Comparison of assessment tools to score recovery of function after repair of traumatic lesions of the median nerve

Endoscopic Release Superficial Rather Than Deep to the Transverse Carpal Ligament for Carpal Tunnel Syndrome Improves Immediate Postoperative Transient Symptomatic Exacerbation With Fewer Absences From Work

PURPOSE

To determine the endoscopic release superficially rather than deep to the transverse carpal ligament to reduce the incidence of transient symptomatic exacerbation and postoperative absence from work in patients with carpal tunnel syndrome.

METHODS

From January 2012 to January 2018, patients with idiopathic carpal tunnel syndrome who underwent one-portal endoscopic release superficial to the transverse carpal ligament (ERSTCL) were analyzed. For comparison, a cohort treated with the conventional Chow endoscopic release between February 2008 and October 2013 were included. Transient worsening of symptoms, discrimination sensation, and days off work were assessed. The minimal clinically important difference was calculated for discrimination sensation. Severity of symptom and functional status also were assessed using the Levine-Katz Questionnaire. Significance was set at P < .05.

RESULTS

There was a significant difference between the ERSTCL group and the control group regarding the incidence of symptomatic exacerbation 1 week after surgery (2% vs 9%; P = .003) but no difference in other time intervals within the initial 3 months. There was a significant difference in 2-point discrimination 1 week (mean change = -0.13, 95% confidence interval [CI] -0.30 to 0.04, P = .01) and 2 weeks after surgery (mean change = -0.18, 95% CI -0.36 to -0.01, P = .033). Postoperative 1 and 2 weeks, 28% and 35% patients in ERSTCL group achieved a minimal clinically important difference, respectively. Compared with control group, the difference in frequencies was statistically significant (28% vs 45%; P = .027; 35% vs 57%; P = .015). The difference between the 2 groups in postoperative absence from work was statistically significant (95% CI 1.083-4.724; P = .002), with an average reduction in sick leave of 3 days in ERSTCL group. At a mean follow-up of 3 years, no significant difference was found between the groups regarding symptom and function statuses.

CONCLUSIONS

Endoscopic release superficial rather than deep to transverse carpal ligament for carpal tunnel syndrome improves immediate postoperative transient symptomatic exacerbation, which allows the patients to return to work earlier.

LEVEL OF EVIDENCE

Level III, retrospective comparative study.

Relationship Between Sensibility Tests and Functional Outcomes in Patients With Traumatic Upper Limb Nerve Injuries: A Systematic Review

OBJECTIVE

To investigate which tests of hand sensibility correlate with functional outcomes in patients with upper limb traumatic nerve injuries and to assess if composite scales of sensibility correlate with functions.

DATA SOURCES

MEDLINE, Embase, and Cochrane Central Register of Controlled Trials were searched in May 2020, with a supplementary search in July 2020. Reference lists of the included publications were hand searched.

STUDY SELECTION

Database search found 2437 records. Eligible studies reported on inferential association between sensibility tests and functions pertaining to adults after upper limb nerve repair. Two reviewers independently assessed eligibility. Fifteen publications were included.

DATA EXTRACTION

Extracted data contain patient characteristics, surgical procedure, follow-up duration, sensibility tests, and functional assessments. Two reviewers independently assessed data quality.

DATA SYNTHESIS

Fifteen publications involving 849 patients were reviewed. All publications reported on median and/or ulnar nerve injuries. Monofilament tests correlated with Short-Form Health Survey (r=0.548, P<.05), pick-up test (r=0.45, P<.05), and function domain of Patient-Rated Wrist and Hand Evaluation Questionnaire (PRWHE) (r=0.58, P<.05). The 8 studies of static and moving 2-point discrimination provided conflicting correlations with activities of daily living (ADL) and/or the pick-up test. Data for area localization and object/shape identification were equivocal as well. No data were found for Ten test and vibration tests. Rosén score sensory domain correlated with ADL (r=0.59; 95% confidence interval [CI], 0.41-0.72) and PRWHE function domain (r=-0.56, P<.05). Medical Research Council sensory scale was related to pick-up test; return to work status; and Disabilities of the Arm, Shoulder, and Hand questionnaire.

CONCLUSIONS

Monofilament tests allow practitioners to gather sensibility data meaningful to patients' overall recovery of functions after upper limb nerve trauma. For 2-point discrimination and other sensibility tests, practitioners should be aware that improvement in test performance does not necessarily translate to improved hand function. Findings from the composite scales indicate that hand sensibility, in general, is related to functions. Future research on other common sensibility tests is recommended to explore how the test relates to patients' functions.

Long-term sensibility outcomes of secondary digital nerve reconstruction with sural nerve autografts: a retrospective study

Background

Recovery of sensibility after digital nerve injury is crucial for restoring normal hand function. We evaluated long-term outcomes of digital nerve reconstruction with autografts.

Methods

This retrospective study included patients who underwent secondary reconstruction of digital nerves with nerve autografting. Recovery of sensibility was evaluated based on the following: patient self-assessment, two-point discrimination (2PD), and a total sensation score (sum of proprioception, temperature sensation, and sharp/dull discrimination). Mixed models regression was used to study predictors of sensibility outcomes. The predictors analyzed were age, sex, smoking status, number of fingers involved in a patient (as a measure of injury severity), time to reconstruction, and time to follow-up.

Results

In 61 patients, 174 digital nerves in 126 fingers were reconstructed after an average of 33.1 weeks from injury. The mean follow-up was 6.4 years from reconstruction. The mean graft length was 3.6 cm. Self-rated sensibility in the affected area was very good in 13% of patients, good in 33%, satisfactory in 40%, and poor in 24%. 2PD at 6 mm was present in 17% of patients, at 10 mm in 12%, and at 15 mm in 18% (mean 2PD was 10.8). Proprioception was preserved in 107 (85%) fingers, sensation of temperature was preserved in 99 (75%) of fingers, and sharp/dull discrimination in 88 (70%) fingers. Time from injury to reconstruction was the only significant predictor of the total sensation score.

Conclusion

Our data indicate that earlier reconstruction is associated with a favorable outcome.

A comparison of the bipedicled nerve flap with the Littler flap for reconstructing a neurocutaneous defect of digits

BACKGROUND

Complex digital injuries involving soft-tissue loss and digital nerve defect continues to pose a reconstructive challenge. This study reports the repair of such neurocutaneous defect with the bipedicled nerve flap or the Littler flap and compares the results of the two techniques.

METHODS

A retrospective study was conducted in 59 patients who had a neurocutaneous defect in the single digit treated with the bipedicled nerve flap or the Littler flap from Jul 2008 to May 2016. The patients were divided into two groups based on which flap was chosen. At the final follow-up, the two groups were compared for static two-point discrimination and Semmes-Weinstein monofilament scores on both flap and pulp, and pain, cold intolerance and patient satisfaction of the reconstructed digit.

RESULTS

Significant differences were found in static two-point discrimination, pain, cold intolerance, and patient satisfaction (p < 0.05). In comparison with the bipedicled flap group, the Littler flap group presented better discriminatory sensation in the flap and pulp, but exhibited higher incidence of pain and cold intolerance in the reconstructed digit. In the donor digits, the bipedicled flap group achieved lower pain incidence. Finally, the bipedicled flap group attained a larger degree of satisfaction than the Littler flap group.

CONCLUSIONS

When reconstructing a complex neurocutaneous defect in the digit, choosing the bipedicled nerve flap rather than the Littler flap attains lower incidence of pain and cold intolerance, and higher patient satisfaction. Our results suggest that repair of the transected digital nerves can reduce neuroma incidence.

Superficial Radial Nerve Transection Improves Sensory Outcomes in First Dorsal Metacarpal Artery Flaps

BACKGROUND

This article reports the operative technique and clinical effect of repairing thumb pulp defects using a modified first dorsal metacarpal artery flap method. In this method, the dorsal branches of the radial and ulnar proper digital nerves of the index finger were preserved but the superficial branches of the radial nerve were transected.

METHODS

Data obtained from 121 patients with thumb pulp defects who were admitted to the authors' hospital from June of 2011 to December of 2014 were retrospectively analyzed. Patients were divided into two groups based on whether the superficial branches of the radial nerve were transected. The dorsal branches of the radial and ulnar proper digital nerves of the index finger and the proper digital nerves in the wound were coapted using the end-to-end style. Static two-point discrimination, Semmes-Weinstein monofilament scores, pain, cold intolerance of the reconstructed finger, allachesthesia, and patient satisfaction were compared between the two groups.

RESULTS

The authors observed significant differences in static two-point discrimination, Semmes-Weinstein monofilament flap score, pain of finger pulp, allachesthesia duration, and patient satisfaction (p < 0.05). The transection group presented slightly better discriminatory sensation in the flap and higher patient satisfaction. In addition, the duration of allachesthesia in the transection group was significantly shorter than that in the preservation group.

CONCLUSION

In the repair of thumb pulp defects using a modified first dorsal metacarpal artery flap carrying the dorsal branches of the radial and ulnar proper digital nerves of the index finger, transecting the superficial branches of the radial nerve achieved better clinical outcome compared with preserving them.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Reconstruction of two fingertip amputations using a double thenar flap and comparison of outcomes of surgery using a single thenar flap

BACKGROUND

Although thenar flap for single fingertip amputation is a common and popular surgical technique, double thenar flap technique for patients with two fingertip amputations has rarely been reported in the literature. The purpose of this case-control study was to introduce the double thenar technique and compare the clinical outcomes between single thenar flap and double thenar flap surgical treatments.

METHODS

From January 2005 to December 2014, 92 patients with single fingertip amputations were treated with thenar flap (Group I) and 28 patients with two fingertip amputations were treated with double thenar flap (Group II). These 120 patients were followed-up for a minimum of 12 months postoperatively. At the latest follow-up, the two groups were assessed for pain, cold intolerance in the reconstructed finger, functional outcomes by Chen's criteria, and subjective patient satisfaction.

RESULTS

At the final follow-up, all flaps in both groups had survived. No flap failure occurred. There was no significant difference in cold intolerance (p=0.783), donor site pain (p=0.728), fingertip pain (p=1.000), or paresthesia (p=0.514) between the two groups. A total of 100 (83.3%) patients were completely or fairly satisfied. There was no significant difference in satisfaction between the two groups (p=0.801). According to the Chen criteria, 102 (85%) patients had excellent or good results.

CONCLUSION

This study demonstrated that the double thenar flap technique used for patients with two fingertip amputations produced complete survival with functional outcomes comparable to those of the single thenar flap technique at the last follow-up.

Sensory reconstruction in different regions of the digits: A review of 151 cases

BACKGROUND

Soft tissue defects of the digits are very common in hand trauma and can result in functional disability. The purpose of the study is to introduce the use of several modified and traditional sensate flaps to reconstruct different regions of the digits and to evaluate the efficacy of these techniques.

METHODS

A retrospective study was conducted with 151 patients who had soft tissue defects of the digits treated with the sensate flaps from February 2005 to March 2014. Based on different regions of the soft tissue defects, the patients in the study were divided into four groups [1]: thumb group treated with the dual-innervated and traditional kite flaps [2]; distal finger group treated with the single- and dual-innervated dorsal digital flaps [3]; proximal finger group treated with the heterodigital neurocutaneous island flap; and [4] awkward region group treated with the Litter flap. The main outcomes were static 2PD and Semmes-Weinstein monofilament scores of the flap, pain and patient satisfaction.

RESULTS

Significant difference was found between dual-innervated and traditional kite flaps, and between single- and dual-innervated dorsal digital flaps in static 2PD, pain and patient satisfaction (P<0.05). Double nerve repairs presented better discriminatory sensation on the flap, lower incidence of pain in the injured digit and larger satisfaction degree than single nerve repair.

CONCLUSIONS

Compared to single-innervated flap, dual-innervated flap exhibited better sensory recovery and lower pain incidence. Being an additional treatment option, Littler flap may be better choice for sensory coverage in some specific situations including border injuries.

Comparison of short- with long-term regeneration results after digital nerve reconstruction with muscle-in-vein conduits

Muscle-in-vein conduits are used alternatively to nerve grafts for bridging nerve defects. The purpose of this study was to examine short- and long-term regeneration results after digital nerve reconstruction with muscle-in-vein conduits. Static and moving two-point discriminations and Semmes-Weinstein Monofilaments were used to evaluate sensory recovery 6–12 months and 14–35 months after repair of digital nerves with muscle-in-vein in 7 cases. Both follow-ups were performed after clinical signs of progressing regeneration disappeared. In 4 of 7 cases, a further recovery of both two-point discriminations and in another case of only the static two-point discrimination of 1–3 mm could be found between the short-term and long-term follow-up examination. Moreover, a late recovery of both two-point discriminations was demonstrated in another case. Four of 7 cases showed a sensory improvement by one Semmes-Weinstein Monofilaments. This pilot study suggests that sensory recovery still takes place even when clinical signs of progressing regeneration disappear.

Direct and reversed dorsal digital island flaps: a review of 65 cases

BACKGROUND

Reconstruction of soft tissue defects in fingers continues to be a challenging problem. The purpose of this study is to report the reconstruction of small-to-moderate defects of fingers with dorsal digital island flap (DDIF) and to evaluate the efficacy of use of the flap.

METHODS

Over last six years, a retrospective study was conducted with 65 patients who had soft tissue defects of fingers treated with the DDIF. Sixty-nine soft-tissue defects were found in 69 fingers in 65 patients. Based on the flow direction of blood supply, the patients were divided into two groups: the direct (n=35) and reversed (n=30) DDIF groups. In addition, based on the different donor sites, the direct DDIF group was divided into two subgroups: the proximal phalangeal direct DDIF subgroup (n=16) and the extended pedicle direct DDIF subgroup (n=19). The main outcomes were static 2-point discrimination and Semmes-Weinstein monofilament scores of flap and joint motion.

RESULTS

At the final follow-up, the mean static two-point discrimination of the flaps was 9.7mm (range, 8 to 12mm) in the proximal phalangeal direct DDIF subgroup and 8.3mm (range, 7 to 11mm) in the extended pedicle direct DDIF subgroup, with a significant difference (p=0.005). In the direct DDIF group, there was no significant difference in total active motion between the donor fingers and the opposite sides. In the reversed DDIF group, the mean total active motion of the donor fingers was 170° and the data of the opposite sides was 181°, with a significant difference (p=0.024). Maximum amplitude losses of 15° were seen in 12% of patients in the distal interphalangeal joint.

CONCLUSIONS

The DDIF is reliable and technically easy for reconstructing small-to-moderate defects of fingers. The extended pedicle direct DDIF may be an optional solution when sensory reconstruction is needed.

Bilaterally innervated dorsal digital flap for sensory reconstruction of digits

BACKGROUND

Providing sensory coverage in digits continues to be a challenging problem. This study reports the sensory reconstruction of digits with bilaterally innervated dorsal digital flaps and compares the results between dual- and single-innervated flaps.

METHODS

Over 7 years, a retrospective study was conducted with 73 patients who had soft-tissue defect of the digit treated with the bilaterally innervated dorsal digital flap. There were 73 soft-tissue defects in 73 digits. The size of the defects ranged from 1.8 to 2.7cm in length (mean, 2.2cm) and from 1.6 to 2.2cm in width (mean, 1.9cm). The bilateral dorsal branches of the digital nerves were attached with the flap for the sensory reconstruction of digits. Reconstructive techniques included the cross-finger flap in 35 cases, the dorsal digital island flap in 24 cases, and the dorsal digital free flap in 14 cases. To objectively evaluate the efficacy of the bilaterally innervated flaps, we selected a comparison group that included 42 patients treated with the single-innervated flap.

RESULTS

A significant difference was found between the dual- and single-innervated flaps in two-point discrimination, pain, Tinel's sign, and patient satisfaction results. By comparison, the dual-innervated flap presented better discriminatory sensation on the flap, lower incidence of pain and Tinel's sign, and a larger degree of satisfaction than the single-innervated flap. Of the dual-innervated flap group, the mean joint motion of the donor finger was similar to that of the opposite side.

CONCLUSIONS

The bilaterally innervated dorsal digital flap is a reliable alternative for the sensory reconstruction of digits. Performing double neurorrhaphies can improve flap sensation and reduce digital neuroma incidence when reconstructing a soft-tissue defect associated with both transected digital nerves.

Use of vein conduit and isolated nerve graft in peripheral nerve repair: a comparative study

Aims and Objectives. The aim of this study was to evaluate the effectiveness of vein conduit in nerve repair compared with isolated nerve graft. Materials and Methods. This retrospective study was conducted at author's centre and included a total of 40 patients. All the patients had nerve defect of more than 3 cm and underwent nerve repair using nerve graft from sural nerve. In 20 cases, vein conduit (study group) was used whereas no conduit was used in other 20 cases. Patients were followed up for 2 years at the intervals of 3 months. Results. Patients had varying degree of recovery. Sensations reached to all the digits at 1 year in study groups compared to 18 months in control group. At the end of second year, 84% patients of the study group achieved 2-point discrimination of <10 mm compared to 60% only in control group. In terms of motor recovery, 82% patients achieved satisfactory hand function in study group compared to 56% in control group (P < .05). Conclusions. It was concluded that the use of vein conduit in peripheral nerve repair is more effective method than isolated nerve graft providing good sensory and motor recovery.

Evaluation of sensory recovery after reconstruction of digital nerves of the hand using muscle-in-vein conduits in comparison to nerve suture or nerve autografting

BACKGROUND

Muscle-in-vein conduits are a good alternative solution to nerve autografts for bridging peripheral nerve defects since enough graft material is available and no loss of sensation at the harvesting area is expected. The purpose of this study was to compare regeneration results after digital nerve reconstruction with muscle-in-vein conduits, nerve autografts, or direct suture.

PATIENTS AND METHODS

46 patients with 53 digital nerve injuries of the hand subjected to direct suture (n = 22) or reconstruction of 1-6 cm long defects with either nerve autografts (n = 14) or muscle-in-vein conduits (n = 17) between 2008 and 2012, were examined using the two-point discrimination and Semmes-Weinstein Monofilaments.

RESULTS

The follow-up examinations took place 12 to 58 months after surgery. A median reduction of sensibility of 2 Semmes-Weinstein monofilaments compared with intact digits was observed after direct suture (DS) and of 2.5 and 2 Semmes-Weinstein monofilaments after reconstruction with autologous nerve grafts (ANG) and muscle-in-vein conduits (MVC), respectively. No statistically significant differences between all three groups could be found with a significance level set by a P < 0.006 (PDS-ANG = 0.24, PDS-MVC = 0.03, PANG-MVC = 0.52). After harvesting a nerve graft, reduction of sensibility at the donor site occurred in 10 of 14 cases but only in one case after harvesting a muscle-in-vein conduit.

CONCLUSIONS

Muscle-in-vein conduits may be a good alternative solution to autografts for the reconstruction of digital nerves, since no significant differences could be demonstrated between the two methods.

Direct and reversed dorsal digito-metacarpal flaps: a review of 24 cases

BACKGROUND AND AIM

The common source for reconstruction of soft tissue defects of the fingers is either the same finger or the adjacent finger. However, when the donor areas are damaged by concomitant injuries, these options are not available. The purpose of this study was to report on reconstruction of these complex digital injuries using the dorsal digito-metacarpal flaps (DDMFs) and to evaluate the efficacy of this technique.

METHODS

A retrospective study was conducted with 24 patients who had their fingers reconstructed using the DDMF from April 2009 to September 2011. The patients were divided into two groups based on the flow direction of the blood supply. Among them, nine patients had their fingers reconstructed with the direct DDMFs. Fifteen patients underwent tissue reconstruction in the distal phalanx with the reversed DDMFs.

RESULTS

At a mean follow-up of 20 months (range, 18-24 months), the mean static two-point discrimination on the flaps was 8.3 mm (range, 7-10 mm) in the direct DDMF group and 10.4 mm (range, 9-14 mm) in the reversed DDMF group, with a significant difference (P=0.001). The range of motion of the donor fingers was similar to that of the opposite hands. According to the Michigan Hand Outcomes Questionnaire, 11 patients were very satisfied, 10 were satisfied and three were neither satisfied nor dissatisfied with functional recovery of the reconstructed finger.

CONCLUSIONS

The DDMF is an additional option for coverage of a soft tissue defect of the finger when the commonly used local and regional flaps are not feasible.

CLINICALTRIALSGOV ID

NCT 01927003.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic/IV.

Reconstruction of a neurocutaneous defect of the proximal phalanx with a heterodigital arterialised nerve pedicle flap

BACKGROUND

Complex digital injuries involving soft-tissue loss and digital nerve defect pose a challenging problem for hand surgeons. The purpose of this study was to evaluate the efficacy of transferring the heterodigital arterialised nerve pedicle flap for reconstructing the digital neurocutaneous defects and to compare the results with those of transferring the cross-finger flap and secondary nerve grafting.

METHODS

From March 2008 to September 2011, the nerve pedicle flap was used in 12 patients who had a combination of soft-tissue and digital nerve defects. The injured fingers included four index, four long, three ring and one little finger. The mean size of the soft-tissue losses was 2.4×1.9 cm (range, 2.3×1.3 to 3.2×2.0 cm). The mean flap size was 2.6×2.1 cm (range, 2.5×1.5 to 3.4×2.2 cm). The length of the nerve defects ranged from 1.5 to 3.8 cm (mean, 2.8 cm). The nerve defect was reconstructed with transfer of the digital nerve dorsal branch. For comparison, we collected a series of 24 patients with similar defects treated with the cross-finger flap and secondary free nerve grafting.

RESULTS

Significant differences were found between the two groups in static two-point discrimination (p<.01) and pain (p=.03) in the reconstructed finger. In comparison, the study group presented better discriminatory sensation on the finger pulp and lower incidence of pain sensibility in the injured finger. There was no significant difference in cold intolerance and Semmes-Weinstein monofilament. In the study group, the total active motion of the donor fingers was similar to that of the opposite hands.

CONCLUSIONS

The heterodigital arterialised nerve pedicle flap is useful and reliable for reconstructing the neurocutaneous defects in the proximal phalanx. Comparable sensory recovery and lower pain incidence can be achieved using our nerve pedicle flap instead of conventional nerve grafting.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

A comparison of the dorsal digital island flap with the dorsal branch of the digital nerve versus the dorsal digital nerve for fingertip and finger pulp reconstruction

BACKGROUND

Traumatic fingertip and finger pulp defects can be treated with dorsal digital island flaps. Either the dorsal branch of the digital nerve or the dorsal digital nerve can be included in the flap for sensory reconstruction. However, it is still unclear whether there are differences in the results between the two donor nerves.

METHODS

A retrospective study was conducted in 71 patients who had a fingertip or finger pulp defect treated with an innervated dorsal digital island flap from February of 2005 to June of 2011. The patients were divided into two groups based on which donor nerve was chosen. The donor nerve was coaptated to the digital nerve in the defect. At the final follow-up, the two groups were compared for static two-point discrimination, Semmes-Weinstein monofilament scores, pain, cold intolerance of the reconstructed finger, and patient satisfaction.

RESULTS

Significant differences were found in static two-point discrimination, pain, cold intolerance, and patient satisfaction (p < 0.05). The dorsal branch group presented slightly better discriminatory sensation in the flap and lower incidence of pain and cold intolerance in the injured finger. In addition, the dorsal branch group had a larger degree of satisfaction than the dorsal digital nerve group. No significant differences were found regarding Semmes-Weinstein monofilament flap score and total active motion of the finger.

CONCLUSION

When utilizing dorsal digital island flaps to reconstruct traumatic fingertip and finger pulp defects, choosing the dorsal branch rather than the dorsal digital nerve as the donor may attain better outcomes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Repair of multiple finger defects using the dorsal homodigital island flaps

BACKGROUND

Providing soft-tissue coverage for multiple finger defects remains a challenge for the hand surgeons. This article reports reconstruction of multiple digital defects using the dorsal homodigital island flaps based on the dorsal branch of the digital artery.

METHODS

Over 3 years, a retrospective study was conducted with 12 patients who had multiple finger defects treated with the dorsal homodigital island flaps. Our series included nine male and three female patients. There were 30 soft-tissue defects in 30 fingers. The injured fingers included seven index, nine long, nine ring and five little fingers. The average size of soft-tissue defects and flaps was 2.4 ± 0.4 cm × 1.7 ± 0.2 cm and 2.6 ± 0.4 cm × 1.9 ± 0.2 cm, and the mean pedicle length was 1.1 ± 0.2 cm.

RESULTS

Full flap survival was achieved in 26 fingers. Partial distal flap necrosis was noted in four fingers, which healed without surgical intervention. At a median of 20 (range, 19-23) months' follow-up, the static two-point discrimination on the flap averaged 9.1 ± 1.6 mm, and the median (range) Semmes-Weinstein monofilament score was 3.84 (3.84-4.17). The donor-site morbidity was accepted. According to the Michigan Hand Outcomes Questionnaire, seven patients were strongly satisfied and five were satisfied with functional recovery of the reconstructed fingers.

CONCLUSIONS

The dorsal homodigital island flap, based on the dorsal branch of the digital artery, is less invasive, versatile and technically easy for simultaneous coverage of small-to-moderate defects in multiple fingers.

Reconstruction of a soft tissue defect in the finger using the heterodigital neurocutaneous island flap

BACKGROUND

This article describes reconstruction of a soft tissue defect in the finger using the heterodigital neurocutaneous island flap and reports the results of the use of the flap.

METHODS

From February of 2008 to March of 2011, the neurocutaneous island flap was used in 12 patients with soft tissue defects in the middle phalanx or the proximal interphalangeal joint, or both. The injured fingers included 4 index, 3 middle, 3 ring and 2 little fingers. The donor fingers included 7 middle fingers and 5 ring fingers. The mean size of soft tissue defects and the flaps was 2.4 cm × 1.8 cm and 2.7 cm × 2.0 cm, respectively. The mean pedicle length was 2.8 cm.

RESULTS

Full flap survival was achieved in 11 cases. Partial distal flap necrosis was noted in one case, which healed without surgical intervention. At a mean follow-up of 22 months, the mean static 2-point discrimination and Semmes-Weinstein monofilament scores on the flap were 8.3mm and 3.94, respectively. Based on the modified American Society for Surgery of the Hand guidelines for stratification of 2-point discrimination, 10 (83%) of 12 flaps achieved good results. According to the Michigan Hand Outcomes Questionnaire, 5 patients were strongly satisfied and 7 were satisfied with functional recovery of the reconstructed finger.

CONCLUSIONS

The neurocutaneous island flap of the dorsal branch of the digital nerve is useful, reliable, and technically easy for reconstructing a defect in the adjacent fingers, especially when sensory reconstruction is needed.

Use of a bipedicled nerve flap taken from the dorsum of the digit for reconstruction of neurocutaneous defect in the adjacent finger

A digital nerve defect complicated by an associated soft-tissue loss poses a reconstructive challenge. This article reports reconstruction of a similar complex injury using a bipedicled nerve flap including a nerve graft from the dorsal branch of the digital nerve. From July 2008 to May 2010, a retrospective study was conducted with nine consecutive patients who had a combination of soft tissue and digital nerve defects. The injured fingers requiring reconstruction included three index, four middle and two ring fingers. The mean size of the soft-tissue losses was 2.8×2.1 cm. The flap is supplied by the digital artery and the venous drainage is by means of a dorsal vein. The mean flap size was 3.1×2.3 cm. The nerve gaps were bridged with the nerve graft attached with the flap. The average length of the nerve grafts was 3.0 cm. All flaps survived completely, and the defects were reconstructed successfully. Venous congestion was not observed in our series. At a mean follow-up period of 23 months, the average scores of static two-point discrimination (2PD) and Semmes-Weinstein monofilament on the finger pulp of the injured side were 7.5 mm and 3.93, respectively. The donor site morbidity was acceptable. According to the Michigan Hand Outcomes Questionnaire, four patients were strongly satisfied and five were satisfied with functional recovery of the injured finger. The bipedicled nerve flap is a safe and effective option for reconstruction of complex digital injury involving soft tissue and nerve defects. Our technique has been shown to provide sufficient sensory recovery. ClinicalTrials.gov ID: NCT01707654.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Identification of three movement phases of the hand during lateral and pulp pinches using video motion capture

BACKGROUND

Hand injuries affect a person's ability to engage successfully in activities of daily living (ADLs). Video motion capture (VMC) facilitates measurement of dynamic movement. No study to date has used VMC as a means of quantifying the simultaneous movement patterns of all joints of all digits of the hand during active purposeful movement.

METHOD

The purpose of this study was to analyze all joints of all five digits during active completion of the lateral and pulp pinches. VMC data were collected from four participants during completion of two pinches. Joint angles were plotted to facilitate identification of movement patterns.

RESULTS

Range of motion recorded in all joints with VMC, excluding flexion of the thumb carpometacarpal of both pinches, coincided with the normative goniometric data. Three phases were observed: initiation, preshaping, and pinch phases. Patterns of movement in all digits were identified for the two pinches.

CONCLUSION

VMC is a feasible and valid method for objectively quantifying dynamic movement of multiple joints simultaneously. The results provide new insight to the dynamics of hand movement as well as a basis for subsequent evaluations of movement patterns performed in ADLs and instrumental ADLs.

Reconstruction of proper digital nerve defects in the thumb using a pedicle nerve graft

BACKGROUND

Traumatic defects of the proper digital nerve in the thumb affect tactile perception of the thumb pulp. This article reports on the treatment of the defect using a pedicle nerve graft taken from the dorsal branch of the proper digital nerve of the index or long finger, or both.

METHODS

From May of 2006 to March of 2010, the pedicle nerve graft was used in 16 thumbs in 16 patients. There were 13 male and three female patients, with an average age of 33 years. Nerve repair was performed on one side in six thumbs and on both sides in 10 thumbs. The average length of the defects was 2.5 cm, between the middle of the distal phalanx and metacarpophalangeal joint. The average length of the nerve grafts was 2.7 cm. For comparison, we also collected a consecutive series of 27 patients with thumb proper digital nerve defects treated using a nonvascularized graft taken from the sural nerve (n = 15) or the medial antebrachial cutaneous nerve (n = 12).

RESULTS

At a mean follow-up of 22 months, the mean static two-point discrimination and Semmes-Weinstein monofilament scores on the thumb pulps were 6.7 mm and 3.62, respectively. The measurements of patients treated using nonvascularized nerve grafts were 9.4 mm and 3.90, respectively. The outcomes of the two groups were significantly different.

CONCLUSIONS

The pedicle nerve graft is useful and reliable for reconstructing proper digital nerve defects in the thumb. Superior sensory recovery was achieved using vascularized instead of unvascularized nerve grafts.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Finger sensory reconstruction with transfer of the proper digital nerve dorsal branch

PURPOSE

To report reconstruction of proper digital nerve (PDN) defects using a nerve transfer from the dorsal branch of the uninjured PDN and compare the results with those of nerve grafting.

METHODS

A retrospective study was conducted with 17 consecutive patients who had PDN defects treated with a nerve transfer from the dorsal branch of the PDN from May 2007 to July 2009. The patients included 14 male and 3 female patients, with an average age of 32 years. There were 21 PDN defects in 20 fingers. The injured fingers included 5 index, 8 long, 5 ring, and 2 little fingers. The average length of the nerve defects was 2.3 cm (range, 1.4-3.5 cm). The uninjured dorsal branch of the other PDN of the same digit or the dorsal branch of the PDN of the adjacent digit was selected as a donor nerve. Neurorrhaphy was performed between the dorsal branch and the distal end of the PDN. For comparison, we collected a series of 31 patients with PDN defects treated with conventional sural nerve grafting.

RESULTS

At a mean follow-up of 25 months (range, 20-26 mo), the mean static 2-point discrimination (2PD) and Semmes-Weinstein monofilament (SWM) scores on the finger pulp of the nerve transfer were 6.4 mm and 3.63, respectively. In the comparison group (mean follow-up, 23 mo; range, 19-27 mo), the mean static 2PD and SWM scores on the pulp were 9.2 mm and 4.10 mm. Significant differences were found in static 2PD and SWM results.

CONCLUSIONS

Nerve transfer with the digital nerve dorsal sensory branch was useful for reconstruction of the PDN defect located between the proximal interphalangeal joint and the common digital nerve bifurcation. Sensory recovery using local nerve transfer was superior to conventional sural nerve graft.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic III.

Reconstruction of thumb pulp defects using a modified kite flap

PURPOSE

We report on a modified kite flap for the reconstruction of thumb pulp defects. We performed nerve repair to improve thumb pulp sensation.

METHODS

From May 2005 to December 2008, 42 thumbs in 42 patients were treated. The average size of the thumb pulp defects was 2.1 × 2.6 cm (range, 1.6 × 1.8 cm to 2.8 × 3.1 cm). The mean flap size was 2.5 × 2.9 cm (range, 1.8 × 2.2 cm to 3.2 × 3.5 cm). The radial branch of the second dorsal digital nerve was coapted to one of the proper digital nerves of the thumb. The required average length of the nerve branch was 1.2 cm (range, 0.7 to 1.6 cm). At follow-up, flap sensation was assessed using a static 2-point discrimination (2PD) test. For comparison, we also included 32 patients without nerve repair from April 2003 to April 2005. Outcomes were rated using the modified American Society for Surgery of the Hand Guidelines for Stratification of 2PD.

RESULTS

In the study group, full flap survival was achieved in 40 thumbs, and partial distal flap necrosis was noted in 2 thumbs. At final follow-up (mean, 26 mo; range, 24 to 27 mo), we obtained a fair result, with a mean 2PD of 7.9 mm (range, 7 to 10 mm) on all flaps. In the comparison group without nerve repair, there were 26 fair and 6 poor results, with a mean 2PD of 12 mm (range, 8 to 18 mm) at final follow-up (mean, 24 mo; range, 22 to 26 mo). There was a highly significant difference between the 2 groups.

CONCLUSIONS

We suggest performing nerve repair to improve the sensation of the kite flap when reconstructing a thumb pulp defect.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Neuropathic pain in patients with upper-extremity nerve injury

PURPOSE

The purpose of this review was to present an analysis of the literature of the outcome studies reported in patients following traumatic upper-extremity (UE) nerve injuries (excluding amputation), to assess the presence of an association between neuropathic pain and outcome in patients following traumatic UE nerve injuries, and to provide recommendations for inclusion of more comprehensive outcome measures by clinicians who treat these patients.

SUMMARY OF KEY POINTS

A Medline and CINAHL literature search retrieved 48 articles. This review identified very few studies of patients with peripheral nerve injury that reported neuropathic pain. When pain was reported, visual analogue or numeric rating scales were most frequently used; standardized questionnaires measuring pain or psychosocial function were rarely administered. Recent evidence shows substantial long-term disability and pain in patients following peripheral nerve injury.

RECOMMENDATION

To better understand neuropathic pain in patients following peripheral nerve injury, future outcome studies should include valid, reliable measures of physical impairment, pain, disability, health-related quality of life, and psychosocial functioning.

Coverage of fingertip defect using a dorsal island pedicle flap including both dorsal digital nerves

PURPOSE

Fingertip or pulp resurfacing is a challenging reconstructive problem, as the treatment varies widely. In this study, we report the results of a dorsal island pedicle flap raised from an adjacent finger, including the bilateral dorsal digital nerves, for coverage of extensive soft tissue defect in the fingertip or pulp.

METHODS

The mean defect and the flap were 3.7 x 2.2 cm and 3.9 x 2.4 cm in size, respectively. In all cases, bilateral coaptation between the dorsal digital nerves and the proper digital nerves were performed. Patient follow-up lasted 25 to 34 months (mean, 27 months). The range of motion of the injured digits was measured. Sensibility of both radial and ulnar sides of the flap in the finger pulp was evaluated by the Semmes-Weinstein monofilament test and 2-point discrimination. Satisfaction with the appearance, pain, and cold intolerance were also assessed.

RESULTS

All flaps survived completely with maintenance of the normal-length digit. Full motion was maintained at the distal and proximal interphalangeal joints of both the injured and donor fingers. The mean values of Semmes-Weinstein sensitivity were 4.22 g and 4.31 g on the radial and ulnar sides of the flap in the pulp, respectively. The mean values of static 2-point discrimination were 4.4 mm and 4.5 mm on the radial and ulnar sides, respectively. All patients were satisfied with appearance of the fingertips.

CONCLUSIONS

The dorsal island pedicle flap from an adjacent finger can be used for coverage of extensive fingertip or pulp defects, with maintenance of a normal-length digit and restoration of sensation on both the radial and ulnar sides of the finger pulp. The sensation recovery of this series is superior to those dorsal island pedicle flaps previously described in the literature, which did not include incorporation of both dorsal digital nerves.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Clinimetric evaluation of measurement tools used in hand therapy to assess activity and participation

STUDY DESIGN

Systematic review.

INTRODUCTION

A number of measurement tools with strong clinimetric properties address activities and participation in hand-injured persons.

PURPOSE OF THE STUDY

To evaluate clinimetric quality of measurement tools assessing activities and participation in patients with hand injuries.

METHODS

The electronic databases Medline, Cochrane library, EMBASE, PEDro, Cumulative Index to Nursing and Allied Health Literature (ClNAHL), and Allied and Complementary Medicine Database (AMED) were searched for appropriate literature. Descriptive data of included tools were given, and their clinimetric quality was scored with specific criteria.

RESULTS

The literature search identified 696 publications, referring to 15 measurement tools that met the inclusion criteria. For most of the included tests, applicability was good, whereas information on clinimetric properties was often lacking, especially for the performance tests. Overall, the Disabilities of the Arm, Shoulder, and Hand (DASH) was the most extensively studied tool with positive ratings for all criteria, closely followed by the Michigan Hand Outcomes Questionnaire (MHQ). Of the performance tests, the Functional Dexterity Test (FDT) received the best ratings.

CONCLUSIONS

Optimal measurement tool selection depends highly on the purpose of measurement and the type of hand injury.

LEVEL OF EVIDENCE

2a-.