Hand injuries during hand surgery: a survey of intraoperative sharp injuries of the hand among hand surgeons.

An e-mail survey comprising 19 questions was directed towards members of the American Society for Surgery of the Hand (ASSH) to investigate the prevalence and nature of intraoperative injuries to hand surgeons during hand surgery. The responses were collected, statistical analysis was done and trends were extrapolated. Two hundred members of the ASSH completed the e-mail survey. A hand surgeon in practice for greater than 10 years has a 97% chance of sustaining an intraoperative "sharps" injury. The injury is self-inflicted (88%) in most cases and the index finger (94%) of the left hand (87%) is the most likely site. The suture needle was the cause in 91% of cases. Awareness of the risks and factors associated with hand injuries during hand surgery and adopting intraoperative measures are important strategies for preventing these potentially serious and life-threatening accidents.

Subungual carcinomas in multiple digits.

We report a patient with subungual squamous cell carcinoma arising in more than one digit who also had positive immunostaining for human papillomavirus (HPV). The patient worked for a wastewater utility company for 22 years and placed his hands in stagnant wastewater daily.

Non-Dupuytren's disease of the palmar fascia.

The typical Dupuytren's disease patient is of Northern European descent with bilateral progressive multiple digital contractures and is genetically predisposed, with a family history. Palmar fascial proliferations sometimes present as a different entity without the typical Dupuytren's disease characteristics. We identified 39 patients (20 women and 19 men) over a 4-year period with "Non-Dupuytren's palmar fascial disease", with unilateral involvement, without family history or ectopic manifestations. Twenty-three patients presented with unrelated complaints and were discovered, incidentally, to have the condition. In 28 patients, prior ipsilateral hand surgery or trauma precipitated the condition. Other related factors were diabetes mellitus and cardiovascular disease. Ten patients had skin tethering and subcutaneous thickening akin to Dupuytren's nodules and 29 had palmar fascial thickening into ill-defined pretendinous cords. The diseased tissue was in the line of the ring finger in 30 patients. The time from insult to onset of contracture averaged 3.6 months and from onset to follow-up averaged 5.3 years. The condition was non-progressive, or partially regressive, in 33 patients. Seven patients had operations for unrelated conditions and underwent simultaneous fasciectomy without recurrence. Environmental factors, especially trauma, surgery and diabetes, are important in the pathogenesis of Non-Dupuytren's palmar fascial disease, but these patients do not appear to be genetically predisposed for Dupuytren's disease. Typical Dupuytren's disease and Non-Dupuytren's palmar fascial disease are two clinical entities that run different courses and do not share a similar prognosis. This should be taken into account in future epidemiological and outcome studies.

V-Y slide of the common extensor origin for lateral elbow tendonopathy.

Twenty-two patients (23 limbs) with chronic lateral elbow tendonopathy were examined retrospectively after surgical management. Thirteen men and 9 women with an average age of 43 years (range, 32-54 years) had a mean follow-up time of 41.2 months (range, 9-97 months). All patients underwent at least 6 months of nonsurgical treatment without favorable response. V-Y slide of the common extensor origin was done for all patients. Sixteen patients (17 elbows) were examined after surgery and 6 were interviewed by telephone. None of the patients had major complications or permanent loss of elbow motion. A pain rating scale of 1 to 10 (10 being the worst) showed a difference from a rating of 9.0 (range, 7-10) before surgery to 1.4 (range, 0-4) after surgery. Grip strength increased from 57 lb (range, 5-125 lb) to 99 lb (range, 60-135 lb). Five patients (23%) reported some degree of cold intolerance. Twenty-one patients (95%) returned to their preoperative occupation with 1 patient not returning to work because of elbow pain caused by heavy and repetitive elbow stress especially from vibrating tools. Twenty-one patients (95%) reported no limitations in daily activities; 1 patient reported difficulty with opening jars. Seven people (32%) reported limitations in high-demand recreational activities. All patients were rated as poor before surgery and excellent or good after surgery by a grading scale. All patients were satisfied with the outcome of surgery. After surgical treatment for lateral elbow tendonopathy, pain relief and restoration of elbow function can be achieved. V-Y slide of the extensor origin has low morbidity, does not violate the joint space or lateral stabilizing ligaments of the elbow, allows adequate release, and has a high rate of satisfaction.

Treatment of trapeziometacarpal arthritis with silastic and metallic implant arthroplasty.

Implant arthroplasty was once viewed as a feasible and effective trapeziometacarpal joint disease. Silastic implants are now used rarely because of concerns of implant failure and particulate synovitis. Metallic implants, including total joint prostheses and those utilizing a spacer concept, have been used with some success. Indications, technical consideration, and potential complications of these implants are discussed.

Ulnar polydactyly.

A retrospective review of 148 patients with ulnar polydactyly was conducted to analyze the types, patterns of involvement, associated anomalies, treatments, and outcomes of this malformation. The hands only were involved in 123 patients, both hands and feet in 20 patients, and five patients had mixed radial and ulnar polydactyly. Ulnar polydactyly was more prevalent among males. Among African Americans, the condition was often bilateral. When unilateral, ulnar polydactyly occurred more often on the left side. The racial distribution was 103 African Americans (70 percent), 37 Caucasians (25 percent), four Native Americans, three Latin Americans, and one Asian. Five types were encountered: type I cutaneous nubbin, type II pedunculated digit, type III articulating digit with fifth metacarpal, type IV fully developed digit with sixth metacarpal, and type V polysyndactyly. The distribution of types in order of frequency was type II, III, V, I, and IV. Types I and II ulnar polydactyly combined were more prevalent (82 percent) than types III, IV, and V (18 percent). Types I and II were more common among African Americans. Types III, IV, and V ulnar polydactyly occurred more frequently among Caucasians, but these were slightly less prevalent than types I and II in this racial group. Five patients were syndromic; four were Caucasians, and one Asian. Most cases of ulnar polydactyly of the hand were treated by ligation (71 percent) in the nursery, whereas polydactyly of the foot was more often referred to a specialist to be treated by surgical ablation (92 percent). Treatment complications occurred more frequently in the hands than in the feet. The complication rate after ligation of ulnar polydactyly of the hand was 23.5 percent. The two main complications were tender or unacceptable nubbins and infections.

The sagittal band: anatomic and biomechanical study.

Forty-eight digits from 12 human adult fresh-frozen and formalin-preserved cadaveric hands were used to study the anatomy and biomechanics of the sagittal band (SB) and to investigate the mechanism of its injury. The SB was observed to be part of a complex retinacular system in proximity to the metacarpophalangeal (MCP) joint collateral ligaments and the palmar plate. Dynamic changes in SB fiber orientation were observed with different positions of the MCP and wrist joints. The fibers were perpendicular (0 degrees ) to the extensor tendon in neutral position, distally angulated 25 degrees at 45 degrees of MCP flexion, and 55 degrees with full flexion. Swan-Ganz catheter measurements were obtained deep to the SB in varying positions of the MCP joint. The average pressure generation was greatest (50 mm Hg) during full MCP joint flexion and least (30 mm Hg) during 45 degrees flexion. When MCP joint radial or ulnar deviation was added the average measurement was greatest (57) in neutral MCP position and least (35 mm Hg) in 45 degrees flexion. Serial sectioning of the ulnar SB produced no extensor tendon instability. Partial proximal but not distal sectioning of the radial SB produced tendon subluxation. Complete sectioning of the radial SB produced tendon dislocation. Wrist flexion increased tendon instability after radial SB sectioning. We conclude that (1) extensor tendon instability following SB disruption is most common in the long finger and least common in the small finger; (2) ulnar instability of the extensor tendon is due to partial or complete radial SB disruption, (3) the degree of extensor tendon instability is determined by the extent of SB disruption, (4) proximal rather than distal SB compromise contributes to extensor tendon instability, (5) great forces are inflicted on the SB while the MCP joint is in full extension or less frequently in full flexion, which may be the mechanism of its injury, and (6) wrist flexion contributes to extensor tendon instability after SB disruption and may exacerbate the severity of its injury.

Thumb digital neuropathy caused by splinting.

Healthcare professionals are currently faced with a great variety of splints and splinting materials. Choices range from prefabricated products to custom splints made on-site from plaster, orthoplast, or fiberglass. In addition to providing immobilization to maintain a particular posture, a splint must protect important soft tissues. Patients with hand or wrist injuries often receive a prefabricated metal cock-up wrist splint in emergency departments. Complications from splints are not uncommon but are infrequently reported. We report a case in which a metal wrist cock-up splint caused compression of the thumb ulnar digital nerve. Preventive measures for such complication are included.

Triple central ray amputation for clear cell sarcoma of the hand.

A 16-year-old girl presented for evaluation and management of a recurrent soft-tissue mass in her left hand after excision at another facility. She was given a diagnosis of clear cell sarcoma. She chose a limb salvage procedure over amputation. A triple central ray amputation of her index, middle, and ring fingers was performed. After 3 years, she has reasonable grasp function with her remaining fingers and has chosen not to use a prosthesis. Long-term follow-up is necessary for this tumor, as local recurrence and metastatic disease have been reported frequently.

Outcome following nonoperative treatment of displaced distal radius fractures in low-demand patients older than 60 years.

Twenty-five sedentary, low-demand patients older than 60 years were retrospectively evaluated for function and radiographic results following nonoperative treatment of displaced distal radius fractures. The mean age was 72 years and the average follow-up period was 34 months. All patients had radiographic and functional evaluations. The radiographic assessment included a scoring system based on measurements of the final dorsal angle, loss of radial length, and the final radial inclination. The development of radiocarpal and distal radioulnar joint arthrosis was also investigated. The functional assessment included subjective and objective criteria. Overall satisfaction, ability to return to previous activity level or occupation, concern over wrist appearance, and a functional task questionnaire were part of the subjective assessment. Objective assessment included neuromuscular evaluation and measurements of range of motion and grip strength. The final radiographic scores revealed that 6 patients (24%) had excellent results, 11 (44%) had good results, 2 (8%) had fair results, and 6 (24%) had poor results. Six of 10 patients with intra-articular fractures developed progressive wrist arthrosis. Two of 6 patients with radiographic arthrosis had unsatisfactory functional outcome. Five of 8 patients with intra-articular fractures that healed with a residual stepoff >/=2 mm had satisfactory functional outcome; 3 of these 8 patients had unsatisfactory functional outcome. The functional assessment revealed that 22 patients (88%) had excellent or good results and 3 (12%) had fair or poor results. The radiographic outcome did not correlate with the functional outcome. Twenty-three of 25 patients (92%) were satisfied with the overall outcome of the treatment and 22 (88%) were able to return to their previous activity level or occupation. Despite an obvious clinical deformity in over half of the patients, none were unhappy with the clinical appearance of the wrist. According to the functional task questionnaire, jar opening was by far the most difficult task to perform after fracture healing. Functional outcome was satisfactory in most cases; a high level of personal satisfaction and return to previous activity level was observed, regardless of the radiographic result. Nonoperative treatment of distal radius fractures yields satisfactory outcome, especially in those with low functional demands. It also is indicated in poor operative candidates. (J Hand Surg 2000; 25A:19-28.

Basement membrane chondroitin sulfate proteoglycan and vascularization of the developing mammalian limb bud.

We used immunocytochemistry to study the basement membrane-chondroitin sulfate proteoglycan (BM-CSPG) distribution in mammalian limb bud and its relationship to and possible role in limb development. Anti-BM-CSPG immunostaining was examined in the developing limb buds of 24 Sprague-Dawley rats at embryonic days 12 to 14 and 19. BM-CSPG immunostaining was present in 3 regions. The first region was located peripherally in the limb bud ectodermal basement membrane (BM) that separates ectoderm from mesoderm and was present at all embryonic stages examined. The second region was in the mesenchymal extracellular matrix independent of the vascular system. This staining pattern was diffuse, granular, and often homogeneous, except for clustering adjacent to developing vessels, and was observed distally in the limb bud. In the mesenchymal extracellular matrix adjacent to the distal BM this staining pattern formed fibrils that were perpendicular and connected to the limb bud BM and extended into the underlying mesenchyme. The third region was localized to the BM of developing blood vessels of the limb bud. Blood vessel staining allowed analysis of limb bud vessel formation. The early developing blood vessels at the proximal limb bud were organized differently from those located distally. Large central vessels were present proximally, whereas a rich plexus of smaller vascular channels was present at the distal margin. A subectodermal avascular zone was observed at the margin of the limb bud, except beneath the apical ectodermal ridge where immunostained blood vessels extended from the distal vascular plexus toward the apical ectodermal ridge. The formation of central larger vessels occurs proximally, whereas formation of peripheral smaller vessels seems to take place locally and distally under the influence of the apical ectodermal ridge. BM-CSPG plays an important role in blood vessel formation and mammalian limb bud development. (J Hand Surg 2000; 25A:150-158.

Osteolipoma of the hand: a case report.

A 61-year-old, healthy woman presented with a six-month history of a mass on the radial volar aspect of her dominant right hand. The patient had a history of trauma to the hand six years previously. Radiographs showed a bony lesion in the index metacarpal shaft and the MRI showed a bony lesion and soft tissue mass suggestive of a parosteal lipoma. Surgical excision of the lesion revealed a lipoma overlying a bony exostosis or osteolipoma of the hand. Post-operatively, the patient's symptoms resolved and she had no recurrence of the tumor.

Carpal tunnel syndrome between two centuries.

Compression neuropathy is one of the most frequently encountered conditions in a hand surgeon's daily practice. Median nerve compression at the wrist or carpal tunnel syndrome (CTS) is the most common of all nerve compression syndromes of the upper extremity1.3 and CTS has been used as a model for studying compression neuropathy (CN). This compressive lesion of the median nerve occurs in a tunnel located within the wrist called the carpal tunnel. Severe chronic inappropriately treated CTS can cause prolonged symptoms and lead to permanent nerve damage. Carpal tunnel release (CTR) is currently among the most commonly performed surgical procedures on the hand in the United States. The profound economic impact of this trend is reflected by the escalating tangible and intangible costs associated with its management. This article contains current information and cumulative knowledge up to the turn of the century on the basic science, etiology, diagnosis, and management of CTS.

Arthrodesis of the spastic wrist.

The clinical and radiographic results of 9 patients (11 wrists) who had wrist arthrodeses for severe spastic flexion contracture were evaluated. The spasticity was due to cerebral palsy, traumatic head injury, and cerebrovascular accident. All wrist deformities were aesthetically unappealing and the patients or their caretakers had difficulty with hygiene or function. The subjective evaluation included overall satisfaction, hand hygiene, wrist deformity, functional improvement, and willingness to have surgery again given the same preoperative circumstances. A standardized hand function questionnaire was used to determine functional improvement following surgery. The objective evaluation included clinical evidence of fusion, skin condition, wrist position, and radiographic assessment. The average age of the patients was 22 years at the time of surgery and the average follow-up period was 32 months. All patients were satisfied with the results of the surgery and hygiene improved in all cases. None had palmar skin maceration or breakdown. All patients or their caretakers rated the overall appearance or wrist and hand deformity as improved and all but one patient would agree to have the surgery over again given the same preoperative circumstances. According to a 17-task hand function questionnaire, 8 of 9 patients (10 wrists) reported improved function after surgery. Face washing, propelling a wheelchair, and picking up both large and small objects were among the most frequently improved functions. Radiographic fusion was present in all cases. The average position of wrist fusion was 15 degrees flexion and the average amount of wrist correction was 85 degrees. Improved appearance, hygiene, and a certain degree of upper extremity function, regardless of cognitive abilities, can be expected following arthrodesis for severe spastic wrist deformity.

The cubital tunnel: anatomic, histologic, and biomechanical study.

The anatomy of the cubital tunnel was examined in 19 human cadaveric elbows. Pressure measurements within the cubital tunnel were recorded at the medial epicondyle level and 3 cm distal to the epicondyle in various positions of elbow flexion. Histologic examination of the ulnar nerve was carried out at different levels. A common flexor aponeurosis (CFA) was consistently present in all specimens between the flexor carpi ulnaris and the flexor digitorum superficialis. Pressure measurements were greater distally at the CFA level than proximally in the fibrosseous tunnel. The pressure inside the cubital tunnel increased with increasing flexion at the 3 levels examined. Releasing the arcuate ligament decreased the pressure in the fibrosseous tunnel but not distally at the level of the CFA. An oligofascicular pattern of the ulnar nerve was observed at the level of the medial epicondyle and CFA. This finding was in contrast to the polyfascicular pattern present both proximal and distal to these structures. The findings of our study have shown that an intimate anatomic relationship exists between the ulnar nerve and the CFA. This proximity appears to affect the biomechanics of the cubital tunnel and to contribute to nerve compression by the CFA in the distal tunnel. We also found that elbow flexion increases the pressure in the distal tunnel and that releasing the arcuate ligament alone does not decompress the ulnar nerve in the distal tunnel.

Hemophilic pseudotumor of the soft tissue of the hand: a case report.

A 25-year-old, right hand dominant man with a history of Hemophilia A, presented with an enlarging 2 x 3.5 cm mass on the dorsum of his dominant hand following minor trauma. Factor VIII activity level was 12 percent of normal. A diagnosis of hemophilic pseudotumor was made and the mass continued to enlarge despite medical management. Surgical intervention was carried out in order to prevent impending skin necrosis or rupture. The patient was treated by surgical excision of the lesion along with factor replacement therapy. The patient's symptoms resolved and he had no recurrence of the tumor.

Distribution of type IV collagen during avian limb bud development.

Normal limb development is dependent on an epithelial-mesenchymal interaction between the overlying apical ectodermal ridge (AER) and the underlying mesenchyme. The basement membrane between the epithelium and the mesenchyme has been proposed to play an important role in regulating epithelial-mesenchymal interactions during development. To explore the role basement membrane type IV collagen may play during limb development we investigated the distribution of type IV collagen by immunolocalization. Developing avian leg buds were examined at 2 developmental stages: stage 23, when the AER is inductively active, and stage 28, when the AER is regressing. The proximal basement membrane in stage 23 limb buds stained much more intensely than the distal basement membrane. This proximal-distal immunostaining difference was less in stage 28 limb buds. We used the monoclonal antibody IIB12, which recognizes an epitope adjacent to the initial collagenase cleavage site on the type IV collagen molecule, to explore whether this proximal-distal difference in basement membrane staining could result from the loss of type IV collagen. The distal basement membrane of stage 23 limb buds demonstrated little immunostaining with the IIB12 antibody, suggesting enhanced collagenase-associated degradation. The immunostaining was increased in stage 28 limb buds. Consistent with a loss of type IV collagen, we also found that unfixed stage 23 leg bud cryostat sections stored at 4 degrees C lost their immunostaining for type IV collagen, in contrast to stored stage 28 limb bud cryostat sections. These results demonstrate that type IV collagen is distributed in a proximal-distal pattern in the basement membrane of the developing chick limb bud and suggest that this pattern may be the result of a selective degradation of type IV collagen in the basement membrane underlying the active AER. These results are consistent with the hypothesis that the basement membrane plays a role in regulating the epithelial-mesenchymal interaction responsible for induction of limb outgrowth.

Extensor tendon dislocation in cerebral palsy.

An 18-year-old man with cerebral palsy presented with a flexion deformity of the middle finger particularly at the metacarpophalangeal joint and ulnar dislocation of the extensor tendon. Releasing the tight ulnar sagittal band and imbricating the attenuated radial sagittal band allowed centralization of the extensor tendon. For complete correction of other deformities intrinsic release and extrinsic flexor muscle lengthening were done. Extensor tendon instability in this case was due to the combined forces of the extrinsic and intrinsic muscles on the retinacular system of the extensor mechanism.

Adjunctive treatment of enchondromas with CO2 laser.

STUDY DESIGN/MATERIALS AND METHODS: Fourteen enchondromas, in eight patients, involving the tubular bones of the hand, were treated with curettage, CO2 laser sterilization of the tumor margins followed by autologous bone grafting. Average follow-up time was 35.4 months (14-106 months). Average patients age was 29 years. RESULTS: At follow-up there were no clinical recurrences, none had pain, and all patients reported satisfactory hand function without limitations. Minimal decrease in range of motion without functional limitation was encountered following excision of two lesions (14%) in one patient. One patient reported an increase in range of motion after excision. Grip strength was only minimally decreased. There was no radiographic evidence of recurrence. CONCLUSION: The use of CO2 laser is safe and effective as an adjunct to curettage and bone grafting in the management of relatively large enchondromas of the tubular bones of the hand.