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Children are one of the most vulnerable populations to burns, and hands are frequently burned anatomical structures. Restoring function in a severely burned pediatric hand is challenging. We present our experience with pediatric toe-to-thumb transfers for burn reconstruction. A retrospective review was conducted of all pediatric toe-to-thumb transfer patients between 2009 and 2014. Children younger than the age of 18 who underwent secondary reconstruction after electrical or thermal burn injuries with at least a 5-year follow-up were included. Functional outcomes were measured with the modified Kapandji score. Complications of the reconstructed hand as well as the donor foot were recorded. Four children with 10 toe-to-hand transfers (four great toes, two second toes, and two combined second–third toes) met the inclusion criteria. The average follow-up length was 104 months (range 60–144 months). Two children sustained thermal burn injuries and two sustained electrical burn injuries. Three children achieved opposition of the reconstructed toe-to-thumb transfer to the small finger (Kapandji score 5), and one child achieved opposition of the reconstructed toe-to-thumb transfer to the proximal phalanx of the middle finger, the only remaining finger (Kapandji score 3). No donor foot morbidities were noted postoperatively. Toe-to-thumb transfers should be considered the standard of care for thumb reconstruction in children with severe burn injuries of their hands to provide restoration of sensation, pinch, grasp, and opposition with minimal morbidity of the donor foot.

To report the clinical and radiographic results of arthrodesis of relatively small-sized distal interphalangeal joints (DIPJs) using only K-wire fixation.Between January 2000 and December 2018 28 arthrodesis in 21 patients (9 males and 12 females with an average age of 52.1 years) with relatively small-sized DIPJs were performed using only K-wires. Data on patient's characteristics, such as age, sex, affected finger, and the number and size of the used k-wires were collected from the medical database. The narrowest diameter of the cortex and medulla of the distal phalanx was measured on preoperative plain radiographs. The time to union and the arthrodesis angle was determined using serial X-ray radiography follow-up. Preoperatively and at the latest follow-up examination, pain using the visual analogue scale (VAS) and the quick DASH score was registered. In addition, complications were investigated.Average follow-up period was 11.4 months. The small finger was mostly affected (n = 12; 42.9 %). The narrowest diameters of the distal phalanx cortex and the medulla measured on preoperative X-ray images were 2.8 mm (SD 0.5) and 1.2 mm (SD 0.4), respectively. Seven fusions were done with use of 1 K-wire, 20 with 2 (71.4 %), and 1 with 3 K-wires. The most common K-wire sizes were 1.1-inch (24 K-wires = 48 %), and 0.9 inch (21 K-wires = 42 %) The preoperative VAS score and quick DASH score improved from 6.1 (range: 0-9) and 25.8 (range: 2-38) to 0.4 (range: 0-2) and 3.4 (range: 0-10.2), respectively. 25 (89.3 %) out of 28 fingers achieved bony union in an average of 96.1 days (range: 58-114) with three non-union.Arthrodesis of small DIPJs with K-wire fixation has a high success rate. Therefore, we suggest K-wire fixation as an acceptable alternative for patients with a small phalanx which may be at risk of mismatch with bigger implants. However, concerns remain in terms of fusion delay with K-wire only fixation.ZIEL: Ziel der Untersuchung war die Evaluierung der klinischen und radiologischen Ergebnisse nach Versteifung kleiner Fingerendgelenke unter ausschließlicher Verwendung von K-Drähten.Zwischen Januar 2000 und Dezember 2018 wurden bei 21 Patienten (9 Männer und 12 Frauen mit einem mittleren Alter von 52,1 Jahren) 28 Arthrodesen kleiner Fingerendgelenke durchgeführt. Angaben bzgl. des Alters und Geschlechts der Patienten, des betroffenen Fingers sowie der Anzahl und Größe der verwendeten K-Drähte wurden den Patientenakten entnommen. Der Durchmesser der Endglieder sowie deren Markraumes wurde jeweils an der engsten Stelle auf präoperativ gefertigten Röntgenbildern ausgemessen. Die Zeit bis zur knöchernen Heilung sowie der Arthrodesenwinkel wurde anhand von postoperativen Röntgenserienaufnahmen bestimmt. Präoperativ und bei der letzten Nachuntersuchung wurden die Schmerzen mittels der visuellen Analogskala (VAS) und der Quick-DASH-Score erhoben. Des Weiteren wurden Komplikationen erfasst.Die durchschnittliche Nachbeobachtungszeit betrug 11,4 Monate. Der kleine Finger war am häufigsten betroffen (n = 12; 42,9 %). Der engste Durchmesser der distalen Phalanx betrug 2,8 mm (SD 0,5), des Markraumes 1,2 mm (SD 0,4). Bei sieben Arthrodesen wurde 1 K-Draht, bei 20 (71,4 %) 2 Drähte und einmal 3 Drähte verwand. Die meisten K-Drähte wiesen einen Durchmesser von 1,1 inches (n = 24; 48 %) bzw. 0,9 inches (n = 21; 42 %) auf. Schmerzen und Quick-DASH-Score verbesserten sich von durchschnittlich präoperativ 6,1 (0 – 9) resp. 25,8 (2–38) bis zur letzten Nachuntersuchung auf 0,4 (0–2) resp. 3,4 (0–10,2). Bei 25 (89,3 %) der 28 Endgelenke kam es zur knöchernen Heilung, 3mal entwickelte sich eine Pseudarthrose.Die Versteifung kleiner Fingerendgelenke unter ausschließlicher Verwendung von K-Drähten hat eine hohe Erfolgsrate, weshalb wir sie für Patienten mit kleinen Endgliedern empfehlen, bei denen die Gefahr besteht, dass es bei Verwendung dickerer Implantate zu Problemen kommen kann. Allerdings ist die lange Zeitdauer bis zur knöchernen Durchbauung zu bedenken.

In difficult cases of replantation following small finger avulsion injury, in which amputation occurs at the proximal interphalangeal joint, the ulnar parametacarpal island flap, rotated 180° (propeller flap), can be used as an alternative method for covering a skin defect of the proximal phalanx. This flap can prevent metacarpophalangeal joint dysfunction and additional finger shortening. We propose the use of an ulnar parametacarpal flap for this purpose and report the outcomes of two successful cases treated with this method and followed up for 12 months.

Background Traumatic digit amputations can result in significant impairment. Optimal surgical treatment is unclear for certain digits in various amputation patterns. Our aim was to compare the contribution of revision amputation vs replantation for each particular digit to functional outcomes. Materials and methods Prospective cohort study at three tertiary hospitals was conducted in China. Eligible participants were 3192 patients with traumatic digit amputations enrolled from January 1, 2014, to January 1, 2018. The primary outcome was Michigan Hand Outcomes Questionnaire (MHQ) scores 2 years after initial surgery. Secondary outcome was score on the Disabilities of the Arm, Shoulder, and Hand (DASH). Results Of 3192 enrolled patients, 2890 completed the study. Main-effect linear regression showed that participants with replantation of thumb, index, long, and ring (proximal to the proximal interphalangeal [PIP] joint) fingers had significantly better MHQ scores compared to participants with the corresponding finger revision amputation. DASH results were comparable. Finger-finger interaction analyses conducted with multifactor dimensionality reduction (MDR) revealed that the small finger and ring finger had the smallest and greatest interactions with other fingers, respectively. After stratification by amputation level of thumb, index finger, or long finger, linear regression showed that replantation of the ring finger distal to the PIP joint resulted in better MHQ and DASH when the thumb or long finger was also traumatically amputated proximal to the IP/PIP joint. Conclusions Replantation of the thumb, index, long, and ring (proximal to PIP joint) fingers is preferable to revision amputation, regardless of amputation pattern. Replantation of the ring finger amputated distal to PIP was beneficial only when the thumb or long finger was amputated proximal to IP/PIP joint. Replantation or revision amputation of the small finger was indistinguishable in terms of functional outcome. Future investigations and clinical decisions should take into account the role of finger-finger interactions.

Dupuytren’s contracture is a disease involving abnormal myofibroblast proliferation and collagen deposition leading to the formation of pathologic cords in the hand. Given that Dupuytren’s contractures rarely extend to the distal interphalangeal joint (DIP), affecting only 5% of patients, there are few cases reported in the literature. Collagenase injection is a frequently used option for minimally invasive treatment of Dupuytren’s disease with greater than a 20-degree joint contracture. Unfortunately, there is limited research on the effectiveness of these injections in isolated DIP joint deformities. We present a case of a 61-year-old right hand-dominant male with a 2-year history of isolated right small finger Dupuytren’s contracture at the DIP joint who achieved significant improvement after collagenase injection.

We describe a simple and effective method to assess the integrity of the flexor carpi ulnaris muscle and tendon. This method is called the Small Finger Abduction Test. The study also evaluates the efficacy and practicality of the test.Level of Evidence: Level II.

Demographic and clinical features of 32 patients diagnosed with dupuytren contracture and operated by partial fasciectomy were included in this study. Functional results, complications and recurrence rates were discussed with current literature. In our study male/female ratio was 7/1, mean age at onset of disease was 55.4±7.1, mean age at surgery was 60.4±8.1. There were etiological factors such as a family history in 7 patients (21.875%), smoking in 22 patients (68.75%), regular alcohol use in 6 patients (%18,75), type 2 diabetes in 10 patients (31.25%), hepatic disease in 2 patients (6.25%), long term barbiturate use for epilepsy in 1 patients (3.125%). The most often involved finger was the ring finger in 26 patients (81.25%), the small finger in 18 patients (56.25%), middle finger in 8 patients (25%) and index finger in 1 patient (3.125%). The pre-operative mean total passive extension deficit (TPEK) was 89.68o ± 30.29, the post-operative mean TPED was 6.09o ± 6.44. The post-operative mean total extension gain was 93.2%. The mean follow-up was 70±44 months, 1 patient (3.125%) had a recurrence in this period. The overall complications occured in 3 patients (9.375%), including skin necrosis in 2 patients (treated with dressings) and temporary hypoesthesia in 1 patient. The partial faciectomy is an effective and reliable method for the surgical treatment of dupuyren contracture because of improvement enough correction in the MCF and PIP joint contracture, the low rate of complication and recurrence rates.

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.

The reconstruction of finger defects requires improved functional outcomes and acceptable esthetic outcomes, and small free flaps present a good alternative technique for repairing finger skin defects. From January 2006 to December 2018, we investigated the number and diameter of proximal digital artery perforators, medial plantar artery perforators, and peroneal proper plantar digital arteries of the hallux by dissection and then transplanted free digital arterial perforator flaps, free medial plantar flaps, and free peroneal flaps from the hallux to repair small finger skin defects. The number (SD) of perforators from the medial plantar artery was approximately 2.2 (0.5), and these perforators measured 0.53 (0.20) mm in diameter. The diameter (SD) of the first metatarsal dorsal artery was approximately 1.16 (0.30) mm. A total of 25 patients were included in this study. The transplantation times (SD) for free digital arterial perforator flaps, free medial plantar flaps, and free peroneal flaps from the hallux were 3.5 (0.5) hours, 3.2 (0.7) hours, and 2.0 (0.4) hours, respectively. The follow-up period ranged from 8 to 15 months. All flaps survived and were appropriately shaped. The donor site was either covered with a free flap or directly sutured. Among these 3 types of small flaps, the free peroneal flap from the hallux can be recommended for clinical use because of the large diameter of the contributing vessels, the short operative time, the ease of access, and the improved appearance of the donor site.

Highlights • The lateral band snapping syndrome (LBSS) in the proximal interphalangeal joint (PIPJ) is the subluxation of lateral band of the extensor tendon resulting from injury of the retinacular ligament, causing finger snapping during flexion of the PIPJ. • Ultrasonography can visualize the subluxation of lateral band, facilitating diagnosis of LBSS in the PIPJ. • Patients with LBSS may benefit from prompt repair of the retinacular ligament without sequela., Background Snapping fingers resulting from flexor tendon tenosynovitis at the metacarpophalangeal (MCP) joint, is common. However lateral band snapping syndrome (LPSS) in the proximal interphalangeal joint (PIPJ) are extremely rare. Case presentation A 43-year-old female was diagnosed with LPSS in the PIPJ of fifth finger which was confirmed by dynamic evaluation upon ultrasound. Repair of retinacular ligament of the extensor tendon was performed. At the six-month follow up, the patient had regained full ROM with no discomfort, without evidence of recurrence. Discussion The diagnosis of LPSS at the PIPJ is challenging. Dynamic evaluation of the extensor tendon over PIPJ is necessary to diagnose LBSS. Ultrasound was used to assess the movement of the lateral band of the extensor tendon when the fingers flexed and to demonstrate dynamically the snapping and subluxation of the lateral band, so as to facilitate confirming the diagnosis of LBSS. Conclusion Given clinical suspicion of LBSS, we recommend ultrasonography as a feasible tool to confirm the diagnosis. Patients with LBSS may thus benefit from prompt repair of the retinacular ligament without sequela.

INTRODUCTION The incidence of high-pressure injection injuries of the hand is low. Although the occurrence is rare, the precarious progression of the injury exacts prompt surgical evaluation in order to avoid complications and amputation. The current study was devised in order to make comparisons to the current data, in addition to supplementing the literature with observations regarding clinical course and management. METHODS A multisurgeon, retrospective chart review from a single institution was performed. Inclusion criteria included cases involving a high-pressure injection injury to the hand that underwent surgical management. Patient demographics, injury details, and hospital course were all reviewed and recorded. RESULTS This retrospective review identified 20 cases meeting criteria, all of which involved males. The average age at time of injury was 39.7 years (range, 21-71 years). The incidence of injection injuries over a 10-year time period was 2.1 cases per year. The nondominant hand was injured in 11 cases (63%). The most common site of injury was the index finger with 11 recorded incidents (55%). Other reported locations included the metacarpal (40%) and small finger (5%). Occupational data included 10 construction workers, 5 painters, and 2 cleaning crew members, and 3 had nonmanual occupations. Paint was the most commonly injected substance with 17 reported cases (85%). On average, the delay until surgery was observed to be 21.9 hours (n = 16). Only 1 patient underwent surgery at 6 hours after surgery. The average number of procedures performed was 1.8 (range, 1-4). Hospitalization duration was on average 3.9 days (range, 1-9 days), and the average follow-up length was 69 days (range, 7-112 days). There were no identified cases that necessitated amputation. CONCLUSIONS This form of injury most commonly affects male, middle-aged laborers. Our study found very low amputation rates when compared with the current literature, despite observing longer delays to surgery according to current recommendations. Limited comparisons can be made from data regarding clinical course and management because of the small sample size of the current study and the limited published data. This indicates a need for further exploration and collection of data involving parameters such as clinical course and management.

CASE A Salter-Harris II fracture of the small finger middle phalanx with complete extrusion of the epiphyseal fragment in a 6-year-old boy is described. Closed reduction was unsuccessful. Open reduction was performed, the epiphysis was reduced, and a single Kirschner wire was placed obliquely across the fracture and joint. CONCLUSION This is an extremely rare injury. Open reduction and pinning was successful in preserving functional range of motion. Despite eventual growth arrest, there was no clinically significant angular deformity, and the joint was preserved. Surgical technique and early hand therapy allowed the patient to return to high-level activity without pain or functional limitation thus far at the 27-month follow-up.

A 43-year-old female suffered a degloving injury of her left hand in a printing machine during her work. She was admitted to our hospital 2 h after the injury. The skin was avulsed from the distal forearm to the fingertip (Fig. 7.1). The bone, joint, tendon, nerves of the thumb and fingers, and the intrinsic muscle remained relatively intact. Complete debridement was performed under axillary block anesthesia in the emergency room. Relative intact of the degloved skin was found. The dorsal skin and palmar skin were bruised. The proper digital arteries of the index, middle, ring, and small finger were amputated at the level of the distal interphalangeal joint, and their nerves were extracted at the wrist level. The proper digital arteries of the thumb were amputated at the level of the fingertip.

Summary:. Gout can lead to the deposition of tophi and chronic arthritis, for which surgical management is indicated when tophi interfere with the function of the finger. This case report discusses the management of a 37-year-old man with a past medical history of gout who presented with triggering of his small finger from gouty infiltration of his flexor digitorum profundus (FDP) tendon. An exploratory procedure that included tenolysis and release of the A1 pulley was performed. Gouty infiltration of the FDP tendon was noted intraoperatively and biopsied, which was later confirmed by histopathological analysis as being gouty tophus. The patient regained full function of the affected finger postoperatively and has since had no recurrence. Gouty tenosynovitis is a rare cause of trigger finger and should be considered as part of the differential diagnosis. Treatment for gouty tenosynovitis consists of A1 pulley release and careful excision of gouty tophus to restore tendon glide and hand function.

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.

Purpose There are several potential donor muscle–tendon units for a thumb opposition transfer. The extensor carpi ulnaris (ECU) is useful when the more usual donor units are not available. The technique and results of a simplified ECU opposition transfer elongated with a free tendon graft are described. Methods Ten ECU opposition transfers were performed using this modification of Henderson technique in 5 adults after complex trauma, 3 adults with median and ulnar nerve palsies, and 2 children with congenital hand differences. Results Seven patients achieved a Kapandji opposition score of 6 to the distal phalanx of the small finger, and 3 patients achieved a Kapandji score of 5 to the distal phalanx of the ring finger. None of the patients required a secondary tenolysis or developed a radial deviation imbalance of their wrist. Conclusions This modification of the Henderson technique using ECU elongated with a free tendon graft and inserted directly and only into the abductor pollicis brevis tendon is an effective method of restoring opposition to the thumb, especially when other conventional donor muscle–tendon units are not available. Type of study/level of evidence Therapeutic V.

Comminuted intra-articular phalanx fractures are complicated injuries often treated with external fixation. The ideal external fixation system should be affordable, readily available, adaptable, and easy to use. The use of dynamic external fixation has advanced the care of these injuries but can be difficult to implement. The authors present a case example of a patient with a comminuted intra-articular phalangeal fracture of the left small finger treated using a syringe as a static uniplanar fixator that was converted to a dynamic fixator during postoperative recovery.

This article describes the authors' experience with, and recent advancement in, the techniques that have allowed the development of many new arthroscopic procedures in the finger joints. It also describes the role and techniques of arthroscopy in small finger joints. Because the intra-articular anatomy of the first to the fifth metacarpophalangeal (MCP) joints is similar, this article discusses the hand MCP joints without distinguishing thumb from fingers.

Glomus tumours are lesions of the glomus body. A solitary glomus tumour is a more common, characteristically painful lesion, frequently located under the nail, whereas multiple glomus tumours are a rare clinical and genetic entity. Multiple glomus tumours are rarely subungual and do not show preference for any particular region of the body. We report a rare case of painful multidigit subungual glomus tumours in both hands.A 34-year-old male patient complained of painful fingertips (right: thumb, index finger, long finger, and ring finger; left: thumb, long finger, ring finger, small finger) on both hands for more than 5 years. Magnetic resonance imaging (MRI) detected multiple subungual glomus tumours in the fingertips (right long finger, ring finger, and left thumb, long, ring, and small finger) of both his hands, so the authors conducted tumour resection and sent biopsies for relevant fingers. We found the glomus tumour underneath the nail bed and achieved final diagnosis with histological confirmation. No remnant or newly developed lesion was detected at the 1 year outpatient clinic.Our case differed from the usual multiple glomus tumours because its characteristics were similar to those of a solitary glomus tumour, including the classic symptom triad: severe pain, localised pain, and cold hypersensitivity. In case report, we suggest the possibility that multidigit subungual glomus tumour is different from the common single subungual glomus tumour.Glomustumoren gehen vom Glomusorgan aus. Solitäre Glomustumoren kommen häufig vor, sind schmerzhaft und häufig unter dem Fingernagel lokalisiert, wohingegen multiple Glomustumoren eine seltene klinische und genetische Entität darstellen. Multiple Glomustumoren liegen selten subungual. Sie bevorzugen keine Körperregion. Wir berichten über den seltenen Fall schmerzhafter multipler Glomustumoren an beiden Händen. Ein 34jähriger Mann beklagte Schmerzen an den Fingerbeeren des rechten Daumens, Zeige-, Mittel- und Ringfingers sowie des linken Daumens, Mittel-, Ring- und Kleinfingers seit mehr als 5 Jahren. Nachdem eine Kernspinuntersuchung multiple, subungual gelegene Glomustumoren am rechten Mittel- und Ringfinger sowie am linken Daumen, Mittel-, Ring- und Kleinfinger zeigte, wurden die Tumoren entfernt. Histologisch wurde die Diagnose „multiple Glomustumoren“ bestätigt. Bei der Nachuntersuchung nach einem Jahr ergab sich kein Hinweis auf ein Rezidiv.Unser Fall unterscheidet sich von anderen Fällen mit multiplen Glomustumoren, da er die Charakteristika solitärer Glomustumoren aufwies: starke, klar lokalisierte Schmerzen, Kälteempfindlichkeit.

The ideal rehabilitation regimen of paediatric flexor tendon injuries of the hand is discussed controversially. In this study, the clinical outcome of paediatric patients with flexor tendon injuries treated with a dynamic postoperative protocol was assessed. All children with flexor tendon injuries of the hand who were treated by a dynamic postoperative protocol between 1999 and 2011 were included. Patients were invited for a follow-up examination consisting of clinical examination, the TAM and Buck-Gramcko scores, and the linear measurement system. In total, 144 patients (mean age 9.1 years, range 1-17 years) with 267 flexor tendon injuries (128 flexor digitorum superficialis (FDS), 126 flexor digitorum profundus (FDP) and 13 flexor pollicis longus (FPL)) of 191 digits were treated. Of them, 43% (n = 62; 49 male, 13 female) with 88 digits (thumb n = 4, index finger n = 17, middle finger n = 25, ring finger n = 20, small finger n = 22) with 123 injured tendons (FDS n = 62, FDP n = 57, FPL n = 4) were included in the follow-up at a mean post-operative interval of 7.2 years (range 1-13 years). Using the Total Active Motion (TAM) score, an excellent and good outcome could be achieved in 41% and 48% of the patients, respectively. The zone of injury did not influence the objective outcome measures. Subjective and objective outcomes were not statistically different between young children (≤6 years) and older children (>6 years). The present study demonstrates good to excellent outcome in a large cohort of paediatric patients with flexor tendon injuries of the hand treated with a dynamic mobilisation protocol irrespective of patient age.

Malrotation is common after oblique or spiral proximal and middle phalangeal fractures. Although a small degree of malrotation may be acceptable for many patients, greater degrees of malrotation result in functional impairment, pain due to distortion of the joints, and diminished grip strength [1]. Osteotomy is usually required, preferably through the phalanx. Recent progress in computed tomography (CT) imaging and computer technology has enabled clinicians to evaluate the 3-dimensional (3D) kinematics of joint motion and to simulate accurate 3D corrective osteotomy using CT bone models [2,3]. We developed a novel simulation system named “linkage simulation” in which each phalanx is considered a linked arm, which makes it possible to analyze multiple joint motions preoperatively. Here, we report the case of a patient with a malunited little finger proximal phalangeal fracture that was successfully treated using the linkage simulation system. This system consisted of an original 3D computer program, which was designed to reproduce preoperative 3D motion. We have not identified any previous reports of corrective osteotomy for a malunited upper extremity fracture using 3D kinematics and linkage simulation.

Background: The purpose of this cadaveric study is to evaluate the trajectory of percutaneous transverse Kirschner wire (K-wire) placement for fifth metacarpal fractures relative to the sagittal profile of the fifth metacarpal in order to develop a targeting strategy for the treatment of fifth metacarpal fractures. Methods: Using 12 unmatched fresh human upper limbs, we evaluated the trajectory of percutaneous transverse K-wire placement relative to the sagittal profile of the fifth metacarpal in order to develop a targeting strategy for treatment of fifth metacarpal fractures. The midpoint of the small and ring finger metacarpals in the sagittal plane was identified at 3 points. At each point, a K-wire was inserted from the small finger metacarpal into the midpoint of the ring finger metacarpal (“center-center” position). Results: The angle of the transverse K-wire relative to the table needed to achieve a center-center position averaged 20.8°, 18.9°, and 16.7° for the proximal diaphysis, middiaphysis, and the collateral recess, respectively. Approximately 80% of transversely placed K-wires obtained purchase in the long finger metacarpal. Conclusions: These results can serve as a guide to help surgeons in the accurate placement of percutaneous K-wires for small finger metacarpal fractures and may aid in surgeon training.

Loss of a fourth digit below the level of the proximal phalanx results in a weakened grip, loss of skilled movements, and the amputation stump is repeatedly traumatized. Transposition of an adjacent fifth digital ray can improve hand function and cosmetic appearance by closing the gap created by the missing digit. Digital ray amputation is not a commonly performed procedure. However, when performed correctly it can dramatically improve hand function and cosmesis. The aim of this study was to evaluate the functional and aesthetic results of the fifth ray radial translation and intercarpal arthrodesis in mutilating ring finger injuries. In this retrospective study, nine consecutive patients who sustained mutilating ring finger injury were managed by fourth ray amputation with fifth ray transposition between January 2008 and December 2014. There were six males and three females with a mean age of 30.2 ± 12.2 years (age range, 16–56 years) at the time of surgery who underwent delayed fourth ray amputation with fifth ray transposition (after 14 days of injury). Eight cases had undergone previous surgical interventions: three ORIF using intramedullary K-wire fixation, one failed reimplantation, four debridement and application of split thickness skin graft. Primary skin closure of the amputated finger was not considered as previous surgery (one patient). All patients were followed up for a mean period of 17.1 ± 4.1 months (range, 12–24 months). Grip strength and RAS score improved after fourth ray resection. The postoperative grip strength and RAS (score) were not compromised by the associated hand dominance. The following conclusions can be made despite the fact that this was a limited study as well as a retrospective analysis: 1-In technical terms, resection of the fourth ray with transposition of the small finger with a wedge-shaped hamate-capitate arthrodesis secured by screw fixation is easier than metacarpal osteotomy/transposition and less liable to post-operative complications. 2-The results of this study suggest that fourth ray resection and transposition of the small finger with a hamate-capitate arthrodesis restores hand function and cosmetics.

Background: To describe the rate and predictors of pathologic fractures in benign neoplasms of the finger, as variables from prediction models for pathologic fractures of the long bones of the extremities are not necessarily applicable to the bones of the hand. Methods: In this retrospective chart review, 69 histologically confirmed neoplasms affecting the bones of the fingers, 49 phalanges and 20 metacarpals, were identified in patients presenting at 2 urban hospitals over a 24-year period. Different variables were studied as possible predictors of pathologic fractures. Results: Forty-nine percent of the tumors presented as a pathologic fracture. The small finger was independently associated with pathologic fractures compared to the other fingers. Tumors of the metacarpal bones were the least likely to fracture compared to other bones. Conclusions: Almost half of neoplasms affecting the bones of the fingers presented initially with a pathologic fracture, most commonly the small finger. Therefore, a lower threshold for surgical treatment of a bone neoplasm affecting the small finger may be reasonable.

Backgrounds: Syndactyly is failure of differentiation in which the fingers fail to separate into individual appendages. It is the most common congenital hand anomaly, with an incidence of 1 in 2,000 to 2,500 live births. Surgical separation of fingers as early as 6 month-old is indicated when syndactyly involves digits of unequal length (i.e., ring and little fingers). Early separation is also required in complex syndactyly and cases of acrosyndactyly. The timing of surgery of all other cases of syndactyly remains somewhat controversial; most suggest surgical correction before age of 18 months, whereas others prefer to wait until after this age.Case Presentation and Operation Technique: A 13-year old boy, presented with fusion of all fingers of the right hand at birth. Prior to his current visit, he underwent partial separation of the right fingers at the age of 6 y.o. at a local hospital. Following partial separation, the fingers did not grow normally. Current X-ray showed atrophy and deviation of middle phalanx. We performed separation of syndactyly between index and middle finger, and between fourth and small finger in our hospital. Interdigital webbings are released using local flap and the remaining raw surface is covered using full-thickness skin grafts. On follow up, the patient showed good functional and aesthetic outcome. He is able to write with his right hand with better coordination.Discussion: Complex syndactyly reconstruction is a challenging surgical problem. Common post surgical findings include rotational deformity, angular deformity, and nail deformity. We describe how we have altered our approach in these findings.Conclusion: Congenital syndactyly should be corrected early in life. Careful dissection, the use of a dorsal rectangular flap in combination with 2 volar triangular flaps, and use of full thickness skin grafts ensure a satisfactory outcome and minimize the number of operations per web

Avulsion of the flexor digitorum profundus (FDP) tendon associated to an enchondroma fracture in the distal phalanx is very rare. We report a subacute case of a type II FDP tendon avulsion of the small finger at its insertion, in combination with a fracture of the distal phalanx due to enchondroma. The bone lesion was curated and grafted using autogenous bone harvested from the ipsilateral radius. The FDP tendon was reattached to the distal phalanx using the pullout transosseous technique. Delayed protected active mobilization was used to treat the repaired tendon. According to the adjusted Strickland score, a good result was obtained and grip strength was similar between hands and PRWHE score was very low at 5 months from surgery. Early diagnosis leads to a fast surgery with good functional mobility and pain outcomes. If closely monitored by an experienced medical team, as this case demonstrates, an attempt to treat the benign tumor with a curettage, bone filling and reattachment of the tendon through the pullout technique in young motivated patients can be an alternative.

Background Anal dilatation is performed after repair of anorectal malformations(ARMs) and is vital in prevention of anal stricture formation. The ideal protocol utilizes Hegar dilators. In our setup, few parents will acquire Hegar dilators for home based anal dilatation but majority will use fingers as an alternative. The basis of this study was to determine the effectiveness of digital anal dilatations in preventing anal strictures. Materials and methods This was a descriptive cross-sectional study carried out at Kenyatta National Hospital (KNH) which recruited children post ARM repair undergoing digital anal dilatation. The diameters of the digits used for anal dilatation were assessed for adequacy using the desired anal size as a reference point. The main outcome variable was the presence of anal strictures. Data were entered in a data collection sheet and analyzed by use of SPSS (V.21.0 Chicago, Illinois). Chi-square test and Fisher's exact test were used to ascertain association among variables. A P-value of less than 0.05 was considered statistically significant. Results 50 patients with ARM post repair were recruited in the study. The rate of occurrence of anal stricture was 22%. Among the participants with anal strictures, only 27% were compliant to the dilatation regimen while 73% reported noncompliance. The mean diameter(mm) of the dilating digits at the level of the middle phalanx was Index finger (15.4 ± 0.58), middle finger (15.2 ± 0.61), ring finger (14.2 ± 0.71), small finger (12.5 ± 0.91) and thumb (17.6 ± 0.78). 46% of the participants were dilated with appropriately sized digits. The remainder had dilatations done with larger (22%) or smaller digits (32%). Notably, anal strictures occurred in participants who were dilated with inappropriately sized digits (P = 0.001). Conclusion Digital anal dilatation is safe and effective as a mode of anal dilation in the setting of compliance to a strict dilatation protocol, daily frequency of dilations and use of appropriately sized digits. Owing to the variability in the finger size, we recommend that digits be calibrated and education given to the caregivers on the use of the appropriately sized digit. Level of evidence Treatment study. Level III.

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.

Skin envelope degloving of fingers are rare injuries that require rapid care and surgical treatment. Mostly caused by ring finger injuries, these traumas include bone, tendon and neurovascular pedicle damage. The authors present an unusual case of finger degloving limited exclusively to the skin envelope, without skeletal, tendinous or vascular lesion. This rare case of skin envelope degloving rendered microsurgical revascularization impossible. The authors report the results at 12 months following salvage reconstruction combining a partial second toe pulp free flap for the volar side and a dermal substitute with a thin skin graft for the dorsum.

Post-traumatic arthritis is common in long-term follow-up of patients undergoing hemi-hamate arthroplasty (HHA). We hypothesize that anatomic mismatch could play a role in the development of arthritis. The purpose of this study is to establish a novel, computed tomography (CT)-based imaging technique for pre-operative assessment in HHA. With this technique, our group aims to identify digits with a high likelihood for anatomical mismatch between the donor graft and recipient interphalangeal joint. Using this technique to eliminate cases with high-likelihood of incongruent anatomy, we hypothesize the rates of arthritis could be reduced. We conducted a retrospective review of upper extremity CT scans from 2007 to 2014 at our institution. Those studies meeting our inclusion criteria were exported to a clinical radiology software suite. Subsequently, angular and linear measurements of the hamate and potential recipient proximal interphalangeal joints were collected. Angular and linear comparisons were then made between the donor hamate graft and the individual recipient sites. Using pre-established cutoff values, matches were deemed to be inconsistent or consistent. The study included 31 CT scans. The rate of anatomical consistency was low; the small finger was most often consistent (38.7 %) and the index finger was least often consistent (12.9 %). Linear inconsistency was common in all joints besides the small finger; angular inconsistency was most prevalent in the index and long fingers. This novel use of CT scans as a tool for pre-operative HHA planning is a crucial first step in trying to reduce the observed rates of arthritis after HHA.

Purpose To assess whether or not attempted closed reduction of fifth metacarpal neck fractures results in decreased fracture angulation at final follow-up. Methods Retrospective chart review of all patients aged 18 and older managed for isolated fifth metacarpal neck fractures between 2004 and 2014. Results Sixty-six patients managed for an isolated boxer fracture met inclusion criteria. Twenty-three patients underwent attempted reduction and 43 patients did not. Patients undergoing attempted reduction had a statistically significant improvement in fracture angulation following reduction compared with patients not undergoing attempted reduction. At final follow-up, there was no difference in fracture angle between the 2 groups. Conclusions Closed reduction and splint immobilization of fifth metacarpal neck fractures was not an effective means of maintaining a significant improvement in fracture alignment upon healing. Other means, such as closed reduction with pin fixation or open reduction internal fixation, should be considered when maintenance of reduction is desired. Type of study/level of evidence Therapeutic III.

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.

An 18-year-old right-hand dominant woman presented with an enlarging right medial elbow mass which was associated with worsening paresthesias during the past 2 months, primarily affecting her ring and small fingers. She denied any weakness or loss of function. There was no family history of soft tissue tumors, neurocutaneous disorders, or neuropathy. Physical examination revealed an elongated soft tissue mass along the posteromedial aspect of her right elbow. The mass was fairly firm, did not transilluminate, and was mobile in the mediolateral plane. Although the mass was not tender to palpation, percussion of the mass reproduced her paresthesias (a positive Tinel’s sign). Moreover, light touch sensation was intact. Further evaluationof her right upper extremity revealed normal ROM, vascular status, and no atrophy of the upperextremity muscles. Small finger abduction strength was 4/5 with remaining strength testing revealing no other weakness. There was no associated lymphadenopathy. Laboratory tests, including a complete blood count with differential, a comprehensive metabolic panel, sedimentation rate, C-reactive protein, and lactate dehydrogenase levels, were normal. Imaging studies included AP and lateral radiographs of the humerus (Fig. 1) and MRI (Fig. 2). Based on the history, physical examination, laboratory studies, and imaging studies, what is the differential diagnosis at this point?

Background: The metacarpophalangeal joints exhibit range of motion that is influenced by wrist position. Synergistic motion occurs between the wrist and the metacarpophalangeal joints with different static wrist positions affecting joints’ motion capability. The aim of this study was to determine how different wrist positions influence the active range of motion of the index through small finger metacarpophalangeal joints. Methods: The active range of motion of the index through small finger metacarpophalangeal joints of 31 healthy subjects was measured in flexion/extension and radial/ulnar deviation in 5 different flexion/extension wrist positions, using biaxial electrogoniometers. Results: There was a difference in range of motion of all fingers depending on the wrist position. The minimum metacarpophalangeal joint range of motion was found in 80° wrist extension, the maximum in neutral wrist position. For the index finger, flexion/extension was 84.7° (±8.6°) to 25.9° (±10.2°) and radial/ulnar deviation was 32.1° (±11.3°) to 22.6° (±12.8°). For the middle finger, flexion/extension was 84.8° (±8.5°) to 25.9° (±10.1°) and radial/ulnar deviation 28.8° (±11.1°) to 22.1° (±8.9). The fourth finger showed a range of motion for flexion/extension of 87.2° (±11.5°) to 22.8° (±11.6°) and radial/ulnar deviation of 8.1° (±5.8°) to 32.3° (±12.4°). The highest range of motion was measured at the fifth finger with flexion/extension of 84.0° (±8.6°) to 32.1°(±16.8°) and radial/ulnar deviation of 15.1° (±12.9°) up to 54.6° (±18.7°). Conclusions: The range of motion of the index through small finger metacarpophalangeal joints was significantly influenced by wrist position. The highest metacarpophalangeal joint range of motion of all fingers was conducted in neutral wrist positions. Apart from ergonomic implications, we conclude that metacarpophalangeal joint motion should be assessed under standardized wrist positions.

Background: The extensor digiti minimi (EDM) tendon is commonly divided into a radial slip (EDM-R) and an ulnar slip (EDM-U). To our knowledge, the degree to which each EDM slip concomitantly abducts the small finger with active extension has not been formally tested. This study sought to characterize the comparative contributions of finger abduction inherent to each slip of the EDM to observe the sequelae of active small finger extension following transfer of the contralateral slip. Methods: Eighteen fresh-frozen cadaveric hands were used in this study. Starting with the hand in resting position, a controlled traction of 10 N was applied to each slip of the EDM tendon. The range of small finger abduction with respect to the fixed ring finger was recorded utilizing infrared reflective markers tracked through the range of motion using a digital video camera. Results: The mean abduction of the small finger when the radial slip of the EDM tendon was tested was 13.33° (95% confidence interval [CI]: 10.10°-16.55°), which was significantly different ( P ≤ .001) than small finger abduction produced by the ulnar slip of the EDM, with a mean of 23.72° (95% CI: 19.40°-28.04°). Conclusions: Given the fact that the ulnar slip of the EDM tendon is shown to be the major contributor of aberrant abduction with active small finger extension, as traction on this slip produces almost twice as much abduction as the radial slip, the EDM-U is the ideal donor graft with respect to tendon transfers of the EDM.

Background: The purpose of this study was to determine whether placing the suture-button device between the long and small finger metacarpals following ring finger ray amputation may better close the intermetacarpal gap and allow early range of motion without increasing the risk of malrotation than soft tissue repair alone. Methods: We performed ray amputation of the ring finger of 14 cadaver specimens by performing an osteotomy of the base of the ring finger metacarpal and then excising the remainder of the digit. We first performed a soft tissue repair of the transverse metacarpal ligaments and then cycled the fingers in simulated active flexion and extension on a custom computer-controlled device to re-create 6 weeks of range of motion. We then placed a suture-button device across the long and small finger metacarpals and tested the specimens again, thereby using each hand as an internal control. Results: The distance between the ring and small finger metacarpals was reduced following suture-button device placement compared with the initial control; this spacing was maintained following complete cycling of the fingers. The angle between the metacarpals was divergent following soft tissue repair, and then became slightly convergent after insertion of the suture-button device. None of the hands developed clinically relevant scissoring of the digits before or after application of the suture-button device. Conclusions: The suture-button device provides stable fixation to withstand early range of motion following ring finger ray amputation and significantly closes the gap and angle between the adjacent metacarpals without causing scissoring.

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.

The aim of the study is to introduce a new minimally invasive technique for ulnar nerve release and transposition.From January 2010 to May 2011, 51 patients with cubital tunnel syndrome were treated through a 1.5 to 2 cm incision. Limb functional recovery, scar esthetics, sensitivity of scar, numbness of the operating area, and patient satisfaction were assessed.No wound hematoma nor infection was observed in the group. The time of operation was 36 ± 17.2 minutes. At the final follow-up of 63 ± 7.3 months, 2-point discrimination of the small finger was improved from 6.3 ± 2.2 mm to 5.2 ± 2.4 mm. Grip and pinch strength of the hand were improved from 14.2 ± 7.7 kg and 3.7 ± 2.4 kg to 35.2 ± 12.7 kg and 4.1 ± 2.8 kg, respectively. The motor nerve conduction velocity was improved from 36.5 ± 11.2 to 44.6 ± 6.7 (m/sec). The Disabilities of the Shoulder, Arm, and Hand questionnaire score was improved from 37.2 ± 23.8 to 10.5 ± 9.6. No patients reported scar pain, sensitivity of scar, or numbness of the operating area. No revision surgery was needed. Michigan Hand Outcome score for aesthetics was 94.6%±5.1 and satisfaction was 92 ± 8, respectively. We obtained 33 excellent, 12 good, 5 fair, and 1 poor result.Ulnar nerve decompression with anterior transposition can be safely and effectively accomplished through the small incision. It can be an alternative technique producing good appearance.

Background Headless compression screws have been used for arthrodesis of the distal interphalangeal joint with good clinical results. However, some distal phalanges are too small, thus precluding their use, or increasing complication rates. Methods In order to validate our digital measurements, radiographs of five cadaveric hands were obtained. The distal phalanges of these fingers were measured using our institution's digital radiograph software. The cadavers were then dissected, and the actual phalanges were measured to confirm the accuracy of the digital measurements; 200 consecutive hand radiographs were then measured to obtain average width and heights of the narrowest measurements of the distal phalanx of each finger. Subgroup analysis of each finger for age and gender was completed. Results and Conclusions Females were routinely smaller than their male counterparts. No age-related differences were seen. A substantial number of fingers were found to be too small to allow for use of headless compression screws; 42 % of small finger distal phalanges are too small to accommodate 2.8-mm threads, and that number increases to 81 % with 3.2-mm threads and 97 % with 3.5-mm threads. Few distal phalanges, regardless of which finger, are large enough to accommodate 3.5-mm-diameter threads; 22% of female ring finger distal phalanges are smaller than 2.8 mm, and 66 % of ring fingers are smaller than 3.2 mm. Based on our measurements, a surprising number of distal phalanges are smaller than the trailing thread diameter of commonly commercially available headless screws. Care must be taken in selecting implants for distal interphalangeal (DIP) fusion.

Summary:. Finger amputations are common injuries which result in significant long-term morbidity and loss of function. In this report, we describe a creative operative solution for a 21-year-old man who was in a motorcycle crash and sustained severely comminuted open fractures of the left small and ring fingers with severe crush injury and soft tissue avulsion. Of the tissues and bones in the small finger, only the distal half of the proximal phalanx remained intact and was vascularized via the remaining ulnar neurovascular bundle. In the ring finger, the extensor mechanism and ulnar neurovascular bundle were avulsed and the distal half of the proximal phalanx was absent, but the flexor tendons were intact. A small finger ray amputation was performed. Then, using an osteocutaneous fillet flap based on the ulnar neurovascular bundle from the small finger, the bony gap and soft tissue deficits in the ring finger were reconstructed. The ring finger extensor tendon was then reconstructed. Subsequently, the patient had evidence of bony union on follow-up X-rays and he had a sensate filet flap over the ulnar aspect of the ring finger. This case demonstrates the creative use of a “spare-parts” osteocutaneous fillet flap in the reconstruction of a traumatic finger injury. This example highlights the importance of assessing all available reconstructive options to avoid the morbidity of a finger amputation.

Purpose To evaluate the outcomes of the Thompson procedure for chronic mallet finger deformity and review the utility of this procedure. Methods Seven cases of chronic mallet finger with a swan neck deformity were treated by the Thompson procedure. Ranges of motion for the distal interphalangeal (DIP) and proximal interphalangeal (PIP) joints were measured, and complications were investigated at the final examination. Patients were evaluated using the criteria reported by Abouna and Brown. Results Four patients were men, and 3 were women. The average age at the time of surgery was 44 years (range, 25 to 71 y). The middle finger was affected in 4 cases, and the index, ring, and small finger were involved in 1 case each. The average extensor lag on the DIP joint was 42° (range, 35° to 50°). All cases were treated with the Thompson procedure. The swan neck deformity was corrected in all cases. The average motion at the final examination was −4° (range, −30° to 0°) in extension and 91° (range, 85° to 110°) in flexion for the PIP joint and −5° (range, −10° to 0 °) in extension and 63° (range, 45° to 85°) in flexion for the DIP joint. A buttonhole deformity and a dimple at the proximal tied end of the graft were seen in 1 case. Assessment by the criteria of Abouna and Brown revealed that 6 of 7 patients were categorized as cured and one as improved. No patient was categorized as unchanged. Conclusions The procedure provides a predictable method for correcting loss of DIP joint extension with or without PIP joint hyperextension. We believe that the Thompson procedure is an effective technique for the salvage, following failed treatment, of a closed mallet injury with an associated swan neck deformity. Type of study/level of evidence Therapeutic IV.

In patients with severe thenar atrophy secondary to carpal tunnel syndrome, we hypothesize that following open carpal tunnel release, concomitant transfer of the abductor pollicis brevis (APB) origin to the flexor carpi radialis (FCR) tendon will lead to improved patient function restoring palmar abduction and thumb opposition. We evaluated 14 patients through questionnaires and seven patients through additional physical examination (thumb range of motion, ability to tip pinch, grip/pinch strength) for a mean follow-up of 2.8 years. All patients showed evidence of palmar abduction with 71% demonstrating the ability to oppose the thumb to the tip and base of the small finger. The transfer of the APB origin to the FCR tendon can restore thumb abduction and opposition for thenar paralysis secondary to severe carpal tunnel syndrome. Patients experience good functional outcomes with the majority experiencing restored thumb opposition.

A composite graft for reattachment of an amputated fingertip is a very controversial and challenging procedure. An osteocutaneous composite graft is rarely conducted and has a low success rate following fingertip amputation. A 21-year-old male patient was referred to our emergency clinic with dorsal oblique amputation of the middle, ring and small fingers of the left hand through the distal interphalangeal joint and middle phalanx. The amputated parts of the middle and ring fingers were reattached with osteocutaneous composite grafts. The amputated part of the small finger was revascularised to the ulnar palmar digital artery of the small finger. The composite grafts of the middle and ring fingers and the revascularised small finger survived completely. We suggest that careful patient selection will allow an osteocutaneous composite graft to become an acceptable method for the treatment of fingertip amputation. A large-scale study of osteocutaneous graft of amputated fingertips is required to improve the survival rate.

This study estimated the prevalence of independent flexor digitorum superficialis function in the small fingers of 90 violin and viola players. The hypothesis tested was that the independent digital movements required in this population would select out those with absent flexor digitorum superficialis function. Professional string players were tested clinically, using standard and modified tests, for flexor digitorum superficialis function. Two additional physical tests were applied: the gap and stretch tests. These tests assess ring finger movement once the small finger is placed and the instrument is held in the chin-hold position. A statistically significant reduction in the prevalence of absent flexor digitorum superficialis function was confirmed in the musicians compared with a control group and published meta-analysis. This suggests that independent flexor digitorum superficialis function is important for professional musicians playing at an elite level.

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.

A 48-year-old male presented himself in my office with painful dorsal nodules on his fingers in association with a recurrent Dupuytren’s contracture of his small finger of his right dominant hand. Prior, he underwent surgery with open selective fasciectomy 4 years ago for his right small finger due to Dupuytren’s contracture. However, Dupuytren’s contracture recurred within 18 months following conventional open surgery as limited fasciectomy. He had a positive family history for Dupuytren’s contracture. Regarding knuckle pads in his family history, the patient was not quite sure about.

Purpose There is a need for objective measures of pediatric intrinsic hand muscle strength as the current standard, the manual muscle test, lacks sensitivity to clinically important changes in muscle strength. We report the development, reliability, and normative values of the Peg Restrained Intrinsic Muscle Evaluator (PRIME), a device that quantifies intrinsic hand muscle strength. Methods Typically developing children, ages 4 to 16 years (n = 119), established normative values of intrinsic strength for thumb palmar abduction, thumb opposition, and index and small finger abduction. A subset of 30 children (15 boys, 15 girls), ages 7 to 16 years, determined inter-rater and intra-rater reliability. We calculated mean, standard deviation, intraclass correlation coefficients, and smallest detectable differences. Results Normative results indicate that gender and age were significant predictors of strength. Although the dominant hand generated higher strength measurements on average, differences were not statistically significant. Mean index and small finger abduction strength was significantly lower than thumb abduction and opposition in both genders. Intraclass correlation coefficients ranged from 0.85 to 0.94 for inter-rater reliability and 0.88 to 0.98 for intra-rater reliability. Bland-Altman plots showed an even distribution across the zero line. Conclusions The PRIME device is a reliable tool for the quantification of intrinsic hand muscle strength in children. Age-specific and gender-specific normative values in typically developing children can serve as a future resource for clinicians treating pediatric hand or neuromuscular conditions. Type of study/level of evidence Diagnostic II.

The purpose of this study was to analyse motion patterns of the finger joints dynamically while making a fist. 10 subjects were examined using the TUB-sensor glove, which was equipped with 14 joint angle sensors. The median time it takes the finger joints to complete flexion until reaching the state of a closed fist ranges between 0.5 to 1.0 s. A specific pattern can be seen for every finger. The PIP and DIP joints appear to be linked, with the DIP trailing the PIP joint. At the thumb the IP is trailing the MCP joint. The MCP joint shows more variation at the beginning of flexion: while in some cases it initiates movement in a finger, in other cases its flexion falls behind the PIP joint movements. The completion of flexion is achieved by the MCP joints, with the PIP and DIP joints reaching their end of motion first. The range of motion (ROM) at the MCP joints shows a finger-dependent median of 79-97°. At the PIP joints the median lies between 87° and 90°, at the DIP joints between 52° and 68°. At the thumb it is 21° for the MCP and 24° for the IP joint. The linkage between PIP and DIP joints can also be seen when analysing the ROM. The coupling ratio amounts to 0.77 at the index finger, 0.75 at the middle and ring finger and 0.57 at the small finger.

The present study analyses force distribution patterns during primary grips. 10 subjects were examined using the TUB-sensor glove, which was equipped with 10 pressure sensors. 5 proximal sensors at the MCP joints and 5 distal sensors at the DIP joints were attached palmarly. 9 different gripping motions were examined: the cylinder grip using 4 different objects, the pinch grip and 4 different kinds of precision grips. The force distribution patterns can be clearly divided into 2 groups. On the one hand there are the "power grips", in which the force is distributed over the proximal and distal sensors. On the other hand there are the "precision grips", which only show a force distribution at the distal sensors. Therefore Napier's concept of the existence of primarily 2 gripping patterns, which is based on visual analysis, can be verified objectively. For the "power grips" the force distribution is shifted further distally with increasing size of the objects. In conclusion, their distribution pattern shifts towards the pattern of the "precision grips". At the small finger the distal sensor is already dominant during the "power grips" of smaller objects. The thumb plays a subordinate role during the "power grip" of smaller objects, since these grips are similar to the "closing fist motion" and the objects can be held between the fingers and the palm of the hand. However, with increasing object sizes the thumb gains more importance, since its opposing movement is now required to accomplish the grip.