[Classification of congenital hand anomalies]. / Classification des anomalies congénitales de la main.

Increasing knowledge of the molecular basis of embryonic development has improved our understanding of congenital limb malformations. The most popular current surgical classification of congenital limb anomalies is the Swanson/IFSSH classification. This is based on morphology (appearance). Such a classification is unable to indicate the site in the molecular pathway and/or the anatomical site in the limb bud, nor the time at which the insult occurs. Attempts to alter a classification based on morphology according to increased knowledge of the molecular basis of limb development are flawed. Perhaps it is better to simply describe and document the malformations appearing in any particular limb until such time as a valid classification relating to causation and aetiology at a molecular level can be established.

Plexiform neurofibroma with dual nerve origin within the palm: a case report.

We describe a unique case of a 44-year-old gentleman who presented to our hand department with a history of a lump within his right palm that spanned several decades. Its gradual increase in size together with pain on palpation merited further investigation and subsequent surgical excision. Extensive tumour emanating from both ulnar and median nerves was resected, the histopathological diagnosis of which was plexiform neurofibroma. We believe this is the first description of an isolated plexiform neurofibroma of the hand with dual nerve origin.

Classification of congenital anomalies of the hand and upper limb.

The Oberg, Manske, Tonkin Classification of congenital anomalies of the hand and upper limb utilizes dysmorphological concepts to distinguish Malformations from Deformations and Dysplasias. Malformations are abnormalities of Formation and/or Differentiation of tissues. Deformations are abnormalities which occur after tissue is formed. Dysplasias are abnormalities which result from a lack of normal organization of cells into tissue. Malformations are sub-grouped according to whether the abnormality affects the hand alone or the whole of the upper limb; and according to which, if any, of the three main axes of development are primarily involved. It is not possible to satisfy all criteria which would define an ideal classification. However, this system is practical in that it retains the surgical diagnoses and sub-classifications familiar to surgeons and is easily utilized; it is expandable and may be modified without destroying its structure; it may be used to accumulate prevalence data; and, in the future, gene and chromosomal defects which are identified for specific diagnoses may be incorporated into the system.

Description of congenital hand anomalies: a personal view.

A series of four congenital hand cases exhibiting central clefting are presented. The cases are morphologically similar and exhibit characteristics of both symbrachydactyly and central longitudinal deficiency. The cases demonstrate difficulties in classification by either the IFSSH classification system or the JSSH modification of it. An alternative descriptive approach to classification is suggested.

Long term follow-up of composite non-vascularized toe phalanx transfers for aphalangia.

The results of 21 non-vascularized toe phalanx transfers in 13 patients were reviewed radiologically with respect to function, physeal patency, growth and donor site morbidity at a mean follow-up of 7.4 (range 2.9-13.6) years. Physeal patency was maintained in 4 of 18 surviving transfers. The length of the transferred phalanx averaged 75% of the contralateral comparable toe phalanx and 44% of the contralateral digit proximal phalanx. Most patients had good or simple use of the hand with active joint motion. There was universal shortening of the donor toe with hypoplasia of the middle and distal phalanges. This review suggests that transfer of a non-vascularized toe phalanx provides a reliable but limited means for increasing length of a digit, stabilizing soft tissue "nubbins" and improving function. Longer follow-up has shown more modest gains in growth than in some previous reports.

The results of pollicization for congenital thumb hypoplasia.

We assessed pollicizations performed by one surgeon; compared function of the pollicized digit in patients with and without forearm/wrist anomalies; and determined if hand function changed with age. A total of 42 hands were assessed an average of 5.7 years post-operatively, 21 with a forearm/wrist anomaly (Group 1) and 21 without (Group 2). Fourteen patients with 16 pollicizations were assessed on two occasions 3.5 years apart. Carpometacarpal joint motion was near normal in both groups (decreased retropulsion in Group 1). Metacarpophalangeal and interphalangeal joint flexion, grip, thumb lateral and tip pinch strengths, and Jebsen timed test were superior in Group 2. Subjective assessment by patients/parents found 72% excellent/good results for function and 94% for appearance. Doctor excellent/good assessments were 60% and 70%, respectively. Forearm/wrist anomalies significantly compromised results but are not a contraindication for pollicization. Strength and Jebsen timed test measurements improved at the second assessment of 16 thumbs, but this was consistent with age-related improvement. LEVEL OF EVIDENCE 4.

Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon.

We reviewed 21 patients with 22 ruptures of the extensor pollicis longus at a mean of 5.3 years after transfer of the extensor indicis proprius tendon. Of these, 19 with 21 transfers described the result as good, and two as fair. The mean deficit of extension between the operated and unoperated thumbs was 1.4 cm, and the mean flexion deficit 0.6 cm. Pressure gauge measurements showed that the strength of the transfer was 51% of that of the uninjured extensor. The two fair results had an extensor lag of over 1.5 cm. Independent extension of the index was maintained in all patients, none having a discernible lag, but the strength of index extension was reduced to 49% of that of the normal finger. There was no evidence of functional loss. Extensor indicis proprius transfer for rupture of the extensor pollicis longus tendon is a simple and reliable procedure with few complications. It gives satisfactory long-term extension of the thumb.

Posterior interosseous nerve axonotmesis from compression by a ganglion.

A complete posterior interosseous nerve palsy resulted from axonotmesis caused by pressure from a ganglion cyst. Excision of the neuroma and interpositional nerve grafting gave a most satisfactory outcome.

Spontaneous rupture of the flexor carpi radialis tendon.

Three cases of closed rupture of the flexor carpi radialis tendon associated with scapho-trapezio-trapezoidal arthritis are reported. Carpal tunnel surgery preceded all three ruptures. Local steroid injection preceded two ruptures. Long-term disability was minimal.

Acute calcific tendinitis in the hand and wrist.

Three cases of acute calcific tendinitis in the hand and wrist are described. The frequent misdiagnosis of this condition is discussed in the light of these cases and a review of the literature.

Dermofasciectomy and proximal interphalangeal joint replacement in Dupuytren's disease.

A case of Dupuytren's Disease is presented in which a combination of dermofasciectomy and proximal interphalangeal joint replacement using a Swanson's prosthesis improved hand function and avoided further digit amputation.

The posterior interosseous artery free flap.

A case is reported in which retrograde flow in the posterior interosseous artery did not perfuse the posterior interosseous artery flap, which was subsequently transferred as a free tissue transfer based on the proximal posterior interosseous vessels.

Wild platypus attack in the antipodes. A case report.

The platypus (ornithorhynchus anatinus) is a furry duck-billed mammal that inhabits the waterways of eastern Australia. The male may reach 60 cm in length with a 20 cm beaver-like tail. We report the case of an American naturalist stung whilst trying to study the male in the wild. This resulted in an intense local reaction. Warning signs should therefore be erected at air and sea ports warning tourists of the dangers of these venomous Australians.

The chauffeur's fracture: simple or complex?

14 chauffeur's-type fractures were treated by open reduction and internal fixation, mainly with Herbert screws. At average follow-up of 18 months, all had good or excellent functional results. The presence of an associated carpal injury in four cases indicates that the mechanism of injury may not be one of simple "backfire" and that a radial styloid fracture may represent the first stage of a more complex pattern.

Dorsal Dupuytren's disease causing a swan-neck deformity.

A previously undescribed lesion of Dupuytren's disease is presented. An oblique cord coursed parallel to the oblique retinacular ligament of Landsmeer, but inserted proximal to the proximal interphalangeal joint, tethering the central slip and radial lateral band across the intervening transverse retinacular ligament. Contraction of this cord caused a rigid swan-neck deformity. Excision of the cord resulted in complete resolution of the deformity and a full range of motion in the affected digit.

Brachial plexus palsy and carotid artery dissection.

We report a case of stroke due to carotid artery dissection in a young man following a traumatic brachial plexus palsy associated with a pseudoaneurysm of the axillary artery.

Nonunion of a distal radial fracture in a healthy child.

Nonunion of distal radial fractures in children are rare. We report a case of a closed distal radial fracture in a healthy child, which developed a nonunion following closed reduction and plaster immobilization.

Pre-operative distraction lengthening for radial longitudinal deficiency.

Patients treated for total radial aplasia have been reviewed. It was possible to re-align the carpus by radialization in five out of six limbs treated with pre-operative distraction, but in only one out of six treated without distraction. The average improvement in radial angulation in the non-distraction group was 19 degrees and in the distraction group 38 degrees. The average improvement in radial translation was 16 mm and 17 mm in the two groups respectively. Pre-operative distraction with the Kessler device permits re-alignment of the hand without skeletal resection or excessive tension on the radial neurovascular structures.

Wrist arthrodesis using a sliding radial graft and plate fixation.

In a retrospective study, the results of 18 wrist fusions with a radial sliding graft and a dynamic compression plate are reviewed. All 18 fusions united, with an average position of 16 degrees of extension and 7 degrees of ulnar deviation. Wrist strength and stability and diminished pain allowed improved function. However, decreased maneuverability impaired function for some activities.

The proximal interphalangeal joint in Dupuytren's disease.

In one hundred patients with Dupuytren's disease, one hundred and fifty-four operations were performed. The average pre-operative proximal interphalangeal joint contracture was 42 degrees and the average percentage improvement in proximal interphalangeal joint extension at post-operative review was 41%. Fourteen amputations were performed (9.1%). The primary deformity is caused by disease involvement of the palmar fascial structures. Secondary changes may prevent correction of the deformity despite excision of the contracted fascia. The anatomy of the joint is reviewed together with the primary and secondary mechanisms of joint contracture in Dupuytren's disease. Arthrodesis, osteotomy of the proximal phalanx and joint replacement are considered as alternatives to amputation when a systematic surgical approach fails to correct the flexion contracture.