James W. Strickland

Digital function following flexor tendon repair in Zone II: A comparison of immobilization and controlled passive motion techniques

The performance of 50 consecutive digits in 37 patients was analyzed following flexor tendon repair in Zone II. Twenty-five digits were managed by 3 1/2 weeks of immobilization followed by a program of gradually increased motion; 25 other digits by intermittent passive motion initiated within the first 5 days with active flexion commenced at 4 1/2 weeks. Results were graded according to the percentage of return of motion at the proximal and distal interphalangeal joints. There were four ruptures in the immobilization group with no excellent results, 12% being rated good, 28% fair, and 11% poor. In the digits managed by early mobilization there were 36% excellent, 20% good, 16% fair, 24% poor; there was one rupture in this group. Early passive motion appeared to be an effective technique to improve the results of flexor tendon repairs in this area.

Nerve tumors of the hand and forearm

Peripheral nerve tumors comprise less than 5% of all tumors of the hand. The most common solitary nerve tumor is the neurilemmoma, which arises from the neural sheath, is well encapsulated, minimally symptomatic, and may be surgically enucleated without producing a neurological deficit. Neurofibromas may be solitary, multiple, or associated with von Recklinghausens disease. They are usually centrally placed with nerve fibers traversing the tumor mass making it more difficult to remove the tumor without producing permanent neurological damage. Malignant tumors include neurofibrosarcomas which often are very aggressive, requiring wide excision or amputation, and the rare neuroepitheliomas. Reported nerve tumors, intraneural in location but nonneural in origin, include fibrofatty infiltration of the median and digital nerves, intraneural lipoma, hemangioma, and ganglion cysts. These lesions may be treated by decompression or excision, depending on the nature of the tumor. Four unusual cases are described.

safe Carpal Tunnel Release via a Limited Palmar Incision

&NA; Despite its demonstrated advantages in postoperative recovery, endoscopic carpal tunnel release has not been adopted by most surgeons because of the associated complications of neurovascular injury. A technique of carpal tunnel release is presented that utilizes a 1.0 to 1.5‐cm palmar incision and a specially designed carpal tunnel “tome.” Any aberrant anatomy of adjacent neurovascular structures may be identified under direct vision. Anatomic dissection in 28 cadaveric specimens following the procedure showed complete decompression of carpal tunnel and preservation with safe margins of the palmar cutaneous branch and thenar motor branch of median nerve, ulnar artery and nerve, and superficial palmar arch. Clinical experience with the technique in two centers consisted of 525 patients and 694 hands over a 29‐month period. The great majority of patients derived complete (72.6 percent) or near‐complete (19.6 percent) symptomatic relief from the procedure, and two complications (0.29 percent) of median nerve lacerations occurred. Postoperative incisional and pillar tenderness and grip, key pinch, and three‐point pinch strengths were comparable with those in published series of endoscopic carpal tunnel release. We conclude that this technique of carpal tunnel release combines the simplicity and safety of traditional open release and the reduced tissue trauma and improved postoperative recovery of the endoscopic modality. (Plast. Reconstr. Surg. 101: 418, 1998.)

Upper extremity function after wrist arthrodesis.

Several studies have examined the normal range of wrist motion used to accomplish activities of daily living. Little information is present, however, on what functional limitations might be experienced by patients actually undergoing formal wrist arthrodesis. This study undertook comprehensive functional evaluation of 23 patients who underwent wrist arthrodesis for post-traumatic conditions. Follow-up evaluation averaged 54 months and consisted of a clinical questionnaire, the Jebsen Hand Function Test, and a functional rating devised by Buck-Gramcko/Lohmann. Fifteen of the 23 patients returned to their original jobs, and all patients noted that although the vast majority of tasks could still be performed, these tasks were undertaken in a modified fashion. The most difficult daily tasks for patients with a wrist arthrodesis to perform involved perineal care and manipulating the hand in tight spaces. The Jebsen Hand Function Test demonstrated a 64% task completion rate with the fused wrist compared to a 78% task completion rate for the normal wrist. The Buck-Gramcko/Lohmann evaluations demonstrated an average score of 8.3 out of a possible 10. Patients who have undergone wrist arthrodesis can accomplish most activities of daily living and other functional requirements, although some adaptation to accomplish these tasks is required.

Glomus tumor of the digits

Eight cases of glomus tumor of the digits seen during an 8-year period are reviewed. This number comprised 1.2% of all hand tumors encountered. Symptoms of cold intolerance and exquisite tenderness were common to all. The average duration of symptoms prior to diagnosis and treatment was 7 years. Five patients gave a history of either frostbite (two) or trauma (three) prior to onset of symptoms. The tumor was subungual in six of the eight patients, with a relatively even distribution among all digits. Roentgenographic changes of erosion of the distal phalanx were present in 50% of the tumors. Surgical excision was curative in all instances.

Arthrodesis of the Wrist for Post-Traumatic Disorders*

We retrospectively reviewed the records of eighty-nine consecutive patients (ninety wrists) who had had a total arthrodesis of the wrist for the treatment of a post-traumatic disorder at one center. Fifty-six patients (fifty-seven wrists) had the arthrodesis with plate fixation, and thirty-three patients (thirty-three wrists) had the arthrodesis with a variety of other techniques. The average age of the patients at the time of the arthrodesis was forty-two years, and the dominant wrist was treated in forty-two patients. Fifty-six (98 per cent) of the fifty-seven wrists that had been fixed with a plate had a successful union at an average of 10.3 weeks postoperatively. Twenty-seven (82 per cent) of the thirty-three wrists that had been treated with other methods had a successful union at an average of 12.2 weeks postoperatively. The difference in the rates of union between the wrists fixed with a plate and those treated with alternative techniques was significant (p = 0.009; Fisher exact test). A total of thirty-nine complications were associated with twenty-nine (51 per cent) of the fifty-seven arthrodeses with plate fixation. Sixteen (41 per cent) of the complications (thirteen wrists) resolved with non-operative treatment. Twenty-six (79 per cent) of the thirty-three arthrodeses with alternative methods of fixation were associated with a total of twenty-nine complications. Twenty-three (79 per cent) of those complications (twenty wrists) resolved with non-operative treatment. The difference between the rate of complications associated with the arthrodeses with plate fixation and that associated with the arthrodeses with alternative methods of fixation was significant (p = 0.03; Fisher exact test).

An evaluation of the two-stage flexor tendon reconstruction technique.

The performance of 43 two-stage flexor tendon reconstructions in 39 patients was reviewed. Results were graded by comparing the preoperative passive motion of the proximal and distal interphalangeal joints after stage one to the active motion of these same joints after stage two. The procedures returned 16% excellent, 23% good, 26% fair, and 35% poor results with three graft ruptures. Following the tenolysis of 20 grafts (47%) the results for the entire group were improved to 27% excellent, 28% good, 30% fair, and 16% poor. Stage reconstruction, including tenolysis, was felt to be the best available method for restoration of digital function following flexor tendon loss in the badly scarred digit.

Management of chronic rotary subluxation of the scaphoid by scapho-trapezio-trapezoid arthrodesis

The natural history of untreated rotary subluxation of the scaphoid is traumatic radiocarpal arthritis, with loss of grip strength, pain with axial loading or dorsiflexion, and decrease in the total active arc of wrist motion. Operative reduction of the proximal scaphoid pole and stabilization of the distal pole by scapho-trapezio-trapezoid arthrodesis in 12 cases showed elimination of the perpendicular scaphoid attitude, closure of scapholunate diastasis, and neither loss of reduction nor degenerative changes on follow-up for over 2 years. Postoperative cineradiographic studies showed loss of normal reciprocal motion within proximal and distal carpal rows, a marked decrease in capitoscaphoid motion, but preservation of lunocapitate motion in addition to radiocarpal motion. Nine of 12 patients without complications returned to activities performed prior to injury, without wrist pain and with 80% of preoperative motion.

Flexor tendon surgery Part 2: Free tendon grafts and tenolysis

We have attempted to review the development and current status of flexor tendon surgery. The methods of acute flexor tendon repair, conventional free tendon grafting, staged flexor tendon reconstruction, tenolysis and pulley restoration have been discussed, with the published results included for each procedure. The role of rehabilitation has also been reviewed and the ongoing quest for an active flexor tendon prosthetic implant has been briefly mentioned. It may be seen that flexor tendon surgery is a complex and difficult art which requires a thorough appreciation of the normal flexor tendon system, the exact status of that system following injury and surgery and a strong understanding of the techniques which may be best utilised to restore tendon gliding and digital joint motion. The procedures described require both technical skill and experience and the post-operative therapy programmes must be carefully chosen for each patient. With the important laboratory and clinical advancements occurring in many areas of flexor tendon surgery, it is realistic to believe that in the future the techniques described here will be substantially altered and modified and to hope that results will continue to improve until the patient and surgeon can expect to restore most digits to nearly full function after flexor tendon interruption.

Flexor tendon surgery

In those instances where flexor tendons divided in zone 1 or zone 2 have not been or cannot be directly repaired, conventional free tendon grafting may represent the best procedure for restoring digital function. In recent years there has been a disconcerting tendency to immediately opt for staged flexor tendon reconstruction when a digit is biologically suitable for a single stage free graft. Free flexor tendon grafts were apparently first used in the hand by Lexer in 1912 (Lexer, 1912; Adamson and Wilson, 1961; Schneider, 1985). He used grafts to repair flexor tendons after rupture, old lacerations, infections and “hopeless cases” of ischaemic contracture. Leo Mayer (1916) published three articles that have served as the basis for the present-day concepts of flexor tendon surgery. He emphasised the need for exacting operative technique, the direct juncture of the tendon to bone, the use of an adequate muscle as a motor, and the necessity of peritenon around a flexor graft. In January 1918, Sterling Bunnell published a classic article on tendon grafting in which he stressed atraumatic technique, a bloodless field, perfect asepsis and the preservation of pulleys. He preferred the palmaris longus tendon as the donor graft and described a modified corkborer that could be used as a tendon stripper. Mason and Allen carried out experiments in 1941 which indicated that tendon grafts should not be moved for 21 to 25 days. In the first edition of his textbook on surgery of the hand in 1944, Bunnell described the pull-out wire suture technique, the success of which was confirmed by Moberg in 1951. The surgical methods and results of free flexor tendon grafting have subsequently been modified and reviewed by various leaders in the field of hand surgery, including Pulvertaft in England (1948, 1956, 1959, 1960, 1965, 1975, 1984), Graham (1947) Littler (1947, 1960, 1977), Boyes (1950, 1964, 1970, 1971), Boyes and Stark (1971) and White (1956, 1960) in the United States and Rank and Wakefield (1952, 1960, 1973) in Australia. Important contributions have also been made by Verdan in Switzerland (Verdan, 1960; Verdan, 1964; Verdan, 1966; Verdan, 1972; Verdan, 1979; Verdan and Crawford, 1979; Verdan and Michon, 1961; Verdan et al., 1971) and Tubiana (1964, 1966, 1972, 1979) in France.