Anomalous tendon to the middle finger for sagittal band reconstruction: report of 2 cases

Multiple techniques with good outcomes have been described for sagittal band reconstruction. We describe 2 cases of sagittal band reconstruction using an anomalous slip of the extensor tendon to the middle finger. This anomalous slip can be a resource for surgical reconstruction that can add stability to primary sagittal band repair.     

掌腱膜挛缩症中手指屈曲畸形治疗的临床研究

目的 研究掌腱膜挛缩症中手指屈曲畸形矫治方法 及其疗效.方法 本组患者17例,其中男性15例,女性2例;平均年龄58岁.均有掌腱膜挛缩症,伴小指屈曲挛缩8侧,伴环小指屈曲挛缩8侧,伴中环指屈曲挛缩1侧,伴环指屈曲挛缩2侧,共19侧.沿掌腱膜挛缩索带纵轴设计锯齿状切口,彻底切除病变的挛缩腱膜组织及其附近5 mm范围的腱膜组织.然后稍加外力松解指关节周围的挛缩组织,使手指恢复伸直位.术后2周给予手指伸直位石膏托制动.结果 所有患者随访6～24个月.锯齿形皮瓣均存活,未见神经肌腱损伤并发症.手掌部皮瓣尖角出现血运障碍2例,经换药后完全愈合.未见手指屈曲挛缩复发,手指屈伸活动度恢复优良率100%.结论 采用锯齿状切口,应注意保护皮瓣血运和指神经血管束,彻底切除松解病变的腱膜组织,可有效矫正掌腱膜挛缩引起的手指屈曲畸形,避免并发症的发生.     

Classification of congenital thumb hypoplasia and deformity

BackgroundCongenital thumb deformities account for one-third or more of all cases of congenital hand deformity. However, the current classification schemes of congenital thumb hypoplasia are no longer adequate due to their lack of adaptability to increasing knowledge in the field. Hence, a modified system with the potential to adapt to ongoing advances in knowledge and understanding is desperately needed.MethodsBased on the photographs collected from thousands of cases of congenital deformities of the hand and upper limb over multiple decades in our department, we subdivided thumb hypoplasia according to the variables of morphological characteristics, anatomical structures, functional status, the relationship between thumb deformity and hand deformity, the relationship between congenital hand deformity syndrome and thumb hypoplasia, and the selection of treatment methods.ResultsA total of 10 types were presented, which were elucidated with nomenclatures as well as pathological feature and symptoms.ConclusionThis modified system may shed additional light on the classification of congenital thumb anomalies, which will assist in a more effective selection of treatment modalities and offers significant benefits to both patients and practice.     

Congenital flexion deformities of the thumb

A congenital flexion deformity of the IP joint of the thumb is usually due to a trigger finger. The diagnosis is based on the thumb being normal except for a fixed, flexed posture of the IP joint and a palpable nodule in the FPL tendon at the level of the A-1 pulley. Treatment can be postponed until after age 1, as spontaneous regression probably occurs in about 30 per cent of cases. After that age, surgical correction is the best approach to treatment and usually results in normal thumb function. Congenital soft tissue flexion deformities of the MP joint of the thumb vary from passively correctable deformities due to loss of extensor power to severe, fixed contractures involving multiple thumb structures and associated with significant anomalies of the wrists and fingers. The passively correctable deformities will frequently respond to cast immobilization in the very young but can otherwise be treated by an appropriate tendon transfer to re-institute active extension. Complex clasped thumb deformities require elucidation of the specific pathologic features of the deformity, based both on clinical evaluation and surgical exploration. These digits will require not only an extensive release to correct the fixed contracture but also reconstructive procedures to correct lax ligaments and to substitute for absent muscles and skin as appropriate. The latter deformities are often associated with a syndrome affecting numerous body structures. It is hoped that recognition of these syndromes and documentation of the pattern of pathology present in these thumbs will result in a better method of classification.     

先天性风吹手畸形的治疗

目的探讨先天性风吹手畸形(windblown hand)的治疗。方法对18例患者采用分次手术的方法:一期改善拇指功能;二期纠正手指尺偏畸形;三期解决手掌、手指屈曲。结果术后随访6～72个月,3例患者失访。15例中有11例拇指外展、对掌、对指功能恢复,效果满意;9例手指尺偏畸形得到纠正,5例再次手术,经系统康复训练后4例畸形纠正,1例部分纠正。结论先天性风吹手畸形的治疗应分次手术,每次解决1个主要问题,配合系统的康复才能获得满意的效果。     

In vivo flexor tendon forces increase with finger and wrist flexion during active finger flexion and extension.

The effects of different hand motions and positions used during early protected motion rehabilitation on tendon forces are not well understood. The goal of this study was to determine in vivo forces in human flexor digitorum profundus (FDP) and flexor digitorum superficialis (FDS) tendons of the index finger during active unresisted finger flexion and extension. During open carpal tunnel surgery (n = 12), flexor tendon forces were acquired with buckle force transducers, and finger positions were recorded on video while subjects actively flexed and extended the fingers at two different wrist angles. Mean in vivo FDP tendon forces varied between 1.3N +/- 0.9 N and 4.0 N +/- 2.9 N while mean FDS tendon forces ranged from 1.3N +/- 0.5 N to 8.5 N +/- 10.7 N. FDP force increased with active finger flexion at both wrist angles of 0 degrees or 30 degrees flexion. FDS force increased with finger flexion when the wrist was in 30 degrees flexion, but was unchanged when the wrist was in 0 degrees of flexion. Tendon forces were similar regardless of whether the fingers were moving in the flexion or extension direction. Active finger flexion and extension with the wrist at 0 degrees and 30 degrees flexion may be used during early rehabilitation protocols with limited risk of repair rupture. This risk can be further decreased for a FDS tendon repair by reducing wrist flexion angle.     

Epidemiologic study of the mallet finger deformity

An epidemiologic survey of 24 members of a three-generation family revealed an unusually high incidence of mallet fingers. Twenty mallet fingers were found in seven family members by clinical examination, suggesting a familial predisposition to develop this deformity. Multiple mallet fingers (range, two to six) occurred in four individuals. Classification of these mallet fingers based on the mechanism of injury demonstrated a high incidence (85%) resulting from minimal trauma or occurring spontaneously. Symptoms and signs of bilateral carpal tunnel syndrome were documented in five family members with mallet fingers (71%), and three individuals with mallet finger deformities also had associated trigger fingers (43%).     

Assessing rotational deformity of the little finger

Excessive scissoring or overlap of fingers can cause discomfort, weaken grip strength, and affect cosmesis. The treatment of little finger fractures is guided by the degree of scissoring or rotational deformity perceived in the digit. The purpose of this study is to assess the variation of little finger scissoring or overlap in the normal population using standard clinical examination. We evaluated 80 uninjured little fingers in 40 normal patients. The digital images of photographed hands, taken in both extension and flexion, were used to evaluate the overlap percentage of the adjacent fingernail as a proxy for rotation of the digits. Paired t tests were used for statistical analysis. The average fingernail overlap was 25% ± 20%, ranging from 0% to 71%. The average overlap on the left hand was significantly less at 21% ± 18% as compared to 30% ± 21% on the right (P < .01). The average variation between hands in individuals was 16% ± 13%.This study confirms that overlap or scissoring of the little finger varies between the hands of a given individual. Our results question the usefulness of assessing rotational deformity of the little finger by checking for overlap and comparing with the contralateral side. This has implications not only in assessing patients for possible surgery, but also in planning and performing surgical reductions of acute fractures and for correction of malunions.     

Rotational deformity of the index finger caused by reversed finger sucking

Five patients with deformities of the index finger are presented. We believe all five are due to finger sucking. The deformity usually consists of a combination of rotation, radial deviation in the metacarpal phalangeal joint, and hyperextension in the proximal interphalangeal joint; one of these is more pronounced. In our series the rotational deformity and deviation were the most prominent features. Cause, incidence, and other factors influencing this deformity as well as spontaneous regression and therapy are discussed.     

Radiographic analysis of spondylolisthesis and sagittal spinopelvic deformity

Traditional radiographic analysis of spondylolisthesis focuses on the regional sagittal deformity at the lumbosacral junction. Pelvic morphology has also been cited as an important factor that contributes to the development of high-grade spondylolisthesis. However, the importance of global sagittal balance of the spine and pelvis in patients with spondylolisthesis has been emphasized recently. Patients with this condition can develop abnormal sagittal spinopelvic balance; restoration of sagittal spinal alignment can improve their health-related quality of life. Reduction has been used to restore alignment, but its role in the management of high-grade spondylolisthesis is controversial. None of the current classification systems take sagittal sacropelvic and spinopelvic balance into account. Improved understanding of the relationship between the spine and pelvis has led to the development of a new classification system that incorporates analysis of spinopelvic balance in the radiographic assessment. This new system may aid surgeons in identifying patients who would benefit from a partial reduction procedure.     

Effect of knee replacement on flexion deformity

One of the objectives of knee replacement is to correct flexion deformity, the frequent consequence of rheumatoid arthritis and osteoarthritis. A review of 697 primary and revision replacements carried out between 1969 and 1985 and followed up from 1 to 16 years found that such deformity was present in 61% of knees before the primary operation. Replacement reduced this to 17% and the improvement was usually maintained. The deformity was present in only 21% of the replacements which required revision and the second operation reduced this to 8%. Flexion contractures affected rheumatoid knees more often and more seriously than osteoarthritic knees, but arthroplasty was more successful in correcting the deformity in the former. All of the 11 types of prosthesis used achieved some degree of correction, but the Walldius hinge and the variants of the Freeman condylar design were the most successful. Surprisingly, the best outcome, in terms of pain and reduced need for revision, was found in the rheumatoid knees most seriously deformed before operation, but this association was absent in the osteoarthritic knees. Postoperative deformity in knees without pain or extreme weakness did not appear to influence the patients' ability to walk or to use stairs or a chair, as measured by unexacting tests in the clinic.     

Importance of sagittal alignment in spinal deformity

To maintain proper function and an erect posture, the spine compensates by changing the amount of kyphosis or lordosis at each region. However, in the setting of severe spinal malalignment, the compensatory motion of the spine may be inadequate, and may lead to compensatory spinopelvic and postural changes, which increase energy for standing and ambulation. Sagittal alignment has been shown through numerous studies to affect patient reported outcome scores. The goals of sagittal alignment are SVA < 50 mm, PI –LL < 20°, with various other equations (PI − LL < 10°, PI + LL + TK ≤ 45°, LL = [(PI + TK)/2] + 10) described to optimize surgical outcomes following correction. This review will look at the importance of sagittal alignment, how to measure spinopelvic alignment parameters, contributing variables to spinal alignment, and the clinical importance when spinal malalignment causes imbalance.     

Pollicization of the index finger for radial hypoplasia

Background

Associated with anomalies such as VACTERL and Fanconi anemia, congenital hypoplasia of the thumb has a strong association with radial hypoplasia. The majority of patients have bilateral thumb underdevelopment, and those that have a unilateral deformity tend to have the right hand more commonly affected. In order to gain an opposable thumb, patients with a deficient carpometacarpal (CMC) joint, a floating thumb, or complete absence of the thumb can benefit with a thumb amputation and a translocation of the index finger (pollicization) to the thumb position. This video demonstrates the technical steps involved in performing a pollicization procedure in a patient with radial hypoplasia. The video is available electronically.

Methods

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all individual participants included in the video. The authors declare that they have no conflict of interest.

Results

Pollicization allows for improved functional results in patients with radial hypoplasia.

Conclusions

This video has reviewed the essential steps in performing a pollicization procedure in patients with radial hypoplasia.

Electronic supplementary material

The online version of this article (doi:10.1007/s11552-014-9693-z) contains supplementary material, which is available to authorized users.