Background. Traditional teaching recommends against arthroplasty in the index finger, due to concerns over failure with pinch stress, and prefers arthrodesis is for its stability. We aim to allay these fears and present the results of our series of index finger silastic PIPJ arthroplasties. Methods: Between 2007 & 2018 48 silastic index finger PIPJ arthroplasties were undertaken in 37 patients at our Hand Unit. All were performed under local anaesthetic ring block. Eleven patients underwent PIPJ arthroplasty in both Index fingers. Thirty-five women and two men made up the cohort with a mean age of 69 years. A retrospective analysis of all patients has been undertaken to determine the clinical results including patient satisfaction, grip and pinch strength and reoperation rates. Mean follow up was 5.1 years. Results. Six index fingers developed ulnar deviation greater than 10 degrees and there were five reoperations (10.2%). There was an excellent arc of movement of mean 44 degrees with high patient satisfaction and functional scores (mean VAS pain score 1.1, Quickdash 34, PEM 44). 90% of patients would undergo the procedure again and no patient would prefer a fusion. Conclusions: Silastic Interposition arthroplasty of the PIPJ of the Index finger is a durable procedure with excellent clinical outcomes. Our large study refutes the established technique of arthrodesis for Index finger OA, with low incidence of ulnar deviation and excellent patient satisfaction

The digital nerves to the thumb and index finger have been studied by dissecting twenty-five embalmed upper limbs. The palmar digital nerves to the thumb were constant in position and course, with a short lateral cutaneous branch from the radial palmar digital nerve in 30 per cent of cases. The palmar digital nerves to the index finger had a variable pattern, the commonest arrangement, well described in Gray's Anatomy, occurring in 74 per cent of cases. The variations and their frequency are described. By examining histological cross-sections of the index finger it was found that of about 5,000 endoneurial tubes entering the finger, 60 per cent passed beyond the distal digital crease to supply the pulp and nail bed. The depth of the palmar digital nerves was about 3 millimetres, but less at the digital creases, and their diameter lay between 1 and 1·5 millimetres as far as the distal digital crease. Clinical applications of the findings are discussed

We have reviewed 11 patients with congenital absence of the thumb, treated by pollicisation of the index finger, after follow-up for 20 to 38 years. Seven of the hands also had an associated radial club-hand deformity. Function as assessed by the Percival score was excellent in six, good in three, fair in two and poor in four; three of the poor results were in patients with radial club hand. Ten of the 15 transfers were used as normal thumbs, but in five hands function required trick movements. Of the seven unilateral cases, two transplants were used as the dominant hand, and in another two thumb strength was more than 50% of that on the opposite side. For patients with isolated congenital absence of the thumb, pollicisation of the index finger gives good functional and cosmetic results which are maintained. The results are less reliable for those with radial club hand

Author’s experience in surgical treatment of aplasia of the thumb according to the Buck-Gramcko procedure introduced by this author in 1971 is reported. Inidcation of the pollicization of the index finger according to Buck-Gramcko is aplasia of the thumb in the 3rd, 4th and 5th stages (Blauth’s classification). The surgical technique is particulary complex because of knowledge of microsurgery and soft-tissue reconstruction necessary. The different surgical phases may be schematically divided into a cutaneous stage which calls for the reconstruction of the web space, a vacular stage, a skeletal stage in which the reduction of the trapezium radial I metacarpal is reduced and a miotendinous stage. Surgery is carried out on patients of at least one year of age as it is necessary their cardial-pulmonary system be adequately mature, development of the endostal circle, thicker vascular walls and a suitably developed bimanual grasp, as well. The revision of these cases treated is especially significant because an average follow-up of the 17 years puts in good light the functionality of the hand, both from the points of view of strength and movement (Percival’s classification). After a revision of the case studies with a long term f.-u. we may affirm that the pollicization of the index finger according Buck-Gramcko, to achieve the development of the first finger in opposition, is the best-choice surgery in the reconstruction of the aplasial thumb and owes its effectiveness to the association of microsurgical techniques for preparing an island pedicle composite-tissue flap to the cardinal principles of articular reconstruction and of tendon transfers

The October 2024 Wrist & Hand Roundup360 looks at: Circumferential casting versus plaster splinting in preventing redisplacement of distal radial fractures; Comparable outcomes for operative versus nonoperative treatment of scapholunate ligament injuries in distal radius fractures; Perceived pain during the reduction of Colles fracture without anaesthesia; Diagnostic delays and physician training are key to reducing scaphoid fracture nonunion; Necrotizing fasciitis originating in the hand: a systematic review and meta-analysis; Study design influences outcomes in distal radial fracture research; Long-term results of index finger pollicization for congenital thumb anomalies: a systematic review; Enhancing nerve injury diagnosis: the evolving role of imaging and electrodiagnostic tools

Linburg-Comstock syndrome is characterised by an anomalous tendon slip from the flexor pollicis longus to the flexor digitorum profundus, usually of the index finger. An incidence as high as 60% to 70% has been reported. Post-traumatic inflammation of inter-tendinous connections between the flexor pollicis longus and flexor digitorum profundus, usually of the index finger, may cause unexplained chronic pain in the distal forearm. A total of 11 patients (eight females, three males), mean age 29.1 years (14 to 47) with a clinical diagnosis of Linburg-Comstock syndrome underwent surgical release of the inter-tendinous connection. The mean follow-up was for 27 months (2 to 48). Ten patients reported excellent relief of pain in the forearm, with independent flexion of flexor pollicis longus and flexor digitorum profundus to the index finger. Surgical release was an effective treatment for the Linburg-Comstock syndrome in this series

Aims: To describe a new & safe technique of gradual distraction for pollicisation of index finger, to which the blood supply is doubtful. This procedure was used in cases where conventional methods of pollicisation are not possible or are risky. Methods: This technique has been utilised in 5 cases (2 traumatic loss of thumb at carpo-metacarpal joint, and 3 cases of absence of thumb associated with radial club hand). The age group was 3–18 years. The procedure consisted of first stage, a webplasty between second & third fingers, osteotomy of the base of second metacarpal and gradual wide abduction of the index finger by distraction. In second stage, the second metacarpal is recessed and rotated, to the position of thumb. At third stage, tendon transfer may be needed for securing the forceful opposition. Results: In all operated 5 cases, desired position of the thumb was obtained along with good function. Conclusion: Gradual distraction for pollicisation may be used in cases where the blood supply of index finger is not based on known specific blood vessel but depends on collateral blood supply. Conventional methods cannot be used or are risky. This technique provides a safe and economical alternative for reconstruction of the thumb, which is a new addition to the armamentarium in thumb reconstruction

We studied 21 patients with a spontaneous palsy of the anterior interosseous nerve. There were 11 men and 10 women with a mean age at onset of 39 years (17 to 65). Pain around the elbow or another region (forearm, shoulder, upper arm, systemic arthralgia) was present in 17 patients and typically lasted for two to three weeks. It had settled within six weeks in every case. In ten cases the palsy developed as the pain settled. A complete palsy of flexor pollicis longus and flexor digitorum profundus to the index finger was seen in 13 cases and an isolated palsy of flexor pollicis longus in five. All patients were treated without operation. The mean time to initial muscle contraction was nine months (2 to 18) in palsy of the flexor digitorum profundus to the index finger, and ten months (1 to 24) for a complete palsy of flexor pollicis longus. An improvement in muscle strength to British Medical Research Council grade 4 or better was seen in all 15 patients with a complete palsy of the flexor digitorum profundus and in 16 of 18 with a complete palsy of flexor pollicis longus. There was no significant correlation between the duration of pain and either the time to initial muscle contraction or final muscle strength. Prolonged pain was not always associated with a poor outcome but the age of the patient when the palsy developed was strongly correlated. Recovery occurred within 12 months in patients under the age of 40 years who achieved a final British Medical Research Council grade of 4 or better. Surgical decompression does not appear to be indicated for young patients with this condition

Background. Bouchard -arthrose is often familial and affect predominantly females. It starts as acute inflammation of the soft tissue and with time may progress to severe deformity and limitation of movement. In the early phases one of the most commen operation in the management is the synovialectomy. In late stages with severe destruction and deformity of the joint arthrodesis can be carried out. However, arthrodesis may lead to severe loss of function. One of the most commonly and world wide used prothesis to maintain movement is the Swanson –spacer. Material and Methods. 20 Swanson-implants in 14 patients (12 female,2 male) were evaluated subjectively and objectively using PIJA-score (Interphalangeal-joint –score) and Dash –score. The follow period was 4.6 years (range 1-11 years). Results. The IPJA-score ranged 8-14 points (median 11.8) and the median Dash- score was 28 points. Improvement of pain was oberserved in 90% of the cases. Flexion more than 30° in 85% and full extention in 75%. Ulnar deviation was noted in 7 patients (35%), mostly of the index finger. Fracture of the prothesis occurred only in 1 case. No loosening was observed radiologically. Discussion. Swansin prothesis is good alternative to arthrodesis and be restricted only in cases where the musculotendinous structures are intact. In cases where the index finger is affected, arthrodesis is preferred

Clinician expectation and anatomical studies suggest that the distribution of sensory dysfunction in carpal tunnel syndrome (CTS) should be confined to the thumb, index, middle and half of the ring fingers. We mapped the distribution of disturbance to evaluate the accuracy of these assumptions. We evaluated 64 wrists in 64 patients with nerve conduction study confirmed CTS. Each patient filled out a Katz hand diagram and we collated the distribution of pain and non-painful (tingling, numbness & decreased sensation) sensory disturbance. Frequency of reporting was analysed; dividing symptoms into thenar and hypo-thenar eminence, distal palm, each digit, posterior hand and forearm. Non-painful sensory disturbance occurred in all patients. The index finger was the most common location (94%) followed by the middle finger (91%), the distal palm (84%), the ring finger (72%), the thumb (69%), the thenar eminence (63%), the little finger (39%), the dorsal hand (31%), the hypothenar eminence (25%) and the forearm (13%). Pain was less common, reported in 59% of cases. Pain occurred most frequently over the wrist crease (33%) followed by thenar eminence (27%), the forearm (20%), the middle finger (23%), the index finger (22%), the ring finger (19%), the distal palm (16%), the thumb (14%), the dorsal hand (11%), the little finger (11%) and least frequently the hypothenar eminence (6%). In CTS sensory disturbance occurs most frequently in the median nerve distribution; however it occurs almost as often elsewhere. An atypical distribution of symptoms should not discourage diagnosis of CTS

Purpose. To analyse the early results of unconstrained pyrocarbon joint replacements in patients with osteo-arthritis of the metacarpo-phalangeal joints. Background. Silicone arthroplasty, as introduced by Swanson in 1962 has remained the most popular procedure to treat arthritis of the metacarpo-phalangeal (MCP) joints. However, despite providing good pain relief, they have shown to demonstrate breakage rates up to 82% at 5 years. This is of great concern in the osteoarthritis (OA) patient group, who tend to be younger and have higher functional demands compared to their rheumatoid counterparts. The newer unconstrained pyrolytic carbon MCP joint prostheses may therefore be more suitable in OA patients whose soft tissue constraints are intact and whose hand function is strong. This study is the first to analyse the results of this implant in a cohort of OA patients only, with prospective data. Methods. 19 primary pyrocarbon metacarpo-phalangeal joint replacements, in 11 patients (5 men and 6 women) were reviewed, with prospective data collection. The diagnosis was primary osteoarthritis in all patients. The mean age at operation was 66.4 years (range 55–82 years). 2 patients underwent concomitant trapiezectomy and one underwent DIPJ fusion. All patients were right hand dominant −75% underwent surgery in their dominant hand. Eleven of the nineteen joints were performed in the index finger, with the remainder in the middle finger. Mean follow up is 22.1 months (range 11–37). Results. At the 3 month post-operative hand therapy assessment, the arc of motion had improved from a mean of 32 degrees to 45 degrees and flexion had improved from a mean of 51 degrees to 66 degrees. Grip strength improved from a mean 20 to 27Kg. DASH scores significantly improved from a mean of 40 to 10 (p=0.01). All patients were satisfied with their outcomes and would have the surgery again. Pre-operative radiographs demonstrated joint narrowing in all patients but no evidence of heterotopic ossification, cystic change or erosions. Post-operatively, there has been no radiographic evidence of joint dislocation, resorption stress-shielding, loosening, migration or heterotopic ossification. There were three intra-operative complications of phalangeal fractures that were immediately treated with a cerclage wire. In one patient there has been a fracture of the proximal phalangeal implant at 14 months which was asymptomatic. One patient has required revision for mal-rotation of the implant leading to loss of index finger supination. Conclusion. Our results demonstrate excellent early results of pyrocarbon MCP joint arthroplasty in OA patients

1. The intrinsic paralysis that occurs in leprosy has been treated by the sublimis transfer of Stiles and Bunnell for the past nine years. Since 1951 300 hands have been operated upon, and 150 patients selected geographically have been followed up in this study. 2. The patients have been assessed by a standard method involving: 1) Measurement of range of movement of the interphalangeal joint (unassisted movement, assisted active movement and passive movement); 2) grasp index; and 3) photographs of each hand in six standard positions. 3. Assessment of the open hand—The Stiles-Bunnell procedure is effective in achieving a fully open hand: 73 per cent of the fingers scored good or excellent results. A defect in the operation is that it sometimes hyperextends the interphalangeal joint, producing an "intrinsic plus" hand. 4. Assessment of sequence of joint flexion—The Stiles-Bunnell operation restores satisfactory mechanism of closure of the hand in 93 per cent of cases—that is, the metacarpo-phalangeal joints flex before the interphalangeal joints. 5. The closedfist assessment—About 30 per cent of patients had some defect in the complete closure of the fist after operation. In 5 per cent of cases the fingers did not reach the palm after operation. 6. Complications—The "intrinsic plus" defect is commonest in the best and most mobile hands. This is a late complication which gets worse in succeeding years. It can be corrected by Littler's operation together with a profundus tenodesis in the middle segment of the finger. Lateral deviation of fingers due to radial-side attachment of the transferred tendon can be avoided by ulnar-side attachment of the tendon used for the index finger. Bowstringing of the sublimis stump in the flexor sheath may be avoided by division of the sublimis at it insertion. Weakness of grasp and pinch from loss of sublimis may be avoided by using only one or two sublimis tendons split into several strands. The index finger sublimis should be left in position. 7. It is concluded that the sublimis transfer of Stiles and Bunnell is a very powerful corrective of intrinsic paralysis of the fingers. Its chief defect is that it is too powerful and produces the opposite deformity. For this reason the use of this operation should be restricted to fingers in which there is some limitation of passive extension. For fully mobile fingers an operation should be selected which does not remove the sublimis from its normal position

Objective. We explanted NeuFlex metacarpophalangeal (MP) joint prostheses to identify common features, such as position of fracture, and thus better understand the reasons for implant failure. Methods. Explanted NeuFlex MP joint prostheses were retrieved as part of an-ongoing implant retrieval programme. Following revision MP joint surgery the implants were cleaned and sent for assessment. Ethical advice was sought but not required. The explants were photographed. The position of fracture, if any, was noted. Patient demographics were recorded. Results. Thirty NeuFlex MP explants were available. Seven (23%) were not fractured. Eleven explants (37%) had fractured at the hinge; nine (30%) had fractured at the junction of the distal stem and hinge; and three (10%) had fractured at both the hinge and distal stem. NeuFlex MP joint explants ranged in size from 0 to 40. Smaller sizes were retrieved from smaller fingers; larger implants came from the middle and index fingers. The age at revision ranged from 43 to 81 (median 58) years. Time in vivo ranged from 6 to 120 (median 58.5) months. All but two implants were obtained from rheumatoid joints, the remainder had osteoarthritis. Discolouration of some explants had occurred; other explants appeared to show no colour change. Conclusions. This is the first report of the position of fracture of NeuFlex explants. It is also the largest report of silicone arthroplasty explants. The majority (77%) had fractured. Nine (30%) NeuFlex explants had fractured at the junction of the distal stem and hinge; the typical position seen with Swanson and Sutter/Avanta MP joint explants. Eleven (37%) fractured across the hinge; this has not previously been reported although has been seen in in vitro testing. The hinge is thinner than the hinge-stem junction so may be at risk of more rapid failure, however the median time in vivo for hinge fractures was 63 months as opposed to 54 months for fractures at the distal stem. Intriguingly, 3 (10%) NeuFlex explants suffered fractures both at the hinge and at the junction of the distal stem and hinge which has also never been reported previously. Fracture at the junction of the distal stem and hinge shows the importance of subluxing forces in rheumatoid MP joints and therefore suggests these need to be mitigated as much as possible. Fracture across the hinge could indicate this as a position which could be increased in thickness, to increase the time taken to fracture, although there may be a concomitant increase in stiffness of the implant. With improved designs, patients might suffer fewer or later failures. The latest Norwegian Arthroplasty Registry report shows that revision MP joint arthroplasties accounted for 42% of all MP joint replacement operations in 2015. Therefore, this is an important area where opportunities exist to reduce revision rates

This annotation reviews current concepts on the three most common surgical approaches used for proximal interphalangeal joint arthroplasty: dorsal, volar, and lateral. Advantages and disadvantages of each are highlighted, and the outcomes are discussed.

Cite this article: Bone Joint J 2022;104-B(12):1329–1333.

A case of intramedullary neurilemmoma of the terminal phalanx of the right index finger is reported, and the cases previously reported are briefly reviewed

1. Three cases of cement injection into the tissues of the thumb and index finger are recorded. 2. This is probably the first description of this type of injection injury. 3. Recommendations are made for the prevention of the injury

Aggressive digital papillary adenocarcinoma (ADPACa) is a rare skin adnexal tumour, which has a predilection for the digits. We report a case with this tumour in a 51 year old insulin dependent diabetic man, who presented as a paronychia of right index finger. After histopathological confirmation as an ADPACa partial amputation was performed. This case emphasizes the presentation of this tumour as a simple nail bed infection occasionally

1. Two cases of locking of the metacarpo-phalangeal joint of the index finger are presented. 2. A simple classification of metacarpo-phalangeal joint locking is suggested, and the clinical features of the two main groups—degenerative and spontaneous—are described. 3. A routine approach to the treatment of the condition is suggested