Compartment reconstruction for De Quervain's disease.

A new surgical treatment for De Quervain's disease is presented, in which the anatomy and function of the first dorsal compartment is preserved. Our findings in 11 wrists in ten patients revealed complete relief of the pre-operative symptoms in all instances. The advantages of this technique are its ease, its restoration of normal anatomy, and the prevention of tendon prolapse.

The Littler line method and the area under a Gaussian curve: a new method of assessing digital range of motion.

A new method of measuring digital range of motion (the Littler line method) is presented. When a Gaussian curve is centered over the Littler line and the appropriate area under the curve is computed, this area can provide a measure of the functional range of motion regained by an injured digit. Seventeen children (24 digits) with flexor tendon injuries were evaluated at an average follow-up period of 58 months (range, 12-121 months). The Littler line/Gaussian curve method was found to be more reproducible than total active motion, particularly in zone I and II injuries. This method can serve as a more meaningful functional assessment tool than a linear measurement such as total active motion, because it emphasizes digital motion in the mid-ranges of digital motion. (J Hand Surg 2001;26A:23-30.

Distal scaphoid resection arthroplasty for the treatment of degenerative arthritis secondary to scaphoid nonunion.

Nineteen patients with chronic scaphoid nonunion and associated degenerative arthritis between the distal fragment and the radial styloid were treated by resection of the distal fragment. All patients had a dorsal intercalated segment instability wrist collapse pattern with an average radiolunate angle of -32 degrees and a 10% reduction in the carpal height, both of which changed minimally during the follow-up period. The duration of the nonunion averaged 12 years and the follow-up period averaged 49 months. Range of motion improved 85% and grip improved 134%. Thirteen of the patients experienced complete pain relief. One patient required additional surgery and elected wrist arthrodesis. Resection of the distal fragment is not recommended for patients with capitolunate arthritis. Two of the 4 patients with capitolunate arthritis had persistent symptoms; 3 had progressive degenerative changes.

Vascular leiomyomas in the hand.

Vascular leiomyomas or angioleiomyomas are benign solitary smooth muscle tumors that occur uncommonly in the hand. The peak incidence is in the third to fifth decades of life, and men are more often affected than women. This tumor is rarely diagnosed before surgery. The usual treatment is simple excision of the mass and ligation of feeder vessels. Although the tumors occur anywhere in the hand, there are only two previous cases of vascular leiomyoma involving the digital artery. A recent case of this tumor involving a digital artery documented by arteriography and treated by excision of the mass and end-to-end anastomosis of the artery is presented. The authors review their experience with vascular leiomyomas in the hand and present four cases along with a review of 105 cases found in the English literature.

Ligament replacement for chronic instability of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb.

Static and dynamic procedures have been described for reconstruction of chronic instability of the ulnar collateral ligament of the thumb metacarpophalangeal joint. This study presents a technique of ligament replacement utilizing a free tendon graft passed through two gouge tracks in the proximal phalanx and one in the metacarpal in a manner that closely approximates normal anatomy. We retrospectively reviewed 26 patients who underwent replacement. The follow-up period averaged 4.5 years. In 24 of 26 cases the joint was rendered stable by the replacement and the patient was relieved of pain. Eighty-five percent of the arc of motion was maintained. Postoperative key pinch measured 20 lb. on the operated side compared to 21 lb. on the unoperated side. Results were excellent in 20 patients, good in 4, and fair in 2. This technique successfully restores stability to the ulnar collateral ligament of the thumb metacarpophalangeal joint, diminishes pain and weakness with minimal loss of motion, and holds up over time.

Trapeziometacarpal joint injuries.

This article begins with discussions of anatomy and thumb movement. Palmar (anterior) ligament reconstruction is then discussed. Peritrapezial arthritis is also discussed.

Injection injuries to the median and ulnar nerves at the wrist.

Carpal tunnel syndrome is often treated nonoperatively with temporary wrist immobilization and local steroid injections. A direct injection into a peripheral nerve can result in permanent damage. Two cases of median nerve injection injury and one involving the ulnar nerve are presented; all were treated with neurolysis and debridement of the injected material. At follow-up ranging from 1 to 11 years, all patients showed significant improvement, but with some functional loss. The literature is confusing because of the variety of injection techniques used for the treatment of carpal tunnel syndrome, some of which put the median nerve at risk. We recommend that the injection be made midway between the palmaris longus tendon and the flexor carpi ulnaris tendon just proximal to the proximal edge of the transverse carpal ligament in a line with the superficialis tendon of the ring finger. The injection should be stopped and redirected if the patient experiences paresthesia of any kind.

Surgical treatment of infections and lesions of the perionychium.

This article will discuss acute and chronic bacterial, viral, and fungal infections involving the perionychium. Special emphasis will be placed on the surgical treatment of these entities including the surgical approach to subungual tumors and the technique of total onychectomy.

[Dissection technic for the superficial flexor tendon of the ring finger]. / Technique de prélèvement du tendon fléchisseur superficiel de l'annulaire.

Raising of the superficial flexor of the ring finger for tendon transfer may leave major sequelae, especially if the blood supply of the deep tendon is damaged. For this reason, the authors stress two important points: raising of the flap proximal to the chiasma to avoid damage to the blood supply of the deep tendon, stepped section for opening of the tendon sheath to prevent any mechanism of adherence. The intersection should be followed by gentle traction by means of a splint.

The finger extensor system. Some approaches to the correction of its disabilities.

A brief historical, anatomic, and functional review of the finger extensor system is complemented by more recent refinements relative to possible surgical restoration of tendon and retinacular disruption at the three articular levels.

Tendon interposition arthroplasty for degenerative arthritis of the trapeziometacarpal joint of the thumb.

Arthrosis of the trapeziometacarpal joint of the thumb is a predictable sequelae of ligament laxity. A new technique of tendon interposition arthroplasty with ligament reconstruction using the flexor carpi radialis tendon for a painful arthritic trapeziometacarpal joint of the thumb is described. Twenty-one patients had 25 operative procedures; 14 were women and seven were men. All of the patients presented with intractable pain, crepitus, and varying degrees of laxity of the basal joint. Pinch strength was diminished. Follow-up averaged 37 1/2 months. After surgery, 91.7% of patients had good to excellent results, and 56% were completely pain free. Range of motion and grip and pinch strengths were equal on the operated and unoperated sides.

Ligament reconstruction for the painful thumb carpometacarpal joint: a long-term assessment.

An extra-articular ligament reconstruction to stabilize the thumb carpometacarpal (CMC) (basal) joint by routing a portion of the flexor carpi radialis (FCR) through the base of the thumb metacarpal has been performed on more than 100 patients since 1967. This study reviews the first 50 consecutive reconstructions with an average follow-up of 7 years. Intractable pain was the primary indication for surgery. Each joint was examined both pre and postoperatively and rated as a stage I through stage IV according to the radiographic appearance. Of the patients with zero or minimal articular changes (stages I and II), 95% achieved good or excellent results because of having little or no postoperative pain. Of the patients with moderate to advanced degenerative changes (stages III and IV), 74% achieved good or excellent results. All stage I cases and 82% of stage II cases were free of recognizable degeneration on follow-up radiographs up to 13 years postoperatively. These findings suggest that ligament reconstruction that is now recommended only for stage I or stage II disease will restore stability, reduce pain, and possibly even retard joint degeneration in a large proportion of patients with painful instability of the thumb CMC joint.

Transferring the flexor superficialis tendon: technical considerations in the prevention of proximal interphalangeal joint disability.

Transfer of the flexor digitorum superficialis tendon to restore functional loss may result in a flexion contracture or hyperextension deformity of the proximal interphalangeal joint of the donor finger. Removal of the flexor tendon through the membranous interval in the fibro-osseous sheath between the annular pulley (A2) and the proximal collar (A1) avoids scarring of the structures volar to the proximal interphalangeal joint. Sixteen flexor superficialis tendons were removed at this membranous interval for transfer. No functional impairment from flexion contracture or hyperextension deformity developed after operation in the donor fingers, although an average 8 degrees of loss of extension was noted at the proximal interphalangeal joint in 50% of the donor fingers.

Restoration of power pinch.

Loss of the ulnar innervated intrinsic musculature resulting in weakness of pinch constitutes a significant functional deficit. Twenty-two patients with ulnar intrinsic paralysis underwent transfer of the ring flexor superficialis tendon across the palm, stimulating the course of the adductor pollicis. Preoperative pinch loss averaged 14.3 pounds, reducing pinch power to 30% of the opposite, normal hand. The transfer achieved an average increase of pinch of 8.3 pounds, restoring pinch to 71% of the opposite, uninvolved hand.

Primary care of the injured hand, part 2.

Nerve injuries in the forearm and hand are common, especially with concomitant tendon lacerations. The optimal time for repair of a clean sharp laceration is within the first 24 to 48 hours using magnification to achieve precise surgical reapproximation. Transfer to a facility equipped to perform replantation is indicated for multiple digit amputations, any thumb amputation, transmetacarpal amputation, wrist and arm amputation, and major amputations in children. Acute paronychial infections are treated with warm soaks, antibiotics, elevation, and immobilization. Surgical drainage is often indicated for a felon and should be done through a high midaxial incision. fractures of the hand are extremely common and require accurate diagnosis and precise anatomic reduction. Ensheathment syndromes--carpal tunnel syndrome, trigger finger, de Quervain's disease--are the most common nontraumatic disorders of the hand. If recognized and treated early they may resolve without need for surgery.

Primary care of the injured hand, part 1.

Because the hand is the most frequently injured part of the body, primary recognition of injured structures, careful assessment of damage, and appropriate treatment or referral by the primary care physician are critical. Most fingertip injuries heal with conservative care. Ideally, the healed wound should be covered with well-padded skin, be free of scar tissue, and not adhere to underlying bone. Crushing fingertip injuries associated with underlying fractures are often overlooked initially, with resultant infection, nonunion, and nail deformity. In the evaluation of flexor tendon injuries, recognition of the location of severed tendon is critical. Improved surgical techniques, when performed by an experienced hand surgeon, have yielded gratifying results, especially in the primary repair of tendon severance in the distal portion of the digit and palm. Mallet deformities at the distal interphalangeal joint are treated with extension splinting for minimum of six weeks without immobilization of the proximal interphalangeal joint. Open reduction is often required when an associated fracture involves more than 30% of the articular surface.