Herbert H. Stark

Fracture of the hook of the hamate in athletes

During an eight-year period, four tennis players, seven golfers, and nine baseball players were seen with a fracture of the hook of the hamate. Eighteen of these twenty patients were disabled by pain and after the fracture fragment was removed, all eighteen were relieved so that they returned to their athletic pursuits. Two patients were asymptomatic, their old fracture being discovered accidentally when they were treated for other injuries. Nineteen of the twenty patients had been examined before coming under our care, but the correct diagnosis had been made in only two. Conservative treatment, including rest, physical therapy, and injections of steroids into the wrist and hand, had not been beneficial. From the history and findings, we believe that these fractures were caused by a direct blow against the hook of the hamate caused by the handle of the tennis racket, golf club, or bat during a swing, and not by indirect force produced by the ligaments and muscles attached to the hook. The fracture was demonstrated in all twenty patients by a roentgenogram (profile view) of the carpal tunnel.

Flexor-tendon grafts in the fingers and thumb. A study of factors influencing results in 1000 cases.

A study of 1000 consecutive grafts of flexor tendons in the fingers and thumbs has allowed us to develop a consistent technique and a system of evaluation. The first 300 were reported previously. Detailed analysis of the last 700 grafts, 607 in the fingers and ninety-three in the thumb, permits the following conclusions. Scarring from injury or additional scarring from inept previous surgery, or failed primary reparative procedures, compromised the results of secondary tendon grafting. Fingers in which joints had been damaged or in which the interphalangeal joints had become stiffened from neglect did not respond well to tendon grafting, even though the joints were mobilized well before surgery. In fingers with minimum scarring and only one nerve injured, the results were not impaired, but fingers with both nerves damaged had much less motion. The level of tendon injury, whether in the proximal, middle, or distal portion of no-mans land was not a determining factor on the result, nor was the time from injury to operation. Injury of the tendons in more than one digit in itself was not important. The condition of the individual digit determined the outcome for each finger. Other things being equal, patients over forty years of age did not obtain as much motion from tendon grafts as did the patients in younger age groups. The palmaris longus tendon was the best donor tendon, but there was little difference noted when a good superficialis tendon was used. The superficialis of the littie finger and the plantaris tendons are not recommended because of their small size and tendency to rupture. Pulley reconstruction done at the same time as the tendon grafting does not compromise the result. Loss of a few degrees of extension of the interphalangeal joints is not detrimental, but if the total loss of the two joints exceeds 40 degrees in the index or long fingers and 60 degrees in the ring or little fingers, the limitation of extension is significant. When a graft separates at the palmar junction or at its insertion, prompt resuture will salvage at least one-half of the digits. In flexor-tendon grafting in the thumb, the source of the donor tendon, the site of injury, and the presence of considerable scar do not affect the result adversely. The degree of nerve damage had only a minor effect on the result. Grafts extending from the musculotendinous juncture to the terminal phalanx gave better results than the shorter ones. Fingers treated by primary wound closure and insertion of a tendon graft as a secondary procedure had significantly better results than those treated by grafting after an attempted primary tendon repair had failed.

Treatment of ununited fractures of the scaphoid by iliac bone grafts and Kirschner-wire fixation.

Of 151 ununited fractures of the scaphoid that were treated with iliac bone grafts and Kirschner-wire fixation through a volar approach, all but four (97 per cent) healed in an average of seventeen weeks, Three of the four failures resulted from obvious technical errors. Neither the preoperative existence of necrosis of the proximal fragment nor the location of the fracture affected the results. When there was mild radiocarpal arthritis preoperatively, it did not progress postoperatively; if there was moderate radiocarpal arthritis preoperatively, progression seldom was seen if a radial styloidectomy was done. Displaced and unstable ununited fractures healed even if the deformity was not corrected completely. The principal benefit of the procedure was relief of pain rather than an increase either in motion of the wrist or in strength of grip.

Fusion of the first metacarpotrapezial joint for degenerative arthritis

During a twelve-year period, twenty-eight patients (thirty thumbs) were treated for painful idiopathic arthritis of the metacarpotrapezial joint of the thumb by fusion. Failure of fusion occurred in two thumbs, and in both instances a solid fusion followed a second procedure. Fusion of the metacarpotrapezial joint did not predispose to painful arthritis of the trapezioscaphoid joint, even in patients with pre-existing roentgenographic evidence of minor degenerative changes in this joint. The results after long-term follow-up were gratifying, the patients having painless and stable thumbs with excellent strength. Although patients noted a minor loss of thumb motion, they did not consider this a problem. Fusion is a satisfactory procedure for patients who need or desire a strong, painless thumb, and seems especially worth while in the dominant thumb when both thumbs require surgical treatment.

Silicone-rubber interposition arthroplasty of the carpometacarpal joint of the thumb

Since 1969, a slightly modified silicone-rubber neurosurgical burr-hole cover has been used for a type of interposition arthroplasty of the carpometacarpal joint of the thumb. The short stem of the device fits into a hole burred into the distal surface of the trapezium. The flat surface of the device covers the distal surface of the trapezium. Forty-nine operations were done on 42 patients, 35 women and seven men. The age range of the patients was 34 years to 72 years, with an average of 55 years. The average follow-up time was 31 months. Forty results were rated as excellent. There were two failures due to breakage of the device, and in both cases the breakage was due to a technical error.

Paint-gun Injuries of the Hand

Fourteen patients were treated for injuries caused by paint injected into the hand and fingers under high pressure. A study of the results comparing the location, the time interval from injury to operation, and the functional recovery indicates that this type of injury causes a severe chemical infla

Tendon transfers for radial nerve palsy: Use of superficialis tendons for digital extension

Since 1959, 22 patients have had wrist extension restored by transfer of the pronator teres to the extensor carpi radialis longus and brevis, common finger extension by transfer of the superficialis of the long finger, independent thumb and index finger extension by transfer of the superficialis of the ring finger, and abduction of the thumb by transfer of the flexor carpi radialis at the wrist joint level. Twenty-one of 22 patients have been evaluated from 8 months to 15 years after operation, with an average follow-up of 4.5 years. By our new system of evaluation, there were 10 excellent results, six good results, five fair results, and all patients improved. Sixteen patients obtained full, independent thumb-index finger extension, three had fair function, and two obtained thumb-index extension by tenodesis of the transfer. This procedure allows full metacarpophalangeal extension independent of wrist position, provides thumb-index finger extension independent of the ulnar three digits, and maintains the dorsal-radial-to-volar-ulnar plane of functional motion of the wrist by retaining the flexor carpi ulnaris.

The use of paratenon, polyethylene film, or silastic sheeting to prevent restricting adhesions to tendons in the hand

We treated 132 patients by insertion of paratenon, polyethylene, or Silastic between a digital tendon and a bone, ligament, or fixed fascial structure to prevent adhesions. From 1950 to 1974, autogenous paratenon was used in thirty patients; from 1956 to 1965, polyethylene film was used in sixty-three patients; and from 1965 to 1974, Silastic sheeting was used in thirty-nine patients. By comparing the preoperative and postoperative measurements of joint motion and the changes in the distance separating the pulp of a finger from the palm during flexion, these patients were calssified as improved, unchanged, or worse. In some areas the material used appeared to make little difference, but in other areas one or the other was superior. Silastic sheeting (non-reinforced) proved to be the best material for most conditions, but it should not be employed when the skin is of poor quality or beneath a pedicle flap, and it should not be used adjacent to a tendon graft in an area that has recovered from an infection. Under those circumstances, paratenon is the preferred material.

Operative treatment of intra-articular fractures of the dorsal aspect of the distal phalanx of digits.

Thirty-six digits with an intra-articular fracture of the dorsal aspect of the distal phalanx that involved one-third or more of the articular surface were treated by open reduction and internal fixation with Kirschner wires. After an average length of follow-up of forty-six months, roentgenograms of the distal joint in twenty-six digits appeared essentially normal. Ten digits had minor roentgenographic changes but, with the exception of one digit, the joint space was congruous and free of significant abnormalities. The average loss of extension of the distal joint was 2 degrees, and the average arc of flexion of the distal joint was 69 degrees. The average strength of pinch in all digits that were operated on was essentially equal to the strength of pinch in the contralateral digit. Exact reduction and internal fixation using the technique described resulted in excellent motion and function.

Flexor tendon graft through intact superficialis tendon

During a 14-year period, the flexor profundus mechanism was reconstructed with a free tendon graft in 25 fingers. The graft was passed either through or alongside the intact superficialis tendon. Five of the profundus tendons had ruptured, and 21 had been severed. One patient was under 10 years of age and only three were over 21 years of age. The result was considered to be satisfactory if the finger flexed to 3.2 cm or less of the mid-palm, had at least 20° of voluntary flexion of the distal joint, and lacked no more than 30° of extension of the proximal interphalangeal joint. Additionally, to be satisfactory, the combined loss of extension of the proximal interphalangeal and distal interphalangeal joints had to be 40° or less for an index or middle finger, and 60° or less for a ring or little finger. Using these criteria, 20 patients were satisfactory, four were unsatisfactory, and one was unchanged. Selected patients who are between the ages of 10 and 21 years will benefit from this operation, providing that the finger has limber joints and minimal scar, and the superficialis tendon flexes the proximal interphalangeal joint at least 80°.