Hand Surgery

The surgical aims in managing displaced intra-articular fractures of the base of the middle phalanx include early joint reduction, maintaining congruence and early mobilization. Achieving this can be a challenge. However dynamic external fixators offer a solution. The study aim was to evaluate the use and outcomes of the Ligamentotaxor external fixator in patients with such injuries.

RESUMO Introdução: Atualmente, existe uma carência de exposição à cirurgia plástica durante a graduação. A maioria dos currículos univer-sitários não possui uma forma específica de ensino em cirurgia plástica. Para reverter essa situação, algumas universidades fomentam o contato precoce com a cirurgia plástica através de cursos extracurriculares. Método: Foi desenvolvido um Curso Básico de Mi-crocirurgia para acadêmicos de Medicina com uma aula teórica e uma prática, anualmente e ao longo de 3 anos; na última edição, foi aplicado um questionário sobre o interesse na área e a importância no ensino durante a graduação. Resultados: Dentre os alunos, 65% apresentaram grande interesse pela microcirurgia, 95% relataram um aumento de interesse. Todos os alunos concordaram que os acadêmicos de Medicina devem ser mais envolvidos e treinados na área microcirúrgica durante a graduação. Conclusões: O de-senvolvimento de um curso de treinamento básico de microcirurgia para acadêmicos de Medicina é benéfico para o aprendizado dos alunos, para obtenção de informações acerca da disciplina e para o aprimoramento de habilidades. ABSTRACT Introduction: Currently there is a lack of exposure to plastic surgery during medical graduation. Most college curricula do not have a specific form of education in plastic surgery. To reverse this situation, some universities encourage early contact with plastic surgery through extracurricular courses. Methods: We developed a basic course of microsurgery for medical students with a lecture and a practical class, annually and over 3 years; in the last edition, a questionnaire on the interest in the area and the importance in education during graduation was applied. Results: Among the students, 65% showed great interest in microsurgery, and 95% reported an increase of interest. All students agreed that medical students should be more involved and trained in the microsurgical area during graduation. Conclusions: The development of a basic training course of microsurgery for medical students is beneficial for student learning, obtaining information about the discipline, and improving skills.

This Atlas is the result of research about 3142 patients recruited prospectively and consecutively since 2004. As the clinic gives us opportunity to observe many more Aβ axonal lesions (axonotmesis) than transections (neurotmesis), the mapped hypoaesthetic territories are partial. The Authors, therefore, defined, for each cutaneous nerve branch, the autonomous territory and the boundary markers of the largest territory of cutaneous origin. Each anatomical plate of a cutaneous branch is the superposition of tens, even hundreds of observations seen in clinical practice - 3133 maps of cutaneous hypoaesthetic territories observed. We also cross-referenced these with data published in 99 anatomy books.

This 1st English edition - stemming from the previous 3rd French edition published by Sauramps Médical - illustrates the usefulness of anatomical knowledge for clinical practice.

Fifty years after Chen has performed the first forearm replantation, we report our first case of
hand replantation in a sub‑Saharan African country. The etiology of the amputation was machete
due to interpersonal violence. The amputation was trans‑carpal, guillotine‑type, subtotal non‑viable
maintained with a small skin bridge. The replantation procedure was successful. At one year follow‑up,
the functional result according to Chen’s criteria was excellent. Through this first experience, we
can state that hand replantation can be performed successfully both in survival and function in a
non‑specialized hospital of a sub‑Saharan African country.

Purpose This study was designed to analyze the long-term clinical and radiological outcomes of a series of patients with Kienböck disease stage IIIA treated with radius core decompression. Methods This retrospective study included 15 patients with Kienböck disease (Lichtman stage IIIA) who underwent distal radius metaphyseal core decompression between 1998 and 2005 and who were followed-up for at least 10 years. At the last follow-up, the patients were evaluated for wrist range of motion and grip strength. The overall results were evaluated by the modified Mayo wrist score and visual analog scale pain score. We also compared the radiological changes between the preoperative and the final follow-up in their Lichtman classification and the modified carpal height ratio. Results The mean follow-up period was 13 years (range, 10e18 years). Based on the modified Mayo wrist score, clinical results were excellent in 6 patients, good in 8 patients, and poor in 1 patient who required a proximal row carpectomy as revision surgery. The mean preoperative pain according to the visual analog scale was 7 (range, 6e10) and was 1.2 (range, 0e6) at the final follow-up. Compared with the opposite side, the average flexion/extension arc was 77% and the grip strength was 80%. All patients, except 1, returned to their original employment. At the final follow-up, 3 patients had decreased modified carpal height ratio, 12 remained unchanged. Radiographic disease progression according to the Lichtman classification to stages IIIB to IV occurred in only 2 wrists. There were no complications related to the core decompression. Conclusions In this limited series, the radius core decompression demonstrated favorable long-term results and could be considered as a surgical alternative for stage IIIA of Kienböck disease. (J Hand Surg Am. 2017;-(-):1.e1-e6. Type of study/level of evidence Therapeutic IV.

En août 2016 (Finnerup et al., PAIN®), un groupe d’experts internationaux a publié un NOUVEAU consensus quant au diagnostic des douleurs neuropathiques. Un algorithme a été proposé, où la neurographie sensitive pure n’est que la dernière de quatre étapes – et NON pas la seule et unique façon de diagnostiquer des douleurs neuropathiques . Ces quatre étapes d’un raison-nement clinique qui mènent au diagnostic de douleurs neuropathiques sont les suivantes :
1. La plainte du patient ;
2. L’anamnèse clinique ;
3. L’examen clinique ;
4. La neurographie sensitive pure.

Ce groupe d’experts a été mandaté par l'International Association for the Study of Pain (IASP), sous l’égide de son ancien président, médecin allemand et professeur de neurophysiologie : Prof. Dr. med. Rolf–Detlef Treede.

La troisième édition de l’Atlas des territoires cutanés pour le diagnostic des douleurs neuropathiques vient de paraître chez Sauramps Médical. Les deux premières avaient été préfacées par Bernard Moxham (Cardiff, Royaume-Uni) et par Stephen Carmichael (Rochester, États-Unis), celle-ci l’a été par John Fraher (Cork, Irlande). À partir de 2519 patients et des données de 97 ouvrages d’anatomie consultés, les auteurs définissent les territoires cutanés des nerfs spinaux et de leurs branches principales en précisant les bornes limitrophes de leur territoire maximal de distribution, et leur territoire autonome, qu’elles ne partagent avec aucun autre nerf.

Une atteinte partielle des nerfs périphériques peut entraîner des phénomènes douloureux neuropathiques, associés à des troubles de la sensibilité, tels qu’une hypoesthésie tactile ou une allodynie mécanique. Si elles ne sont pas traitées, les douleurs neuropathiques peuvent devenir chroniques et affecter la qualité de vie des patient·e·s. La méthode de rééducation sensitive de la douleur est une technique non invasive qui permet d’évaluer et de traiter les troubles somesthésiques afin, essentiellement, de diminuer les douleurs neuropathiques spontanées – névralgie – et/ou provoquées – allodynie mécanique. Elle est enseignée depuis 2001 et compte, à ce jour, 1348 clinicien·ne·s de 42 pays d’origines différentes qui sont organisé·e·s en une communauté de pratique. Elle est fondée sur le concept novateur de la plasticité neuronale adaptative du système nerveux somatosensible et sur le renversement de certains mécanismes de sensibilisation, même de nombreuses années après l’apparition des troubles. Dans cette méthode, une grande place est donnée à l’évaluation de la sensibilité cutanée. Une cartographie précise de ces troubles de la sensibilité permet de mettre en œuvre un traitement rééducatif adapté, à l’aide d’une ou plusieurs des cinq techniques. L’enseignement d’exercices pluriquotidiens à réaliser à domicile et l’évaluation de l’évolution des symptômes sensitifs des patient·e·s sont ensuite effectués lors de chaque séance hebdomadaire.

INTRODUCTION: Hypermobility of the carpometacarpal (CMC) joint is a well described etiological factor in the development of thumb arthritis. Hypermobility leads to joint subluxation and osteoarthritis secondary to resultant joint incongruity. We hypothesize that activation of the
First Dorsal Interosseous (FDI) muscle will radiographically reduce subluxation of the 1st metacarpal relative to the trapezium.

METHODS: Subjects at least 18 years old were recruited. Exclusion criteria included positive grind test, pregnancy, and major conditions of ligamentous laxity. A certified hand therapist performed a grind test on all subjects. Using a hand-held manometer, maximal voluntary
contraction of the FDI as measured by the Rotterdam Intrinsic Myometer; lateral pinch strength, and grip strength were measured. Fluoroscopy was used to obtain true AP radiographs of the
CMC joint at (1) rest, (2) while stressed without activation of the FDI, and (3) while stressed with activation of the FDI. Radial subluxation of the base of the first metacarpal and metacarpal width
were measured by 3 blinded surgeons as described by Wolf (2011). The ratio of radial subluxation to the articular width was calculated.

RESULTS: Seventeen subjects with 34 thumbs including 5 males and 12 females participated. Average age was 25.9 (21-59). Thirteen right-handed, 1 left-handed, and 3 ambidextrous subjects were included. Two thumbs were excluded for a positive grind and one for poor
radiograph quality. Thirty-one thumbs were evaluated. Average maximal voluntary contraction of the FDI was 27N, lateral pinch 81N, and grip strength 347N. Twenty-six thumbs demonstrated subluxation when stressed and reduction after firing of the
FDI. Three thumbs were not subluxed at rest and did not sublux with stress, consistent with stiff CMC joints. Two thumbs were subluxed at rest but did not further sublux with stress. Inter-rater reliability was high (96%). In the 26 thumbs that demonstrated increased subluxation with stress, subluxation while stressed averaged 48% (29-75) of metacarpal articular width. FDI activation reduced subluxation by an average of 80% (20-120). The two thumbs with the same degree of subluxation at rest and with stress had subluxation 43% and 63% of articular width. Reduction with FDI activation was 67% and 28%, respectively.

CONCLUSION: The FDI radiographically reduces subluxation of the thumb CMC joint.Strengthening the FDI may be effective in preventing thumb arthritis.

Tout patient souffrant de douleurs neuropathiques aiguës ou chroniques et présentant une allodynie mécanique au niveau du membre supérieur, c’est-à-dire une « hypersensibilité » au toucher, peuvent bénéficier d’un traitement de rééducation sensitive, par la technique de contre stimulation vibrotactile à distance. La mise en place et la bonne évolution du traitement est dépendante non seulement de la sévérité de l’atteinte, mais aussi de facteurs personnels, environnementaux et des habitudes de vie propre à chaque patient. Et n’oublions pas l’importance de l’évaluation rigoureuse, et de l’ « éducation thérapeutique » donnée par le thérapeute.

As a Regimental Medical Officer to an Infantry Battalion you are seeing your first patient of the day. The soldier concerned has recently joined the unit and during platoon PT has 'gone over on his ankle'. Following appropriate assessment in the local Emergency Department, he has been given a compression bandage and some anti-inflammatories. His platoon sergeant is keen that you see him in order that he is 'fit for the JNCO cadre' starting the following week.

The aim of this retrospective study was to analyse the results of 20 thumb replantations with special and
exhaustive attention on functional outcomes. Twenty patients with traumatic thumb amputation were
enrolled in the study. Range of motion, grip strength, sensory recovery, and subjective perception of
overall hand function recovery were measured. The average age at the time of surgery was 35 years
(range, 13–73 years). The mean follow-up was 3.25 years (range, 1.9–10.25 years). The long-term results
of thumb replantation confirmed satisfactory outcomes in terms of general upper limb function,
handgrip and pinch strength, and social and work reintegration. Sensory recovery remained
unsatisfactory despite the fact that we did not need to perform any kind of revision surgery as a
consequence of inadequate thumb sensibility. For the first time in the existing literature, no functional
parameter that contributes to the assessment of the function of replanted thumbs has been excluded. We
resume in the same study the analysis of all functional parameters that are useful to define results of
thumb replantation.

There is every reason to believe it is an inflammation: a red, swollen, warmer hand or foot with boiling-burning sensations in the joint. All these appalling symptoms leaving the person exhausted following a night of restless sleep. In Budapest, after three days of deliberations, a consensus meeting of 38 experts validated the precise diagnostic criteria of this syndrome: the Complex Regional Pain Syndrome (CRPS). NOT incurable.

Background Thoracic neuropathic pain may be related to an area of altered skin sensation over the territory of cutaneous thoracic branches. The somatosensory rehabilitation method (SRM), a non-pharmacological treatment, focuses on the detection, classification and treatment of this condition. The aim of this prospective observational case series of 66 thoracic neuropathic pain patients (tNPP) was to evaluate a management algorithm of two different types of neuropathic pain: spontaneous ongoing neuropathic pain (type A) and touch-evoked neuropathic pain (type B). Material and methods The authors precisely explain the assessment and treatment algorithm for findings of tactile hypoaesthesia versus static mechanical allodynia (SMA). 66 chronic tNPP referred in a single centre were assessed by two mapping techniques of the skin A) aesthesiography (in case of tactile hypoaesthesia) or B) allodynography (in case of SMA) and pre/post treatment evaluations with the McGill pain questionnaire (MPQ). In clinical practice, hypoaesthetic territories were treated by basic somatosensory rehabilitation. Allodynic territories were treated initially by distant vibratory counter-stimulation (DVCS), then by basic somatosensory rehabilitation once the allodynia disappeared. Results All tNPP presented somatosensory abnormality on at least one damaged cutaneous thoracic branch: 52 hypoaesthetic and 47 allodynic. At a mean of 76 days, 34 of these 47 were converted by DVCS into hypoaesthetic territory, which finally is amenable to treatment by basic somatosensory rehabilitation. 61 % of the tNPP treated with SRM had a pain reduction of at least 50% on the MPQ. Conclusion These observations illustrate a management algorithm for assessing and treating A) hypoaesthesia and B) SMA.

Les critères diagnostiques du SDRC tels qu’ils sont présentés
dans le Tableau 3 sont aujourd’hui incontournables
[5,11]. Ce syndrome de douleur continue se manifeste
comme une sensation de cuisson, associée à un dysfonctionnement
vasomoteur, sudomoteur et ultérieurement à des
troubles trophiques. Pour permettre la comparaison des
études concernant le SDRC, nous proposons d’utiliser les
critères de Bruehl et al. [5] (Tableau 3). En dehors de la
recherche clinique, les « critères de Budapest », moins restrictifs
(au minimum un symptôme présent dans trois caté-
gories) (Tableau 3), peuvent être utilisés. Enfin, notez que,
depuis 2011 et jusqu’à nouvel avis, les anciens critères de
l’IASP ne sont plus reconnus par cette association. De nouvelles
données, en particulier la progression de la connaissance
des mécanismes sous-tendant le SDRC, pourraient
conduire à une évolution des critères diagnostiques de ce
syndrome.

To the readers of e-News Somatosens Rehab and to those who will read this article by reference, I am delighted to count you among this growing network and to notice that we share a common interest, namely the management of neuropathic pain and their symptoms via somatosensory rehabilitation.

Let me introduce myself. I am an occupational therapist working in a private clinic since 2014, also practicing with a physical and mental health clientele living with chronic pain.

Having a keen interest in understanding and managing pain, I completed a 2.5-year graduate certificate on chronic pain management at McGill University. Still not having satisfactory answers concerning the management of neuropathic pain after my graduation in 2018, I followed the training on somatosensory rehabilitation of pain the next year.

It was during this training that I saw great potential in the approach and came to realize that I could have used it with my past problematic cases of neuropathic pain. Unfortunately, their condition had been ignored/not treated effectively by all of the professionals in their file, due to a lack of knowledge.

Agenesis, functional deficiency and the common type of the flexor digitorum superficialis of the little finger: A meta-analysis Age´ne´sie, de´ficit fonctionnel, et variations anatomiques les plus courantes du flexor digitorum superficialis de l'auriculaire : une me´ta-analyse Agenesis, functional deficiency and the common type of the flexor digitorum superficialis of the little finger are reported in the literature to be highly variable with significant discrepancy between clinical and cadaveric frequencies. The aim of this systematic review was to generate overall clinical and cadaveric weighted frequencies, along with ancestry-based, side-based, sex-based and laterality-based frequencies. A systematic literature search identified 34 studies including 12,213 forearms/hands that met the inclusion criteria. Functional deficit of the FDS tendon of the little finger was significantly more prevalent among Iranian and Caucasian populations as compared to Indian, East African and Chinese populations. The weighted ''clinical'' frequency of functional absence of the FDS tendon of the little finger was 7.45%, while prevalence of the common type was 37.5%. The weighted ''cadaveric'' prevalence of muscle absence of the FDS-5 in the forearm was 2.5% while tendon absence in the hands was nil. An expanded examination technique proved to be the most accurate test for FDS function. In case of injury, inadequate knowledge of different connections or substitutions of the FDS-5 could lead to a total loss of flexion of the little finger. These findings support the hypothesis of a dual origin of the FDS-5 where the muscle portion originates in the forearm, while the tendon portion originates in the hand. C 2018 SFCM. Published by Elsevier Masson SAS. All rights reserved. R E ´ S U M E ´ L'agé né sie, le dé ficit fonctionnel et les variations anatomiques les plus courantes du flexor digitorum superficialis de l'auriculaire (FDS-5) sont rapporté s dans la litté rature avec une grande variabilité et une divergence significative entre les fré quences cliniques et cadavé riques. Le but de cette revue systé matique e ´ tait de gé né rer des valeurs pondé ré es de fré quence clinique et cadavé rique avec celles basé es sur l'ethnicité , le côté , le sexe et la laté ralité. Une recherche systé matique dans la litté rature a identifié 34 e ´ tudes, comprenant 12.213 avant-bras et mains, et remplissant les critè res d'inclusion. Le dé ficit fonctionnel du tendon du FDS-5 e ´ tait significativement plus fré quent parmi les populations iraniennes et caucasiennes que parmi les populations indiennes, chinoise et de l'Afrique de l'Est. La fré quence clinique pondé ré e de l'absence fonctionnelle du tendon du FDS-5 e ´ tait de 7,45 % tandis que celle du type commun e ´ tait calculé e a ` 37,5 %. La pré valence cadavé rique pondé ré e de l'absence du muscle FDS-5 a ` l'avant-bras e ´ tait de 2,5 % et celle de son tendon a ` la main e ´ tait de 0 %. La technique de G Model HANSUR-198; No. of Pages 9 Please cite this article in press as: Yammine K, Eric´M. Agenesis, functional deficiency and the common type of the flexor digitorum superficialis of the little finger: A meta-analysis. Hand Surg Rehab (2018), https://doi.

Clinicians and researchers work hand in hand to investigate and understand functions und dysfunctions of pain. So could we dream of a life without pain ? Certainly not, when it comes to its function as a necessary protection mechanisms that accompanies us through our development. But when it comes to pain that becomes a conqueror who invades our bodies we dare to dream of a life without it.

Background: Hand trauma is a top presenting complaint to hospital emergency departments (EDs) and can become costly if not treated effectively. The cornerstone for initial management of the traumatized hand is application of a splint. Improving splinting practice could potentially produce tangible benefits in terms of quality of care and costs to society. Objectives: We sought to determine the following: 1) whether the present standard of ED splint-ing was appropriate and 2) whether a strategically planned educational intervention could improve the existing care. Methods: We used a pre-and postprospective educational intervention study design. In the preintervention phase, patients referred to our hand clinic were assessed for injury and splint type. Splinting appropriateness was evaluated according to a predetermined hand surgeons' expert consensus. Next, an educational intervention was targeted at all ED staff at our institution. Postintervention, all patients were again evaluated for splint appropriateness. A follow-up evaluation was performed at 1 year to see the long-term effects of the intervention. Results: The most common mechanism of injury of referred patients was falling (35%), and the most frequent injury was metacarpal fracture (40%). Splint appropriateness increased significantly postintervention from 49% to 69% (p = 0.048). At follow-up after 1 year, splinting appropriateness was 70% (p = 0.041). Conclusion: Appropriate hand splinting practice is essential for hand trauma management. Our results show that an educational intervention can successfully improve splinting practice. This quality of care initiative was low-cost and demonstrated persistence at 1 year of follow-up.

Application of carbon-fiber-reinforced-polymer (CFRP) artifacts in humans has been promoted in Orthopedic and Trauma Surgery. Literature documents the biocompatibility of materials used, namely carbon fibers (CF) and poly-ether thermoplastics, like poly-ether-ether-ketone (PEEK). A properly designed and accurately implanted composite artifact should not expose its fibers during or after surgery: however this may happen. A white Caucasian woman came to our attention 11 months after surgery for a wrist fracture. She had a severe impairment, being unable to flex the thumb; index finger and distal phalanx of third finger. We retrieved a correctly positioned plate and documented an aggressive erosive flexor tendons synovitis with eroded stumps of flexor tendons. The plate and soft tissues were analyzed by Visible Light and Scanning Electron

Who has never suffered from pain? It does not matter if this pain was physical or emotional. Oh God, and how difficult it is to describe it! Many times the people around us do not seem to understand the extent of our pain. And this is legitimate. Each one interprets his/her pain according to his/her own threshold of pain, but also, in relation to previous experiences of pain. These experiences are either from situations we have lived ourselves or from the observation of the suffering of others.

Imagine that you are a therapist. A young woman has just arrived in the waiting room of your clinic while you are treating another patient. You notice that she is wearing a splint on her left hand and holding her left arm in a protective manner. At that moment, you remember that she is under investigation for a complaint of pain in her left hand. You also remember reading in her medical record that she is twenty-three years old and had a high-speed car accident in which she sustained a displaced fracture of the distal end of the radius five months ago. The fracture was treated with a cast below the elbow. Two weeks after the accident, she complained of numbness in her hand, along the ulnar border. After removing the cast, eight weeks post-injury, she still complained of pain in her hand.

Study Design: Retrospective cohort study.
Introduction: Somatosensory rehabilitation is a standardized method of evaluation and conservative treatment of painful disorders of vibrotactile sensation, including the mechanical allodynia and burning pain of complex regional pain syndrome (CRPS).
Purpose of the Study: The purpose of this study was to examine the effectiveness of somatosensory rehabilitation for reducing allodynia in persons with CRPS of 1 upper limb in a retrospective consecutive cohort of patients.
Methods: An independent chart review of all client records (May 2004-August 2015) in the Somatosensory Rehabilitation Centre (Fribourg, Switzerland) identified 48 persons meeting the Budapest criteria for CRPS of 1 limb who had undergone assessment and treatment. Outcomes of interest were the French version of the McGill Pain Questionnaire (Questionnaire de la Douleur St-Antoine [QDSA]), total area of
allodynia as recorded by mapping the area of skin where a 15-g monofilament was perceived as painful, and the allodynia threshold (minimum pressure required to elicit pain within the allodynic territory).
Results: This cohort was primarily women (70%), with a mean age of 45 years (range: 18-74). Mean duration of burning pain was 31 months (range: 1 week-27.5 years), and baseline QDSA core was 48. The average primary area of allodynia was 66 cm2 (range: 2.6-320), and the most common allodynia threshold was 4.0 g. The average duration of treatment was 81 days. At cessation of treatment, the average QDSA score was 20 (effect size Cohen’s d ¼ 1.64). Allodynia completely resolved in 27 persons (56% of the total sample where only 58% completed treatment).
Discussion: This uncontrolled retrospective study suggests that somatosensory rehabilitation may be an effective treatment with a large effect size for reducing the allodynia and painful sensations associated with CRPS of the upper limb. More work is in progress to provide estimates of reliability and validity for the measurement tools for allodynia employed by this method.
Level of Evidence: 2c.