The psychoflexed hand: New perspectives in diagnosis,classification and treatment

The psychoflexed hand is a rare clinical condition characterized by fixed finger contractures undetermined by organic etiology, often associated with a psychiatric pathology. We report a series of 20 patients (nine males and 11 females, mean aged 56.2 years). We have introduced a new classification of the various possible patterns of finger deformities: 1) Type 1: prevalent flexion contracture at the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints of the last two or three fingers; the thumb and the index are not affected; 2) type 2: prevalent flexion contracture at the PIP and distal interphalangeal (DIP) joints of the last two or three fingers; 3) type 3: flexion contracture of all the long fingers; 4) type 4: flexion contracture of all the fingers of the hand, including the thumb (clenched fist syndrome); 5) type 5: isolated flexus-adductus thumb (the long fingers are not affected); 6) type 6: flexion of digits associated with flexion contractures of other joints of the upper extremity. The treatment was conservative in 14 patients with recent deformities and surgical in six patients. Both forms of treatment were followed by a rigorous rehabilitation program, mostly based on home self-rehabilitation. The correction of the deformities was obtained in all cases and maintained over time.     

Limited joint mobility syndrome in diabetes mellitus: A minireview

Limited joint mobility syndrome(LJMS) or diabetic cheiroarthropathy is a long term complication of diabetes mellitus. The diagnosis of LJMS is based on clinical features: progression of painless stiffness of hands and fingers, fixed flexion contractures of the small hand and foot joints, impairment of fine motion and impaired grip strength in the hands. As the syndrome progresses, it can also affect other joints. It is important to properly diagnose such a complication as LJMS. Moreover, it is important to diagnose LJMS because it is known that the presence of LJMS is associated with micro- and macrovascular complications of diabetes. Due to the lack of curative treatment options, the suggested method to prevent or decelerate the development of LJMS is improving or maintaining good glycemic control. Daily stretching excercises of joints aim to prevent or delay progression of joint stiffness, may reduce the risk of inadvertent falls and will add to maintain quality of life.     

Curvatures of the DIP joints of the hand

Background

The distal interphalangeal (DIP) joints of the hand are highly susceptible to osteoarthritis and trauma. Surgical treatment options mandate accurate characterization of their osseous anatomy; however, there are few studies that describe this. We describe the curvatures of the DIP joints by measuring the bone morphology using advanced imaging and modeling methods.

Methods

The fingers of 16 right hand fresh frozen human cadavers were analyzed. Fingers showing signs of DIP joint arthritis were excluded. The fingers were scanned using microtomography (microCT). Measurements of the bony morphology were made using models created from the scans.

Results

In each finger, there is no statistically significant difference between the radii of curvature of the ulnar and radial condyles of the middle phalanx head. Conversely, the radius of curvature of the distal phalanx ulnar groove is significantly greater than that of the radial groove. The radii of curvature of the groove of the distal phalanx and the condyles of the middle phalanx displayed nonconformity with disparity increasing from the index to small fingers. Remarkably, the radius of curvature of the distal phalanx central ridge and the mean radius of the middle phalanx condyles are essentially the same.

Conclusion

The purpose of this study is to gain better insight into the DIP joints of the hand. The asymmetry between the distal phalanx grooves and the middle phalanx condyles suggests that there may be a translational component to DIP joint motion. Our understanding of morphology may lend insight into the biomechanics and disease progression within the DIP joints.     

Symphalangism in children. Case report and review of the literature

Symphalangism is an uncommon syndrome characterized by fusion of the interphalangeal joints of the hands and feet. The fusion can involve the proximal or the distal joints; however, involvement of the proximal interphalangeal joints is more common. Symphalangism often is associated with several other skeletal and nonskeletal abnormalities. Analysis of the pedigrees of affected families reveals this trait to be autosomal dominant. The authors present the case of a 9-year-old boy with bilateral symphalangism of the proximal interphalangeal joints in the fingers and toes. His father is affected similarly. A comparison of these cases with those published in the literature indicates that although the radiologic appearance of symphalangism appears disabling, the fused phalanges seldom cause disability or loss of function of the hand. Surgical intervention is not required in most patients. The father and son reported also had capitellar hypoplasia and subluxation of the radial head associated with limitation of elbow flexion and extension.     

Treatment of the windblown hand

The windblown hand deformity, also known as congenital ulnar drift of the fingers and congenital contractures of the digits is reported infrequently in the literature. Although the syndrome is well described, authors' use of different terms is confusing. In more than 20 years of practice, we have observed 11 patients with the windblown hand and have operated on 7 hands in 4 patients. The anomaly appears to be inherited as an autosomal dominant trait and may represent a variation of some type of arthrogryposis. Ulnar drift of the digits is often present at birth and becomes more pronounced as the child grows. The one factor common to all case reports is a flexion contracture of the metacarpophalangeal joints, with ulnar deviation of the fingers. Also, the thumb is webbed to the palm by a soft tissue bridge. Most cases of the windblown hand should be treated within the first 2 years of life. Because the windblown hand has many variations, each patient must be treated individually. We report a series on the windblown hand and propose a treatment plan for this rare anomaly.     

The accuracy of goniometric measurements of proximal interphalangeal joints in fresh cadavers: comparison between methods of measurement, types of goniometers, and fingers.

This study evaluates the accuracy of goniometric measurement of fixated proximal interphalangeal (PIP) joints using fresh cadavers. Sixteen fingers in four right hands were evaluated. Angles of PIP joints obtained by three examiners, two methods (lateral, dorsal), three goniometers (plastic A, B, and a metal model), and four different fingers were compared for the accuracy of measurement. The difference of angles obtained from goniometric measurement and x-ray films of cadaver fingers was defined as "angle discrepancy." Analysis of interrater reliability proved that there was a high correlation coefficient between examiners. With the lateral method, no statistically significant difference in angle discrepancy between goniometers was observed. On the other hand, with the dorsal method, the angle discrepancy of plastic A was statistically significantly greater than plastic B in the results of two examiners (p<0.05). In both lateral and dorsal methods, the angle discrepancy of the index and ring fingers is statistically significantly greater than that of the middle and little fingers. We recommend use of the lateral method with any of the three goniometers for measurement of PIP range of motion. Goniometers with short arms are considered to be suitable for the dorsal method.     

Classification and Surgical Treatment of Symphalangism in Interphalangeal Joints of the Hand

Background

Symphalangism is a rare congenital difference characterized by ankylosis of interphalangeal (IP) joints of the fingers and toes. In adults, there were several attempts to restore the stiff joints into mobile ones, but these treatment options resulted in poor outcomes and could not be applied to growing children. Here, we report our experiences on surgical treatment for children who had symphalangism of the hand.

Methods

We treated 36 joints in 17 children with symphalangism of the hand using dorsal capsulotomy and collateral ligament release. The diagnoses were based on history, physical examination, and simple radiographs. Affected fingers were classified according to our grading system. Simple compressive dressing was applied using Coban after surgery. Passive range of motion (ROM) exercise was started on day one or 2 postoperative, with the help of a hand therapist and patients'' parents. The patients were prescribed passive ROM exercises for at least 2 hours a day over a period of 6 months.

Results

A single surgeon operated on 30 proximal IP joints, 3 distal IP joints, and 3 IP joints of the thumb. Twenty six joints were classified as grade I, and 10 as grade II. The ROM of affected joints, which was 7.8 ± 8.1 (mean ± SD) degrees preoperatively, increased to 46.8 ± 18.6 degrees at final follow-up. The final ROM was significantly better in grade I joints, especially when the children had operations at ages 24 months or younger.

Conclusions

Symphalangism of the hand in children, can be restored into a mobile joint by release of the collateral ligament, a dorsal capsulotomy, and postoperative physical therapy.     

Arthroscopy of the trapeziometacarpal and metacarpophalangeal joints

Indications for small joint arthroscopy in the hand remain poorly understood. This is due to a paucity of articles discussing these techniques in the literature, as well as inadequate hands-on training in the pearls and pitfalls regarding this application within the routine "scope" of hand surgery. Despite the fact that small joint arthroscopes have been available for more than a decade, hand surgeons have been slow to adopt this technique for the treatment of both traumatic and degenerative conditions involving the thumb and the digital metacarpophalangeal joints. An arthroscopic classification for basal joint osteoarthritis provides additional clinical information and can direct further treatment depending on the stage of disease. This article will also review the brief history of trapeziometacarpal arthroscopy and provide insight as to how this technique can be incorporated into a treatment algorithm in managing this common affliction. Metacarpophalangeal joint arthroscopy is even less commonly utilized, while traumatic and overuse injuries are frequently seen in the thumb and constitute ideal indications in certain scenarios. Painful conditions affecting the metacarpophalangeal joints of the fingers are less commonly seen, yet the small joint arthroscope presents a much clearer picture of the pathology compared with other imaging techniques or even open, potentially deleterious surgery. The application of this technology to the smaller joints will soon make the treating surgeon realize that a myriad of pathologies are readily visible and can augment treatment, as well as diagnosis. Similar to the wrist, small joint arthroscopy may one day supplant imaging techniques such as magnetic resonance imaging or computed tomography for establishing an accurate diagnosis.     

Stabilization of finger ulnar deviation in rheumatoid arthritis: extensor indicis proprius tenodesis

Ulnar deviation of fingers in rheumatoid arthritis is a common deformity that can markedly compromise hand function. These deformities also result in an aesthetic impairment that is often troubling to patients. A variety of surgical procedures have been recommended to correct the ulnar deviation, either at the wrist level or at the metacarpophalangeal (MCP) joints. We present a surgical technique that uses the extensor indicis proprius as a tenodesis across the dorsum of the MCP joints of the fingers. The technique can also be used in conjunction with other surgical procedures, including prosthetic replacement arthroplasties of the MCP joints. The procedure has been used in 6 patients. Ulnar deviation averaged 62 degrees preoperatively and 15 degrees postoperatively. All patients have been satisfied with the results.     

Brachydactyly type C

Brachydactyly type C is an autosomal dominant disorder with markedly variable penetrance. A patient with limited gene expression has shortening limited to the middle phalanges and the first metacarpal and an elongation of the radial side of the base of the second proximal phalanx. When completely expressed the characteristic radiographic findings are shortening of all the metacarpals, greatest in the thumb, followed by the little, ring, middle, and index fingers; brachymesophalangy (shortening of the middle phalanges); shortening of the proximal phalanges of the index and middle fingers, with the proximal phalanges of the ring and small fingers of normal length; elongation of the radial side of the base of the second proximal phalanx resulting in a trapezoidal shaped epiphysis; ulnar deviation at the second and third metacarpophalangeal joints; and hypersegmentation (extra phalanx) of the index and middle fingers. The ulnar deviation of the index and middle fingers may result in scissoring and require surgical correction. The hand deformities of 10 patients with brachydactyly type C are presented to characterize the hand abnormalities in the syndrome and its variable presentation.     

Operative Behandlung der Krallenhand mittels Lassoplastik

Objectives

The aim is correction of claw deformity of the fingers by intrinsic paralysis.

Indications

Indications are claw deformity of fingers caused by palsy or functional loss of the interosseus or lumbrical muscles as far as the function of the superficial and deep flexors of the finger is intact.

Contraindications

Contraindications are loss or paralysis of finger flexors supplied by the median nerve, fixed extension or flexion contracture of the finger joints, osteoarthritis and other malfunctions of the finger joints, no active flexion and extension of the interphalangeal joints due to compromised tendon gliding. Relative: Upper ulnar nerve palsy with functional loss of the deep flexor of the small and ring finger and possibly of the middle finger.

Surgical technique

The operation technique involves detachment of the flexor digitorum superficialis IV tendon (FDS IV) distal to Camper’s chiasm, division of the tendon into separate strips, interweaving of each tendon strip into the proximal part of the A2 pulley of the affected fingers. In cases of claw deformity of all fingers it may be advantageous to apply the superficial flexor tendon of the long finger in addition to the FDS IV tendon as otherwise the FDS IV tendon has to be divided into four strips resulting in relatively thin tendon strips. If the FDS III and IV tendons are applied, the two strips of the FDS IV tendon are used for lassoplasty of the small and ring fingers and the FDS III tendon for lassoplasty of the middle and index fingers.

Postoperative management

Postoperative management includes immobilization of the operated fingers by a dorsoulnar forearm plaster cast including the metacarpophalangeal joints which are flexed to 70°. After 2 weeks replacement of the cast by a thermoplastic splint for another 4 weeks. During the whole period exercises for the finger and thumb should be carried out.

Results

From April 2003 to June 2012 a total of 17 patients, 8 female and 9 male were surgically treated for claw deformity. The dominant hand was affected in seven patients. The average age was 46?±?15 (22–80) years, the average interval from onset of ulnar palsy to lassoplasty was 61?±?91 (3–288) months. The final follow-up was performed after an average of 42?±?32 (2–112) months. Claw deformity was resolved in 14 out of the 17 patients. The grip strength was on average 58?±?28?% (11–96 %) of the unaffected hand, the mean disabilities of the arm, shoulder and hand (DASH) score was 32?±?18 (5–68) points and the degree of patient satisfaction 7?±?2 (0–10). According to own results and those in the literature lassoplasty can be recommended for the treatment of claw deformity.     

Microvascular free on-top plasty in multidigital amputations.

Bidigital amputations proximal to the PIP joints severely impair function and cosmesis of the hand. The author presents a clinical series of five patients in which a three-fingered hand was reconstructed through microvascular transfer of one of the stumps on top of the other. Five male patients with amputation of two fingers proximal to the PIP joint were treated surgically. One of the stumps was transferred as a local free composite flap on top of the other stump. All five transfers were successful. The mean operative time was 2 h 15 min. The subjective improvement on hand function and cosmesis, as evaluated by the patients, was positive. Free microvascular on-top plasty is a straightforward and reliable procedure for improving cosmesis and function in hands with two fingers amputated proximal to the PIP joint, without additional donor morbidity outside the already injured hand.     

Arthroscopy of the trapeziometacarpal and metacarpophalangeal joints

Indications for small joint arthroscopy in the hand remain poorly understood. This is due to a paucity of papers discussing this technique in the literature, as well as inadequate hands on training in the pearls and pitfalls regarding this application within the commonly used "scope" of arthroscopy. Despite the fact that small joint arthroscopes have been available for over a decade, hand surgeons have been slow to adopt this technique within their treatment armamentarium for the treatment of both traumatic and degenerative conditions involving the thumb and the digital metacarpophalangeal joints. A proposed arthroscopic classification for basal joint osteoarthritis provides additional clinical information and can direct further treatment depending on the stage of disease. This chapter will also review the brief history of trapeziometacarpal arthroscopy and provide insight as to how this technique can be incorporated into a treatment algorithm in managing this common affliction. Metacarpophalangeal joint arthroscopy is even less commonly used, while traumatic and overuse injuries are frequently seen in the thumb, and present an ideal indication in certain scenarios. Painful conditions affecting the metacarpophalangeal joints of the fingers are less commonly seen, yet the small joint arthroscope presents a much clearer picture of the present pathology compared to other imaging techniques or even open, and potentially deleterious, surgery. The application of this technology to the smaller joints will soon make the treating surgeon realize that a myriad of pathologies are readily visible and can augment treatment, as well as diagnosis. Similar to the wrist, small joint arthroscopy may one day supplant imaging techniques such as MRI or CT in establishing an accurate diagnosis.     

Successful replantation of four fingers by a single common digital artery anastomosis

The replantation of 4 digits of 1 hand was attempted in a patient who had completely amputated his fingers at the level of the metacarpophalangeal joints. Anastomosis of the severed ends of the third common volar digital artery proved to be successful not only in re-establishing arterial circulation in the middle and ring fingers but also in the index and little fingers, as evidenced by survival of the digits and as evaluated by postoperative angiography. The reasons for this success are discussed in light of anatomic studies.     

The influence of age and exercise on the mobility of hand joints: 2: Interphalangeal joints of the three phalangeal fingers

This report is a continuation of the study about mobility of the metacarpophalangeal (MP) joints of the three-phalangeal fingers. We measured flexion of proximal (PIP) and distal (DIP) interphalangeal joints in university students (52 males and 49 females), senior citizens (30 males and 30 females), and pianists (21 males and 31 females). Students were considered as a control group characterized by normal mobility of hand joints. In all three groups, the smallest flexion in the PIP joints is in the little finger, in the DIP joints in the index and ring fingers. In the control group the flexion in the PIP joints is greater in females compared to males, in the DIP joints it is greater on the left side compared to the right. With the exception of DIP joints in females, the situation is also similar in seniors. In pianists, however, the gender and lateral differences are less pronounced, due to exercise. Seniors of both genders show significant limitation of flexion in all PIP as well as DIP joints, as compared to students, while pianists have the same range of flexion compared to students, which also corresponds to the situation in MP joints. The previous study, however, showed that pianists have a greater ability to abduct and hyperextend fingers.     

Simultaneous subluxation of the metacarpophalangeal joints of all four fingers: a case report

Simultaneous subluxation of the metacarpophalangeal joints of all four fingers is rare, and we have found no cases in the literature. A 45-year-old construction worker fell and dislocated the metacarpophalangeal joints of all the fingers of his left hand. Closed reduction by manipulation was successfully accomplished, and the patient returned to work within 5 months of his accident. He had a full range of motion 1 year later.     

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.     

The thoracodorsal vascular tree-based combined fascial flaps

In this study, combined fascial flaps pedicled on the thoracodorsal artery and vein were raised and used for thin coverage of dorsal surfaces of the fingers and the dorsum of hand and foot with favorable results. The combined fascial flaps consist of the serratus anterior fascia and the axillary fascia at the entrance of the latissimus dorsi. These flaps were used for reconstruction of the hand, fingers, or foot in nine patients. Reconstruction was performed for burn or burn scar contracture, after resection of malignant tumors, posttraumatic skin defects, and chronic regional pain syndrome. The sites of reconstruction were dorsal surfaces of fingers, dorsum of hand, wrist and palm, forearm, lower leg, and foot. The flaps were used in various configurations including two independent fascial flaps, two-lobed fascial flap with separate feeding vessels, and composite fascial and thoracodorsal artery perforator flap. The fascial and skin flaps survived in all nine patients, with favorable results both functionally and esthetically. Good coverage of soft tissue defects and good recovery of range of motion in resurfaced joints were achieved. There were no complications. The scars at the sites of harvest were not noticeable. The advantage of this method is that not only a single flap but flaps of a variety of configurations can be harvested for different purposes. The thoracodorsal vascular tree-based combined fascial flaps are useful for the reconstruction of soft tissue defects in the extremities.     

Intrinsic contractures of the hand

Contractures of the intrinsic muscles of the fingers disrupt the delicate and complex balance of intrinsic and extrinsic muscles, which allows the hand to be so versatile and functional. The loss of muscle function primarily affects the interphalangeal joints but also may affect etacarpophalangeal joints. The resulting clinical picture is often termed, intrinsic contracture or intrinsic-plus hand. Disruption of the balance between intrinsic and extrinsic muscles has many causes and may be secondary to changes within the intrinsic musculature or the tendon unit. This article reviews diagnosis, etiology, and treatment algorithms in the management of intrinsic contractures of the fingers.     

Ulnar clasp failure or again "the nail file sign", a little known sign of disorders of the ulnar nerve

Besides the well known signs of the ulnar palsy, there is a new sign, unknown till now: the "failing ulnar hook". It could be named the "nail file sign", because it was discovered from a woman who could not file the nail of her little finger. Practically, the patient is asked, in a first time, to roll his little and ring fingers around the index of the same hand of the examinator. As the patient is resisting, the other index of the examinator tries to extend these two fingers. If they cannot resist, there is an ulnar palsy at an upper level. The explanation is that the flexor profundus of the ring and the little fingers are commanded by the ulnar nerf, whereas those of the index and the middle finger are by the median nerve. So, when this sign is present, the block is located from the elbow to the brachial plexus. When it is absent, whereas other signs of ulnar palsy are present, it evoques a lower palsy. This sign is of great interest because it confirms the diagnosis of ulnar palsy and allows the localization of the block. It is very useful to search it in every neurologic examination of the hand. In a carpal tunnel syndrome, it allows to eliminate or not an ulnar participation without using of electrical tests.