Kirscner wire fixation versus suture anchor technique for mallet finger: A meta-analysis

PURPOSE

Though the previous studies had described various surgical techniques for the treatment of mallet finger injuries, consensus on which technique was the most effective and appropriate surgical methods had not yet reached. This review aimed to systematically compare the effectiveness and safety of the treatment for mallet finger injuries via Kirschner wire fixation versus suture anchor technique to recommend an optimum option.

METHODS

All literatures published until December 31, 2019 compared Kirschner wire fixation versus suture anchor technique to treat mallet finger were acquired through a comprehensive search in multiple databases. A meta-analysis was performed by the Cochrane Collaboration's RevMan 5.3 software.

RESULTS

A total of 8 trials with 362 cases consisted of 4 randomized controlled trials and 4 prospective studies. The results suggested that the groups treated with kirschner wire fixation experienced more significant advantage in less complications than suture anchor groups (P  < .05). On the other hand, no significant differences were found in terms of the total active range motion of the distal interphalangeal joint, the average distal interphalangeal joint extensor lag, Visual Analogue Scale scores, recurrence, as well as functional assessment at the final follow-up (P > .05, respectively) between the two surgical procedures.

CONCLUSIONS

No obvious superiority were shown for the effectiveness between the two surgical interventions based on the above results. But in view of the less economic spending and complications, Kirschner wire fixation should be a better alternative relative to the suture anchor technique for inevitable surgical treatment of mallet finger lesions. However, a prudent attitude is still necessary to choose the two operative managements before a large sample and high-quality randomized controlled trials had been performed.

Assessment of Tree-Based Statistical Learning to Estimate Optimal Personalized Treatment Decision Rules for Traumatic Finger Amputations

IMPORTANCE

Optimal treatment for traumatic finger amputation is unknown to date.

OBJECTIVE

To use statistical learning methods to estimate evidence-based treatment assignment rules to enhance long-term functional and patient-reported outcomes in patients after traumatic amputation of fingers distal to the metacarpophalangeal joint.

DESIGN, SETTING, AND PARTICIPANTS

This decision analytical model used data from a retrospective cohort study of 338 consenting adult patients who underwent revision amputation or replantation at 19 centers in the United States and Asia from August 1, 2016, to April 12, 2018. Of those, data on 185 patients were included in the primary analysis.

EXPOSURES

Treatment with revision amputation or replantation.

MAIN OUTCOMES AND MEASURES

Outcome measures were hand strength, dexterity, hand-related quality of life, and pain. A tree-based statistical learning method was used to derive clinical decision rules for treatment of traumatic finger amputation.

RESULTS

Among 185 study participants (mean [SD] age, 45 [16] years; 156 [84%] male), the median number of fingers amputated per patient was 1 (range, 1-5); 115 amputations (62%) were distal to the proximal interphalangeal joint, and 110 (60%) affected the nondominant hand. On the basis of the tree-based statistical learning estimates, to maximize hand dexterity or to minimize patient-reported pain, replantation was found to be the best strategy. To maximize hand strength, revision amputation was the best strategy for patients with a single-finger amputation but replantation was preferred for all other injury patterns. To maximize patient-reported quality of life, revision amputation was the best approach for patients with dominant hand injuries, and replantation was the best strategy for patients with nondominant hand injuries.

CONCLUSIONS AND RELEVANCE

The findings suggest that the approach to treating traumatic finger amputations varies based on the patient's injury characteristics and functional needs.

A New Clinical Sign of Lumbrical Plus Finger

Paradoxical finger extension is the classical clinical presentation of the lumbrical plus syndrome. We report a new additional sign, increased metacarpophalangeal flexion of the involved finger when the patient tries to make a fist. Three cases of lumbrical tightness are discussed, illustrating this new sign in 3 different clinical settings. The new sign was present in all 3 cases. Lumbrical tenotomy corrected the paradoxical interphalangeal extension and partly the increased metacarpophalangeal flexion. The lumbrical tendon has a relatively high moment arm relative to the metacarpophalangeal joint, which could explain the basis of this clinical sign. This new physical examination sign may help in diagnosing the lumbrical plus syndrome, a subtle complication of flexor digitorum profundus lesions that is not easily diagnosed but which is easily addressed.

Hand Posturing Is a Nonverbal Indicator of Catastrophic Thinking for Finger, Hand, or Wrist Injury

BACKGROUND

Prior research documents that greater psychologic distress (anxiety/depression) and less effective coping strategies (catastrophic thinking, kinesophobia) are associated with greater pain intensity and greater limitations. Recognition and acknowledgment of verbal and nonverbal indicators of psychologic factors might raise opportunities for improved psychologic health. There is evidence that specific patient words and phrases indicate greater catastrophic thinking. This study tested proposed nonverbal indicators (such as flexion of the wrist during attempted finger flexion or extension of uninjured fingers as the stiff and painful finger is flexed) for their association with catastrophic thinking.

QUESTIONS/PURPOSES

(1) Do patients with specific protective hand postures during physical examination have greater pain interference (limitation of activity in response to nociception), limitations, symptoms of depression, catastrophic thinking (protectiveness, preparation for the worst), and kinesophobia (fear of movement)? (2) Do greater numbers of protective hand postures correlate with worse scores on these measures?

METHODS

Between October 2014 and September 2016, 156 adult patients with stiff or painful fingers within 2 months after sustaining a finger, hand, or wrist injury were invited to participate in this study. Six patients chose not to participate as a result of time constraints and one patient was excluded as a result of inconsistent scoring of a possible hand posture, leaving 149 patients for analysis. We asked all patients to complete a set of questionnaires and a sociodemographic survey. We used Patient Reported Outcomes Measurement Information System (PROMIS) Depression, Upper Extremity Physical Function, and Pain Interference computer adaptive test (CAT) questionnaires. We used the Abbreviated Pain Catastrophizing Scale (PCS-4) to measure catastrophic thinking in response to nociception. Finally, we used the Tampa Scale of Kinesophobia (TSK) to assess fear of movement. The occurrence of protective hand postures during the physical examination was noted by both the physician and researcher. For uncertainty or disagreement, a video of the physical examination was recorded and a group decision was made.

RESULTS

Patients with one or more protective hand postures did not score higher on the PROMIS Pain Interference CAT (hand posture: 59 [56-64]; no posture: 59 [54-63]; difference of medians: 0; p = 0.273), Physical Function CAT (32 ± 8 versus 34 ± 8; mean difference: 2 [confidence interval {CI}, -0.5 to 5]; p = 0.107), nor the Depression CAT (48 [41-55] versus 48 [42-53]; difference of medians: 0; p = 0.662). However, having at least one hand posture was associated with a higher degree of catastrophic thinking (PCS scores: 13 [6-26] versus 10 [3-16]; difference of medians: 3; p = 0.0104) and a higher level of kinesophobia (TSK: 40 ± 6 versus 38 ± 6; mean difference: -2 [CI, -4 to -1]; p = 0.0420). Greater catastrophic thinking was associated with a greater number of protective hand postures on average (rho: 0.20, p = 0.0138).

CONCLUSIONS

Protective hand postures and (based on prior research) specific words and phrases are associated with catastrophic thinking and kinesophobia, less effective coping strategies that hinder recovery. Surgeons can learn to recognize these signs and begin to treat catastrophic thinking and kinesophobia starting with compassion, empathy, and patience and be prepared to add formal support (such as cognitive-behavioral therapy) to help facilitate recovery.

LEVEL OF EVIDENCE

Level III, diagnostic study.

Post-Traumatic Raynaud's Phenomenon: A Case Report

BACKGROUND

Raynaud's phenomenon has multiple etiologies, ranging from occupational causes to systemic disease. Most occupational causes of Raynaud's phenomenon usually present with vascular compromise.

CASE REPORT

A 41-year-old Chinese woman presented to the emergency department with progressive pain and bluish discoloration over her right index finger after minor trauma. The clinical examination revealed discoloration over multiple fingertips on both hands. She was diagnosed with Raynaud's phenomenon with possible underlying systemic disease. Additional laboratory workup led to the diagnosis of systemic lupus erythematosus with complex regional pain syndrome. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: It is rare for the emergency physician to diagnose Raynaud's phenomenon in the setting of minor trauma. It is important to diagnose this condition because of its potential complications.

First Insights into Human Fingertip Regeneration by Echo-Doppler Imaging and Wound Microenvironment Assessment

Fingertip response to trauma represents a fascinating example of tissue regeneration. Regeneration derives from proliferative mesenchymal cells (blastema) that subsequently differentiate into soft and skeletal tissues. Clinically, conservative treatment of the amputated fingertip under occlusive dressing can shift the response to tissue loss from a wound repair process towards regeneration. When analyzing by Immunoassay the wound exudate from occlusive dressings, the concentrations of brain-derived neurotrophic factor (BDNF) and leukemia inhibitory factor (LIF) were higher in fingertip exudates than in burn wounds (used as controls for wound repair versus regeneration). Vascular endothelial growth factor A (VEGF-A) and platelet-derived growth factor (PDGF) were highly expressed in both samples in comparable levels. In our study, pro-inflammatory cytokines were relatively higher expressed in regenerative fingertips than in the burn wound exudates while chemokines were present in lower levels. Functional, vascular and mechanical properties of the regenerated fingertips were analyzed three months after trauma and the data were compared to the corresponding fingertip on the collateral uninjured side. While sensory recovery and morphology (pulp thickness and texture) were similar to uninjured sides, mechanical parameters (elasticity, vascularization) were increased in the regenerated fingertips. Further studies should be done to clarify the importance of inflammatory cells, immunity and growth factors in determining the outcome of the regenerative process and its influence on the clinical outcome.

Clinical outcomes of operative repair of complete rupture of the proximal interphalangeal joint collateral ligament: Comparison with non-operative treatment

Objectives

The purpose of this study was to compare the outcomes of non-operative treatment and operative repair of grade III injuries with complete rupture of the collateral ligament of the proximal interphalangeal (PIP) joint.

Patients and methods

Seventeen patients with grade III injuries with at least 6 months of follow-up were included. Seven patients underwent non-operative treatment and 10 patients underwent operative treatment. We evaluated the following clinical outcomes after treatment: 1) range of motion of the PIP and distal interphalangeal (DIP) joints, 2) joint stability, 3) pain score, and 4) amount of fusiform deformity of the PIP joint.

Results

There was no instability in the lateral stress test in either group. The ranges of motion of the PIP and DIP joints were not statistically different between the two groups at final follow-up. However, the ranges of motion recovered more quickly in the operative group than the non-operative group within the first 3 months after treatment. Patients in the operative group had less pain and better cosmetic appearance of the PIP joint.

Conclusion

Our results suggest that operative repair of the PIP collateral ligament can provide good joint stability, rapid functional recovery, and minimize fusiform deformity of the PIP joint.

Level of evidence

Level III, Therapeutic study.

The Need for Clinical Hand Education in Emergency Medicine Residency Programs

BACKGROUND

Complaints related to the hands, wrists, and fingers comprise approximately 3.7 million emergency department visits annually. The complexity of this subject can confound timely diagnosis and treatment, particularly if the treating physician has not received specialized training. We set out to determine whether emergency medicine training in the USA provides adequate preparation for dealing with the identification, management, and treatment of hand, wrist, and finger injuries.

METHODS

The curricula for 160 accredited U.S. emergency medicine programs were obtained. Each of these was examined to see whether a clinical "hand" rotation was included as a required module. Clinical hand rotations were then classified by length of rotation, the postgraduate years in which they were offered, and if they were offered as stand-alone modules or combined with other rotations.

RESULTS

Of the 160 programs, 21 (13.1%) require a clinical hand rotation. Sixteen offer a dedicated module, and five are part of another rotation. The mean amount of time dedicated to hand education was 3 weeks. The 16 dedicated hand rotations had a mean duration of 2.69 weeks; combined rotations were 4 weeks. Four incorporated hand education in the first postgraduate year (PGY-1), 13 into the second (PGY-2), and 3 into the third (PGY-3).

CONCLUSIONS

Despite the preponderance of hand injuries seen by emergency physicians, the clinical and legal pitfalls that accompany these conditions, and the benefits to be gained from specialized training, very few programs emphasize clinical hand training in an equivalent fashion.

Internal Fixation of Unstable Fracture Dislocations of the Proximal Interphalangeal Joint

We report a group of 14 patients with fracture dislocations of the proximal interphalangeal joint with fracture fragments of adequate size to allow reduction of the proximal interphalangeal joint and internal mini screw fixation of the bone fragment attached to the palmar plate to the base of the middle phalanx. Three years after surgery, (range 25–52 months) the average total active range of motion of the proximal interphalangeal joint was 100° (range 65–115°) for the acute group (operation within 14 days of injury, n = 7) and 86° (range 60–110°) for the chronic group (operation on average 46 days after injury, range 21–120 days, n = 7). Longer delay from injury was associated with a decreased total range of motion ( P = 0.028). Further subluxation occurred in three chronic group patients, one required further surgery. The key to successful treatment of this injury is the re-establishment of joint congruity and early mobilization. With appropriate patient selection, pain free, satisfactory range of motion can be achieved. There is a risk of persistent subluxation or dislocation, particularly if treatment is delayed.

Open Reduction and Screw Fixation of Mallet Fractures

Twelve patients with mallet fractures treated by open reduction and internal fixation with small screws were reviewed at an average of 31 months after surgery. The indication for surgery was a fracture involving more than one-third of the distal phalanx articular surface or with subluxation of the distal interphalangeal joint. Loss of reduction occurred in one patient and in another one screw loosened slightly without loss of reduction. There were no nail deformities, infections, or secondary procedures. The mean range of motion was from 6° (range, 0–30°) (extensor lag) to 70° (range, 60–90°) flexion. Ten patients had no evidence of degenerative changes, one had minor joint space narrowing and one had significant deformity. Open reduction and screw fixation with small screws can lead to satisfactory outcome in appropriate patients.

Delayed Single Kirschner Wire Compression Technique for Mallet Fracture

Twenty-four mallet fractures which involved at least one third % of the articular surface of the distal interphalangeal joint were treated by open reduction and internal fixation using a single double-ended Kirschner wire at a mean of 9 days after injury (range 4–15). At a mean follow-up of 43 (range 12–18) months the active range of motion, pain and the Warren and Norris criteria were evaluated. The mean active range of motion was from −2° extension (range 0–10°) to 72° flexion (range 50–90°). Nineteen patients were pain free and five suffered from mild pain during strenuous work. The Warren and Norris results were successful in 22 and improved in two cases. Radiographs showed, that all the fractures united in a near-anatomic position but with joint narrowing in six digits.

Closed Rupture of the Flexor Tendons of the Little Finger Secondary to Non-Union of Fractures of the Hook of the Hamate

We report six patients with closed flexor tendon rupture affecting the little finger, occurring secondarily to non-union of the hook of the hamate bone. The ununited fragments were separated from the basal part of the hook by more than 1 mm. The fragments were also rounded and showed marginal sclerosis. Non-union was located in the middle part of the hook in three patients, the tip in two, and the base in one. At operation, the fragments were removed in all patients. Five patients were treated by free tendon grafts using three palmaris and two plantaris grafts and one underwent tendon transfer. Postoperative total range of active motion of the little finger averaged 218° (range 185–265°). All patients returned to their original employment. This series would suggest that flexor tendon rupture can occur after fracture of the hook of the hamate bone, even when the ununited fragment is small and/or rounded.

Reconstruction of Fingertip Defects with the Neurovascular Tranquilli-Leali Flap

For many years, bipedicled palmar advancement flaps were used rarely in fingers because they sacrificed the dorsal branches of the digital arteries, risking dorsal skin necrosis. In 1995, a short bipedicled neurovascular VY advancement flap raised distally to the PIP flexion crease, which spared the dorsal blood supply, was described by Elliot et al. (1995) . This paper includes an anatomical study on 28 fresh cadaver fingers to evaluate the advancement potential of this flap. It also reviews 22 fingertip reconstructions in 22 patients using this flap. The mean advancement of the flap in the cadaver study was 14 (range 10–16) mm. This procedure gave good clinical results in respect of healing, sensibility, bone cover and appearance. Complications occurred in four fingers (18%), viz. two infections, one neuroma and one stiff proximal interphalangeal joint. Our study suggests that this flap can be used to treat fingertip defects of a size of approximately half of the pulp of the distal phalangeal segment of the finger.

Tension Band Wiring of Unstable Transverse Fractures of the Proximal and Middle Phalanges of the Hand

Twenty-three isolated, unstable and closed transverse middle and proximal phalangeal shaft fractures in 23 patients were treated by tension band wiring. The tension band was applied with two transverse Kirschner wires that did not cross the fracture line. All of the fractures united and achieved satisfactory functional outcomes. No patient required either physiotherapy or tenolysis or capsulotomy surgery.

Dorsal Fracture Dislocations of the Proximal Interphalangeal Joint Treated by Open Reduction and Interfragmentary Screw Fixation: Indications, Approaches and Results

Many operative and non-operative treatments of dorsal fracture dislocations of the proximal interphalageal (PIP) joint have been described. Return of good joint function requires anatomical reduction of the articular fragments and restoration of joint congruity and a stable functional arc of motion, with the fixation construct stable enough for early mobilization. To prevent recurrent dorsal subluxation, the attachments of the ligamentous palmar restraints and the bony buttress provided by the palmar lip of the middle phalanx base must be restored. Open reduction and internal interfragmentary screw fixation using 1.5 or 1.3 mm screws was employed in 12 fingers in 10 patients with unstable dorsal fracture dislocations of the PIP joints of Schenck grades III and IV. At an average follow-up of 8.7 months, all patients in this series achieved good to excellent results and an average total active interphalangeal motion of 132° (range 105°–165°). Additional benefits over non-operative techniques included improved patient comfort and simplified nursing care and therapy supervision.

The Effectiveness of Using a Lipido-Colloid Dressing for Patients With Traumatic Digital Wounds

This study compares the effect of a daily gauze dressing with that of a lipidocolloid dressing on the time taken to make up the dressing and efficacy of the management of traumatic digitalwounds. This is a randomized controlled trial of 28 patients (16 experimental and 12 control) with injuries to their fingers and loss of tissue. The patients in the experimental and control groups were given a lipido-colloid dressing and a daily gauze dressing, respectively. The patients'wounds were assessed in terms of the size of thewound and the time it took for thewound to heal. The findings showed that patients in the experimental group had a faster recovery time from the healing of their wound than the control group ( p= .024). The findings can help to establish an evidence-based practice in the management of traumatic digital wounds in clinical settings.

Inter- and intra-tester reliability of sensibility testing in digital nerve repair

The aim of this study was to investigate the inter- and intra-tester reliability of the static two-point discrimination and Semmes-Weinstein monofilament tests in digital nerve repair. A total of 100 digital nerves from 67 patients were included into the study. An experienced orthopaedic surgeon and a physiotherapist examined the sensory nerve recovery. The reproducibility score of both tests was at a poor level, but the reliability of the Semmes-Weinstein monofilament test was higher than the static two-point discrimination test. These tests should not be used alone in the quantitative monitoring of sensory recovery, but should be interpreted with the clinical findings.Level 3 non-randomized controlled study.

[CLIMBING HIGHER--COMMON INJURIES IN ROCK CLIMBERS]

Rock climbing is becoming an increasingly popular sport in Israel with more and more climbing walls being built in the cities and new routes being traced on cliffs around the country. Our account describes the case of a 15 years old climber with chronic pain (without trauma) in the 3rd finger of the right hand. A stress fracture, involving the proximal interphalangeal joint (SH3) of the middle phalanx, was diagnosed. The fracture healed following two months of rest with gradual return to activity. As this sport becomes more common, there is an increasing need for knowledge about the characteristic injuries, their diagnosis and treatment. Although considered an extreme sport, most of the injuries are overuse injuries, mainly to the upper limbs. Finger flexor tendon pulley rupture being one of the most common. Diagnosis is based on history, physical examination and ultrasonography. Conservative treatment is successful for most injuries, while more complicated cases require surgical intervention.

[Recovery after deep defects of the fingers covering tissues in daily surgical hospital]

The article describes the experience of reconstructive and restorative operative treatment of patients with, defects of the skin of the fingers at the daily surgical hospital. It is shown that surgeons applying standard instruments and having additional training in hand surgery, using a technique non -free skin plastic flap on a temporary pedicle and using inpatient technology, get cosmetic and functional results compared to-those of treatment in hospitals. Cited in -the article data on the direct and separate treatment outcomes, quility of life of patients, the estimated non-specfic and organ-specific method, clearly show that non-free skin plastic flap on a temporary pedicle - a reliable and effective method of restoration of the skin fingers defects which can be accompanied wit the use of resource-saving technologies in health care.

Closed Rupture of the Flexor Profundus Tendon of Ring Finger: Case Report and Treatment Recommendations

Zone III midsubstance flexor tendon rupture without underlying pathology is rare. The most common mechanism of injury for a spontaneous rupture is forced extension of an actively flexed distal interphalangeal joint. We describe a patient who experienced closed midsubstance zone III rupture of the flexor digitorum profundus (FDP) tendon of the ring finger at the lumbrical origin in the palm while lifting a heavy object. On exploration, there was no evidence of underlying tendon pathology, and primary end-to-end repair of the FDP was possible. This case highlights the importance of correct preoperative clinical localization of the rupture level, as well as a suggested surgical plan in equivocal cases.

Treatment of mallet fracture using a percutaneous fixation technique with an 18-gauge needle

The purpose of this paper is to introduce a simple and intuitive treatment method using an 18-gauge needle for mallet fractures that involve more than one-third of the articular surface. We performed a retrospective review of 17 patients who underwent closed reduction using an 18-gauge needle with transfixation of Kirschner wire between March 2007 and October 2013. According to the Wehbe and Schneider classification, 15 cases were type IB, 1 was type IIB, and 1 was type IIC. The mean size of bony fragments at the time of injury was 53 percent of the articular surface of the distal phalanx. According to Crawford's criteria, 6 of 17 patients had an excellent result, 9 had a good result and 2 had fair results. Our method of percutaneous reduction using an 18-gauge needle with transfixation of Kirschner wire is minimally invasive and is useful for the fixation of mallet fractures.

Digit Replantation The First 50 Years

Since the first successful digit replantation by Japanese surgeons Komatsu and Tamai, the past half century has seen the field of digit replantation in the USA experience exponential growth followed by a steady decline in volume of cases and percentage of successful viable digits. The initial enthusiasm and technical progress of digital replantation has been tempered by mediocre functional outcomes, rising healthcare costs, and limited healthcare resources. The history and approach to digit replantation is reviewed and highlights the likely push toward the development of regional replant centers staffed by highly skilled teams to improve the functional outcomes following these complex procedures. More than 50 years have passed since the first successful digit replantation by Komatsu and Tamai who replanted a sharply amputated thumb in a 28-year-old male at the metacarpal-phalangeal joint level in a 4.5 hour procedure. Two arteries and 2 veins were anastomosed using 8-0 monofilament nylon and 7-0 braided silk suture. The patient remained in the hospital for 40 days and did not return to work for 4 months. News of this triumph of microvascular skill was heralded throughout the world as the first successful replantation of a completely amputated digit. Over the past half century, the field of digit replantation in the USA experienced exponential growth followed by a steady decline in volume of cases and percentage of successful viable digits. The initial enthusiasm and technical progress of digital replantation has been tempered by mediocre functional outcomes, rising healthcare costs, and limited healthcare resources. In the next 50 years, it is possible that the majority of digit replantation procedures in the USA may be performed in tertiary centers or regional replant centers by highly skilled teams.

Flexor digitorum superficialis repair outside the A2 pulley after zone II laceration: gliding and bowstringing

PURPOSE

To evaluate the changes in maximum flexion angle, gliding coefficient, and bowstringing after a combined repair of both flexor tendons with the flexor digitorum superficialis (FDS) rerouted outside the A2 pulley in cadaveric hands.

METHODS

We performed 4 different repairs on cadaveric hands, with each repair tested on 9 unique digits. In total, 12 cadaveric hands and 36 digits were used. The thumb and little finger were removed from each hand and excluded from testing. Group 1 was sham surgery. Group 2 combined flexor digitorum profundus (FDP) and FDS laceration and repair with both slips of the FDS repaired inside the A2 pulley. Group 3 was FDP repair with one slip of the FDS repaired inside A2 and the other slip left unrepaired. Group 4 was FDP repair with both slips of the FDS rerouted and repaired outside the A2 pulley. Maximum flexion angle, gliding coefficient, and bowstringing were measured in simulated active digital motion for each group.

RESULTS

Rerouting and repairing the FDS outside the A2 pulley (group 4) significantly lowered gliding coefficient compared with repairs with both slips inside A2, with values similar to sham surgery. We observed no significant differences in maximum flexion angle among the 4 groups. Increased bowstringing was observed with both slips of the FDS repaired and rerouted outside the A2 pulley.

CONCLUSIONS

In this cadaveric model, repair of both slips of the FDS outside the A2 pulley improved the gliding coefficient relative to repair within the A2 pulley, which suggests decreased resistance to finger flexion. Repair of the FDS outside the A2 pulley led to a slight increase in bowstringing of the FDS tendon.

CLINICAL RELEVANCE

We describe a technique for managing combined laceration of the FDP and FDS tendons that improves gliding function and merits consideration.

Homodigital artery flap reconstruction for fingertip amputation: a comparative study of the oblique triangular neurovascular advancement flap and the reverse digital artery island flap

This fingertip reconstruction study retrospectively compared sensory recovery and active range of motion outcomes in neurovascular island advancement and reverse digital artery island flaps. Seventeen oblique triangular flaps and 14 reverse digital artery island flaps were performed for nail bed level fingertip amputations (Ishikawa subzone II). There was no significant difference between the two procedures in the Semmes-Weinstein monofilament test and range of motion results. For static and moving two-point discrimination tests, however, those with a reverse digital artery island flap required a longer period for sensory recovery compared to those with an oblique triangular advancement flap. This trend equilibrated at 12 months after surgery showing no significant difference in both static and moving two-point discrimination tests between the procedures.

[Diagnosis and management of metacarpophalangeal joint locking with extension lag]

OBJECTIVE

To investigate the clinical characteristics, diagnosis, and treatment of metacarpophalangeal (MCP) joint locking with extension lag.

METHODS

Between February 2009 and April 2014, 17 patients (17 fingers) with MCP joint locking with extension lag were treated. The patients included 4 males and 13 females, and the average age was 40.7 years (range, 20-72 years). The index finger was locked in 12 cases and the middle finger in 5 cases. All patients could not fully extend the MCP joint at about 30° flexion without flexion limitation of the interphalangeal joint. The range of motion (ROM) of the MCP joint was (41.2 ± 5.1)°. The visual analogue scale (VAS) score was 2.7 ± 0.5. X-ray and CT scanning showed that there was a bony prominence on radial condyle of the metacarpal head in 15 primary patients, and a hook like osteophyte on ulnar condyle in 2 degenerative patients. All patients were treated with close reduction first, and open reduction was conducted when the manipulation failed.

RESULTS

Successful close reduction was achieved in 5 cases, and successful open reduction in 8 cases; 4 cases gave up treatment after failure for close reduction. All patients who achieved successful reduction were followed up 2.3 years on average (range, 6 months to 5 years and 2 months). The ROM of the MCP joint was increased to (80.4 ± 6.6)° at last follow-up, showing significant difference when compared with ROM before reduction (t = -19.46, P = 0.00). The VAS score decreased to 0.2 ± 0.4 at last follow-up, also showing significant difference when compared with score before reduction (t = 13.44, P = 0.00).

CONCLUSION

Accessory collateral ligament caught at the bony prominence on the radial condyle of the metacarpal head is the most common cause of the MCP joint locking with extension lag. Close reduction is feasible, but recurrence of locking is possible. Surgical treatment is advised in the event of manipulation failure or recurrent locking.

PXL01 in sodium hyaluronate for improvement of hand recovery after flexor tendon repair surgery: randomized controlled trial

Background

Postoperative adhesions constitute a substantial clinical problem in hand surgery. Fexor tendon injury and repair result in adhesion formation around the tendon, which restricts the gliding function of the tendon, leading to decreased digit mobility and impaired hand recovery. This study evaluated the efficacy and safety of the peptide PXL01 in preventing adhesions, and correspondingly improving hand function, in flexor tendon repair surgery.

Methods

This prospective, randomised, double-blind trial included 138 patients admitted for flexor tendon repair surgery. PXL01 in carrier sodium hyaluronate or placebo was administered around the repaired tendon. Efficacy was assessed by total active motion of the injured finger, tip-to-crease distance, sensory function, tenolysis rate and grip strength, and safety parameters were followed, for 12 months post-surgery.

Results

The most pronounced difference between the treatment groups was observed at 6 months post-surgery. At this timepoint, the total active motion of the distal finger joint was improved in the PXL01 group (60 vs. 41 degrees for PXL01 vs. placebo group, p = 0.016 in PPAS). The proportion of patients with excellent/good digit mobility was higher in the PXL01 group (61% vs. 38%, p = 0.0499 in PPAS). Consistently, the PXL01 group presented improved tip-to-crease distance (5.0 vs. 15.5 mm for PXL01 vs. placebo group, p = 0.048 in PPAS). Sensory evaluation showed that more patients in the PXL01 group felt the thinnest monofilaments (FAS: 74% vs. 35%, p = 0.021; PPAS: 76% vs. 35%, p = 0.016). At 12 months post-surgery, more patients in the placebo group were considered to benefit from tenolysis (30% vs. 12%, p = 0.086 in PPAS). The treatment was safe, well tolerated, and did not increase the rate of tendon rupture.

Conclusions

Treatment with PXL01 in sodium hyaluronate improves hand recovery after flexor tendon repair surgery. Further clinical trials are warranted to determine the most efficient dose and health economic benefits.

Trial Registration

ClinicalTrials.gov NCT01022242; EU Clinical Trials 2009-012703-25.

Outcomes of free adipofascial flaps combined with tenolysis in scarred beds

PURPOSE

To review our outcomes of transferring vascularized free adipofascial flaps used to change the local tissue conditions at the time of tenolysis in adhesion-prone beds.

METHODS

Eleven free adipofascial flaps were transplanted in 10 patients after tenolysis on the forearm (3 cases), the dorsum of the hand (5 cases), or the dorsum of the proximal phalanx (3 cases). All recipient areas had badly scarred beds, 7 of which had previously failed tenolyses. In addition to tenolysis (10) or the insertion of bridging tendon grafts (1), arthrolysis of several involved joints and bone fixation for nonunion (3 cases) were carried out simultaneously. The adipofascial flap was then wrapped around the tendons or interposed between the scarred tissue and the freed tendons. In 8 cases, the flap was the lateral arm adipofascial flap, whereas adipose flaps from the toes were used for the fingers.

RESULTS

All flaps survived without vascular crisis. In all cases, total active motion was similar to the passive motion obtained at surgery. Average Disabilities of the Arm, Shoulder, and Hand score improved from 69 to 10, and average Patient-Rated Wrist Hand Evaluation score improved from 65 to 9. Secondary surgery was needed to reduce the bulk of the flap in 3 patients. One patient required an additional procedure to obtain an optimum result.

CONCLUSIONS

Free adipofascial flaps provided satisfying results in this group of patients. The flaps should be considered when the bed is scarred or after a failed tenolysis.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

One digit interruption: the altered force patterns during functionally cylindrical grasping tasks in patients with trigger digits

Most trigger digit (TD) patients complain that they have problems using their hand in daily or occupational tasks due to single or multiple digits being affected. Unfortunately, clinicians do not know much about how this disease affects the subtle force coordination among digits during manipulation. Thus, this study examined the differences in force patterns during cylindrical grasp between TD and healthy subjects. Forty-two TD patients with single digit involvement were included and sorted into four groups based on the involved digits, including thumb, index, middle and ring fingers. Twelve healthy subjects volunteered as healthy controls. Two testing tasks, holding and drinking, were performed by natural grasping with minimal forces. The relations between the force of the thumb and each finger were examined by Pearson correlation coefficients. The force amount and contribution of each digit were compared between healthy controls and each TD group by the independent t test. The results showed all TD groups demonstrated altered correlation patterns of the thumb relative to each finger. Larger forces and higher contributions of the index finger were found during holding by patients with index finger involved, and also during drinking by patients with affected thumb and with affected middle finger. Although no triggering symptom occurred during grasping, the patients showed altered force patterns which may be related to the role of the affected digit in natural grasping function. In conclusion, even if only one digit was affected, the subtle force coordination of all the digits was altered during simple tasks among the TD patients. This study provides the information for the future studies to further comprehend the possible injuries secondary to the altered finger coordination and also to adopt suitable treatment strategies.

Type IIb bony mallet finger: is anatomical reduction of the fracture necessary?

One-third of all mallet fingers are associated with a fracture. Many different management strategies have been described. Some authors recommend nonsurgical management for all mallet fractures. In contrast, others suggest mandatory open reduction and internal fixation for bony mallet injuries with a large displaced dorsal fragment and associated distal interphalangeal (DIP) joint subluxation. We retrospectively studied 3 cases of a mallet fracture with a large displaced dorsal fragment and subsequent DIP joint subluxation managed with closed reduction using only percutaneous pinning of the DIP joint. All 3 patients had satisfactory pain-free and functional clinical outcomes at their particular follow-up (4, 6, or 19 months). Closed reduction and internal fixation of the subluxated joint using only Kirschner wires produced satisfactory outcomes for the 3 type IIb bony mallet fingers. Anatomical reduction of the fracture may be unnecessary in patients such as those in our case series. One aim of this pilot study is to justify larger, prospective studies.

Alternate technique in managing adhesions after zone 3 extensor tendon repair: a case report

Extensor tendon injuries are given less importance than the flexor tendon injuries; however, the extensor mechanism is more complicated than flexor tendon system, and regaining satisfactory function is a challenge. It has been reported that loss of digital flexion would affect grasp and power grip imposing greater functional loss than digital extensor lag. Zone 3 extensor tendon management is complex because of excessive scar formation limiting composite digital flexion and extension. The adhesions are more common if the tendon is immobilized for long period. The purpose of this care report is to describe the alternate technique in managing adhesion after prolong immobilization in zone 3 extensor tendon injuries.

[Results of surgical treatment of post-traumatic deformation of three-phalangeal fingers]

Results of surgical treatment of 168 patients with consequences o injury of long fingers were analyzed. After a trauma and emergency surgery in 139 patients had deformation of 200 fingers. Flexion contracture in proximal interphalangeal joint, bone deformation of phalanxes, and also insufficiency of a tendon sutures that resulted need of carrying out corrective operations on 126 (63%) fingers. Results of corrective surgery are estimated as unsatisfactory. Violation in them an arterial blood-supply the retrospective analysis of clinical records, and also clinical inspection of 138 fingers that we consider as the main reason of negative results.

A new surgical treatment for mallet finger deformity: deepithelialised pedicled skin flap technique

INTRODUCTION

Mallet finger, well-known also as drop finger or baseball finger, is a frequent deformity after extensor tendons injury in the fingers. Although numerous nonoperative or operative techniques have been used in managing this deformity, the treatment still remains a debated subject.

PATIENTS AND METHODS

Starting from 1996, 121 fingers in 118 patients with neglected deformity or unsuccessful splinting older than 10 days underwent surgical treatment. In 101 patients a tendinous mallet finger was present, and in 20 patients a bony mallet finger. After immobilising the distal interphalangeal (DIP) joint at 0° extension with a Kirschner wire, the extensor tendon was repaired by using a dorsal deepithelialised skin flap reinserted transosseous. The DIP joint was immobilised for 6 weeks in a thermoplastic splint, and after that it was gradually weaned from the immobilisation. An overnight splint was used for 4-6 weeks after starting the mobilisation.

RESULTS

The mean follow-up period was 10 months (range: 3-120 months). An excellent result in 89 fingers and a good result in 32 fingers were obtained, according to Crawford's evaluation criteria.

CONCLUSION

This method seems to be a new reliable alternative in the treatment of chronic mallet finger.

Primary repair of zone I flexor tendon injuries

Eighty-two patients who were treated by suture repair for zone I flexor tendon injuries over a ten-year period were identified, to determine the incidence of post-operative surgical complications and subsequent re-operations. Eighty-five percent of patients completed 12 weeks follow-up post-surgery. Of these patients almost all had good to excellent outcome in terms of total active movement (TAM). However when assessing the range of motion at the distal interphalangeal joint (DIPJ), only 23% could be classified as having good or excellent results at final follow-up. A total of six patients (7.32%) required surgery for tendon repair complications. This study illustrates that DIPJ ROM is more indicative of functional recovery after tendon repair in flexor zone I. Given the DIPJ is important in providing a fine pinch and a span pinch grip movements, patients should be counselled for inability to perform these functions post-tendon repair.

Salvage of complete degloved digits with reversed vascularized pedicled forearm flap: a new technique

Complete ring avulsion injury necessitates a difficult choice between microvascular repair and revision amputation. Microvascular repair is technically difficult and amputation may leave an unsatisfactory result. We describe an alternative method whereby a reverse radial forearm flap is wrapped around the complete degloved digit. This provides good quality cover to the whole volar, dorsum, and both sides of the finger. We performed 26 pedicle radial forearm flaps for 26 patients in the Hand and Reconstructive Microsurgery Unit, Sohag University Hospital, from 2001 to 2009. Indications included soft tissue coverage of the thumb (n = 8), ring finger (n = 11), index finger (n = 4), middle finger (n = 2), and little finger (n = 1). Finger salvage was successful in 96% of patients. There was complete loss of 1 flap and partial flap loss of a second. Finger range of motion was excellent in 18 fingers, good in 7, and fair in 1. Two donor sites were closed primarily; the rest were closed with split-thickness skin grafts. There were no reports of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution.

The effect of conservative management in extensor plus finger after partial amputation to the ulnar digits--a case report

The extensor plus finger after partial amputation of ulnar digits can affect the functions of the hand. The therapist intricate knowledge of intrinsic and extrinsic mechanism of fingers and creative approach in therapy would solve the puzzle when managing complex problem (extensor plus finger). Here we study a case of extensor plus finger after partial amputation of ulnar digits, its mechanism, and our experience with conservative management in managing extensor plus finger.

Paradoxical extension phenomenon of the little finger due to repetitive trauma to the palm

We report a case of paradoxical extension phenomenon of the little finger, so called "lumbrical plus deformity" due to repetitive trauma to the ulnar side of the palm. The adhesion between the flexor digitorum profundus tendon and the lumbrical muscle was the cause of this phenomenon. The lumbrical muscle release was sufficient to solve this rare problem.

Middle phalangeal distal condylar fracture remodelling in children: a case report

We report on a 9-year-old girl who sustained an injury to her left middle finger with a piece of metal 2 months before she presented to our clinic. In the acute trauma phase she applied ice to her hand and did not consult a medical practitioner about the pain and swelling on her finger. Two months after the injury she came to us with a palpable mass on the volar side of middle phalanx. On lateral radiographic view, an apex volar angulation measuring approximately 45 degrees of vertically splitting midphalangeal fracture was noted. Bone remodelling was also seen dorsally extending from the midphalanx to the level of the DIP joint. During the operation the remodelled bone seemed to be in unity with the DIP joint. The apex volarly angulated distal fragment of the middle phalanx was osteotomized. In the postoperative 24 months a control radiologic view was obtained. Normal phalangeal alignment was noted.

[Fingertip injuries]

Hands are used to interpret and shape the environment. The highly specialized structures of the fingertip enable tasks requiring precision, strength and endurance. Therefore injuries on fingertips have an effect to the entire hand. Thorough study of medical history and clinical examination are required to determine the correct treatment. The goal is to restore the function of the fingertip as well as possible. A good fingertip is pain free, has adequate sensation and is stable. As well as being aesthetically important, the nail adds to the stability and precision of the distal fingertip. Therefore, the structures of the nail should be repaired when possible. Different treatment options of the fingertip injuries range from conservative to operative, including flaps from adjacent areas. In selected cases, reattachment of an amputated fingertip yields best results.

COMPARISON OF METHODS OF SKELETAL FIXATION FOR SEVERELY INJURED DIGITS

Our objective is to compare the results of three different methods of osteosynthesis used in severely injured digits, namely the K-wire group, the K-wire & Wire-loop group and the Plate & Screws group. The results of 38 patients with 50 severely injured fingers managed between 1994 and 2000 were reviewed. Majority of them had serious injury caused by electric-saw and Zone III was the most common level of injury using Biemer's classification. Using the scoring system of Nakamura and Tamai, excellent and good results were obtained in 59.5% of the patients. The rate of bony complications was different among the three methods of osteosynthesis though the final functional outcomes were comparable. The rate of bony complications in this series was 20.4%, which included non-union (7), migration of K-wires (2) and infection (1). All occurred in K-wire and K-wire & Wire-loop groups. Plate & Screws, therefore, is the preferred method of bony fixation if further operation for non-union is to be avoided. This is more so for the proximal injuries.

Vertical locking of the metacarpophalangeal joint in young adults

Locking of the metacarpophalangeal joints has been occasionally reported in older adults, but reports of this problem are rare in younger individuals. We report 8 young adult patients with a metacarpophalangeal joint locked in 90° flexion after minor trauma. The cases included 6 little fingers and 2 thumbs in 1 male and 7 female patients aged 16 to 39 years. All were easily reduced closed. We postulate the mechanism of injury.

Systematic review of flexor tendon rehabilitation protocols in zone II of the hand

BACKGROUND

Restoration of function following flexor tendon repair in zone II represents a difficult clinical problem. Despite many publications on rehabilitation methods, there exists no consensus as to which method is superior. This study was undertaken to determine which flexor tendon rehabilitation protocol provides the best outcome after surgical repair in zone II.

METHODS

Electronic databases were searched for articles published between 1970 and 2009. The population included patients aged 5 years and older who sustained a flexor tendon laceration in zone II. The primary outcome was rupture rate. Secondary outcomes were range of motion and quality of life. The following protocols and their variations were considered: passive flexion and active extension protocols (Kleinert type protocols), controlled passive motion protocols (Duran type protocols), combination of the Kleinert and Duran protocols, and early active motion protocols.

RESULTS

Seventy-nine articles were identified. Fifteen studies met the inclusion criteria. The mean rate of rupture was lowest in the combined Kleinert and Duran protocols (2.3 percent) and highest in the Kleinert protocols (7.1 percent). No statistically significant differences were found. The combined Kleinert and Duran protocols and the early active motion protocols exhibited the highest proportion of digits with excellent or good results using the Strickland and Buck-Gramcko systems. One study included a quality-of-life assessment-meaningful comparison was not possible.

CONCLUSIONS

Both early active motion protocols and combined Kleinert and Duran protocols result in low rates of tendon rupture and acceptable range of motion following flexor tendon repair in zone II. Future studies should include quality-of-life measurements using validated scales.

[Functional and morphologic changes in the tendons and multimicrovacuolar collagen absorbing system of the three-phalanx fingers in disorder of arterial inflow]

Taking into account the fact, that unsatisfactory results of treatment of the thumbs traumatic damage are significantly caused by presence of anatomic disruption of the thumbs palm's own arteries with chronic tissue ischemia occurrence. One of consequences of damage of the three-phalanx thumbs interphalanx joints and the thumbs palm's own arteries is a formation of quickly progressing secondary flexing contracture of proximal interphalanx joints (PIPHJ). In the investigations accomplished there was established, that the changed tissues of the flexors tendons and their sheaths, forming cicatricial blockade distally to the primary trauma site, are taking part in a PIPHJ contracture development while arterial perfusion presence.The tissues damage severity, as well as a severity of clinical features of the tendons and their sheaths damage, depends on a degree of an arterial perfusion disorder present,

Closed traumatic rupture of both extensor tendons of the index finger in zone VI: a case report

The patient with closed traumatic rupture of both extensor tendons of the index finger in zone VI was described.

Post-traumatic combined flexion of the thumb, index and middle finger after intrinsic muscles reconstruction of the hand: a case report

We report a case in which simultaneous flexion of the thumb, index and middle finger occurred 6 months after the surgical reconstruction of the adductor (AM) and first dorsal interosseous (IO) muscles. An anomalous connection in the form of tendon slip associated to fibrous adhesions between the flexor pollicis longus (FPL) tendon, flexor digitorum profundus indicis (FDPI) and middle finger (FDPM) tendons were found. Either ultrasound (US) examination or magnetic resonance imaging (MRI) were unable to detect the site of adhesion. Excision of the slip and radical tenosynoviectomy led to early functional recovery.

Closed rupture of both flexor digitorum profundus and superficialis tendons of the small finger in zone II: case report

We report a rare case of closed rupture of both flexor digitorum profundus (FDP) and flexor digitorum superficialis tendons in zone II in the small finger. We performed delayed, primary end-to-end suture of the FDP and excision of the flexor digitorum superficialis, because myostatic contracture of the FDP tendon was not severe and the FDP tendon remnants were not frayed.

[Peculiarities of using some methods to assess hand and finger functions in clinical practice]

DASH questionnaire constitutes one of universal instrument, which are applied for estimation of the upper extremity function. Its disadvantages are massiveness, subjectivity, necessity of translation on Ukrainian language and adaptation to local conditions, what constitute a hard task. Comparative estimation of DASH questionnaires, short--DASH, Purdue pegboard test, Jebson-Taylor and Hand Tool Dexterity Test application was conducted. The analysis of correlation of the application results suggestion performed, concerning the methods of examination of the lower extremity and the hand function, trusts the possibility of wide application of Purdue pegboard test and Hand Tool Dexterity Test especially. Today the Erchard questionnaire, which is simple and need not to be translated, may serve as an alternative to DASH questionnaire.