Volunteering in the developing world: The 2003-2004 Sterling Bunnell Traveling Fellowship to Honduras and Cambodia

One of the goals of my Sterling Bunnell Traveling Fellowship, sponsored by the American Society for Surgery of the Hand and the American Foundation for Surgery of the Hand, was to serve the poor in developing countries. I had the unique opportunities to work in Honduras and Cambodia, 2 countries with rich cultural heritage residing at opposite ends of the world. This report describes my observations and my experiences in these 2 countries.

Palmaris longus--a muscle with multiple uses in leprosy-affected hands

The present paper reviews the anatomy of palmaris longus muscle and also the situations where palmaris longus muscle has been used as an independent motor or as a donor of tendon graft material. Its relevance in leprosy-affected hands is also discussed because the muscle is usually spared in hand palsies consequent to leprotic neural damage. The advantages and disadvantages of its use in different operative procedures have been analyzed. The author's experience with this muscle in the correction of hand deformities in leprosy is described.

[The "candlestick" technique for the correction of certain types of congenital metacarpal synotosis]

Metacarpal synostosis is a rare congenital hand malformation requiring only occasionally a surgical correction. However in case of divergent epiphyses there is a progressive accentuation of the deformity. In the "Y" type of symmetrical synostosis, the authors propose a trapezoidal osteotomy with upside down relocation allowing realignement of the epiphyses without distant bone donor site.

[The posterior interosseous flap in the child: 13 case reports]

INTRODUCTION

The posterior interosseous flap is used to cover skin defects in the hand, wrist, forearm and elbow. It is currently, commonly indicated for adults, but it may be used for child too.

MATERIALS AND METHOD

Twelve children underwent a posterior interosseus flap (13 flaps). Their ages ranged from 3 to 17.5 years with a mean of 6.5 years. There were seven boys and five girls. The flaps were used to treat different type of lesions: the most frequent etiology was burn injuries or sequels (nine patients), there were one extravasation of anticarcinogenic agent, one syndactyly and one arthrogryposis. The localizations of the skin loss were the first web space (six patients), the dorsal hand (five patients) and the elbow (two patients).

RESULTS

The average of the operation was eighty minutes. The survival of the flaps was excellent. Only one flap had a partial necrosis.

CONCLUSION

Posterior interosseus flap may be used in coverage of children's limb. The diameter of the vessels is not a difficulty in the flap dissection. As the adults, the viability of the flap is excellent and allows to cover most of the skin defect of the dorsal hand or elbow.

The digital extensor mechanism of the hand

In summary, there is a complex interplay between the extrinsic and intrinsic components of the digital extensor mechanism. Numerous examples of dynamic anatomy and pathology of the extensor mechanism in common clinical settings have been described. Treatment principles have been outlined. This review should provide the orthopaedic surgeon with a framework for management of common hand problems.

[Melorheostosis: a case review and review of literature]

The authors present a review of the literature and the diagnostic difficulties in a case of melorheostosis in a 6 year old boy. Melorheostosis is characterized by longitudinal foci of subcutaneous sclerosis, limitation of motion in the joints and swelling of the knee and ankle joints. Radiologically numerous foci of hyperostosis similar to wax flowing down a burning candle have been noted.

Psychological aspects of toe to hand transfer in children. Comparison of views of children and their parents

Thirty-seven children with congenital (n = 32) or post-traumatic (n = 5) hand anomalies underwent unilateral or bilateral toe transfers. All had undergone preoperative counselling. After rehabilitation and more than 1 year after surgery, the children and their parents were reviewed by a clinical psychologist to assess the psychosocial outcome of the surgery. A high level of satisfaction was reported with regard to the surgery, in terms of function, cosmesis, donor site, psychosocial wellbeing and the reactions of others. This was true regardless of the gender of the child. However, there was a tendency for the children to be more positive in their responses than their parents.

[Epidermolysis bullosa hereditaria dystrophica mutilans Hallopeau-Siemens--a complex problem]

Epidermolysis bullosa hereditaria dystrophica mutilans Hallopeau-Siemens is an autosomal recessive, chronically mutilating disease. Causal therapy is not known. In a five-year-old boy suffering from this disease and having the right hand completely clumped to a fist, syndactyly and contraction release was performed. The wounds healed under the care of the silicone-coated polyamide net dressing Mepitel. Under intensive postoperative physio- and ergotherapeutic care, a major part of his previous hand function could be restored. Complete epithelialization occurred within four weeks. Twelve months after the procedure, the area of the previous lesions was marked by an unexpected mechanical stability. It was very impressive to see the improvement in his psychological well-being and his sense of self-esteem during this period of partial recovery of his hand function.

A rare variant of mirror hand: a case report

Mirror hand is one of the rarest congenital differences of the upper extremity. Typically, there is absence of the radius, duplication of the ulna, and 7 digits in mirrored symmetry about the middle finger. We report a case of a rarer subset of hand duplication in which there is a normal radius and ulna and a hand with 8 digits. The patient underwent surgery to excise the radial 3 digits and to reconstruct the remaining radial digit to function as an opposable, 2 phalanx thumb. Wrist extension was augmented by transferring the digital extensors from the excised fingers to the radial wrist extensors.

Strength measurements of the lumbrical muscles

This study was designed to measure the strength of the lumbrical muscles in the index and long fingers in patients with ulnar nerve paralysis. A hand-held dynamometer was used. The results show that in ulnar nerve damage the index and long fingers have a mean metacarpophalangeal (MCP) joint flexion strength of 0.8 kg (range 0.3-1.5), compared with 6.4 kg (range 4.6-7.9) in the noninvolved hand. Thus, the damaged fingers have only about 12% of the strength of those of the noninvolved hand. In the hand with ulnar paralysis, the loss of intrinsic strength (dorsal and palmar interosseous muscles) is considerable (almost 90%). The contribution of the interosseous muscles in maintaining the intrinsic position is considerably greater than that of the lumbricals. Comparing the Medical Research Council (MRC) scale (0-5) with the dynamometry measurements shows that MRC grade 3 correlates with about 0.8 kg, while grade 5 correlates with about 6.5 kg of MCP joint flexion strength.

Surgical treatment and postoperative splinting of recessive dystrophic epidermolysis bullosa

Digital contractures and pseudosyndactyly, common manifestations in recessive dystrophic epidermolysis bullosa, cause significant functional impairment. The deformities progress with time, although surgery may delay the progression. The role of surgical intervention, hand therapy, and the use of prolonged splinting was examined in seven children (nine hands) with recessive dystrophic epidermolysis bullosa with an average age of 5 years, 8 months (range, 1 year, 10 months to 16 years, 4 months). The technique of surgery, postoperative regimen, and splinting differ from those previously reported. Surgery includes "de-cocooning" the hand and fingers, manipulating contracted joints, and full-thickness skin grafting to dermal defects. Surgery and the postoperative regimen of rigid night splints and web-retaining gloves for day wear has allowed arrest or minimal progression of contractures in complaint patients in short-term follow-up study of an average of 17 months (range, 12-28 months). An interdisciplinary team of physicians and surgeons, therapists, and nurses makes this care regimen possible and influences family compliance.

[Psychogenic spastic hand]

Twelve patients seen over a 8-year period with psychogenic spasms of the hand are reported. Six elderly patients presented with extrinsic flexion of the two or three medial fingers with sparing of the thumb and index. Six other patients had various hand attitudes following coincidental but not causal trauma to the upper extremity. Because of the differences in clinical presentation, age of patients and coincident trauma in some cases, the former patients were characterized as type I psychogenic spasms and the latter as type II. A major recurrent depression was the commonest psychiatric diagnosis (DSM-III-R, Axis I) with a concurrent dependent or borderline personality (DSM-III-R, Axis II). The diagnosis of psychogenic spasm of the hand is a diagnosis of exclusion, that requires a multidisciplinary approach including surgeon, neurologist, psychiatrist and rehabilitation therapist. Electromyographic studies are used to rule out a neurological or muscular etiology of the condition. Surgical treatment was uniformly unsuccessful and is probably contraindicated. Only one patient had a nearly complete spontaneous recovery.

The retrograde radial fascial forearm flap: surgical rationale, technique, and clinical application

The retrograde radial fascial forearm flap may be used to provide appropriate tissue coverage for nerve, tendon, or soft tissue defects in the forearm and hand. The procedure is differentiated from the standard radial forearm flap in that the radial artery remains intact when the retrograde radial fascial flap is designed. The rationale, technique, and clinical application of the flap are presented in order to allow surgeons to maintain the radial arterial trunk in continuity while obtaining the advantage of appropriate soft tissue cover in this critical area.

Analysis of finger extensor mechanism strains

Strains in the extensor mechanism of the finger were measured in a cadaver model using Hall-effect transducers. Several components of the mechanism were evaluated at different joint positions, with different intrinsic and extrinsic tendon loading conditions, and after creating a boutonnière deformity. Landsmeer's theory that predictable and obligatory interactions occur within the extensor mechanism during finger movement is strongly supported by our results. The concept of the Bunnell intrinsic-tightness test was confirmed. Results were consistent with clinical observations and current theories on the pathomechanics of claw and boutonnière deformities. Based on our experimental findings, we conclude that strain analysis is an effective method of evaluation of the extensor mechanism with potential for in vivo surgical applications.

Nail plasty in the treatment of duplicated thumb

We present refinements in the treatment of duplicated thumb. When applying the modified Bilhauts procedure including the nail, this design based on a lunula is useful to construct a natural looking nail in Wassel types 2 to 4. No bone fixation of each segment is also effective to produce an even transverse curvature of the reconstructed nail.

Toe-to-hand transfers in children

One hundred three microvascular toe-to-hand transfers were performed on 66 pediatric patients with congenital and posttraumatic deformities. Techniques for dissection and transfer of individual and composite toes were elaborated, and adjunctive procedures were added when indicated.

Magnetic resonance imaging to visualize the internal anatomy in the Baller-Gerold syndrome

The Baller-Gerold syndrome is identified by radial aplasia with craniosynostosis. Only 12 cases have been reported previously in the literature; none of the reports describe surgical treatment for the radial aplasia. We report the case of a 10-month-old female infant with this syndrome, including severe bilateral radial clubhands. A radial anlage, which was tethering growth of the ulna, was suspected on physical examination and confirmed with magnetic resonance imaging. Resection of the anlage resulted in dramatic improvement in elbow extension, but additional follow-up will be necessary to determine the complete functional effect of the procedure.

The anatomy and treatment of camptodactyly of the small finger

Having observed an anomalous insertion of the lumbrical muscle in 74 consecutive operations for correction of camptodactyly of the small finger, we have concluded that the loss of normal lumbrical action is the principal cause of the intrinsic minus deformity seen in this condition. Other anatomic abnormalities observed in this series of patients are those of the superficial tendon in 47%, the x-ray appearance of the proximal interphalangeal (PIP) joint in 15%, and a fixed flexion contracture of the PIP joint in 66%. Fifty-seven percent of our patients had PIP flexion contracture of more than 45 degrees. To determine the contribution of these anomalies to this deformity, we analyzed a series of 53 patients who had been followed up for at least 1 year. The study revealed that these conditions are interdependent and that each had an adverse effect on the final operative results. Treatment included a transfer of the superficial tendon of the ring or little finger to the extensor mechanism of the little finger in all cases and other procedures as dictated by the individual situation. Overall, the joint contracture was reduced from 49 degrees to 25 degrees, but only 33% of the patients regained full flexion of the small finger.

Extensor indicis proprius opponensplasty

An analysis of 39 patients (40 hands) who underwent an extensor indicis proprius opponensplasty was carried out. Of these, 29 hands had simultaneous adjuvant surgery to correct other deformities. The mean follow-up period was 33.8 months. Excellent or good results were seen in 87.5%, fair in 10% and poor in 2.4% hands.