“All in One or (W)hole in One Repair” for Adult Total Brachial Plexus Palsy

Background  Total brachial plexus palsy (TBPP) accounts for nearly 50% of all brachial plexus injuries. Since achieving a good functional hand was almost impossible, the aim was settled to get a good shoulder and elbow function. It was Gu, who popularized the concept of utilizing contralateral C7 (CC7) with vascularized ulnar nerve graft (VUNG) to get some hand function. We have modified it to suit our patients by conducting it as a single-stage procedure, thereby trying to get a functional upper limb. Methods  From 2009 to 2014, we had 20 TBPP patients. We feel nerve reconstruction is always better than any other salvage procedure, including free muscle transfer. We modified Gu''s concept and present our concept of total nerve reconstruction as “ALL IN ONE OR (W)HOLE IN ONE REPAIR.” Results  All patients able to move their reconstructed limbs independently or with the help of contralateral limbs. Three patients developed hook grip and one patient was able to incorporate limbs to do bimanual jobs. One important observation is that all the reconstructed limbs regain the bulk, and to a certain extent, the attitude and appearance looks normal, as patients no longer hide it or hang it in a sling. Conclusion  Adult brachial plexus injury itself is a devastating injury affecting young males. By doing this procedure, the affected limb is not dissociated from the rest of the body and rehabilitation can be aimed to get a supportive limb.     

Restoration of Five Digit Hand in Type III B & C Thumb Hypoplasia–A Game Changer in Surgical Management

Background  Hypoplasia of thumb is the second common congenital difference of the thumb, next only to duplication. It may occur as an isolated hand difference or as a part of radial longitudinal deficiency. In approximately 60% of these children, the radius shows hypoplasia. The incidence of thumb hypoplasia is one in 100,000 live births. In 50% of these children, the other hand will also have similar deficiency, although variable in severity. Hypoplasia of thumb has been classified into five major categories, according to the increasing severity of hypoplasia. Type III hypoplasia of thumb is characterized by skeletal hypoplasia involving the first metacarpal and carpometacarpal joint, absent intrinsic muscles and rudimentary extrinsic muscles. It was further subclassified into types A, B & C. Type III B, described by Manske and McCarroll, involves extensive deficiency of extrinsic and intrinsic musculature with aplasia of the metacarpal base. Type III C, described by Buck-Gramcko, has hypoplastic metacarpal head. Methods  It is widely believed that reconstruction of Type III B & C hypoplastic thumb will not be functionally useful, and they are often included in the indications for pollicization in thumb hypoplasia. In India, we frequently come across parents, who are not willing to remove the hypoplastic digit. This forced us to find out a way to reconstruct the hypoplastic thumb into a functionally useful digit. We describe our surgical technique of reconstruction of hypoplastic thumbs and our experience in utilization of the technique in five children with Type III B & C hypoplasia of thumb. Carpometacarpal joint of thumb was reconstructed and stabilized with a toe phalangeal transfer in the first stage and an opponensplasty was done in the second stage to improve movement. Results  In all the five operated children, our surgical technique yielded a stable thumb which was functional. The donor site morbidity was acceptable. The parents were satisfied with the appearance and functional improvement. Conclusion  Surgical reconstruction of hypoplastic thumbs of Type III B & C is possible, and conversion of these poorly developed remnants into a useful digit by our surgical technique is a gamechanger in the management of thumb hypoplasia.     

Microvascular free on-top plasty in a mutilated hand

Amputation of the index, middle, and ring fingers leaves a poor, unstable pinch and grasp between the thumb and little finger. In this type of mutilated hand, it is necessary to reconstruct one or two fingers for firm chuck pinch and good grasp. Functionally and cosmetically, toe transfer is superior to other methods of finger reconstruction because of its mobility, sensibility, pulp size, and nail availability. However, a transfer from the foot may not always be available. In such a case, any finger stump may be considered as a possible donor finger. The authors performed a microvascular free transfer of the remaining portion of the ring finger including the metacarpophalangeal joint to the top of the remaining portion of the index finger in a mutilated hand with intact thumb and little finger because the patient declined toe transfer. Postoperatively, more effective strength and stability, provided by three converging digits, was achieved in the hand. Accordingly, it was easier for the patient to grip small and large objects. The authors describe this procedure as a microvascular free on-top plasty.     

Ring finger transfer in reconstruction of transmetacarpal amputations

Four cases are described in which the opposite ring finger was used for finger reconstruction in transmetacarpal hand amputations. Thumb reconstruction was required in three of these four cases. This was achieved by hallux transfer, tube pedicle combined with an innervated first foot web neurovascular free flap, and second toe transfer respectively. In the fourth case, where a thumb was not required, double finger reconstruction was performed by the use of a second toe combined with a ring finger. This case highlights the limitations of the second toe for finger reconstruction, particularly in achieving palmar-digital grip. The advantages of the ring finger are length and mobility, especially sophisticated intrinsic muscle movement, sensory capacity, strength, wider span, and esthetic excellence.     

Ulnar digits contribution to grip strength in patients with thumb carpometacarpal osteoarthritis is less than in normal controls

BackgroundGrip testing is commonly used as an objective measure of strength in the hand and upper extremity and is frequently used clinically as a proxy measure of function. Increasing knowledge of hand biomechanics, muscle strength, and prehension patterns can provide us with a better understanding of the functional capabilities of the hand. The objectives of this study were to determine the contribution of ulnar digits to overall grip strength in individuals with thumb carpometacarpal (CMC) osteoarthritis (OA).MethodsThirty-seven subjects participated in the study. This group consisted of 19 patients with CMC OA (aged 60–88 years) and 18 healthy subjects (60–88 years). Three hand configurations were used by the subjects during grip testing: use of the entire hand (index, middle, ring, and little fingers) (IMRL); use of the index, middle, and ring fingers (IMR); and use of only the index and middle fingers (IM).ResultsGrip strength findings for the two groups found that compared to their healthy counterparts, CMC OA patients had, on average, a strength deficiency of 45.6, 35.5, and 28.8 % in IMRL, IMR, and IM, respectively. The small finger contribution to grip is 14.3 % and the ring and small finger contribute 34 % in subjects with CMC OA.DiscussionGrip strength decreases as the number of digits contributing decreased in both groups. The ulnar digits contribution to grip strength is greater than one third of total grip strength in subjects with CMC OA. Individuals with CMC OA demonstrate significantly decreased grip strength when compared to their healthy counterparts.     

双侧多个足趾移植修复全手或多手指缺损

目的 评价应用双侧多个足趾移植修复全手或多手指缺损的临床疗效.方法 临床应用102例,手术方法有4种:①利用双侧第二足趾移植再造拇、手指86例;②一侧甲瓣再造拇指,另一侧第二足趾再造手指11例;③一侧甲瓣与第二足趾再造拇指和示指,另一侧第二足趾移植再造中指8例;④双侧甲瓣与第二足趾移植再造双侧拇指与示指1例. 结果 102例中除1例部分甲瓣坏死,2例第二足趾坏死,其余全部成活.62例获得1年以上的随访.再造拇手指两点辨别觉达8～14mm.小儿移植手指生长与足趾同步.所有的随访病例中除1例不能作对掌对指功能外,余全部恢复.供区:所有病例无跛行,无外翻发生. 结论 对于多手指或全手缺损,应用双侧足部多个足趾再造手指,对足部供区外形和创伤较小,手部可获得最大功能恢复.     

五块游离复合组织修复全手套状撕脱伤的长期随访

目的 通过对患手功能的恢复情况以及足部供区切取组织后功能情况进行长期随访,来评价应用5块游离组织移植一期修复全手撕脱伤的疗效.方法 对7例采用5块游离组织移植一期修复全手撕脱伤的患者进行长期随访,随访离手术时间为3～12年,平均5.8年.对再造手和供足的评价方法:主观指标[DASH评分、Michigan手功能评价、足部Maryland评分(FPCS)];客观指标(捏力、握力、虎口距离、拇手指的关节活动度、再造指的两点分辨觉);采用中华医学会手外科学会拇、手指再造功能评定试用标准评定优良率.结果 主观指标:再造手DASH评分平均为(21.60±16.58)分.Michigan手功能评价(平均):其中整体手功能(67.50±24.05)%,日常活动(99.69±32.58)%,工作情况(49.57±25.45)%,疼痛(24.00±21.38)%,外观(48.20±7.11)%,满意度为(78.40±12.65)%.供足Maryland评分平均为(84.56±2.44)分.客观指标:再造拇掌指关节活动度平均为(56.00±20.77)°,示指掌指关节活动度平均为(78.00±10.33)°,中指掌指关节活动度平均为(76.00±9.00)°;再造手平均握力达健侧的46.70%;拇、示指平均捏力为健侧的66.52%,拇、中指平均捏力为健侧的61.30%;拇指指端两点分辨觉平均为(8.47±0.68)mm,再造手指指端两点分辨觉平均为(10.59±0.82)mm;手掌、手背感觉为S3-;供足除2例患者有色素沉着和少许瘢痕增生外,无疼痛等后遗症.按中华医学会手外科学会上肢部分功能评定试用标准评定:再造手功能优2例、良4例、可1例,优良率为85.71%.结论 用5块游离组织组合移植修复全手套状撕脱伤,恢复了较好的手功能,且随着术后时间的延长,手功能的恢复越好,对供足功能仅有轻微的影响.     

A complex reimplantation of digits: a case report.

In multiple finger amputations, microsurgical reconstruction should concentrate on the thumb, index, and middle fingers. The patient in the case report presented in this paper initially sustained an amputation of all of the digits on the left hand and an amputation of the right thumb. Both thumbs were amputated at the metacarpophalangeal joint. Initial replantation of the left thumb, index, and middle fingers and of the right thumb was carried out. The right thumb replantation failed and, after healing, the right great toe was transferred to the right hand. Subsequent to this, the patient developed useful function of all reconstructed digits. Twenty-one months after the first injury, both thumbs sustained new traumatic amputations 1.0 cm distal to the previous amputations. Both thumbs were replanted again successfully.     

Factors Associated with Increased Risk of Recurrence following Treatment of Trigger Finger with Corticosteroid Injection

Introduction  The aim of the study was to estimate recurrence rates, time to recurrence, and predisposing factors for recurrence of trigger finger when treated with corticosteroid (CS) injection as primary treatment. Materials and Methods  In a retrospective chart review, we identified primary trigger fingers treated with CS injection as primary treatment. Affected hand and finger, recurrence, time to recurrence, duration of symptoms, secondary treatment type, and comorbidities were recorded. A total of 539 patients were included with a mean follow-up of 47.6 months Results  In total, 330/539 (61%) recurrences were registered. Mean time to recurrence was 312 days. Increased risk of recurrence was seen after treatment of the third finger (relative risk [RR]: 1.22; 95% confidence interval [CI]: 1.06–1.39). Several comorbidities were associated with increased risk of recurrence: carpal tunnel syndrome (RR: 1.27; 95% CI: 1.07–1.52), thyroid disease (RR: 1.45; 95% CI: 1.15–1.83), or shoulder diseases (RR: 1.58; 95% CI: 1.36–1.83). Conclusion  We found a recurrence rate after primary treatment of CS injection for trigger finger of 61%. Most recurrences happened within 2 years and we found treatment of third finger, carpal tunnel syndrome, shoulder, or thyroid disease to be associated with an increased risk of recurrence of symptoms.     

双足带有同蒂多叶皮瓣的趾甲皮瓣移植治疗全手皮肤套脱伤

目的 探讨应用组合组织移植修复全手皮肤套脱伤的方法.方法 对3例全手皮肤套脱伤患者,分别采用一侧足部以胫前动脉为蒂的带踝前皮瓣、足背皮瓣、足内侧皮瓣和足外侧皮瓣的拇甲皮瓣再造拇指,修复桡侧手掌手背及虎口区皮肤缺损;另一侧足部带以上相同皮瓣的第二趾甲皮瓣再造示指(或中指),修复尺侧手掌及手背皮肤缺损.结果 术后3例,除一再造示指坏死外,其余组织瓣全部存活.术后随访3～12个月,修复后手部外形和捏、握、抓等功能基本恢复.皮瓣及再造拇、示指(或中指)感觉恢复至S2～S4.结论 双足带有同蒂多叶皮瓣的趾甲皮瓣移植治疗全手皮肤套脱伤是一种有效的治疗方法.     

足趾移植拇指与手指再造的临床研究

目的探讨足趾移植拇指与手指再造的方法和疗效。方法采用部分坶趾移植拇指部分再造22例,躅甲瓣或带足背皮瓣船甲瓣移植拇指再造13例,第2足趾移植再造拇指4例,再造手指3例,及带足背皮瓣的第2足趾移植再造拇指7例,带足背皮瓣的第2,3足趾移植再造手指7例,带足背皮瓣的躅甲瓣或第2趾和第2,3趾组合移植再造拇手指10例,双足第2足趾移植全手缺失二指再造2例,共68例97指。结果再造拇手指和皮瓣全部成活,成活率为100％,术后经3月～10年的随访和信访,按中华医学会手外科学会拇、手指再造功能评定试用标准评定：优62指,良24指,可9指,差2指,优良率达88．66％。结论采用部棚趾、第2足趾棚甲瓣移植再造拇手指,带足背皮瓣的躅甲瓣、第2趾或第2,3趾组合移植行合并手部皮肤缺损的拇手指再造,效果满意。     

Cleft hands with six metacarpals

PURPOSE: The purpose of this study was to identify children with cleft hands whose radiographs showed metacarpal polydactyly with 6 metacarpals to support the hypothesis that cleft hand develops not as a result of a longitudinal failure of formation but through a process of central polydactyly and osseous syndactyly. METHODS: We screened the hand radiographs of all children with a transverse or longitudinal deficiency of the upper limb and identified 8 children with cleft hands containing 6 metacarpals. RESULTS: Six cleft hands had a missing middle finger and consisted of a thumb and index finger separated from the ring and small fingers by a V-shaped central cleft. Two children had a more severe form of cleft hand with absence of both the index and middle fingers but presence of 6 metacarpals. CONCLUSIONS: These 8 cleft hands containing 6 metacarpals showed progression of polydactyly of the middle finger and osseous syndactyly between the 2 middle finger metacarpals and the adjacent index and ring finger metacarpals. This contradicts a longitudinal failure of formation mechanism and supports the alternative hypothesis that cleft hand, polydactyly, and syndactyly develop through a similar teratogenic mechanism. The 2 cleft hands that had more severe suppression of the index and middle fingers yet had 6 metacarpal polydactyly provided confirmatory evidence that both typical cleft hands and the more severe manifestations of cleft hand with absence of multiple digits develop through a similar failure of induction mechanism.     

双足第二趾移植再造多手指缺损的疗效分析

目的研究双足第二趾移植再造多手指缺损的疗效分析及术后对足部功能及外观的影响。方法根据患者手指缺损情况,选择双足第二趾移植再造,其中再造食指和中指缺损10例,再造拇指与食指缺损9例,再造中指与环指缺损1例,共20例40指。结果 19例再造指全部成活,1例再造坏死1指,再造指经3~24个月随访,平均13个月,再造指痛温觉恢复,两点辨别距离在10~12 mm间,双侧供足外观对称,行走无疼痛,步态正常。结论双足第二趾移植是修复多手指缺损的理想修复方法,且对足部外观及功能影响较小,在多指再造中双足第二趾移植是较为理想的选择。     

Scarless Abdominal Fat Graft Harvest for Neurosurgical Procedures: Technical Note

Background Abdominal fat grafts are often harvested for use in skull base reconstruction and cerebrospinal fluid (CSF) leak repairs, and for operations traversing the nasal sinuses or mastoid bone. Although the endoscopic transnasal surgery has gained significant popularity, in part because it is considered “scarless,” a common adjunct, the abdominal fat graft, can result in a disfiguring scar across the abdomen. Objective This is the first report of a scarless abdominal fat graft technique for skull base reconstruction. Methods Ten patients with a median age of 56.5 years (range: 45–73 years) underwent endoscopic transsphenoidal tumor resection with intraumbilical fat graft harvest. Careful circumferential fat dissection at the umbilicus, with progressive retraction of the graft, was crucial to ensure maximal visualization and to prevent injury to the subcutaneous vessels and rectus fascia. Results Following reconstruction of the sellar skull base, all patients did well postoperatively with no evidence of CSF leak. At 12-week follow-up for all patients, there was no evidence of scar, intracavity hematoma, or wound infection. Conclusions Fat graft harvest through an intraumbilical incision results in a scar-free abdominal harvest, and is a useful procedural adjunct to complement “scarless” brain surgery.     

Design,Development, and Validation of a High-Fidelity “Ganglion Cyst” Model for Cadaveric Hand Surgery Training

Introduction  This study presents a design and developmental model with prospective validation. This study was aimed to design, develop, and validate a cadaveric model simulator of a ganglion cyst to train surgeons in its surgical excision. Materials and Methods  A novel “ganglion cyst” was designed using a latex powder-free glove and water-based, water-soluble lubricant (K-Y jelly). This “ganglion cyst” was then inserted subcutaneously into a cadaveric hand, positioned over the dorsum of the wrist to simulate a ganglion lesion. This simulation model was prospectively validated using postsimulation surveys conducted on novices and experts in hand surgery. The simulation was conducted during a basic hand surgery cadaveric workshop that included a practical station on ganglion excision. Results  Both the novices and experts had a concurrent agreement that the simulator provided relevance, realism, and value as a simulator for the teaching, excision and procedural assessment of ganglions in the hand. Conclusion  The role of high-fidelity simulation has been documented in the literature for surgical procedures. This simple and affordable model that we have developed and validated allows for the creation of a high-fidelity ganglion simulator in the cadaveric hand for teaching, excision, and procedural assessment among trainees.     

Two immediate synchronous free flap transfers in a severe traumatic mid-hand defect: A case report

A 66-year-old patient sustained a severe right hand injury resulting in a thumb pulp defect and unreplantable amputation of the index, long, and ring fingers at the metacarpophalangeal joint with joint exposure. There was also an 8 cm defect of the radial digital nerve of the little finger. Immediate one-stage total reconstruction of all of the defects was accomplished by a free groin flap and a free glabrous skin flap from the foot. Opposable function of the hand was thus preserved. © 1995 Wiley-Liss, Inc.     

Precision grip with congenital hypoplasty or hypofunction of the thumb

We tested the grip in four patients with congenital defects of the hand and either a hypoplastic thumb or a thumb with impaired inervation. Small objects were taken by a scissors grip between the fingers. In a hand with radial duction in the manus vara congenita, during strengthening of the wrist, the grip from the ulnar side between the fourth and fifth fingers was changed to the radial side between the second and third fingers. Large objects were gripped by all the three-phalanx fingers into the palm in a horizontal position. In case 4 with hypoplasia of the thumb grade IIIC by the classification of Blauth and Buck-Gramcko, we describe a transposition of the index finger to the site of the thumb and the hypoplastic thumb to the site of the index finger. It is obvious that the precision grip is affected by the thumb length and strengthening of the ulnar side of the wrist. We assume that the scissors grip is the earliest precision grip in the evolution of the primate hand.     

Otto Hilgenfeldt (1900-1983): tribute to an important pioneer of European hand surgery

The German surgeon Otto Hilgenfeldt (1900-1983) was a great innovator in European hand surgery in the 20th century, particularly in respect of the tactile (sensate) thumb and grip reconstruction in amputation injuries. His experience, beginning in the 1930s, helped him to treat hundreds of soldiers with mutilating hand injuries from 1941 to 1945 during World War II. While totally isolated and without any access to international publications, he devised many innovative ideas such as a neurovascular middle finger transposition for pollicization (first case done in July 1943) and a sensory dorsoradial first metacarpal flap for thumb resurfacing. His book Operative thumb replacement and substitution of finger losses published in 1950 is regarded as one of the most important German contributions to modern hand surgery. Hilgenfeldt's life and work remain fascinating and exemplary from a historical and surgical point of view. Many of his pragmatic surgical solutions remain valid despite the advent of microsurgery.     

Indications for microsurgical reconstruction of congenital hand anomalies by toe-to-hand transfers

Background

The indications for microsurgical toe-to-hand transfers in congenital hand surgery have not been defined as clearly as for posttraumatic reconstruction of thumb and finger amputations. The purpose of this study was to develop simple guidelines for referral of children with congenital absent digits for consideration of microsurgical reconstruction with toe-to-hand transfers, based on the morphological or radiographic anatomy of the hand anomaly, not on embryological classifications.

Methods

From a consecutive series of 204 children referred with congenital absence of the thumb and fingers, 100 toe-to-hand transfers were performed. The indications for microsurgical reconstruction of these children were analyzed retrospectively.

Results

Forty-one thumbs were reconstructed in 38 children—15 children with an absent thumb distal to the metacarpal base but with four relatively normal fingers; 12 children with an absent thumb and only one or two digits remaining on the ulnar side of the hand; and 11 children with complete absence of all five digits. Twenty-nine second toes and 12 great toes were transferred to reconstruct congenital absent thumbs. Fifty-nine fingers in 52 children were reconstructed mostly with single second toe transfers—41 children with a thumb but absence of all four fingers and 11 children with absence of all five digits.

Conclusions

The morphological or radiographic anatomy of a child’s hand with congenital absent digits is a more logical indication for microsurgical reconstruction than any embryological classification. The three most common indications for toe transfers for reconstruction of congenital absent thumbs are (1) absent thumb distal to the carpometacarpal joint with four relatively normal fingers, (2) absent thumb with only one or two fingers remaining on the ulnar border of the hand, and (3) complete absence of the thumb and all four fingers. The two indications for toe transfers for reconstruction of congenital absent fingers are (1) absence of all four fingers but with a normal thumb remaining and (2) complete absence of all five digits.     

The Snow-Fink technique as an opposition tendon transfer for children born with a hypoplastic or absent thumb

Background

A novel opposition tendon transfer, previously described by Snow and Fink in adults but not in children, can provide better functional results and cosmetic appearance than the currently preferred Huber transfer.

Methods

Thirty-one children were born either without a thumb (17) or with a hypoplastic thumb (14). Thirty-eight thumbs were classified according to the Blauth classification as stages II, IIIA, IIIB, IV, and V respectively. The opposition tendon transfer was performed between the ages of 4 and 10, using the expendable flexor digitorum superficialis (FDS) tendon from the ring finger which was passed through a 3-mm-diameter window in the transverse carpal ligament, routed subcutaneously across the palm and attached to the insertion of the abductor pollicis brevis on the base of the proximal phalanx of the thumb. This creates a vector of pull from the ulnar side of the hand which both abducts and pronates the thumb. Twenty-one hands underwent additional procedures such as four-flap Z-plasty (11), ulnar collateral ligament reconstruction (6), joint transfer, full-thickness skin grafting, and distraction lengthening.

Results

The ability of each child to oppose their thumb to the index finger (score 2), middle finger (score 3), ring finger (score 4), or small finger (score 5) was assessed preoperatively and postoperatively by their Kapandji score. Thirty-one children (81.6 %) achieved a postoperative Kapandji score of 5, while 7 children (18.4 %) had a postoperative Kapandji score of 4. No deformities were observed, and the metacarpophalangeal (MCP) joint was stabilized with the other slip of the FDS when necessary.

Conclusions

An opposition transfer using the FDS tendon of the ring finger through a window in the transverse carpal ligament is a simple and reliable technique for improving thumb function in children born with an absent or hypoplastic thumb. This transfer does not produce a concave deformity in the hypothenar eminence like the Huber transfer, provides better pronation, and affords concurrent stabilization of the MCP joint.