Jonathan Compson

A diabetic patient presenting with stiff hand following fasciectomy for Dupuytren's contracture: A case report.

Reported is the case of a 68-year-old male presenting with severe wrist and hand stiffness following surgery for a Dupuytrens contracture. Complications of surgery or rehabilitation and complex regional pain syndrome were excluded as factors explaining this stiffness. Given the patients diabetes mellitus and the striking similarity with the typical diabetic stiff hand, it is suggested that diabetes may have contributed to the development of the complication.

Surgical excision of ununited hook of hamate fractures via the carpal tunnel approach

INTRODUCTION Direct excision of a symptomatic ununited hook of hamate fracture is the gold standard, most frequently via a Guyon space approach. The open carpal tunnel approach is another option, which has not previously been commonly considered and not reported in a peer review journal. Our study aims to highlight the carpal tunnel approach as a successful technique in a consecutive series of ununited hook of hamate fractures. PATIENTS AND METHODS Seven patients (all male and mean age 30.7 years) were reviewed with symptomatic ununited fractures following a period of cast immobilization. All the patients operated on underwent excision of the hook of hamate fragment via the open carpal tunnel approach. RESULTS All patients successfully returned to their pre-injury level of functioning after 8-12 weeks and there were no complications. CONCLUSIONS Our study highlights the open carpal tunnel approach as a successful technique for open excision of symptomatic ununited hook of hamate fractures, because of its familiarity, ease of performance, excellent visualization and low morbidity. Level of Evidence IV Case Series.

The osteology of the trapezium

The present anatomical and clinical literature is not detailed enough for a clear understanding of the three-dimensional anatomy of the trapezium. It lacks descriptions of identifiable landmarks needed for the interpretation of two-dimensional radiographs. Fifty dry cadaver trapezia were assessed and an extended surface anatomy described. New consistent landmarks were described and the tubercle of the trapezium was redefined. The incidence of the salient osteological features in Caucasian trapezia was recorded.

An anatomical database of carpal bone measurements for intercarpal arthrodesis

During limited intercarpal fusion it is sometimes difficult to determine correct screw length and staple size. This is because of overlap, and the shape and orientation of the carpal bones on radiography. One hundred complete sets of dry cadaver carpal bones were measured to provide an anatomical database of carpal bone measurements. This should help prevent inadvertent overpenetration of fixation devices during surgery.

A Rare Case of Reverse Oblique Ulnar Head and Neck Fracture

Isolated distal ulnar head and neck fractures are rare. Undisplaced fractures are normally treated non-operatively. We report a case of a reverse oblique ulnar head and neck fracture, which despite the initial undisplaced configuration, was unstable and displaced over the subsequent weeks. We believe that, though this particular fracture pattern could have been treated in a cast, it requires careful follow up, especially early on, or to undergo early internal fixation.

Solitary enchondroma presenting with an intra-articular comminuted fracture treated with ligamentaxis and percutaneous curettage

A 35-year-old right-handed professional flautist presented with pain in the right ring finger after minor trauma. There was tenderness and swelling of the proximal interphalangeal (PIP) joint and reduced movement. Radiographs showed an eccentric lytic lesion in the middle phalanx characteristic of an enchondroma with a pathological fracture extending into the PIP joint (Figure 1). The fracture had intra-articular comminution with loss of joint congruity and collapse of the lesion, leading to radial deviation of the digit. Precise realignment of the digit and restoration of good movement were important treatment goals because of her profession. Treatment was planned in two stages. The first was to restore alignment, allow early movement and wait for healing of the pathological fracture. It was assumed that secondary bone grafting might be necessary. Initial surgery was by the application of a Ligamentotaxor (AREX, Palaiseau, France) under axillary block using two wires, one in the proximal phalanx at the centre of rotation of PIP joint, parallel to the articular surface, and another in the middle phalanx shaft. The middle phalanx was distracted to restore length, alignment and joint congruity (Figure 1). To stimulate bone healing a 19 gauge needle was inserted through the thin ulnar wall and used to curette the cavity. Post-operatively the patient was allowed to mobilize the finger as tolerated. Six weeks later the cavity had filled with new bone, obviating the need for further bone grafting, and the fixator was removed (Figure 1). After hand therapy she returned to her profession at 3 months. At the final 1-year follow-up the range of movement was from 10°–90° and the radiographs showed complete filling of the cavity with bone and a congruent articular surface (Figure 2). Treatment of a pathological fracture though a benign cyst or tumour in the middle phalanx depends on its size, location and displacement (Jacobson and Ruff, 2011). The treatment options vary from simple observation to curettage and filling the gap with bone graft or bone cement (Jacobson and Ruff, 2011). Simple curettage without bone grafting has shown promising results in enchondromas (Goto et al., 2002; Hasselgren et al., 1991). In this patient, early grafting was contraindicated owing to the intra-articular comminution. Also we wanted to restore alignment and mobilize as soon as possible and to avoid open procedures, which may produce stiffness. A dynamic external fixator has been used for unstable fractures at the PIP joint to preserve joint congruity and to prevent stiffness (Ruland et al., 2008). The use of such a fixator allowed early mobilization in this particular situation. Although the clinical and radiological diagnosis was an enchondroma, there was no confirmation by biopsy since it healed so rapidly and we were unable to extract any tissue or fluid though the needle. The curettage using the needle appeared to have the advantage of stimulating bone ingrowth with minimal intervention, without the risk of open Figure 1. (Left) The AP and lateral radiographs showing a communited, intra-articular pathological fracture with radial deviation owing to collapse of the cavity. (Middle) Immediate post-operative radiograph with a congruent joint. (Right) At 6 weeks the cavity was filled with new bone.

Do the dimensions of the distal phalanges allow suture anchor fixation of the flexor digitorum profundus? A cadaver study

This study was done to identify whether the dimensions of the distal phalanges allow suture anchor fixation of the flexor digitorum profundus tendon. Forty pairs of hands were dissected to measure the anteroposterior and lateral dimensions of distal phalanges of all digits. The mean anteroposterior depth of the distal phalanx at the insertion of the tendon was found to be 4.7 mm for the little finger, 5.4 mm for the ring finger, 5.9 mm for the middle finger, 5.4 mm for the index finger and 6.9 mm for the thumb respectively. The commonly available anchors and drill bits for fingers were found to be suboptimal for anchoring the flexor digitorum profundus tendon to the distal phalanx of the little finger. The drill bits used for these anchors were found to be too long for the little fingers and some ring and index fingers.

Small Scope Arthroscopy and Breakages

Wrist arthroscopy has been used for diagnostic purposes since 1979 with therapeutic applications following shortly thereafter.As theuseofsmalldiameter (1.9mm)scopes forwrist and finger arthroscopy increases, the logistics of the common complication of broken scopes prior to surgery should be considered. We would like to report how frequently scopes break due to fragility. During twelve carpometacarpal joint arthroscopies, three 1.9-mm scopes were broken before the surgeon had even handled the instrument. In one case, the scopewas taken out of the sheath andwas already broken. Two further scopes were broken when being placed into their isolation drapes. This is of concern as the patient is already anaesthetized when placing the scope into the drape, so if a spare scope is not available, this would expose the patient to a pointless anesthetic. In all cases, it was fortunate that a secondary scope was available, although a colleague in Hong Kong described a case where two scopes were broken in one operation! Of note, a maxillofacial 1.1-mm scope was used in one case to good effect. We would suggest the following recommendations for all surgeons undertaking small scope arthroscopies:

Commentary on 'Early CT for suspected occult scaphoid fractures' by Stevenson et al. J Hand Surg Eur. 2012, 37: 447-51.

The best way to diagnose occult scaphoid fractures has taxed the mind of multiple authors ever since the use of clinical tests and repeat radiographs was shown to have limited accuracy. Though the methods used have to some extent depended on local facilities, isotope bone scanning, MRI, either full or limited sequences, and CT have all had their advocates. The ideal method would need to be done early, have no false positives to reduce inappropriate immobilisation and obviously no false negatives to avoid the need for long term clinical follow-up and the possibility of missing the significant fracture. It would also help if it could detect significant soft tissue injury like scapho-lunate ligament rupture. This retrospective paper shows the result of CT scanning performed within two weeks on 84 patients considered to have a possible scaphoid fracture. The inclusion criteria were uncontrolled. 64% had no fracture detected, 7% had an occult scaphoid fracture, 18% had another carpal fracture and 5% a distal radial fracture. The authors discuss the advantage of cost and reduced immobilisation and hence the social impact of their regime. There are concerns about this paper: the inclusion criteria were arbitrary; and we cannot presume that negative results were definitely not a scaphoid fracture. Though the negative CT cases were followed up clinically to six weeks this does not totally exclude a scaphoid fracture. The same could be said for those showing another carpal fracture since it does not exclude an associated scaphoid fracture. It has been shown in other studies that CT scans can produce false positives mistaking vascular markings for fractures leading to overtreatment. The paper shows that although CT is a good way to screen occult fractures it may not be any better than MRI or bone scanning in detecting scaphoid fractures without some over treatment. We must remember that no technique is infallible.