: The total number of operations was 117, and total number of procedures was 341. More procedures were performed on the upper extremity (85%) than the lower extremity (15%). Including the primary deformity ACB, 16 different hand deformities secondary to ACB were encountered. Sixteen different surgical methods for the upper extremity were utilized; a primary procedure for ACB and secondary reconstructions for all secondary deformities. Average age at the time of the first procedure was 9.3 months. The most common procedures performed, in order of frequency, were excision of ACB plus Z-plasty, release of partial syndactyly, release of fenestrated syndactyly, full-thickness skin grafts, resection of digital bony overgrowth from amputation stumps, and deepening of first and other digital web spaces. CONCLUSIONS: Many hand and upper extremity deformities secondary to ACB are encountered. Children with ACB may require more than one operation including multiple procedures. Numerous surgical methods of reconstruction for these children's secondary deformities are necessary in addition to the customary primary procedure of excision of ACB and Z-plasty.

Nonoperative treatment of Dupuytren's disease.

Many approaches to nonoperative treatment of Dupuytren's disease have been tried since the disease was originally described in 1831, and most have been abandoned. Nonetheless, the appeal for nonoperative methods persists, in pursuit of lower morbidity and lesser complications than may be encountered with open surgical treatment. A number of nonoperative treatment modalities are in current use for Dupuytren's disease, despite lack of high-level clinical studies supporting these methods. Some of these can be utilized as an adjunct to surgical treatment rather than a replacement for it. The most commonly used nonoperative treatment methods are briefly reviewed.

Functional anatomy of the thumb sagittal band.

PURPOSE: To study the anatomy and kinematics of the thumb sagittal band (SB) and the influence of simulated injury on the stability of the extensor pollicis longus (EPL) tendon. METHODS: Twenty-four below-elbow, cadaveric amputation specimens were used. The study had 3 components: SB anatomy, SB kinematics, and assessment of SB influence on extensor stability through simulated injury by serial sectioning. RESULTS: The radial and ulnar components of the SB originated on their respective sides of the thumb metacarpophalangeal joint from a soft tissue confluence and inserted into the margins of the EPL tendon. The radial component was much more transparent and thinner, but slightly wider (2.4 mm) and longer (0.5 mm) than the ulnar component. The SB fibers were oriented perpendicular to the long axis of the thumb and EPL tendon. Interphalangeal joint motion had the greatest influence on SB fiber angulation and excursion. Partial and complete sectioning of the ulnar SB had minimal influence on EPL tendon stability. Partial sectioning of the radial SB resulted in ulnar EPL tendon subluxation. Complete sectioning of the radial SB resulted in ulnar dislocation of the EPL tendon. CONCLUSIONS: The radial component of the thumb SB seems to be more important to EPL stabilization at the level of the metacarpophalangeal joint than its ulnar counterpart. EPL tendon instability was observed to be proportional to the degree of radial SB injury. Knowledge of the anatomy of the thumb SB and its functional relationship to the extensor apparatus provides an understanding of the repair and reconstructive considerations for conditions of EPL tendon instability associated with trauma and inflammatory and nonrheumatoid thumb deformities.

Axial Rotation Test for Trapeziometacarpal Joint Hypermobility in the Normal Population.

BACKGROUND: The objective was to quantify joint laxity in healthy volunteers by measuring the passive axial rotation of the trapeziometacarpal joint using the axial rotation test. METHODS: Eighty volunteers (34 men and 46 women) were subjected to the axial rotation shear test and the degree of total rotational motion (TRM) was assessed. Volunteers were divided into Group I with a range of 18-50 years old and Group II for 51 years and older. Statistical analysis was performed. RESULTS: The average TRM in Group I was 32.3 mm for women, and 27.4 mm, for men (p = 0.04). The average TRM in women of Groups I and II, was 32.3 and 21.6 mm respectively, (p < 0.001). The average TRM in men of Groups I and II, was 27.4 and 19.4 mm (p < 0.001). In Group II the average TRM of women was 21.6 mm, and for men was 19.4 mm, which was not significantly different. CONCLUSIONS: Young women have greater degree of rotational laxity in the TM joint compared to men of the same age group and to older women. The axial rotation test can quantify the degree of rotational laxity of the TM joint.

Dupuytren's disease: anatomy, pathology, presentation, and treatment.

The disorder called Dupuytren's disease has been recognized for approximately 400 years. Its presentation, although seemingly rather constant, is actually extremely variable, depending on which structures are involved. A thorough knowledge of palmar fascial anatomy is essential to the understanding of Dupuytren's disease.