Frank D. Burke

Five- to 18-Year Follow-Up for Treatment of Trapeziometacarpal Osteoarthritis: A Prospective Comparison of Excision, Tendon Interposition, and Ligament Reconstruction and Tendon Interposition

PURPOSE To investigate whether palmaris longus interposition or flexor carpi radialis ligament reconstruction and tendon interposition improve the outcome of trapezial excision for the treatment of basal joint arthritis after a minimum follow-up of 5 years. METHODS We randomized 174 thumbs with trapeziometacarpal osteoarthritis into 3 groups to undergo simple trapeziectomy, trapeziectomy with palmaris longus interposition, or trapeziectomy with ligament reconstruction and tendon interposition using 50% of the flexor carpi radialis tendon. A K-wire was passed across the trapezial void and retained for 4 weeks, and a thumb spica was used for 6 weeks in all 3 groups. We reviewed 153 thumbs after a minimum of 5 years (median, 6 y; range, 5-18 y) after surgery with subjective and objective assessments of thumb pain, function, and strength. RESULTS There was no difference in the pain relief achieved in the 3 treatment groups, with good results in 120 (78%) patients. Grip strength and key and tip pinch strengths did not differ among the 3 groups and range of movement of the thumb was similar. Few complications persisted after 5 years, and these were distributed evenly among the 3 groups. Compared with the results at 1 year in the same group of patients, the good pain relief achieved was maintained in the longer term, irrespective of the type of surgery. While improvements in grip strength achieved at 1 year after surgery were preserved, the key and tip pinch strengths deteriorated with time, but the type of surgery did not influence this. CONCLUSIONS The outcomes of these 3 variations of trapeziectomy were similar after a minimum follow-up of 5 years. There appears to be no benefit to tendon interposition or ligament reconstruction in the longer term.

Management and referral for trigger finger/thumb

Trigger finger is a common cause of pain and disability in the hand. It is also the fourth most common reason for referral to the hand outpatient clinic and accounts for 1 in 18 of all referrals to our unit. The condition is, however, not solely managed by hand surgeons as it is often treated in the community and by specialist practitioners such as rheumatologists and endocrinologists who encounter it as a secondary manifestation of a primary systemic disorder. From a review of the literature we highlight the presentation of trigger finger, describe the processes involved in developing the condition, and rationalise the treatment options available. We have suggested guidelines and key points of note to aid practitioners in the management and referral of trigger finger and thumb in adults. We searched Medline and PubMed for relevant English language literature. We used the search terms “trigger finger” and “stenosing tenosynovitis.” We identified additional literature from the references of these papers. Trigger finger presents with discomfort in the palm during movement of the involved digits. Gradually, or in some cases acutely, the flexor tendon causes a painful click as the patient flexes and extends the digit. The patient may present with a digit locked in a particular position, usually in flexion, which may need gentle passive manipulation into full extension. Spontaneous resolution of symptoms can occur in patients with trigger thumb.w1 The condition has a reported incidence of 28 cases per 100 000 population per year, or a lifetime risk of 2.6% in the general population.1 This rises to 10% in patients with diabetes. Two peaks in incidence occur—the first under the age of eight and the second (more common) in the fifth and sixth decades of life. This bimodal distribution represents two different clinical groups, not only for …

Primary care management of carpal tunnel syndrome

Carpal tunnel syndrome of mild to moderate severity can often be effectively treated in a primary care environment. Workplace task modification and wrist splints can reduce or defer referral to hospital for surgical decompression. Nerve and tendon gliding exercises may also be of benefit. Steroid injections to the mouth of the carpal tunnel are particularly useful for symptomatic women in the third trimester of pregnancy. However inadvertent neural injection may cause disabling chronic pain. Referral to a minority of practitioners trained in the technique would ensure sufficient patient numbers to maintain skill levels.

Assessing outcome after hand surgery: the current state

An overview of the current state of outcome measurement after hand surgery is presented. The paper focuses on the development, application and strengths and weaknesses of subjective assessment techniques. It also reviews the existing questionnaires and suggests recommendations for use in research or clinical practice.

Hand injuries in children: a prospective study

The purpose of this prospective clinical study was to identify the true incidence, pattern, and location of the injury and nature of fracture after hand injuries in different pediatric age groups attending a hand unit. Three hundred sixty children (237 boys, 123 girls) under 16 years of age who presented with hand injuries between April 1, 2000, and Sept. 30, 2000, were included in the study. Bony injuries accounted for 65.5% (236 injuries); 33.3% (120 injuries) were soft tissue injuries. The projected annual incidence rate for skeletal injuries was 418/100,000 children. The incidence was low in toddlers (34/100,000), more than doubled in preschool children (73/100,000), and steeply increased to around 20-fold after the 10th year (663/100,000). Girls had a higher incidence of hand injuries among toddlers and preschool children. Crushing was the most common cause of hand injury (64%), and most injuries were sustained at home (45%). Toddlers sustained soft tissue injuries predominantly (86%) and older children sustained more bony injuries (77%). Sport was the cause of injures commonly in the older children. There was a higher incidence of fracture in the little finger (52%) followed by the thumb (23%). The proximal phalanx was the most frequently fractured bone (67%) among the phalanges. Diaphyseal fractures (46%) were more common in the metacarpals, and basal fractures (51%) were common in the phalanges. At discharge more than 80% of the patients felt that they were cured or significantly better. This paper highlights the changing pattern and the different varieties of hand injuries in different pediatric age groups.

Validity and responsiveness of the Michigan hand questionnaire in patients with rheumatoid arthritis: A multicenter, international study†

Millions of patients experience the disabling hand manifestations of rheumatoid arthritis (RA), yet few hand‐specific instruments are validated in this population. Our objective was to assess the reliability, validity, and responsiveness of the Michigan Hand Questionnaire (MHQ) in patients with RA.

Carpal tunnel syndrome: reconciling "demand management" with clinical need.

Purchasers of surgical services are seeking justification for operative interventions with increasing frequency. This paper seeks to identify all relevant data currently available for carpal tunnel decompression; one of the commonest operative interventions in hand surgery. Such data, as is available, would suggest carpal tunnel decompression rates in the United Kingdom are relatively low, with fairly prolonged preoperative duration of symptoms.

Trends in elective hand surgery referrals from primary care.

INTRODUCTION Two prospective audits of activity in a hand unit were performed, in 1989-1990 and during 2000-2001, to identify trends in elective hand surgery referrals from primary care. PATIENTS AND METHODS Two 6-month prospective audits of activity in a hand unit were performed, including elective referrals from primary care. Data were collected on all in-district referrals with elective hand disorders. Cross boundary flow was identified to permit assessment of changes in referrals by diagnosis over a decade. RESULTS There was a 36% increase in health authority referrals for elective hand surgery over the decade (from 289 to 392 per 100,000 of population per year). The number of elective hand surgery operations rose 34% over the decade (from 149 to 199 operations per 100,000 of population per year). Carpal tunnel syndrome (the commonest reason for elective referral) almost doubled (from 59.7 to 112 per 100,000 of population per year). Referrals for ganglion, the second most common elective referral, rose modestly. Referrals for osteoarthritis (commonly basal thumb arthritis) almost trebled over the decade to become the fourth commonest condition referred to the hand unit (from 12.7 to 34 per 100,000 of population per year). Referrals for Dupuytrens disease, trigger finger and rheumatoid arthritis were relatively unchanged over the decade. Congenital hand referrals are uncommon but doubled during the decade. CONCLUSIONS Hand surgery referrals rose by 36% over the decade. Analysis of the commoner conditions referred reveal a high prevalence within the community with the possibility of increased referrals in years to come.

Long-term followup for rheumatoid arthritis patients in a multicenter outcomes study of silicone metacarpophalangeal joint arthroplasty.

Rheumatoid arthritis (RA) often results in deformities at the metacarpophalangeal (MCP) joints. Patients with severe deformities can be treated by silicone metacarpophalangeal joint arthroplasty (SMPA). The objective of the study is to prospectively compare long‐term outcomes for an SMPA surgical and a nonsurgical cohort of RA patients.

Basal thumb arthritis

Basal thumb arthritis is a common condition seen in hand clinics across the United Kingdom and is often associated with other pathological conditions such as carpal tunnel syndrome and scaphotrapezial arthritis. Typically, patients complain of pain localised to the base of the thumb. This pain is often activity related, particularly after excessive use involving forceful pinch. A detailed history and examination is normally all that is needed to make the diagnosis. Provocative manoeuvres may be helpful in localising symptoms to the basal joint with degenerative changes or synovitis. Radiographs are useful for confirming the diagnosis and staging the disease in order to plan for surgery. The mainstay of initial treatment of basal thumb arthritis of any stage is activity modifications, rest, nonsteroidal anti-inflammatory drugs, exercises and splinting. A variety of surgical procedures are available to treat the condition when conservative measures have failed, in order to control symptoms and improve function. We review the current literature and discuss the clinical aspects of this condition, staging, and treatment options available, and the difficulties treating this group of patients.