Speciality
Spotlight

   




   


Surgery


   

 





Hand
Surgery



Transplantation

    

  • Dubernard
    J-M, Owen E, Herzberg G, et al [ Hopital Edouard
    Herriot, Lyon, France; Microsearch Found of Australia
    and Outer Sydney Hand and Micro-Surgery Unit; St
    Mary’s Hosp, London; et al]


    Human
    Hand Allograft Report on First 6 Months


    Lancet
    353: 1315-1320, 1999

     


    The results of transplantation of
    the right forearm and hand of a brain-dead male
    donor to a male recipient who had a traumatic
    midforearm amputation are discussed.

      

    The
    technique has been described. There were no surgical
    complications. At 8 weeks there was a rejection
    episode which was treated successfully. Passive
    mobilization was started on day one and continued till
    week six. At 100 days, no stiffness was noted, but
    sensation was lacking. There was good callus formation
    at 3 months and advanced healing at 6 months.
    At 80 days, the patient had some sensation.

      

    They
    conclude that hand transplants can be successfully
    done but sensation and functional analysis are not
    complete.

     

  • Mccabe
    S, Rodocker G, Julliard K, et al [Univ of Louisville,
    Ky]

    Using
    Decision Analysis to Aid in the Introduction of Upper
    Extremity Transplantation

    Transplant
    Proc 30: 2783-2786, 1998

     




    The
    surgical technique for limb transplantation is similar
    to that of replantation.
    Transplantation has been successfully performed
    in a primate model, but has not been attempted in
    humans. The
    authors have evolved a method to help clarify the
    decision process of such transplantation and its
    sequelae, to create utilities for the various health states
    and to perform a sensitivity analysis to clarify the
    direction of future research.

     

    Methods
    – A simple model was created to show the decision
    process. One branch demonstrated negative
    postoperative sequelae and included poor health as a
    summary state. Literature
    was reviewed and experienced health care workers were
    consulted to determine the best estimates of the
    probabilities of events occurring.
    Numeric values were attached to each health
    state, using a time trade-off technique. 22 surrogate
    patients were asked whether they would choose to
    remain in a defined state of poor health or trade
    future years of life for improved heath.
    Willingness to trade relates to the value the
    patient places on the state of health being
    considered. Sensitivity
    analyses were performed.

          

    The
    value of successful transplant was ranked higher than
    the value of amputation, which in turn ranked higher
    than failed transplantation.
    Successful transplantation with poor health was
    preferred to no transplantation. Removal of the limb
    after failed transplantation may be acceptable if the
    patient is in poor health caused by immunosuppressives.

          

  • Smutz
    WP, Kongsayreepong A, Hughes RE, et al[ Mayo Clinic
    and Found, Rochester, Minn]

    Mechanical
    Advantage of the Thumb Muscles

    J
    Biomech 31: 565-570, 1998

     

    The
    moment arms of the thumb muscles at the
    interphalangeal, metacarpophalangeal, and
    carpometacarpal joints were measured throughout
    the range of motion of each joint.

     

    The
    technique is described and the results show that :-

    1.  
    At metacarpophalangeal joint


     

    FPL, FPB, ADPt and ADPo and OPP were the major
    flexors.

     

    2.  
    At carpometacarpal joint


     

    FPL, FPB, ADPt, ADPo and OPP were the major
    flexors.

     

    This
    knowledge can aid in planning rehabilitation.

         

  • Lyons
    RP, Kozin SH, Failla JM [ US Air Force, Aviano, Air
    Force Base, Italy; Temple Univ, Philadelphia; Henry
    Ford Hosp, Detroit]

    The
    Anatomy of the Radial Side of the Thumb: Static
    Restraints in Preventing Subluxation and Rotation
    After Injury

    Am
    J Orthop 27: 759-763, 1998

     

    A
    cadaver study was performed to delineate the anatomic
    variations of the radial side of the thumb MP joint
    and to assess the relative contributions of the volar
    plate, radial collateral ligament, dorsal capsule and
    the extensor pollicis brevis in preventing rotation
    and volar subluxation.

      

    The
    methodology has been described. The results: The
    extensor pollicis brevis insertion was variable [ 61%
    inserted into the base of the proximal phalanx, 26%
    continue as a distal slip to the distal phalanx with
    no discrete insertion, and blending into the capsule
    with no discrete insertion in 10%. Volar subluxation
    varied from 0% to 35% and rotation from 12% to 35%.
    Volar subluxation increased to 26%, and rotation
    increased 20% when the radial collateral ligament was
    sectioned.

        

    Corresponding
    increases after incision of the extensor pollicis
    brevis/dorsal capsule were 12% and 12%, and were 21%
    and 24% after volar plate section. When the extensor
    pollicis brevis/dorsal capsule was sectioned first,
    followed by sectioning of the radial collateral
    ligament and the volar plate, results were 32% and
    14%, 9% and 12%, and 18% and 24% respectively.

            

    They
    conclude that the radial collateral ligament and
    extensor pollicis brevis/ capsule help stabilize the
    joint against rotation and volar subluxation. An X-ray
    after volar displacement is more helpful than after
    pronation for revealing MP instability.

      

  • Romain
    M, Allieu Y [Hopital Lapeyronie, Montepellier, France]

    Overview
    of the Function of Flexor and Extensor Tendons of the
    Hand [French]

    Ann
    Chir Main 17: 259-265, 1998

     
     



    The
    authors describe 4 commonly used methods plus their
    own, of evaluating the flexor tendons of the hands and
    extrapolate their personal method to the evaluation of
    the extensor tendons.

       

    The
    four commonly used methods are –

    1.    
    Total active movement [TAM]

       

    2.    
    Buck-Gramcko Method

       

    3.    
    Kleinert method and

       

    4.    
    Strickland method

       

    Each
    of these methods has drawbacks of their own. Their own
    method takes into account MP flexion, eliminates the
    action of the intrinsic muscles, and can be used in
    every zone. First, the hand is straightened. The MP
    joints are stabilized at 900 of flexion.
    The patient is asked to flex the digits, and the DPPPD
    is measured. Then the hand is placed in 450
    of extension and the extension deficits of the MP, PIP
    and DIP  joints
    are measured. This method was compared with the other
    four methods [ 165 patients]. The greatest number of
    excellent and good results was found with the Buck-Gramcko
    method [76%] followed in descending order by the
    authors method [ 66.6%], the Kleinert method [ 54.5%]
    and the Strickland’s method [53%].

        

    Extrapolation
    to Evaluation of the Extensor Tendons – First, the
    hand is placed in 450 of extension and the
    angle of extension deficit is measured. Then the hand
    is straightened. The MP joints are maintained at 900
    and the DPPPD is measured in passive flexions. [ A
    twist on the method for measuring flexor function].

         

    The
    method is simple and offers a reliable and
    reproducible means of measuring the function of the
    tendons of hands.

     

  • Bouchlis
    G, Bhatia A, Asfazadourian H, et al [Athenes, Greece;
    Pune, India; Institut d’Antomie de Paris; et al]

    Distal Insertions of Abductor
    Pollicis Longus Muscle and Arthritis of the First
    Carpometacarpal Joint in 104 Dissections [ French
    ]

    Ann
    Chir Main 16: 326-338, 1997

         


    This
    study examines the varying types of distal insertions
    of the APL tendons and their possible impact of the
    evolution of arthritis of the CMC joint of the thumb.

     

    104
    cadavers were dissected at the level of the CMC joint
    of the thumb. The appearance of the joint surface was
    noted and the distal insertions of the tendons to the
    level of the CMC joint was observed.
    The type of arthritis was correlated with the
    type of distal insertion of APL tendon.

         

    The
    APL had multiple insertion in 95% of cases.
    There was always an insertion at the base of
    the 1st metacarpal. 70% had an insertion
    into the trapezium as well 42% had an accessory tendon
    to the thenar eminence. 97% showed rhizarthrosis. 71%
    had lateral compartment of the joint surface
    involvement and was probably the starting point of the
    arthritis. The degree of arthritis did not reveal any
    correlation with the type of insertion of APL.

     

    The
    findings suggest that arthritis of the first CMC joint
    is extremely common and appears to start in the
    lateral compartments. 
    There is no correlation with the insertion of
    the APL tendon.  The
    finding do not support the practice of early
    prophylactic tenotomy for arthritis of the first CMC
    joint.

     

  • Gajisin
    S, Bednarkiewicz 
    M, Zbrodowski A [ Centre Medical Universitaire,
    Geneve; Hopital Cantonal Universitaire, Geneve]

    Blood Supply of the Digital Sheath

    Ann
    Chir Main 17: 147-153, 1998

     

    This
    study identifies the sources and describes the network  distributing the arterial blood supply of the digital sheath.

      

    A
    mixture containing india ink and gelatin or colored
    latex was injected into the brachial artery of 100
    fresh human cadavers. After formalin fixation,
    dissection was performed under the stereo-microscope.

       

    The
    digital sheaths of index, middle and ring fingers were
    studied. There
    are two main sources of supply [1] digitopalmar arches
    and [2] palmer digital arteries. Many anastomoses 
    are formed between these branches to create a
    fine arterial network on the inner surface of the
    digital sheath. The floor of the sheath is the most
    vascularized area, next the side wall and lastly the
    palmar side. The proximal dead end of the sheath is
    directly supplied by branches from the arcus palmaris  superficials.

     

  • Clarke
    MT, Lyall HA, Grant JW, et al [Addenbrooke’s Hosp,
    Cambridge, England]

    The
    Histopathology of de Quevain’s Disease

    J
    Hand Surg [Br] 23B:732-734, 1998

       


    De Quervain’s disease is considered to be a
    stenosing tenovaginitis of either acute or chronic
    inflammatory etiology. This was re-examined using a
    staining technique that reveals the accumulation of
    connective tissue mucopolysaccharide suggesting myxoid
    degeneration. This
    was performed on 23 consecutive patients undergoing
    treatment for Dequevain’s disease. There was no sign
    of active inflammation.
    The terms ‘ stenosing tenovaginitis’ and
    ‘ tenosynovitis’ are misnomers.

      

  • Sbernardori
    MC, Montella A, De Santis E [Universita degli Studi di
    Sassari]

    Histo-morphological Findings on
    the Flexor Digitorum Tendons in Human Embryos Hand at
    the End of First Trimester of Gestation [Italian
    ]

    Riv
    Chir Riab Mano Arto Sup 34: 229-233, 1997

    +

    Sbernardori
    MC [Universita Degli Studi di Sassari]

    Ultrastructural Aspects of the Palmar Aponeurosis
    of Fetal Hand [Italian]


    Riv
    Chir Riab Mano Arto Sup 34: 187-191, 1997

       

    These
    two articles are well documented and original studies
    on the development of the human hand.

      

    mm
    thick cross sections of the finger.

     

    The
    palmar aponeurosis [12th week], is easily
    seen under the derma with its typical double layer
    structure with a double oriented perpendicular
    pattern. Strict relationship is shown with
    intertendinous septa.

     

  • A.
    O’Bichere, S. Shurey, P. Sibbons, C. Green and R.K.
    S. Phillips [ St Marks Hospital and Northwick Park
    Institute for Medical Research, Harrow, UK]

    Experimental Model of Anorectal Transplantation

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1534-1539


        

  • S.
    Jain, G.R. Bicknell and M.L. Nicholson [ Department of
    Transplant Surgery, Leicester General Hospital,
    Leicester, UK]

    Tacrolimus has Less
    Fibrogenic  Potential
    Than Cyclosporin A in a Model of Renal Ischaemia-
    Reperfusion Injury

    Br.
    Jour. of  Sur.
    Volume 87, No.11, November 2000, Pgs- 1563-1568


           

    This
    study was aimed at determining the effect of
    Cyclosporin A and Tacrolimus on the expression of
    fibrosis – associated genes.

        

    Male
    Wistar rats underwent clamping of the right renal
    pedicle for 45 min together with left nephrectomy; [
    this model has been shown to be associated with
    upregulation of fibrosis associated genes. The rats
    were divided into groups of 6 animals and received
    either cyclosporin tacrolimus or no drug. These
    animals were killed at 16 weeks and the renal,
    cortical expression of fibrosis associated genes was
    studied.

          

    The
    tacrolimus group showed significantly less proteinuria,
    lower serum creatinine than the cyclosporin 
    group. Tacrolimus also significantly reduced
    the expression of transforming growth factor B and
    tissue inhibitor of metalloproteinases 1, both the
    products of genes associated with fibrosis. Although
    cyclosporin reduced levels of the matrix degrading
    enzymes, matrix degrading enzymes, matrix
    metalloproteinase 2 [MMP] and MMP-9, this was not
    statistically significant.

              

  • Drape J-L, Tardif-Chastenet de Gery S, Silbermann-Hoffman O, et al [ Hopital Cochin, Paris; Hopital Bichat,
    Paris ]

    Closed Ruptures of the Flexor Digitorum Tendons: MRI Evaluation

    Skeletal Radiol 27: 617-624, 1998

      

    This study evaluates the role of MRI in the diagnosis and management of closed flexor digitorum tendon ruptures.

      

    10 patients [7 male, 3 female mean age 48.5 years] with suspected closed ruptures of FDT underwent preoperative MRI of the hand with T1 weighted spin-echo sequences, 3-D gradient-echo images, and curved reconstructions to examine the FDT. The level of rupture, the gap between the tendon ends and the position of the proximal end of the tendon were then compared between MRI and operative findings.

      

    MRI indicated 12 FDT ruptures, FDP alone 4 cases, FDP +FDS rupture 3 cases, and FDS alone 2 cases, and FDL alone 2 cases. These findings were confirmed at surgery. The level of rupture, the gap between the tendon ends correlated well with operative findings; further, MRI could detect tendinitis in 3 adjacent tendons. 

      

    The authors conclude that MRI can accurately identify the level of tendon rupture and the gap between the tendon ends and is useful in the diagnosis and management of tendon ruptures.

         

  • Gabl
    VM, Lener M, Pechlanner S, et al [ Universitatsklinik fur Unfallchirurgie, Innsbruck, Germany; Institut fur Magnetresonanztomographie und Spektroskopie, Innsbruck,
    Germany ]

    Closed Traumatic Rupture or Overuse Syndrome of the Flexor Tendon Pulleys? Early Diagnosis by MRI [German]

    Handchir Microchir Plast Chir 28: 317-321, 1996

     

    This study examines the efficacy of MRI for the diagnosis of closed injuries to the flexor tendon pulleys.

     

    18 rock climbers with recent injuries were studied. 8 [overuse injuries] were treated conservatively along with [short pulley ruptures]. 2 patients with long pulley ruptures were operated [tendon grafting]. They were followed up for 36 months.

     

    An MRI was done in all cases for diagnosis. Bowstringing or flexion contracture after treatment was not clinically detectable in any patient. All but 1 patient had nearly normal range of movement. Lasting swelling was the only clinical feature of partial instability. MRI was able to detect minor bowstringing and scars in most patients.

     

    They conclude that MRI was useful in detecting the presence and extent of pulley injury.

       

  • Failla JM, Jacobson J, van Holsbeeck M [Henry Ford Hosp, Detroit]

    Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/Dislocations

    J Hand Surg [Am] 24A: 257-266, 1999

      

    This study evaluates the usefulness of ultrasonography in the diagnosis of torn interosseous membrane [10M] in forearm fractures/dislocations.

      

    US was performed transversely on 2 cadaver forearms with intact IOM and again to confirm transection after 10M was transected in 1 forearm. Then US was performed in 2 Galeazzi fracture-dislocations 1 Essex-Lopresti injury were and compared with findings at operation. The authors conclude that US is a useful modality to diagnose and locate a torn IOM allowing primary repair to be performed.

       

  • Wallace AL, Haber M, Sesel K, et al [ Prince of Wales Hosp, Sydney, Australia; IIIawarra Private Hosp, Wollongong, Australia]

    Ultrasonic Diagnosis of Interosseous Ligament Failure In Radioulnar Dissociation

    Injury 30: 59-63, 1999

      

    Complex fractures of the elbow can be difficult to diagnose – thus “radioulnar dissociation is sometimes accompanied by interosseous ligament failure. This study used ultrasonography to make a diagnosis of I0M tear with comminuted radial head fracture. They feel that US imaging to an unexpensive, safe and readily available modality for obtaining images at baseline and throughout the healing process and for detecting occult injury of the interosseous ligament.

          

  • Wolf JM, Weiss A-PC [Brown Univ, Providence, RI]

    Portable Mini-fluoroscopy Improves Operative Efficiency In Hand Surgery

    J Hand Surg [Am] 24A: 182-184, 1999

      

    This study compares the use of traditional radiographic confirmation versus mini-fluoroscopy in a paired, retrospective cohort case study.

      

    30 patients underwent closed reduction or internal fixation of phalangeal shaft fractures or metacarpophalangeal or inter-phalangeal joint fusions. Standard intraoperative and lateral radiographs were used in 15 procedures and portable mini-fluoroscopy in the other 15 procedures.

      

    The minifluoscopy reduced operative time by 55% in phalangeal fractures by 39% in wrist fusion and by 48% in the in-situ 4 corner fusion.

      

    They conclude that mini-fluoroscopy is a safe effective and efficient modality in the tested surgical procedures.

         

  • Turgeon TR, MacDermid JC, Roth JH [Univ of Western Ontario, London; St Joseph’s Health Centre, London, Ont]

    Reliability of the NK Dexterity Board

    J Hand Ther 12: 7-15, 1999

      

    This study evaluates the reliability of the NK dexterity test as a part of a comprehensive computerized hand evaluation system.

      

    37 volunteers [24 women and 13 men] were tested on the NK dexterity board on 2 separate occasions. On each occasion individuals moved small, medium and large objects in 3 separate tests and separately with each hand.

      

    Most complained of arm or forearm fatigue, and had difficulty with threading the medium and large screw-type objects. Intraoccasion
    intraclass correlation coefficients [ICCs] [n=12; 3 tests x 2 hands x 2 occasions] were fair in half of the comparisons and excellent in the other half. Reliability was better in the dominant hand. ICCs for tests involving small medium objects were fair but for large objects were excellent.

      

    They conclude that although the NK dexterity board has fair-to-excellent reliability, there is a room for improvement. Suggestions made for improving the insrumentation include adding a steel lining to the plastic receptacle of the small steel screw, changing the T-shaped object in the medium sized test from aluminum to steel reducing the length of threading on the large screw object, and establishing a method to lubricate the large screw object.

      

    Nonetheless, this board has several advantages including its ability to test a wide variety of gross and fine movements, a computerized recording system that reduces operative error and normative data in the software for comparison based on age and sex.

        

  • Marx RG, Bombardier C, Wright JG [Univ of Toronto]

    What do we Know About the Reliability and Validity of Physical Examination Tests Used to Examine the Upper Extremity?

    J Hand Surg [Am] 24A: 185-193, 1999

      

    For a physical examination to be useful each test must be reliable and valid. A review was made of the reliability and validity of commonly used physical examination tests for disorders of the upper extremity.

      

    Relevant articles from literature, standard tests and fro consulting experts, were reviewed and analyzed separately from the point of the impairment of function and diagnosis.

      

    The tests for range of motion and strength testing were considered reliable. The tests used to diagnose upper extremity disorders like carpal tunnel syndrome and rotator cuff tendinopathy have varying degrees of validity. Overall, there is sparse evidence regarding the reliability and validity of physical examination for the upper extremities both from the point of diagnosis and impairment of function.

      

    It is therefore recommended that these tests not be used in isolation. It is important that the properties of each test be documented, so clinicians may reliably and accurately examine patients.

        

  • Sarhadi NS, Shaw-Dunn J[Univ of Glasgow, Scotland]

    Transthecal Digital Nerve Block: An Anatomical Appraisal

    J Hand Surg [Br] 23B: 490-493, 1998

      

    This study investigates the anatomical basis of a transthecal digital nerve block for local anesthesia of digits in 60 digits from 40 cadavers.

      

    Methylene blue and latex were injected into cadaveric digits to determine how anesthesia fluid injected into the flexor tendon sheath may spread around the finger.

      

    In digits when 3cc of solution was injected, irrespective of the puncture site, blotchy dye stains were seen on the dorsum of the proximal part of the finger, and the sides of the interphalangeal joint and the metacarpophalangeal joint and both the neurovascular bundles and the flexor tendon sheath were also stained. Dye stains were seen at the wrist when the injections were given at the thumb base and the little finger. Injections in the other fingers did not stain the proximal palm.

      

    If only 0.5cc were injected into the tendon sheath, staining appeared on the dorsum of the digit at its base and around the p.i.p. joint. It also tracked alongside the vessels. The fatty tissue showed linear staining, but no staining of nerves. Deeper staining was seen at the base of the proximal phalanx or in the region of the middle phalanx.

      

    Transthecal injection of 1 ml, resulted in a pool of dye around the neurovascular bundles, in the tissue space enclosed by Cleland’s ligament and Grayson’s ligament right to the tip of the finger.

      

    The authors conclude that injected dye solution escapes from the flexor tendon sheath around the vincular vessels, through the perivascular loose areolar tissue, and spreads alongside the main digital vessels and nerves and their branches.

        

  • Lundborg G, Rosen B, Lindberg S [Malmo Univ, Sweden]

    Hearing as Substitution for Sensation : A new Principle for Artificial Sensibility

    J Hand Surg [Am] 24A: 219-224, 1999

      

    Sense substitution is commonly used among patients with sensory deficits, such as the use of Braille to read by blind people. This study describes an attempt to use hearing as a substitute for lost sensibility.

      

    This study used vibrotactile stimuli to generate sounds as a substitute for hand sensibility. Miniature condenser microphones were attached to the distal, dorsal side of a glove to magnify the friction sound generated. The signal from the microphone was processed by a stereo amplifier which separated signals from different fingers into different channels. These sounds were then fed through earphones to patients with lost hand sensibility [3 had undergone median nerve repair, 1 had an replantation of an amputated forearm, 1 had a myoelectric prosthesis, and 4 had cosmetic prostheses. The patients participated in studies to assess spatial resolution and differentiation between textures.

     

    The spatial resolution of signals allowed patients to differentiate between the various fingers. Friction sounds enabled the patients to identify textures – such as glass, metal, wood and paper.

      

    The findings suggest that hearing may provide a useful substitute for lost hand sensibility.

        



 

   

Speciality Spotlight

   

   
Surgery
   

 

Hand Surgery
Transplantation
    

  • Dubernard J-M, Owen E, Herzberg G, et al [ Hopital Edouard Herriot, Lyon, France; Microsearch Found of Australia and Outer Sydney Hand and Micro-Surgery Unit; St Mary’s Hosp, London; et al]
    Human Hand Allograft Report on First 6 Months
    Lancet 353: 1315-1320, 1999
     
    The results of transplantation of the right forearm and hand of a brain-dead male donor to a male recipient who had a traumatic midforearm amputation are discussed.
      
    The technique has been described. There were no surgical complications. At 8 weeks there was a rejection episode which was treated successfully. Passive mobilization was started on day one and continued till week six. At 100 days, no stiffness was noted, but sensation was lacking. There was good callus formation at 3 months and advanced healing at 6 months. At 80 days, the patient had some sensation.
      
    They conclude that hand transplants can be successfully done but sensation and functional analysis are not complete.
     

  • Mccabe S, Rodocker G, Julliard K, et al [Univ of Louisville, Ky]
    Using Decision Analysis to Aid in the Introduction of Upper Extremity Transplantation
    Transplant Proc 30: 2783-2786, 1998
     
    The surgical technique for limb transplantation is similar to that of replantation. Transplantation has been successfully performed in a primate model, but has not been attempted in humans. The authors have evolved a method to help clarify the decision process of such transplantation and its sequelae, to create utilities for the various health states and to perform a sensitivity analysis to clarify the direction of future research.
     
    Methods – A simple model was created to show the decision process. One branch demonstrated negative postoperative sequelae and included poor health as a summary state. Literature was reviewed and experienced health care workers were consulted to determine the best estimates of the probabilities of events occurring. Numeric values were attached to each health state, using a time trade-off technique. 22 surrogate patients were asked whether they would choose to remain in a defined state of poor health or trade future years of life for improved heath. Willingness to trade relates to the value the patient places on the state of health being considered. Sensitivity analyses were performed.
          
    The value of successful transplant was ranked higher than the value of amputation, which in turn ranked higher than failed transplantation. Successful transplantation with poor health was preferred to no transplantation. Removal of the limb after failed transplantation may be acceptable if the patient is in poor health caused by immunosuppressives.
          

  • Smutz WP, Kongsayreepong A, Hughes RE, et al[ Mayo Clinic and Found, Rochester, Minn]
    Mechanical Advantage of the Thumb Muscles
    J Biomech 31: 565-570, 1998
     
    The moment arms of the thumb muscles at the interphalangeal, metacarpophalangeal, and carpometacarpal joints were measured throughout the range of motion of each joint.
     
    The technique is described and the results show that :-

    1.   At metacarpophalangeal joint
     
    FPL, FPB, ADPt and ADPo and OPP were the major flexors.
     
    2.   At carpometacarpal joint
     
    FPL, FPB, ADPt, ADPo and OPP were the major flexors.
     
    This knowledge can aid in planning rehabilitation.
         

  • Lyons RP, Kozin SH, Failla JM [ US Air Force, Aviano, Air Force Base, Italy; Temple Univ, Philadelphia; Henry Ford Hosp, Detroit]
    The Anatomy of the Radial Side of the Thumb: Static Restraints in Preventing Subluxation and Rotation After Injury
    Am J Orthop 27: 759-763, 1998
     
    A cadaver study was performed to delineate the anatomic variations of the radial side of the thumb MP joint and to assess the relative contributions of the volar plate, radial collateral ligament, dorsal capsule and the extensor pollicis brevis in preventing rotation and volar subluxation.
      
    The methodology has been described. The results: The extensor pollicis brevis insertion was variable [ 61% inserted into the base of the proximal phalanx, 26% continue as a distal slip to the distal phalanx with no discrete insertion, and blending into the capsule with no discrete insertion in 10%. Volar subluxation varied from 0% to 35% and rotation from 12% to 35%. Volar subluxation increased to 26%, and rotation increased 20% when the radial collateral ligament was sectioned.
        
    Corresponding increases after incision of the extensor pollicis brevis/dorsal capsule were 12% and 12%, and were 21% and 24% after volar plate section. When the extensor pollicis brevis/dorsal capsule was sectioned first, followed by sectioning of the radial collateral ligament and the volar plate, results were 32% and 14%, 9% and 12%, and 18% and 24% respectively.
            
    They conclude that the radial collateral ligament and extensor pollicis brevis/ capsule help stabilize the joint against rotation and volar subluxation. An X-ray after volar displacement is more helpful than after pronation for revealing MP instability.
      

  • Romain M, Allieu Y [Hopital Lapeyronie, Montepellier, France]
    Overview of the Function of Flexor and Extensor Tendons of the Hand [French]
    Ann Chir Main 17: 259-265, 1998
       
    The authors describe 4 commonly used methods plus their own, of evaluating the flexor tendons of the hands and extrapolate their personal method to the evaluation of the extensor tendons.
       
    The four commonly used methods are –

    1.     Total active movement [TAM]
       
    2.     Buck-Gramcko Method
       
    3.     Kleinert method and
       
    4.     Strickland method
       
    Each of these methods has drawbacks of their own. Their own method takes into account MP flexion, eliminates the action of the intrinsic muscles, and can be used in every zone. First, the hand is straightened. The MP joints are stabilized at 900 of flexion. The patient is asked to flex the digits, and the DPPPD is measured. Then the hand is placed in 450 of extension and the extension deficits of the MP, PIP and DIP  joints are measured. This method was compared with the other four methods [ 165 patients]. The greatest number of excellent and good results was found with the Buck-Gramcko method [76%] followed in descending order by the authors method [ 66.6%], the Kleinert method [ 54.5%] and the Strickland’s method [53%].
        
    Extrapolation to Evaluation of the Extensor Tendons – First, the hand is placed in 450 of extension and the angle of extension deficit is measured. Then the hand is straightened. The MP joints are maintained at 900 and the DPPPD is measured in passive flexions. [ A twist on the method for measuring flexor function].
         
    The method is simple and offers a reliable and reproducible means of measuring the function of the tendons of hands.
     

  • Bouchlis G, Bhatia A, Asfazadourian H, et al [Athenes, Greece; Pune, India; Institut d’Antomie de Paris; et al]
    Distal Insertions of Abductor Pollicis Longus Muscle and Arthritis of the First Carpometacarpal Joint in 104 Dissections [ French]
    Ann Chir Main 16: 326-338, 1997
         
    This study examines the varying types of distal insertions of the APL tendons and their possible impact of the evolution of arthritis of the CMC joint of the thumb.
     
    104 cadavers were dissected at the level of the CMC joint of the thumb. The appearance of the joint surface was noted and the distal insertions of the tendons to the level of the CMC joint was observed. The type of arthritis was correlated with the type of distal insertion of APL tendon.
         
    The APL had multiple insertion in 95% of cases. There was always an insertion at the base of the 1st metacarpal. 70% had an insertion into the trapezium as well 42% had an accessory tendon to the thenar eminence. 97% showed rhizarthrosis. 71% had lateral compartment of the joint surface involvement and was probably the starting point of the arthritis. The degree of arthritis did not reveal any correlation with the type of insertion of APL.
     
    The findings suggest that arthritis of the first CMC joint is extremely common and appears to start in the lateral compartments.  There is no correlation with the insertion of the APL tendon.  The finding do not support the practice of early prophylactic tenotomy for arthritis of the first CMC joint.
     

  • Gajisin S, Bednarkiewicz  M, Zbrodowski A [ Centre Medical Universitaire, Geneve; Hopital Cantonal Universitaire, Geneve]
    Blood Supply of the Digital Sheath
    Ann Chir Main 17: 147-153, 1998
     
    This study identifies the sources and describes the network  distributing the arterial blood supply of the digital sheath.
      
    A mixture containing india ink and gelatin or colored latex was injected into the brachial artery of 100 fresh human cadavers. After formalin fixation, dissection was performed under the stereo-microscope.
       
    The digital sheaths of index, middle and ring fingers were studied. There are two main sources of supply [1] digitopalmar arches and [2] palmer digital arteries. Many anastomoses  are formed between these branches to create a fine arterial network on the inner surface of the digital sheath. The floor of the sheath is the most vascularized area, next the side wall and lastly the palmar side. The proximal dead end of the sheath is directly supplied by branches from the arcus palmaris  superficials.
     

  • Clarke MT, Lyall HA, Grant JW, et al [Addenbrooke’s Hosp, Cambridge, England]
    The Histopathology of de Quevain’s Disease
    J Hand Surg [Br] 23B:732-734, 1998
       
    De Quervain’s disease is considered to be a stenosing tenovaginitis of either acute or chronic inflammatory etiology. This was re-examined using a staining technique that reveals the accumulation of connective tissue mucopolysaccharide suggesting myxoid degeneration. This was performed on 23 consecutive patients undergoing treatment for Dequevain’s disease. There was no sign of active inflammation. The terms ‘ stenosing tenovaginitis’ and ‘ tenosynovitis’ are misnomers.
      

  • Sbernardori MC, Montella A, De Santis E [Universita degli Studi di Sassari]
    Histo-morphological Findings on the Flexor Digitorum Tendons in Human Embryos Hand at the End of First Trimester of Gestation [Italian]
    Riv Chir Riab Mano Arto Sup 34: 229-233, 1997

    +

    Sbernardori MC [Universita Degli Studi di Sassari]
    Ultrastructural Aspects of the Palmar Aponeurosis of Fetal Hand [Italian]
    Riv Chir Riab Mano Arto Sup 34: 187-191, 1997
       
    These two articles are well documented and original studies on the development of the human hand.
      
    mm thick cross sections of the finger.
     
    The palmar aponeurosis [12th week], is easily seen under the derma with its typical double layer structure with a double oriented perpendicular pattern. Strict relationship is shown with intertendinous septa.
     

  • A. O’Bichere, S. Shurey, P. Sibbons, C. Green and R.K. S. Phillips [ St Marks Hospital and Northwick Park Institute for Medical Research, Harrow, UK]
    Experimental Model of Anorectal Transplantation
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1534-1539
        

  • S. Jain, G.R. Bicknell and M.L. Nicholson [ Department of Transplant Surgery, Leicester General Hospital, Leicester, UK]
    Tacrolimus has Less Fibrogenic  Potential Than Cyclosporin A in a Model of Renal Ischaemia- Reperfusion Injury
    Br. Jour. of  Sur. Volume 87, No.11, November 2000, Pgs- 1563-1568
           
    This study was aimed at determining the effect of Cyclosporin A and Tacrolimus on the expression of fibrosis – associated genes.
        
    Male Wistar rats underwent clamping of the right renal pedicle for 45 min together with left nephrectomy; [ this model has been shown to be associated with upregulation of fibrosis associated genes. The rats were divided into groups of 6 animals and received either cyclosporin tacrolimus or no drug. These animals were killed at 16 weeks and the renal, cortical expression of fibrosis associated genes was studied.
          
    The tacrolimus group showed significantly less proteinuria, lower serum creatinine than the cyclosporin  group. Tacrolimus also significantly reduced the expression of transforming growth factor B and tissue inhibitor of metalloproteinases 1, both the products of genes associated with fibrosis. Although cyclosporin reduced levels of the matrix degrading enzymes, matrix degrading enzymes, matrix metalloproteinase 2 [MMP] and MMP-9, this was not statistically significant.
              

  • Drape J-L, Tardif-Chastenet de Gery S, Silbermann-Hoffman O, et al [ Hopital Cochin, Paris; Hopital Bichat, Paris ]
    Closed Ruptures of the Flexor Digitorum Tendons: MRI Evaluation
    Skeletal Radiol 27: 617-624, 1998
      
    This study evaluates the role of MRI in the diagnosis and management of closed flexor digitorum tendon ruptures.
      
    10 patients [7 male, 3 female mean age 48.5 years] with suspected closed ruptures of FDT underwent preoperative MRI of the hand with T1 weighted spin-echo sequences, 3-D gradient-echo images, and curved reconstructions to examine the FDT. The level of rupture, the gap between the tendon ends and the position of the proximal end of the tendon were then compared between MRI and operative findings.
      
    MRI indicated 12 FDT ruptures, FDP alone 4 cases, FDP +FDS rupture 3 cases, and FDS alone 2 cases, and FDL alone 2 cases. These findings were confirmed at surgery. The level of rupture, the gap between the tendon ends correlated well with operative findings; further, MRI could detect tendinitis in 3 adjacent tendons. 
      
    The authors conclude that MRI can accurately identify the level of tendon rupture and the gap between the tendon ends and is useful in the diagnosis and management of tendon ruptures.
         

  • Gabl VM, Lener M, Pechlanner S, et al [ Universitatsklinik fur Unfallchirurgie, Innsbruck, Germany; Institut fur Magnetresonanztomographie und Spektroskopie, Innsbruck, Germany ]
    Closed Traumatic Rupture or Overuse Syndrome of the Flexor Tendon Pulleys? Early Diagnosis by MRI [German]
    Handchir Microchir Plast Chir 28: 317-321, 1996
     
    This study examines the efficacy of MRI for the diagnosis of closed injuries to the flexor tendon pulleys.
     
    18 rock climbers with recent injuries were studied. 8 [overuse injuries] were treated conservatively along with [short pulley ruptures]. 2 patients with long pulley ruptures were operated [tendon grafting]. They were followed up for 36 months.
     
    An MRI was done in all cases for diagnosis. Bowstringing or flexion contracture after treatment was not clinically detectable in any patient. All but 1 patient had nearly normal range of movement. Lasting swelling was the only clinical feature of partial instability. MRI was able to detect minor bowstringing and scars in most patients.
     
    They conclude that MRI was useful in detecting the presence and extent of pulley injury.
       

  • Failla JM, Jacobson J, van Holsbeeck M [Henry Ford Hosp, Detroit]
    Ultrasound Diagnosis and Surgical Pathology of the Torn Interosseous Membrane in Forearm Fractures/Dislocations
    J Hand Surg [Am] 24A: 257-266, 1999
      
    This study evaluates the usefulness of ultrasonography in the diagnosis of torn interosseous membrane [10M] in forearm fractures/dislocations.
      
    US was performed transversely on 2 cadaver forearms with intact IOM and again to confirm transection after 10M was transected in 1 forearm. Then US was performed in 2 Galeazzi fracture-dislocations 1 Essex-Lopresti injury were and compared with findings at operation. The authors conclude that US is a useful modality to diagnose and locate a torn IOM allowing primary repair to be performed.
       

  • Wallace AL, Haber M, Sesel K, et al [ Prince of Wales Hosp, Sydney, Australia; IIIawarra Private Hosp, Wollongong, Australia]
    Ultrasonic Diagnosis of Interosseous Ligament Failure In Radioulnar Dissociation
    Injury 30: 59-63, 1999
      
    Complex fractures of the elbow can be difficult to diagnose – thus “radioulnar dissociation is sometimes accompanied by interosseous ligament failure. This study used ultrasonography to make a diagnosis of I0M tear with comminuted radial head fracture. They feel that US imaging to an unexpensive, safe and readily available modality for obtaining images at baseline and throughout the healing process and for detecting occult injury of the interosseous ligament.
          

  • Wolf JM, Weiss A-PC [Brown Univ, Providence, RI]
    Portable Mini-fluoroscopy Improves Operative Efficiency In Hand Surgery
    J Hand Surg [Am] 24A: 182-184, 1999
      
    This study compares the use of traditional radiographic confirmation versus mini-fluoroscopy in a paired, retrospective cohort case study.
      
    30 patients underwent closed reduction or internal fixation of phalangeal shaft fractures or metacarpophalangeal or inter-phalangeal joint fusions. Standard intraoperative and lateral radiographs were used in 15 procedures and portable mini-fluoroscopy in the other 15 procedures.
      
    The minifluoscopy reduced operative time by 55% in phalangeal fractures by 39% in wrist fusion and by 48% in the in-situ 4 corner fusion.
      
    They conclude that mini-fluoroscopy is a safe effective and efficient modality in the tested surgical procedures.
         

  • Turgeon TR, MacDermid JC, Roth JH [Univ of Western Ontario, London; St Joseph’s Health Centre, London, Ont]
    Reliability of the NK Dexterity Board
    J Hand Ther 12: 7-15, 1999
      
    This study evaluates the reliability of the NK dexterity test as a part of a comprehensive computerized hand evaluation system.
      
    37 volunteers [24 women and 13 men] were tested on the NK dexterity board on 2 separate occasions. On each occasion individuals moved small, medium and large objects in 3 separate tests and separately with each hand.
      
    Most complained of arm or forearm fatigue, and had difficulty with threading the medium and large screw-type objects. Intraoccasion intraclass correlation coefficients [ICCs] [n=12; 3 tests x 2 hands x 2 occasions] were fair in half of the comparisons and excellent in the other half. Reliability was better in the dominant hand. ICCs for tests involving small medium objects were fair but for large objects were excellent.
      
    They conclude that although the NK dexterity board has fair-to-excellent reliability, there is a room for improvement. Suggestions made for improving the insrumentation include adding a steel lining to the plastic receptacle of the small steel screw, changing the T-shaped object in the medium sized test from aluminum to steel reducing the length of threading on the large screw object, and establishing a method to lubricate the large screw object.
      
    Nonetheless, this board has several advantages including its ability to test a wide variety of gross and fine movements, a computerized recording system that reduces operative error and normative data in the software for comparison based on age and sex.
        

  • Marx RG, Bombardier C, Wright JG [Univ of Toronto]
    What do we Know About the Reliability and Validity of Physical Examination Tests Used to Examine the Upper Extremity?
    J Hand Surg [Am] 24A: 185-193, 1999
      
    For a physical examination to be useful each test must be reliable and valid. A review was made of the reliability and validity of commonly used physical examination tests for disorders of the upper extremity.
      
    Relevant articles from literature, standard tests and fro consulting experts, were reviewed and analyzed separately from the point of the impairment of function and diagnosis.
      
    The tests for range of motion and strength testing were considered reliable. The tests used to diagnose upper extremity disorders like carpal tunnel syndrome and rotator cuff tendinopathy have varying degrees of validity. Overall, there is sparse evidence regarding the reliability and validity of physical examination for the upper extremities both from the point of diagnosis and impairment of function.
      
    It is therefore recommended that these tests not be used in isolation. It is important that the properties of each test be documented, so clinicians may reliably and accurately examine patients.
        

  • Sarhadi NS, Shaw-Dunn J[Univ of Glasgow, Scotland]
    Transthecal Digital Nerve Block: An Anatomical Appraisal
    J Hand Surg [Br] 23B: 490-493, 1998
      
    This study investigates the anatomical basis of a transthecal digital nerve block for local anesthesia of digits in 60 digits from 40 cadavers.
      
    Methylene blue and latex were injected into cadaveric digits to determine how anesthesia fluid injected into the flexor tendon sheath may spread around the finger.
      
    In digits when 3cc of solution was injected, irrespective of the puncture site, blotchy dye stains were seen on the dorsum of the proximal part of the finger, and the sides of the interphalangeal joint and the metacarpophalangeal joint and both the neurovascular bundles and the flexor tendon sheath were also stained. Dye stains were seen at the wrist when the injections were given at the thumb base and the little finger. Injections in the other fingers did not stain the proximal palm.
      
    If only 0.5cc were injected into the tendon sheath, staining appeared on the dorsum of the digit at its base and around the p.i.p. joint. It also tracked alongside the vessels. The fatty tissue showed linear staining, but no staining of nerves. Deeper staining was seen at the base of the proximal phalanx or in the region of the middle phalanx.
      
    Transthecal injection of 1 ml, resulted in a pool of dye around the neurovascular bundles, in the tissue space enclosed by Cleland’s ligament and Grayson’s ligament right to the tip of the finger.
      
    The authors conclude that injected dye solution escapes from the flexor tendon sheath around the vincular vessels, through the perivascular loose areolar tissue, and spreads alongside the main digital vessels and nerves and their branches.
        

  • Lundborg G, Rosen B, Lindberg S [Malmo Univ, Sweden]
    Hearing as Substitution for Sensation : A new Principle for Artificial Sensibility
    J Hand Surg [Am] 24A: 219-224, 1999
      
    Sense substitution is commonly used among patients with sensory deficits, such as the use of Braille to read by blind people. This study describes an attempt to use hearing as a substitute for lost sensibility.
      
    This study used vibrotactile stimuli to generate sounds as a substitute for hand sensibility. Miniature condenser microphones were attached to the distal, dorsal side of a glove to magnify the friction sound generated. The signal from the microphone was processed by a stereo amplifier which separated signals from different fingers into different channels. These sounds were then fed through earphones to patients with lost hand sensibility [3 had undergone median nerve repair, 1 had an replantation of an amputated forearm, 1 had a myoelectric prosthesis, and 4 had cosmetic prostheses. The patients participated in studies to assess spatial resolution and differentiation between textures.
     
    The spatial resolution of signals allowed patients to differentiate between the various fingers. Friction sounds enabled the patients to identify textures – such as glass, metal, wood and paper.
      
    The findings suggest that hearing may provide a useful substitute for lost hand sensibility.
        

 

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