HAND

Orthopaedic surgeons are often asked to evaluate X-rays of patients admitted to the Accident and Emergency Department with the suspicion of a wrist fracture or, in the case of an evident fracture, to decide the correct treatment. The aim of this study was to evaluate the feasibility of a correct interpretation of the images of injured wrists on the screen of a last generation mobile phone, in order to evaluate if the specialist could make the right diagnosis and choose the correct treatment. Five orthopaedic and one hand surgeons have evaluate the X-rays of 67 patients who sustained an injury to their wrist. In the case of fracture, they were asked to classify it according to the AO and Mayo classification systems. The evaluation of the images was accomplished through the PACS and using a mobile phone, at a different time. In order to check the inter- and intra-observer reliability, the same pattern was followed after a few months. The mobile phone showed basically the same agreement between the observers highlighting the worsening of the inter- and intra-observer reliability with the increment of the variables considered by a classification system. The present paper confirms that a last generation mobile phone can already be used in the clinical practise of orthopaedic surgeons on call who could use it as a useful device in remote or poorly served areas for a rapid and economic consultation The level of evidence of this case is economic and decision analysis, level 2

Tumoral calcinosis is an uncommon lesion, composed of ectopic calcified tissue, most commonly seen in the large joints of the hips, shoulders, and elbows, but may involve the hand and wrist. Patients will often present with localized swelling and reduced mobility around the involved joints. Pain is inconsistent when presenting in the hands or wrists, but the lesions may interfere with daily activities. Multiple variations of the process have been described, ranging from those with no definable etiology (primary), to those associated with disorders (secondary) such as renal insufficiency, hyperparathyroidism, or hypervitaminosis D. The original description of tumoral calcinosis, however, is the familial or hereditary type. Treatment of this process involves optimizing the underlying physiology and complete surgical excision for symptomatic cases.

Long-term vibrations are known to cause neurovascular diseases, which are common in workers who operate handheld power tools or motor vehicles. Understanding the neuropathology of vibration-induced nerve injury is critical to its prevention and treatment. This study aims to evaluate whether light microscopy of longitudinal nerve sections can be used as a simple yet effective method for quantifying nerve injury. The rats were split into two groups that were subjected to vibration (4 h/day) for 7 or 14 days. They were then allowed to rest for varying periods of time. Longitudinal sections of the tail nerves were examined under light microscopy. Injuries to the nerves were classified into three types, counted, tallied, and then divided by the length of the nerve being studied. Both 7 and 14 days of vibration showed significant damage when no recovery time was given. After 1 month of rest, the 7-day group began to show signs of recovery, but the 14-day group did not. After 2 months of rest, the 7-day vibration group showed almost complete recovery, while the 14-day vibration group still showed significant damage when compared to the sham control groups. The amount of damage to the myelin sheath directly correlated with vibration duration. When vibrated for longer than 7 days, nerve recovery was limited. This study also demonstrated that light microscopy of longitudinal slices is a simple yet effective method of quantifying the nerve damage.

This study investigated whether body mass index (BMI) was associated with effectiveness of carpal tunnel release as measured by physical and self-assessment tests. This prospective, longitudinal study was conducted from March 2001 to March 2003 using 598 cases (hands) diagnosed with carpal tunnel syndrome and scheduled for surgery at The Curtis National Hand Center, Baltimore, Maryland, and at the Pulvertaft Hand Centre, Derby, England. Body mass index was calculated, and demographic, clinical, and functional data were collected preoperatively and at 6-month follow-up. Grip, pinch, and Semmes–Weinstein scores were measured preoperatively and at 6-month follow-up. Levine–Katz self-assessment scores for symptom severity and functional status were measured preoperatively and at 6-month follow-up. Grip and pinch increased, whereas Semmes–Weinstein, symptom severity, and functional scores decreased by 6-month follow-up. Cases with BMI >35 had lower grip strength and higher symptom severity in males and higher functional status in both sexes pre- and postoperatively compared to normal-weight BMI cases. BMI had no relationship to patient satisfaction. Although morbidly obese cases did worse on some physical and self-assessment tests compared to normal BMI cases preoperatively, all improved to the same extent postoperatively regardless of BMI.

One of the unfortunate sequelae in obstetric brachial plexus palsy (OBPP) is upper limb length discrepancy. However, the influence of primary nerve reconstruction remains undetermined. In this study, the resultant discrepancy in children with OBPP who underwent primary reconstruction was analyzed in relation to the severity of the lesion, the timing of surgery, and the functional outcome following surgery. Fifty-four patients that met the inclusion criteria were included in this study. Preoperative and postoperative bilateral scanograms were obtained to document the effect of reinnervation on bone growth. The length of the humerus, ulna, third metacarpal, third proximal phalange, and total limb length were measured and the percentage between the affected and normal side were accessed. Correlations between all the measures of limb length and measures of active motion (i.e., three different classification systems) were performed. Spearman’s rank correlation coefficients revealed significant correlations between limb length discrepancies and nearly all measures of active upper extremity movement. The timing of surgery and the severity of the lesion significantly influenced the resultant limb length discrepancy. The prevention of a non-acceptable upper limb discrepancy is fundamental for both the patient and family. The extent of the resultant discrepancy appeared to be strongly related to the time between injury and surgery, degree of severity, and the outcome of surgery. Patients with better functional recoveries of the affected upper extremities showed smaller differences in limb length.

This study aims to compare surgical outcomes of severe carpal tunnel syndrome (CTS) treated with mini-incision versus extensile release. The method employed in this study was a retrospective review of patients with severe CTS, defined by electrophysiologic studies showing non-recordable distal sensory latency of the median nerve. Patients underwent either a mini-incision (2 cm) release of the transverse carpal ligament (group 1) or extensile release proximal to the wrist flexion crease (group 2). Exclusion criteria included prior carpal tunnel release, use of muscle flap, multiple concurrent procedures, or a prior diagnosis of peripheral neuropathy. Group 1 included 70 wrists (40 females, 30 males). Group 2 included 64 wrists (35 females, 29 males). Reported outcomes included pre- and post-operative grip strength as well as Boston Carpal Tunnel Questionnaires (BCTQ). Patients in group 1 had a 22.6 % increase in grip strength postoperatively (4.5 months ± 5.0), while patients in group 2 had a 59.3 % increase (10.0 months ± 6.9). BCTQ surveys from group 1 (n = 46) demonstrated a symptom severity score of 12.93 and functional status score of 9.39 at an average follow-up of 41.9 ± 10.6 months. Group 2 (n = 42) surveys demonstrated averages of 12.88 and 9.10 at 43.1 ± 11.6 months. One patient in the mini-incision cohort required revision surgery after 2 years, while no patient in the extended release cohort underwent revision. No significant differences between the two procedures with regard to patient-rated symptom severity or functional status outcomes were found. Both techniques were demonstrated to be effective treatment options for severe CTS.

Arterialized venous flow-through (AVFT) flaps are useful in reconstructing small soft tissue defects. Currently, no guidelines exist for the use of AVFT flaps for reconstructing soft tissue defects in the digits of the hand. We retrospectively reviewed our experience with AVFT flaps and developed a selection process for vascular anastomoses. We reviewed the use of AVFT flaps in a series of ten consecutive patients requiring reconstruction of small soft tissue defects of the fingers. Between 2006 and 2012, ten consecutive digital reconstructions were performed using AVFT flaps. Flap sizes ranged from 5 to 13.5 cm2. Initial congestion was seen in all flaps and resolved within 3–7 days. Leeches were utilized in two cases. All cases achieved good functional results. Three illustrative cases from our series of ten are presented, each demonstrating key decision-making factors in selecting recipient and flap vessels for anastomosis. AVFT flaps appear congested post-operatively, resolving in days to weeks, and resulting in healthy coverage of digital soft tissue defects with good functionality. We suggest a selection process for the use of AVFT flaps in digital soft tissue reconstruction, based on dorsal vs. volar and proximal vs. distal defect location, and the flap’s inherent venous architecture.

The current gold standard for the diagnosis and staging of hand–arm vibration syndrome (HAVS) is the Stockholm workshop scale, which is subjective and relies on the patient’s recalling ability and honesty. Therefore, great potentials exist for diagnostic and staging errors. The purpose of this study is to determine if objective serum tests, such as levels of soluble thrombomodulin (sTM) and soluble intercellular adhesion molecule-1 (sICAM-1), may be used in the diagnosis and staging of HAVS. Twenty two nonsmokers were divided into a control group (n = 11) and a vibration group (n = 11). The control group included subjects without history of frequent vibrating tool use. The vibration group included construction workers with average vibrating tool use of 12.2 years. All were classified according to the Stockholm workshop scale (SN, sensorineural symptoms; V, vascular symptoms. SN0, no numbness; SN1, intermittent numbness; SN2, reduced sensory perception; SN3, reduced tactile discrimination; V0, no vasospasmic attacks; V1, intermittent vasospasm involving distal phalanges; V2, intermittent vasospasm extending to middle phalanges; V3, intermittent vasospasm extending to proximal phalanges; V4, skin atrophy/necrosis). All control subjects were SN0 V0. Seven out of 11 vibration subjects were SN1 V1, and 4 out of 11 were SN1 V2. A 10-cm3 sample of venous blood was collected from each subject. The sTM and sICAM-1 levels were determined by enzyme-linked immunosorbent assay. The mean plasma sTM levels were as follows: control group = 2.93 ± 0.47 ng/ml, and vibration group = 3.61 ± 0.24 ng/ml. The mean plasma sICAM-1 levels were as follows: control group = 218.8 ± 54.1 ng/ml, and vibration group = 300.3 ± 53.2 ng/ml. The sTM and sICAM-1 differences between control and vibration groups were statistically significant (p < 0.0002 and p < 0.001, respectively). When reference ranges provided by Hemostasis Reference Lab were used as cut-off values, all sTM and sICAM-1 levels were within range, except three vibration individuals (27%) who had sICAM-1 levels greater than the reference range. This was not statistically significant (p = 0.08). When subjects were compared based on the Stockholm workshop scale, mean plasma sTM levels were SN0 V0 group = 2.93 ± 0.47 ng/ml, SN1 V1 group = 3.59 ± 0.25 ng/ml, and SN1 V2 group = 3.65 ± 0.27 ng/ml, and mean plasma sICAM-1 levels were SN0 V0 = 219 ± 54.1 ng/ml, SN1 V1 = 275 ± 33.5 ng/ml, and SN1 V2 = 345 ± 54.6 ng/ml. The difference in sTM level among the three groups was statistically significant (p < 0.001). The difference in sICAM-1 level among the three groups was also statistically significant (p < 0.002). The sTM and sICAM-1 levels are statistically higher in subjects with HAVS, with levels proportional to the disease severity. However, large population studies are needed to determine the “real-life” standard reference ranges for sTM and sICAM-1.