手部近指间关节闭合性损伤的基础与临床研究

目的 探讨近指间关节(proximal interphalangeal joint,PIP)闭合性损伤的解剖特点及不同结构损伤的治疗及预后.方法 通过对20个成年人新鲜尸体手指标本的解剖学研究,了解近指间关节损伤及关节囊挛缩发生的机制.临床上对21例近指间关节损伤的患者进行手术.结果 解剖学研究发现,副韧带及掌板近侧损伤对近指间关节活动度无明显影响.侧副韧带损伤主要破坏关节侧方的稳定性,掌板损伤主要破坏关节前后方的稳定性.21例术后随访3～13个月,平均7个月.各指近指间关节主动屈、伸活动范围:屈曲60°～95°,平均78°;背伸0°～15°,平均8°.被动屈、伸活动范围:屈曲71°～98°,平均82°;背伸0°～18°,平均11°.结论 对于掌板及侧副韧带损伤,应尽早进行手术修复及止点重建,可防止关节囊挛缩.     

Extension splinting of palmar plate avulsion injuries of the proximal interphalangeal joint

Hyperextension injuries of the proximal interphalangeal joint have traditionally been immobilized in flexion. This may lead to a proximal interphalangeal flexion contracture of the joint. In an effort to prevent flexion contracture and to simultaneously avoid hyperextension laxity, we have immobilized these injuries in zero degrees of extension for 7 to 10 days. Immobilization is followed by buddy taping and active range of motion until 3 weeks after injury. Protective buddy taping is used until the 6-week point. We report our results using this treatment for only palmar plate avulsion fractures. We did not include proximal interphalangeal joint injuries associated with dorsal dislocation or major collateral ligament injury. Twenty-two of 45 patients were available for follow-up evaluation. Length of follow-up averaged 30 months (range, 6 to 36 months). A high percentage of patients had good or excellent results. In no patient did hyperextension laxity develop and in only one was there a flexion contracture. On the basis of these results, we recommend this treatment protocol for hyperextension injuries of the palmar plate of the proximal interphalangeal joint associated with small avulsion fractures.     

Effects of reconstructed radial collateral ligament on index finger mechanics

Twenty fresh frozen hand specimens from cadavers were studied. Physiologic levels of extrinsic muscle loads were applied to the extrinsic flexor tendons of the index finger to simulate tip pinch of the finger on a fixed plate. The acute effects of transection of the radial collateral ligament and accessory radial collateral ligament (radial collateral ligament complex) with and without transection of the dorsal capsule and volar plate on the position of the proximal phalanx with respect to the metacarpal bone of the index finger were investigated. The acute effects of reconstruction of the radial collateral ligament, for each of two different surgical techniques, on the position of the proximal phalanx also were investigated. The spatial positions of the metacarpal bone and proximal phalanx were measured with a six-degree-of-freedom digitizing system for flexion angles from 0 degrees to 90 degrees in increments of 15 degrees. Transection of the radial collateral ligament complex resulted in significant increases in ulnar deviation (adduction) of the proximal phalanx and in volar translation. Additional transection of the dorsal capsule and volar plate caused significant increases in ulnar deviation, pronation, volar translation, and ulnar shift. The first surgical technique, one traditionally used to reconstruct the metacarpophalangeal joint of the thumb, failed to return the three-dimensional position of the proximal phalanx on the metacarpal head of the index finger to normal. The second surgical technique, based on anatomy, returned the position of the proximal phalanx to levels not statistically different from normal for most flexion angles.     

Reconstructive hand surgery for scleroderma joint contractures

Systemic scleroderma can cause significant hand deformity and functional impairment. Surgery is often avoided due to the perceived risks of wound healing. The most common surgical procedures have been digital sympathectomy, arthrodesis or arthroplasty of the proximal interphalangeal (PIP) or both, and metacarpophalangeal (MCP) joints. We describe herein successful soft tissue hand surgery in 2 patients for treatment of scleroderma claw deformities without the use of arthrodesis or arthroplasty. At the MCP joint, the tight capsules were excised, and the collateral ligaments and volar plates were released. At the PIP joints, the volar plates were released and the tight palmar skin was released, resulting in marked improvement of joint position. Intensive hand therapy was used to maximize function. In these 2 patients with claw deformity, we found that tight volar skin was the main contributor to flexion contracture at the PIP level. In contrast, joint capsule contracture was the main contributor to hyperextension deformity at the MCP level.     

Posttraumatic proximal interphalangeal joint flexion contractures

Normal motion of the proximal interphalangeal joint requires bony support, intact articular surfaces, unimpeded tendon gliding, and uncompromised integrity of the collateral ligaments and volar plate. Deficiency in any one of these structural requirements can lead to a loss of finger joint motion and decreased hand function. Once finger extension is lost, options include nonsurgical or surgical treatment. Nonsurgical treatment such as splinting or serial casting should be tried before attempting surgical intervention. When severe flexion deformity exists or the vascular status of the finger has been compromised, arthrodesis or amputation should be undertaken instead of procedures to regain motion. Surgical options for regaining motion include external fixators and open surgical release. Although they can lead to improved extension at the proximal interphalangeal joint, external fixators carry a risk of reduced finger flexion and pin site infection. Most clinical series of patients who have undergone surgical release document improvement in flexion contracture between 25 degrees to 30 degrees and a shift of the flexion/extension arc into a more functional range. Close follow-up after surgery is warranted, with frequent physical therapy and splinting.     

手指关节损伤的MRI检查

目的了解MRI检查对手指关节损伤的诊断作用。方法对外伤后致手指损伤的18例24个近侧指间关节或掌指关节进行X线片和MRI检查;其中对6例8个指间关节损伤进行了手术治疗,对12例16个指间关节行石膏固定。结果X线片显示24个损伤关节中发现4例(4个)指关节有损伤并伴有指骨骨折;MRI显示24个指关节均有不同程度的损伤,其中侧副韧带损伤12个关节,侧副韧带损伤伴指骨骨折4个关节,侧副韧带损伤伴掌板撕裂伤8个关节。治疗后3个月,所有病例均获得随访。手功能按TAM评定标准评定疗效:优20个,良4个,优良率达100%。结论MRI检查对手指关节损伤的阳性诊断率很高,检测方便,为临床治疗提供了可靠的依据。     

Palmar arthroplasty for the treatment of the stiff swan-neck deformity

Palmar arthroplasty for the treatment of the stiff swan-neck deformity in rheumatoid arthritis is designed to correct the mechanical block to flexion that is caused by palmar plate adhesions (which obliterate the retrocondylar recess) and by collateral ligament contracture and adhesions. This procedure can be performed at the same time as correction of the primary cause of proximal interphalangeal joint (PIP) hyperextension (e.g., intrinsic tightness or flexor tenosynovitis) and can also be supplemented with superficialis tenodesis to minimize recurrent hyperextension. Postoperative flexor dynamic traction, which is started at 24 to 48 hours and continued for a minimum of 3 to 4 weeks, is critical to the maintenance of motion. Arthroplasty in 47 PIP joints in 14 hands of 9 patients demonstrate an increase in motion from +20 degrees hyperextension and 9.5 degrees flexion to -7 degrees extension and 72 degrees flexion postoperatively.     

Ulnar deviation after volar subluxation of the proximal interphalangeal joint

A rare case of irreducible and progressive ulnar deviation after volar subluxation of the proximal interphalangeal joint is presented. An immobilized proximal interphalangeal joint with remaining volar subluxation after improper reduction showed ulnar deviation at 3 weeks after injury. During surgery, the radial collateral ligament was found to be ruptured at its origin, with formation of concomitant scar tissues. There were no apparent lesions at the central slip, lateral band, and volar plate. Interposition of the ruptured ligament and infiltration of the surrounding scar tissues into the proximal interphalangeal joint were identified. Surgical incision of the capsule along the dorsal margin of the radial collateral ligament readily produced successful reduction. The irreducible and progressive ulnar deviation of the proximal interphalangeal joint seemed to result from gradual infiltration of the scar tissues, subsequent to remaining volar subluxation because of interposition of the ruptured collateral ligament.     

Proximal interphalangeal joint release in Dupuytren's disease of the little finger

We present a prospective study, with 3-year follow-up, of the role and outcome of fasciectomy plus sequential surgical release of structures of the proximal interphalangeal joint in Dupuytren's contracture of the little finger. Our treatment programme involves fasciectomy for all patients followed by sequential release of the accessory collateral ligament and volar plate as necessary. Of the 19 fingers in the study, eight achieved a full correction by fasciectomy alone, and in these cases there was a fixed flexion deformity of 6 degrees at 3 months and 8 degrees at 3 years. The remaining 11 fingers (initial mean deformity 70 degrees flexion) were left with a fixed flexion deformity of 42 degrees after fasciectomy which reduced to 7 degrees with capsulo-ligamentous release. This increased to 26 degrees at 3 months but then remained relatively stable, increasing only to 29 degrees at 3 years. In our experience sequential proximal interphalangeal joint release has led to consistently good results with few complications in the correction of severe Dupuytren's disease of the little finger.     

Open reduction and internal fixation for dorsal fracture dislocations of the proximal interphalangeal joint using a miniplate

Various operative techniques have been described for unstable dorsal fracture dislocations of the proximal interphalangeal (PIP) joint with articular involvement. However, this injury still remains a therapeutic challenge for hand surgeons because no single technique guarantees successful outcomes. We performed a novel procedure using a low-profile miniplate, which allows for anatomic reduction, rigid internal fixation, and early finger joint motion. Between March 2003 and May 2009, 18 consecutive patients who suffered from 19 dorsal fracture dislocations of the PIP joint with volar articular fracture of the middle phalanx involving more than 40% of the articular surface were treated using this technique. The postoperative follow-up period averaged 16.6 months (range, 12-18 mo). Bony union was obtained in all cases. No patient showed residual dorsal subluxation. Active motion of the PIP joint averaged 85.0 degrees (range, 62-105 degrees), flexion contracture averaged 5.4 degrees (range, 0-17 degrees), and percent total active interphalangeal joint motion averaged 89.0% (range, 60%-100%). Two patients had restricted active distal interphalangeal joint flexion owing to tendon adhesion resulting from the use of a relatively long plate in the first few cases of this series. No major complications were reported for the other 16 patients. We describe the surgical technique, indications, complications, and postoperative management for this technique.     

Lateral band release for post-traumatic extension contracture of the proximal interphalangeal joint

Summary In the patient with scarring of just the central band and lateral bands, there is a loss of active and passive flexion of the proximal interphalangeal (PIP) joint because the lateral bands have lost their normal volar shift. Surgical freeing of the lateral bands from the central band using parallel incisions may be required to allow full flexion of the PIP joint. This study reports on 10 patients with post-traumatic extension contracture of the PIP joint treated by lateral band release. All operations were successful, with an average gain in range of motion of 47.5°. This technique is simple, quick, and can be performed effectively on an out-patient basis.     

Severe Dupuytren's contracture of the proximal interphalangeal joint: treatment by two-stage technique

Thirty-four patients with a Dupuytren's contracture in excess of 70 degrees of the proximal interphalangeal (PIP) joint were treated by preliminary palmar fasciotomy, release of the accessory collateral ligaments and PIP joint distraction using the S-Quattro for 6 weeks. A formal fasciectomy with full thickness skin graft was then performed 2 weeks after removal of the fixator.There was a mean residual flexion deformity of the PIP joint of 22 degrees (mean correction of 67 degrees) at an average follow-up of 30 months. There were no infections or amputations. We recommend this technique for the management of severe Dupuytren's contracture of the PIP joint.     

Mini-screw fixation for the treatment of proximal interphalangeal joint dorsal fracture-dislocations

PURPOSE: Surgical intervention may be necessary to treat unstable dorsal fracture-dislocations of the proximal interphalangeal (PIP) joint of the hand. One method of stabilization is open reduction and internal fixation (ORIF). The purpose of this study was to assess the outcomes of ORIF for unstable dorsal fracture-dislocations of the PIP joint using mini-screws via a volar approach. METHODS: A retrospective chart review with clinical follow-up evaluation was performed on 9 patients who had ORIF for unstable dorsal fracture-dislocations of the PIP joint. The fracture fragment(s) from the middle phalangeal base were reduced and secured using mini-screws. RESULTS: A clinical evaluation was performed at an average of 42 months after surgery. The average arc of motion for the involved PIP joint was 70 degrees (range, 55 degrees -90 degrees ). The average PIP joint motion in the 2 patients with 1 fracture fragment was 85 degrees , and the average PIP joint motion for the remaining 7 patients was 65 degrees . One joint was subluxated with an intra-articular screw. Nine patients had an average flexion contracture of 14 degrees . Seven patients had no pain, and 2 had pain only with heavy activity. CONCLUSIONS: Open reduction and internal fixation of unstable dorsal PIP joint fracture-dislocations using mini-screws can be considered if the fracture fragment(s) can accommodate the screws. The procedure attempts to restore the concave contour of the middle phalangeal base and permits early protected range of motion. The procedure should be approached cautiously, especially in the presence of comminution. Proximal interphalangeal joint range of motion is usually compromised; 8 of our 9 joints had a residual flexion contracture. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Simultaneous dislocation of both interphalangeal joints in a finger

Summary. Unlike dislocations of the distal or proximal interphalangeal joints, the simultaneous dislocation in a single finger of both seems to be a rare occurrence. Reduction and checking of the collateral ligament, extensor tendon, and volar plate, followed by 3 weeks of splinting in the intrinsic plus position seems to be the treatment of choice.     

Reconstruction of the unstable proximal interphalangeal joint: The double superficialis tenodesis

A technique is described for reconstructing the unstable proximal interphalangeal joint where there has been a break in continuity of both the volar plate and the collateral ligament. Both slips of the superficialis are used. They are divided proximally and tenodesed in appropriate positions on the proximal phalanx.     

The effects of transection and reconstruction of the ulnar collateral ligament complex on the position of the proximal phalanx of the thumb during simulated tip pinch

Injuries to the ulnar collateral ligament (UCL) of the metacarpophalangeal joint of the thumb are common and may result in functional instability of the joint. Eight cadaveric hands were studied. Physiologic levels of muscle loads were applied to the extrinsic flexor tendon of the thumb to simulate tip pinch of the thumb. We investigated the effects of transection of the UCL and accessory UCL (UCL complex) with and without transection of the dorsal capsule and volar plate and of reconstruction of the UCL, for 2 surgical techniques, on the position of the proximal phalanx with respect to the thumb metacarpal. The spatial positions of the metacarpal and proximal phalanx were measured with a 6 degrees of freedom digitizing system for flexion angles from 0 degrees to 60 degrees in 15 degrees increments. Transection of the UCL complex, dorsal capsule, and volar plate (ulnar capsuloligamentous structures) of the metacarpophalangeal joint did not affect radioulnar deviation or radioulnar shift, but did produce significant increases in supination by 8 degrees and volar translation by 2 mm at 45 degrees and 60 degrees compared with those found for the intact joint. The UCL was reconstructed with a tendon graft using the autogenous extensor digiti quinti. The first surgical technique, a traditional technique, and the second surgical technique, a technique based on anatomy, returned the position of the proximal phalanx on the metacarpal head to normal, with the exceptions of volar translation of the proximal phalanx at 60 degrees and trends toward abnormal supination of the proximal phalanx for flexion angels of 45 degrees and 60 degrees.     

舟月骨间韧带在腕尺桡偏时舟月骨三维运动中的作用

目的 观察在腕关节尺桡偏运动时,舟月骨间韧带(scapholunate interosseous ligament,SLIL)及其各亚区分级切断后对舟骨与月骨三维运动的影响,从亚区水平对SLIL在舟月骨三维运动中的作用进行研究.方法 取12例新鲜冰冻成人上肢标本(左、右侧各6例),共分为正常对照组、断SLIL近侧组、断SLIL近+背侧组、断SLIL近+掌侧组、SLIL全断组(每组6例).采用三维激光扫描及图像重建技术,测定在腕关节尺桡偏时舟骨与月骨的三维运动数据,并进行统计学处理.结果 在正常腕关节做尺桡偏运动时,舟、月骨同时也做尺桡偏运动,但还伴有明显的屈伸方向上的运动;与此同时,舟、月骨还做一定的旋前、旋后活动.在切断近+掌和近+背侧亚区组,舟月骨的活动受到影响.全切断SLIL会导致舟骨掌屈度增加,月骨掌屈活动减弱.结论 采用三维激光扫描及图像重建技术可准确测定腕舟月骨的三维活动度,从SLIL亚区水平上进行的研究表明,部分或全部切断SLIL后会对舟月骨的掌屈程度产生明显影响,但SLIL近侧亚区在控制舟、月骨的活动上不起主要作用.     

舟月骨间韧带在腕尺桡偏时舟月骨三维运动中的作用

目的 观察在腕关节尺桡偏运动时,舟月骨间韧带(scapholunate interosseous ligament,SLIL)及其各亚区分级切断后对舟骨与月骨三维运动的影响,从亚区水平对SLIL在舟月骨三维运动中的作用进行研究.方法 取12例新鲜冰冻成人上肢标本(左、右侧各6例),共分为正常对照组、断SLIL近侧组、断SLIL近+背侧组、断SLIL近+掌侧组、SLIL全断组(每组6例).采用三维激光扫描及图像重建技术,测定在腕关节尺桡偏时舟骨与月骨的三维运动数据,并进行统计学处理.结果 在正常腕关节做尺桡偏运动时,舟、月骨同时也做尺桡偏运动,但还伴有明显的屈伸方向上的运动;与此同时,舟、月骨还做一定的旋前、旋后活动.在切断近+掌和近+背侧亚区组,舟月骨的活动受到影响.全切断SLIL会导致舟骨掌屈度增加,月骨掌屈活动减弱.结论 采用三维激光扫描及图像重建技术可准确测定腕舟月骨的三维活动度,从SLIL亚区水平上进行的研究表明,部分或全部切断SLIL后会对舟月骨的掌屈程度产生明显影响,但SLIL近侧亚区在控制舟、月骨的活动上不起主要作用.     

舟月骨间韧带在腕尺桡偏时舟月骨三维运动中的作用

目的 观察在腕关节尺桡偏运动时,舟月骨间韧带(scapholunate interosseous ligament,SLIL)及其各亚区分级切断后对舟骨与月骨三维运动的影响,从亚区水平对SLIL在舟月骨三维运动中的作用进行研究.方法 取12例新鲜冰冻成人上肢标本(左、右侧各6例),共分为正常对照组、断SLIL近侧组、断SLIL近+背侧组、断SLIL近+掌侧组、SLIL全断组(每组6例).采用三维激光扫描及图像重建技术,测定在腕关节尺桡偏时舟骨与月骨的三维运动数据,并进行统计学处理.结果 在正常腕关节做尺桡偏运动时,舟、月骨同时也做尺桡偏运动,但还伴有明显的屈伸方向上的运动;与此同时,舟、月骨还做一定的旋前、旋后活动.在切断近+掌和近+背侧亚区组,舟月骨的活动受到影响.全切断SLIL会导致舟骨掌屈度增加,月骨掌屈活动减弱.结论 采用三维激光扫描及图像重建技术可准确测定腕舟月骨的三维活动度,从SLIL亚区水平上进行的研究表明,部分或全部切断SLIL后会对舟月骨的掌屈程度产生明显影响,但SLIL近侧亚区在控制舟、月骨的活动上不起主要作用.