The Story of the Hand.

This review describes the Story of the Human Hand. It traces the functional needs that led to evolution of the human hand as well as its embryological development. The various in utero stages of formation of the human hand are covered along with a description of the various molecular and genetic factors that control this process.

Gamekeeper's thumb--a treatment-oriented magnetic resonance imaging classification.

PURPOSE: To investigate by magnetic resonance imaging the degree of ulnar collateral ligament (UCL) displacement in order to create a simple classification to aid in determining which UCL injuries require surgery. METHODS: We evaluated 43 cases of UCL injury with a dedicated extremity magnetic resonance imaging and measured the degree of ligament displacement. This was correlated to clinical outcome with planned surgical intervention reserved for patients with a Stener lesion. By collating results we could generate 4 types of injury based on the appearances of the UCL. RESULTS: Partial and minimally displaced UCL tears (type 1) and tears displaced less than 3 mm (type 2) typically healed by immobilization alone, whereas 90% of tears displaced more than 3 mm (type 3) failed immobilization and required surgery as did all of those with a Stener lesion (type 4). CONCLUSIONS: Our 4-stage, treatment-oriented classification of thumb UCL injury is based on the degree of UCL displacement in, with correlation with the likelihood of success with either immobilization or operative intervention. Tears of the UCL with more than 3 mm of displacement are likely to require operative repair even in the absence of a true Stener lesion.

Comparison of 3 ultrasound-guided brachial plexus block approaches for cubital tunnel release surgery in 120 ambulatory patients.

We wanted to determine whether 1 of 3 brachial plexus blocks was best for one of our most common surgeries, the cubital tunnel release with or without transposition of the ulnar nerve. Brachial plexus blocks can provide excellent results for upper extremity surgery, but we noticed inexplicable block failure for cubital tunnel releases with an incision in the proximal arm. In this case series, we initially reviewed 90 patients receiving axillary, infraclavicular, or supraclavicular blocks to determine if one block performed better for a surgical procedure that proceeds up the inner aspect of the arm. The theory that infraclavicular and supraclavicular blocks were superior for this surgery was not demonstrated in these patients. Success was not determined by the block chosen; however, the intercostobrachial nerve may be inconsistently blocked because it is difficult to visualize on ultrasound. We subsequently reviewed 30 more patients, but this time the volume of the intercostobrachial block was doubled. By increasing the volume, there appeared to be less need for surgeons to "touch up" blocks in the operating room. We suggest that increasing the volume of the intercostobrachial nerve block may improve success. Further studies to identify the intercostobrachial nerve by ultrasound are needed.

Management of Pincer Nail Deformity by Realignment of Nailbed Using a Dermofascial Graft.

Pincer nail deformity is an uncommon entity which can be painful and cosmetically unappealing. We describe our technique of correcting this deformity by realignment of the nailbed using a dermofascial graft. Pain relief as well as a cosmetically good result have been obtained in all patients, and this has been maintained over the long term. The technique has proven to be safe, effective, and reproducible.

Management of Highly Comminuted Intra-articular Fracture Subluxations at the Proximal Interphalangeal Joint by Subchondral Buttress Fixation and Early Mobilization.

This article describes our technique of managing highly comminuted intra-articular fracture subluxations at the proximal interphalangeal joint by subchondral buttress fixation followed by early mobilization. This technique has proven to be reliable and all patients have been able to return to their preinjury level of activity.

Small Finger Abduction Test to Evaluate the Flexor Carpi Ulnaris Tendon.

We describe a simple and effective method to assess the integrity of the flexor carpi ulnaris muscle and tendon. This method is called the Small Finger Abduction Test. The study also evaluates the efficacy and practicality of the test.Level of Evidence: Level II.

Outcomes of the glove-gauze regimen for managing burn injuries of the hand.

We studied the efficacy of the glove-gauze regimen in treating superficial, partial-thickness and small full-thickness hand burns. Outcome measures included healing time, need for surgical intervention, need for formal physical therapy, restoration of range of motion, return to function and incidence of infection. All patients (n = 123) successfully completed the regimen with an average healing time of 3.7 weeks. None required surgical debridement and seven (6%) required formal physical therapy. One hundred and eighteen patients (96%) regained full range of motion and 122 (99%) returned to their previous level of work. We believe that the glove-gauze regimen provides a simplified and effective means of managing hand burns. We conclude from our patients that the glove-gauze regimen is an effective treatment that can ensure uneventful healing of superficial, partial-thickness and small full-thickness burns. A majority of our patients healed with full range of motion and function without formal physical therapy.Level of evidence: IV.

Evaluation of two types of vascular bundles for revascularization of avascular tissue.

PURPOSE: Implantation of vascular bundles into ischemic tissue as a means of revascularization has been performed for many decades, but there is considerable confusion regarding its clinical utility. We believe that the varying results quoted in the literature are a result of using bundles that are different from each other. We propose that vascular bundles are of 2 types: a parallel pipe type and an axial flap type. We propose that in rats, the femoral arteriovenous bundle represents a parallel pipe type and the epigastric bundle an axial flap type. We propose that if ligated and implanted into an isolated sterile environment, the parallel pipe type of vascular bundle will thrombose, whereas the axial flap type of bundle will remain patent and demonstrate neovascular sprouting. METHODS: The study was carried out in 20 rats. Femoral and epigastric bundles were dissected, ligated with 10-0 nylon, and implanted into a tubing of sterile latex. The bundles were analyzed at various time intervals by both gross and histologic examination. RESULTS: The femoral bundle did not demonstrate any arteriovenous cross-communication under magnification, confirming its status as a parallel pipe type. The epigastric bundle demonstrated a rich plexus of arteriovenous channels, confirming its status as an axial flap type. A distinct adherent thrombus was seen at 24 hours in all the ligated femoral bundles and was still present at 3 weeks; none of these demonstrated evidence of neovascular sprouting. The ligated epigastric bundles remained patent in all specimens with no evidence of thrombosis, and all demonstrated exuberant neovascular sprouting. CONCLUSIONS: Our experiment establishes that there are at least 2 distinct types of vascular bundles in the rat. It also indicates that parallel pipe type of vascular bundles implanted into latex tubing thrombose and do not demonstrate neovascularization. On the other hand, under the same circumstances axial flap bundles remain patent and demonstrate exuberant neovascularization.

A technique for using the Ilizarov fixator for primary centralization in radial clubhand.

Radial clubhand is a condition that is cosmetically unappealing and functionally challenging to the patient. Management of this condition aims to achieve a straighter alignment of the hand on the forearm while maintaining a stable wrist without compromise of growth at the distal ulnar epiphysis. We have been using a 2-stage procedure to manage type 3 and 4 radial clubhand since 1993. Centralization is initially obtained by using the Ilizarov fixator in a hinged-distraction mode. Once this is achieved, the correction is secured at a second stage by pinning the carpus to the ulna. We describe in detail the technique of constructing the Ilizarov frame for this purpose.

Interlocking K Wires Followed by Immediate Mobilization for Fractures of the Hand.

We describe a technique of interlocking Kirschner wires to improve stability after fixation of fractures of the hand. This enables immediate mobilization of the injured fingers thus reducing the need for prolonged postoperative physical therapy and consequently diminishing chances of posttraumatic stiffness. This study analyzes outcomes in 83 fractures in 70 patients including 26 metacarpal and 57 phalangeal fractures. The technique has proven to be simple, versatile, and cost-effective. Patient compliance and satisfaction has been high and results have been gratifying.

Internal Bone Grafting for the Treatment of Scaphoid Nonunions.

Scaphoid fracture is the most common carpal fracture of the upper extremity and a significant proportion of these can eventually progress to nonunion. Excision of pseudoarthrosis and fibrous scar tissue at the nonunion site is regarded as one of the important steps in management of scaphoid nonunions. We describe a technique of internal bone grafting, where curettage of the nonunion site was performed through a drill hole in the scaphoid and bone graft was packed through this same hole before fixation with a headless compression screw. We have been able to achieve a union rate of 86% using this technique. The advantage of the technique is that it does not disturb the external fibrocartilaginous shell that would have formed around the nonunion site, thus leaving the articular surface undisturbed.

Aneurysmal Bone Cyst Involving the Pisiform: A Case Report.

BACKGROUND: Aneurysmal bone cysts are an uncommon form of benign primary bone tumors; affection of the hand is very rare. METHODS: A rigorous review of the literature showed that this type of tumor has not previously been described in the pisiform. In this article, we report the occurrence of an aneurysmal bone tumor in the pisiform of the left hand of a 19-year-old male. RESULTS: This tumor was successfully treated through surgical excision with an uneventful recovery. We describe the process behind the diagnosis of the lesion and the subsequent treatment in an attempt to highlight the rare but possible occurrence of aneurysmal bone cysts in the pisiform. CONCLUSION: Appropriate treatment of aneurysmal bone cysts in this location is required, due to the anatomical nature of the pisiform itself with the risks of pathologic fracture and ulnar nerve compression.

A Technique for Treating Dorsal Instability of the Distal Radioulnar Joint.

We describe a technique for the treatment of chronic dorsal instability of the distal radioulnar joint by creating a strong dorsal radioulnar restraint using opposing flaps from the extensor retinaculum and dorsal capsule of the radioulnar joint. This technique has been used in 18 patients and has proven to be very easy and reliable with all patients demonstrating good stability of the distal radioulnar joint at final follow-up.

Mutilating Hand Injuries in Children.

Mutilating hand injuries in children are injuries that are significant not only because of the actual injury caused to tissue but also owing to the significant psychological impact they have on the patient and family alike. Management of these injuries requires significant surgical skill as well as a well-planned and well-executed treatment protocol. This article discusses the etiology, incidence as well as treatment of mutilating hand injuries in a child. Relevant literature has been reviewed and appropriate treatment guidelines have been provided.

Distal Radius Bone Graft From the Second Extensor Compartment: A Safe and Effective Technique.

We describe a technique for harvesting cancellous bone graft from the floor of the second extensor compartment that is both easy and effective. It confines surgery to a single operative field under the same regional anesthesia and tourniquet as the primary hand surgical procedure while at the same time allowing wide visualization for harvesting bone graft. It provides cancellous bone of sufficient quality and quantity for use in most hand surgical cases. The technique has so far been used in 80 patients and has proven to be very safe.

Parsonage-Turner Syndrome: Clinical and Epidemiological Features From a Hand Surgeon's Perspective.

BACKGROUND: Parsonage-Turner Syndrome (PTS) is a rare but serious condition characterized by spontaneous paresis of the upper extremity, typically lasting several months with variable recovery. With little literature on the behavior of PTS from a hand surgeon's perspective, accurate diagnosis and subsequent counseling of patients with PTS can be challenging. METHODS: This study is a retrospective evaluation of the clinical features of all PTS patients seen over a 9-year period. Data was collected for gender, side affected, handedness, inciting event, clinical presentation, nerve involvement, time taken for recovery, and extent of recovery. RESULTS: Thirty-eight adult cases of PTS were identified, representing an incidence of 0.34 per 1000. Fifty-five percent were female, with predomination of right handedness and dominant upper extremity involvement (60% and 58%, respectively). There was an inciting incident identified in 42% of cases, and 37% of these involved surgery. Twenty-nine percent of cases presented without experiencing typical neuropathic pain. There was a predomination of anterior interosseous nerve (AIN) or posterior interosseous nerve (PIN) involvement (42% overall). Only 44% of patients achieved a complete recovery, taking a mean duration of 10 months. CONCLUSIONS: This study highlights both the rarity and atypical spectrum of clinical presentation of PTS, especially considering the more common involvement found for AIN and PIN. This highlights the likelihood that patients presenting with PTS to a hand surgical practice may differ from those typically described in the literature. The poor rate of recovery is in line with other recent reports and contrasts with the more positive outcomes found in earlier studies.

Resurfacing glabrous skin defects in the hand: the thenar base donor site.

Defects of the glabrous skin surfaces of the palm and fingers result from numerous causes including larger fingertip injuries, unhealed burns, and after surgery for diverse pathologies. The qualities of glabrous skin are specifically tailored to the functional requirements of high-shear strength and robustness. Despite these unique properties, graft reconstruction of defects in the glabrous regions of the hand is frequently achieved with skin from nonglabrous donor sites such as the medial forearm. Nonglabrous skin has a poor color and texture match for such applications and is frequently associated with tender and unsightly donor scars. We describe our experiences of harvesting full-thickness grafts from the glabrous skin centered over the proximal flexion crease at the level of the metacarpophalangeal joint of the thumb. We have utilized this site to harvest skin grafts of up to 2 cm in width for the resurfacing of small-sized to medium-sized defects on the palmar surfaces of the hands and fingers in 28 patients under both traumatic and elective circumstances. The skin has an excellent type-match to the defect and is quick and easy to harvest due to its adjacent location to the defect. The donor scar matures quickly, and as it lies along the thumb base crease, it runs along one of the least used contact surfaces, thereby limiting the potential discomfort associated with FTSG harvest sites from other areas. Patient satisfaction with the procedure has been high, and it represents a useful alternative to traditional nonglabrous skin graft donor sites for small-sized to medium-sized defects.

Intraosseous xanthoma of the distal radius - a case report.

An intraosseous xanthoma is a very rare condition. It has an aggressive appearance on radiographs mimicking primary or metastatic malignant bone tumors. We report a case of intraosseous xanthoma of the distal radius in a 51-year-old male with no history of hyperlipidaemia. To the best of our knowledge, this condition has not been reported so far in the wrist and forearm region. The lesion was successfully excised and at last follow-up, there were no signs of recurrence and patient has been symptom-free.

Intraneural malignant granular cell tumor - report of an extremely rare tumor in a child.

We report a case of intraneural malignant granular cell tumor of the upper extremity occurring in a child. This is an exceedingly rare tumor and the incidence has so far been reported only in adults. The tumor was successfully treated surgically and the patient has remained tumor free to date. We describe our approach to the problem so that it will serve as an index case for similar encounters in the future.

The recall DASH score--a novel research tool.

The DASH score is a universally accepted method for assessment of hand function. However, there are occasions when a pre-treatment DASH score is unavailable. This study provides a solution to this situation. An initial DASH score was obtained from all patients at the time of their first clinic visit. A second score was obtained at the time of final follow-up asking the patient to "Recall" their pre-treatment status. The two scores were compared with appropriate statistical analysis. Thirty-eight patients were included in the study and scores were obtained at an average time interval of 32 weeks (6-121 weeks). Excellent agreement was noted for the ability of the patient population to recall their scores with a group correlation of 0.86. This proves that the Recall DASH score is an excellent and useful research tool for use in hand surgery.