Flexor tendon gliding in the hand. Part I. In vivo excursions

The amplitude of gliding of the flexor tendons was measured in 36 hands tagged intraoperatively with buried wire sutures. Finger and wrist position was correlated with tendon excursion as measured on radiographs in the postoperative period. With the wrist in the neutral position, the superficialis tendon achieved an excursion of 24 mm and the profundus tendon 32 mm. Excursion of the flexor pollicis longus tendon was 27 mm. With wrist range of motion, the amplitude of the superficialis tendon became 49 mm, the profundus tendon 50 mm, and the flexor pollicis longus tendon 35 mm.     

Radiocarpal septum after trauma

A case is presented in which trauma, followed by open reduction and pinning, resulted in the formation of a radiocarpal septum that divided the joint into two distinct compartments. A simple resection of the septum was not sufficient, since it uncovered underlying carpal instability that required ligamentous reconstruction.     

Delayed flexor tendon repair in no man's land.

Thirty seven digital flexor tendon injuries in 31 patients were treated by closure of the skin and delayed repair from 24 hours to 21 days later. All skin wounds healed without serious complication, and there were no infections. On examination at a minium of 4 months after repair, 36% had total active motion (TAM) of 220 degrees, 32% from 200 degrees to 220 degrees, 6% from 180 degrees to 200 degrees and 26% with less than 180 degrees. Under proper conditions, repair of flexor tendons can be carried out with the expectation of results comparable to more complex reconstruction procedures.     

Restoration of flexor pollicis longus function by flexor digitorum superficialis transfer

Fourteen patients were treated by flexor digitorum superficialis transfer for irreparable flexor pollicis longus lesions. Results measured by return of interphalangeal joint motion were good in 12 patients, with one patient achieving a fair result and one failure. This is a reliable procedure in thumbs with a grade I or II (Boyes) tendon bed and should be considered as an alternative to free tendon grafting for reconstruction in patients in whom return of interphalangeal motion is desirable.     

Vascular anatomy of flexor tendons. I. Vincular system and blood supply of the profundus tendon in the digital sheath.

The detailed blood supply of the flexor tendons in the digital canal was studied in 35 fresh human hands by means of an India ink-latex vascular injection technique. The specimens were examined by first exposing the pulley system, followed by examination of the intact tendon which had been rendered transparent by immersion in a solution of tributyl and tricresyl phosphate. Five annular and three cruciform pulleys were shown. There were five types of long vincula to the profundus (VLP) and three types of long vincula to the superficialis (VLS). The vincular systems of index and little fingers were symmetrical. Occasionally, neither the VLP nor the VLS was found in either the long or the ring fingers. The vincula received blood supply from four transverse branches of the digital arteries. A volar avascular area of the profundus tendon was seen in the cleared cross-sections, and the cross-over zone of its intrinsic vessels was found to be at the midproximal phalanx.     

Flexor tendon repair in no-man's-land: results of primary repair with controlled mobilization

Fifty-three patients with 60 injuries within the digital sheath, which were treated with primary tendon repair by the Kleinert technique, had follow-up of 6 to 36 months after operation. Seventeen digits had isolated lesions of the profundus tendon and regained an average 38 degrees range of motion (ROM) in the distal interphalangeal (DIP) joint. Forty-three digits had injuries to both the profundus and superficialis tendons, 35 of which flexed within 2 cm from the distal palmar crease (81%), and 21 had a total active motion of at least 200 degrees (49%). The average active ROM in the DIP joint was 30 degrees. The results were superior to our own results with primary repair by the Verdan technique. Comparison with our own results after secondary tendon repair by the Kleinert technique showed that repair of isolated profundus lesions could be done primarily or secondarily within 1 month of injury with equally good results. Primary repair of double tendon lesions gave better results than secondary repair.     

Opera-glass hand in rheumatoid arthritis.

Characteristic deformities occur in the fingers, thumb, and wrist in the opera-glass hand in rheumatoid arthritis. Shortening and instability are the result of bone resorption and dislocation and can be severely disabling. Early spontaneous fusion of the proximal interphalangeal joint preserves digital length. Functional improvement can be obtained in the fingers by interphalangeal joint arthrodesis and metacarpophalangeal prosthetic arthroplasty and in the thumb with metacarpophalangeal and/or interphalangeal arthrodesis. With interphalangeal arthrodesis, interposition grafts often are required in order to restore length and secure fusion. "Prophylactic" arthrodesis of interphalangeal joints should be considered when resorption seems imminent.     

Chondrosarcoma of the hand

Eighteen consecutive cases with the histologic diagnosis of chondrosarcoma of the hand were reviewed and followed up from 1 to 10 years. The primary tumor originated without a preexisting lesion in 78%. Secondary tumors arose in patients who had multiple enchondromas but not in patients with a solitary enchondroma. The onset is usually in the 60- to 80-year age group with the tumor almost always occurring in the epiphyseal area of the proximal phalanx (56%) or the metacarpals (39%). Roentgenographic features included indiscrete lytic areas of bone destruction (83%). The diagnostic finding of intraosseous or extraosseous scattered, punctate, calcific densities of dystrophic calcification occurred in 66%. Ray resection of the tumor is the treatment of choice. Local recurrences occurred in 11% and distant metastases were not seen.     

Sacrifice of the unsatisfactory hand.

A hand which compares unfavorably with a prosthesis in function, comfort, and appearance may be better amputated. This decision must be made conjointly by the surgeon and the patient. Contributory factors are severe tissue loss, pain, appearance, infection, functional requirements, sexual reasons, psychological makeup of the patient, economics, safety, the time elapsed since injury, the patient's body image and his desires, and the surgeon's opinion. Fifteen patients elected hand amputation for various combinations of these factors. Eleven were fitted with a prosthesis at the time of operation and three within 3 weeks. All patients expressed satisfaction with their decision and 12 were successful users of the prosthesis.     

The incomplete anterior interosseous nerve syndrome

The anterior interosseous nerve syndrome involves paralysis of the flexor pollicis longus, flexor digitorum profundus of the index and long fingers, and the pronator quadratus. We have encountered 33 cases of an incomplete syndrome in which only the flexor pollicis longus or the flexor digitorum profundus of the index finger is either paretic or paralyzed. This entity must be distinguished from flexor tendon rupture, flexor tendon adherence or adhesion, and stenosing tenosynovitis. The nerve is usually compressed by fibrous bands that most commonly originate from the deep head of the pronator teres and to the brachialis fascia. Less common causes of compression are: fibrous bands from the superficial head of the pronator teres; bands from the superficialis arcade; the nerve running deep to both heads of the pronator; and compression by a double lacertus fibrosus. Patients presenting with paresis should be observed. Most will improve spontaneously without surgery. We recommend exploration and neurolysis of the anterior interosseous nerve in patients who present with complete paralysis of either muscle-tendon unit and who have shown no improvement as determined by physical examination or repeat electromyography after 12 weeks of observation. Recovery after neurolysis is often rapid and complete.