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Background Recurrent severe Dupuytren contracture of the small finger’s proximal interphalangeal (PIP) joint is a difficult problem. Further surgery carries high risk of complications and poor outcome. Patients are often offered finger amputation. We have devised a novel surgical procedure consisting of middle phalanx monoblock resection and ligament reconstruction to create a new functioning interphalangeal joint. Methods Two patients requesting small-finger amputation because of severe PIP joint contracture after multiple treatments for Dupuytren contracture were offered and accepted this new procedure. Through a dorsal incision the extensor tendon is incised longitudinally exposing the middle phalanx and interphalangeal joints. The collateral ligaments of both interphalangeal joints are detached from the middle phalanx. The middle phalanx is dissected from soft tissues (including the flexor digitorum superficialis tendon) and removed. The distal phalanx is brought proximally and the ends of the collateral ligaments are sutured with non-absorbable sutures with the joint held in full extension and congruency. The two patients were evaluated at 18 months and 15 months after surgery, respectively. Results Both patients regained good finger posture with almost full extension and had normal sensation and no pain. Active flexion in the new interphalangeal joint was 60 degrees and 35 degrees, respectively. Both patients had full metacarpophalangeal joint flexion and extension, normal 2-point discrimination in the small finger and higher grip strength in the treated than the contralateral hand. Radiographs showed a congruent new interphalangeal joint. Both patients were very satisfied with the outcome. Conclusions In patients with Dupuytren disease and severe PIP joint contracture after multiple treatments, this novel procedure consisting of middle-phalanx excision and ligament reconstruction creating a new functioning interphalangeal joint has good short-term outcomes and is a favorable alternative to finger amputation. Longer follow-up will show whether these results are durable.

Background Clinical series have been published using the configuration of 2 intercarpal Kirschner wires (K-wires) adjacent to the fracture being connected, but biomechanical analysis is lacking. The objective of this pilot biomechanical study was to model and compare the effects of externally connecting 2 intermetacarpal K-wires for the stabilization of transverse metacarpal shaft fractures. Our research hypothesis was that the connected constructs would be stiffer than the unconnected K-wires. Methods A 3-dimensional computer-based model of small finger transverse metacarpal fracture stabilization was designed with 3 transverse 1.1 mm K-wires being anchored to the adjacent metacarpal. Three arrangements were tested: all 3 K-wires in parallel, the middle K-wire angled toward the proximal wire, and the middle angled K-wire being rigidly fixed to the proximal K-wire. The proximal wire was proximal to the fracture. A finite element analysis was performed by applying a cantilever force of 100 N at the head of the metacarpal. The metacarpal was considered to be uniform in composition with parameters typical for human bone. Kirschner wire parameters for stainless steel were used. Force (N) versus displacement was measured. Results The configuration with the middle angled K-wire being rigidly fixed to the proximal K-wire showed greater stiffness (12 N/mm) than nonattached constructs. The connected construct was 2.3 times more stiff than the unattached parallel construct and 2.5 times more stiff than angling the middle K-wire without attachment. Conclusions In a computer model simulation, our results show that attaching 2 K-wires adjacent to the fracture provides more than twice the stiffness of unconnected K-wires.

Boxer’s fractures are common injuries. This report describes a case of a rupture of both small finger extensor tendons, following a closed neck fracture of the fifth metacarpal bone. This complication has not been reported before and emphasizes the importance of good clinical examination to rule out additional damage.

Summary:. Ray transposition for central digital amputation has been performed following traumatic injury to the hand for decades. Small finger to ring finger ray transposition has been well described in the literature, with good functional and aesthetic outcomes reported. Originally described by Bunnell, the fourth metacarpal can be disarticulated and the fifth metacarpal base transposed with reconstruction of the intermetacarpal ligament allowing progressive closure between the third and fifth rays. However, osteotomy-based transpositions are utilized placing the osteotomy at the level of the metacarpal, followed by transposition and fixation of the small finger to the base of the ring finger metacarpal; or, by making an intracarpal wedge-osteotomy of the hamate with subsequent radial translocation of the entire small finger ray. Recent literature has suggested the intracarpal wedge osteotomy to be superior technically, and with less postoperative complications. However, for this somewhat uncommon reconstructive procedure, no high-level evidence exists to determine which of these techniques is truly more favorable. Here, we present an interesting case of ray amputation and transposition following an isolated fourth metacarpal traumatic firearm injury, and comprehensive modern surgical technique. Upon review of the literature, small to ring finger ray transposition has been shown to have acceptable functional and aesthetic outcomes regardless of the osteotomy technique used, and should be considered when the nature of presenting injury and the patient’s lifestyle and postoperative expectations are appropriate.

1003 SUMMARY Purpose: To conduct pulse oximetry (PO) and electric pulp test (EPT) on intact frontal teeth in clinically healthy patients aged between 18 and 25 years who do not have periodontal disease. Material/Methods: To achieve the aim 1058 teeth of 31 patients were studied. The following inclusion criteria for the study were set: 1. Age – 18-25 years. 2. Clinically healthy patient, who does not have any systemic diseases, do not take any medicine systematically. 3. Intact frontal teeth – without carious lesions, restorations or root canal treatment. 4. Lack of periodontal disease. Research was conducted with a pulse oximeter ContecTM CMS60D and a custom made probe holder. Results: Average values obtained by pulse oximetry in upper jaw vary between 83% and 85%. In lower jaw – between 82% and 85%. 99% is the maximum and 48% is the minimum registered value. The average value of the measurement of all the teeth is 84%. The average saturation measured on the small finger of the right hand of the patient is 98%. The average value of EPT for all teeth is 4 μA. The maximum measured value is 20 μA, and the minimum 1 mA. Conclusions: 1. Adequate study of the pulp includes two complementary methods – electric pulp test (evaluation of innervation) and pulse oximetry (assessment of pulp microcirculation). 2. Teeth that are larger in size have larger values of PO and EPT, which is in direct relation to the size of their pulp chamber. 3. The total saturation, measured in the little finger of the right hand is greater than the one of the teeth.

The pedicled groin flap as been extensively used for the reconstruction of soft tissue injuries of the hand [1]. Two main disadvantages have limited its use: the hand must be attached to the groin region for three weeks and the flap does not have sensitivity, which is critical to the function of the hand. In 1973, Daniel and Taylor [2] described the free groin flap, obviating the need for a second procedure, improving patient comfort, and allowing early rehabilitation protocols. In 1977, Joshi [3] described a technique involving "neural repair for sensory restoration of a groin flap." In order to obtain innervation, he harvested the lateral cutaneous branch of the twelfth thoracic nerve with the flap and carried out an end-to-end repair with an available sensory nerve branch in the operative field. The procedure was designed for a pedicled groin flap, as the nerve enters the flap opposite to the pedicle. This creates problems in adapting this technique to a free groin flap, because it is difficult to find a donor nerve at the distal aspects of the wound. We describe the use of an innervated free groin flap to repair a post-traumatic soft tissue defect at the volar aspect of the hand. To the best of our knowledge, this is the first reported case of such a procedure. A 46-year-old woman sustained trauma to her right hand with a conveyor belt, producing an injury to the soft tissues of the palm and comminuted fractures of the bases of the proximal phalanxes of the long, ring, and small fingers. All of the digits except for the thumb were ischemic at her arrival to our emergency department, which occurred eight hours after the initial trauma. Three revascularization attempts with vein grafts were unsuccessful. Reperfusion was only achieved for the palmar aspect of the index finger up to the distal interphalangeal joint. Four days later, the patient returned to the operative room for debridement of devitalized tissue at the palm and amputation of the small finger through the metacarpal neck and fingertips of the index, middle and ring fingers. The palmar aspect of the long and ring fingers was also excised. A free groin flap, measuring approximately 10 cm × 6 cm, was obtained from the contralateral side for coverage. The lateral cutaneous branch of the twelfth thoracic nerve was harvested and was coapted with the ulnar collateral nerve of the long finger (Figs. 1, ​,2,2, ​,3).3). The flap required two additional debulking procedures along with syndactyly release; these debulking procedures were performed following the first signs of re-innervation. The debulking procedures were performed in a very specific fashion, starting opposite to the nerve coaptation area and slowly progressing towards it. We stopped 1 cm from the nerve coaptation area; in an attempt to preserve the nascent nerve branches on the flap we focused on the deep fat lobules and tried to preserve the smaller superficial fat lobules [4]. Recovery of sensation was observed two months after the main procedure. Fig. 1 A free groin flap was elevated to cover the defect. The lateral cutaneous branch of the twelfth thoracic nerve was harvested along with the flap and was sutured in an end-to-end fashion with the ulnar collateral nerve of the long finger. Fig. 2 Line diagram showing the anatomy of the donor area. The lateral cutaneous branch of the twelfth thoracic nerve can be seen entering the flap proximally. Fig. 3 Line diagram showing the surgical technique including the vascular anastomosis and the nerve coaptation sites. One year later, the results of the Semmes-Weinstein monofilament test were 4.31 (2 g) on her long finger and 5.07 (10 g) on her ring finger. She was able to discriminate hot and cold temperatures, but had no static or dynamic two-point discrimination. Her grip strength, as measured with a Jamar dynamometer (Baseline Instruments, White Plains, NY, USA) was 10 kg in her right affected hand and 28 kg in the uninjured hand. The patient reported no cold intolerance or discomfort (Figs. 4, ​,55). Fig. 4 Following two debulking procedures, the patient was satisfied with the result. Fig. 5 At the latest follow-up, the patient retained protective sensation on the area of the flap as well as functional pinching ability with her uninjured thumb. In order to innervate a free iliac flap, the surgeon must address the fact that the nerve is located opposite to the pedicle. If preservation of the digital nerves is possible after the early debridement of necrotic tissue at the palm of the hand and digits, neurotisation can be achieved. When the receptor nerves do not reach the distal aspects of the wound, it is also possible to further extend the dissection of the flap and harvest a greater length of donor nerve. According to previous reports describing neurotised pedicled groin flaps, better sensory recovery occurs when a nerve is sutured to a sensory nerve of the groin flap, in comparison to other flaps from the abdomen or the groin without neurotisation [3,5]. In his original article, Joshi [3] states that his procedure led to a result of S2+ on the Highet scale. White and Bain [5] reported static two-point discrimination of 3 mm two years after resurfacing the dorsal aspect of a thumb. Nonetheless, conflicting reports exist in the literature regarding sensation recovery in non-innervated iliac or groin flaps. Tare and Ramakrishnan [6] described the use of a free mini-groin flap for digital resurfacing and found no recovery of sensation, even with radical thinning of the flap. Pan et al. [7] utilized non-innervated free iliac flaps to treat multiple skin defects of the hand and digits, and described an average static two-point discrimination of 15.4 mm in five out of the eight patients after an average of 20.4 months, whereas the remaining patients only exhibited sensation to pressure. For a non-sensate flap to recover two-point discrimination, a random process of nerve ingrowth must originate from the underlying receptor area. This process can take longer than two years and may be facilitated by thinning the flap. However, secondary debulking procedures can hamper this process. Our patient underwent two debulking procedures, which were not found to affect the recovery of sensation. We believe that the earlier recovery of sensation, as was observed in our case, may help in the rehabilitation process and avoid complications involving burns, ulcerations, and cold intolerance during the first two years. Yan et al. [8] reported the results of innervated versus nonsensate flaps for fingertip reconstruction and concluded that insensate flaps resulted in poorer sensation recovery and significant subjective discomfort in terms of cold intolerance. They also observed a trend for lower grip strength measurements in the nonsensate flap group. Neurotisation of a free groin or iliac flap, whenever possible, is a relatively simple and worthwhile procedure, since it enables the quicker recovery of sensation and aids in the prevention of the development of cold intolerance and discomfort. Of the many options available for reconstructing moderately sized to large defects of the palm of the hand and fingers, an innervated free groin flap combines a maximally concealed donor area with functional sensory recovery. It was this combination of concealment and functional recovery that prompted us to choose an innervated free groin flap over other reconstructive options for the management of our patient's condition.

The effect of finger spread on overall drag on a swimmer's hand is relatively small, but could be relevant for elite swimmers. There are many sensitivities in measuring this effect. A comparison between numerical simulations, experiments and theory is urgently required to observe whether the effect is significant. In this study, the beneficial effect of a small finger spread in swimming is confirmed using three different but complementary methods. For the first time numerical simulations and laboratory experiments are conducted on the exact same 3D model of the hand with attached forearm. The virtual version of the hand with forearm was implemented in a numerical code by means of an immersed boundary method and the 3D printed physical version was studied in a wind tunnel experiment. An enhancement of the drag coefficient of 2% and 5% compared to the case with closed fingers was found for the numerical simulation and experiment, respectively. A 5% and 8% favorable effect on the (dimensionless) force moment at an optimal finger spreading of 10° was found, which indicates that the difference is more outspoken in the force moment. Moreover, an analytical model is proposed, using scaling arguments similar to the Betz actuator disk model, to explain the drag coefficient as a function of finger spacing.

Background. Trigger finger is a relatively common clinical entity. The etiology is most often attributable to stenosing tenosynovitis though traumatic cases have been described. When trigger finger is associated with an underlying flexor tendon rupture, previous cases have reported a clear association with overt laceration or previous trauma. Methods. We present the case of a 23-year-old male active duty military service member who presented with a characteristic history and clinical exam consistent with trigger finger. The symptomatic onset was gradual, with no history of inciting trauma. Results. Given symptomatic persistent triggering following failure of conservative management to include cortisone injections, the patient was taken for open A1 pulley release. Intraoperatively, the triggering was found to be attributable to a partial attritional rupture of the small finger flexor digitorum profundus tendon. Tendon debridement, tubularization, and A1 and partial A2 pulley releases were performed with subsequent resolution of triggering. Conclusion. We present the rare case of subclinical atraumatic attritional rupture of the FDP tendon to the small finger as a cause of clinically apparent trigger finger. This is an important consideration as the hand surgeon must be prepared to address more atypical pathologies.

Three cases of ulnar-sided cleft hand are presented in which clefting was accompanied by ring finger absence in 2 and by small finger abduction, supination, shortening, and camptodactyly in all 3. An approach to surgical reconstruction is described with marked improvement in appearance.

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.

Polydactyly is a most common congenital hand defects in which the hand has one or more extra fingers, commonly seen postaxial, that is, on the small finger side. It is usually treated by surgically removing the extra finger typically, when the child is between 1 and 2 years old. Prognosis after removal of extra digit is good if it occurs in isolation though not devoid of complications like scar formation, stiffness, instability, and late deformity which may need additional reconstructive surgery to recover full function and improve the hand's appearance. I have used '' Ksharsutra, '' an Ayurvedic-medicated thread coated with herbal alkaline drugs having simultaneous cutting and healing property, to remove extra finger in a child, whose parents were not willing to undergo surgery and asked for alternative treatment. '' Ksahrsutra ligation'' showed excellent result in postaxial polydactyly. The extra finger started necrosing within 24 hours and sloughed out in just 9 days with minimal scar formation. After observing the prognosis, I believe that more cases should be done to establish and promote this unique parasurgical procedure, '' Ksharsutra '' in the management of polydactyly.

Patients with Parkinson’s disease (PD) have difficulties in movement adaptation to optimize performance in novel environmental contexts such as altered screen cursor-hand relationships. Prior studies have shown that the time course of the distortion differentially affects visuomotor adaptation to screen cursor rotations, suggesting separate mechanisms for gradual and sudden adaptation. Moreover, studies in human and non-human primates suggest that adaptation to sudden kinematic distortions may engage the basal ganglia, whereas adaptation to gradual kinematic distortions involves cerebellar structures. In the present studies, participants were patients with PD, who performed center-out pointing movements, using either a digitizer tablet and pen or a computer trackball, under normal or rotated screen cursor feedback conditions. The initial study tested patients with PD using a cross-over experimental design for adaptation to gradual as compared with sudden rotated hand-screen cursor relationships and revealed significant after-effects for the gradual adaptation task only. Consistent with these results, findings from a follow-up experiment using a trackball that required only small finger movements showed that patients with PD adapt better to gradual as against sudden perturbations, when compared to age-matched healthy controls. We conclude that Parkinson’s disease affects adaptation to sudden visuomotor distortions but spares adaptation to gradual distortions.

We present two patients with a displaced fracture of the small finger metacarpal base, where the shaft of the small finger metacarpal was wedged between the bases of the ring and small finger metacarpals. The striking appearance on radiographs led to initial recommendations for surgery, but both patients preferred non-operative treatment and did well in the short term without surgery

A displaced complete radial collateral ligament avulsion with associated injury to the sagittal band of the metacarpophalangeal joint of the small finger, if left untreated, may result in chronic pain, instability, weakness, and deformity. A case of a displaced radial collateral ligament that ruptured through the radial sagittal band of the small finger, with resultant injury to the extensor mechanism, is described and discussed with a review of the literature. Proper identification of this injury by physical exam and imaging studies along with surgical repair is associated with good outcome.

A case of a left small finger tumour that was diagnosed on histopathological review as Nora's lesion (bizarre parosteal osteochondromatous proliferation) is reported. There have been fewer than 150 cases reported in the literature to date and its pathophysiology is yet to be defined. Due to its rare presentation, Nora's lesion can easily go unrecognized and therefore inappropriately managed.

Anomalies of the flexor digitorum superficialis muscle are extremely uncommon and usually present as a painful mass or pseudotumour within the palm. Diagnosis may be difficult because many other soft tissue tumours (lipomas, ganglions, giant cell tumours and hamartomas) may present similarly. Magnetic resonance imaging helps to define the extent and characteristics of this anomalous muscle belly and to distinguish it from a soft tissue sarcoma, whereas plain radiographs are of little value. Three types of flexor digitorum superficialis muscle anomalies have been described, and treatment consists of subtotal or total surgical debulking of the mass if symptoms persist or if the diagnosis is in question. Most patients have complete resolution and full recovery. To date, 20 cases have been reported in the literature, usually involving the right small finger. In the present paper, the case of an anomalous flexor digitorum superficialis muscle in a 17-year-old male patient's left index finger is reported. Symptoms were relieved following surgical debulking and hand-based occupational therapy.

Objectives It is difficult to determine the extent of synovial involvement early in the course of rheumatoid arthritis. A spectroscopic technique was used to characterize the synovium of the small finger joints in both early and late rheumatoid arthritis. This synovium was also compared against normal joints. Methods Near-infrared spectroscopy assesses the absorption of near-infrared light by specific joints, giving a characteristic "fingerprint" of the properties of the underlying tissues. Triple measurements by infrared spectroscopy were taken at the bilateral second and third metacarpophalangeal joints. Multivariate analysis was applied. Results Analysis was able to demonstrate relationships between the specific sources of spectral variation and joint tenderness or swelling as well as radiographic damage. Further use of multivariate analysis allowed recognition of the spectral patterns seen in early disease vs late rheumatoid arthritis and correct classification of over 74% of the joints. Conclusions The spectral regions where differences occurred were in the absorption bands related to tissue oxygenation status, allowing the provocative implication that this technique could be detecting ischaemic changes within the joint. Near-infrared spectroscopy may thus be able to provide us with some information about the biochemical changes associated with synovitis.

Post-axial polydactyly is a common congenital hand anomaly with a wide range of manifestations. We report here an unusual case of intra-natal torsion of duplicated small finger which presented as gangrene at birth.

Loss of a central digit below the midlevel of the proximal phalanx results in a weakened grip, scissoring of the adjacent fingers, and loss of skilled movements; small objects fall from the hand, and the amputation stump is repeatedly traumatized. Transposition of an adjacent digital ray can improve hand function and cosmetic appearance by closing the gap created by the missing digit and should be considered in any of these cases. Resection of the fourth metacarpal with reconstruction of the deep transverse metacarpal ligament has the following disadvantages: inadequate closure of the gap, loss of the natural divergence of the fifth ray, loss of abduction of the small finger, and angulation and rotation of the adjacent digits.’ Ray transposition is preferably done by osteotomy at the