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Introduction: Hand tumours are frequently encountered in clinical practice. However, large-scale epidemiological data of soft tissue tumours in the hand are infrequently published. Epidemiological data provide diagnostic cues to guide the workup and management of hand tumours. Assessing significant independent demographic factors and tumour characteristics associated with hand tumours is essential in health care., Methods: A retrospective review of patients who underwent excision of hand tumours in Singapore General Hospital between 2004 and 2015 was conducted. The data collected included age, gender, ethnicity, histological diagnosis, malignancy and location of tumour. Generalised linear latent and mixed models (GLLAMM) analyses were performed., Results: A total of 4476 tumours were identified from 4226 patients with a mean age of 51.3 (range 8-101) years and male to female ratio of 1 to 1.15. Most patients were Chinese (75%), followed by Malay (9%), Indian (8%) and others (8%). The most common hand tumours excised were ganglions (43%) (majority in the wrist), followed by giant cell tumours (9%) (commonly in the digits). Most soft tissue tumours were benign (97%), with only 3% of malignant cases. The GLLAMM analyses revealed further potential factors on the status of malignancy, tumour origin and tumour location., Conclusion: Most soft tissue tumours in the hand and wrist are benign. This can guide workup and counselling of patients before the operation. While malignant tumours are uncommon, they have the potential for significant morbidity and mortality if not appropriately evaluated or treated. The application of GLLAMM analyses showed that age, ethnicity and gender were significant predictors of malignancy., (Copyright © 2024 Copyright: © 2024 Singapore Medical Journal.)

The complexity of wrist anatomy and mechanics makes it challenging to develop standardized measurements and establish a normative reference database of wrist biomechanics despite being studied extensively. Moreover, heterogeneity factors in both demographic characteristics (e.g. gender) and physiological properties (e.g. ligament laxity) could lead to differences in biomechanical behaviour even within healthy groups. We investigated the kinematic behaviour of the carpal bones by creating a virtual web-like network between the bones using electromagnetic (EM) sensors. Our objective was to quantify the changes in the carpal bones' biomechanical relative motions and orientations during active wrist motion in the form of orb-web architecture. Models from five cadaveric specimens at different wrist positions: (1) Neutral to 30° Extension, (2) Neutral to 50° Flexion, (3) Neutral to 10° Radial Deviation, (4) Neutral to 20° Ulnar Deviation, and (5) Dart-Throw Motion - Extension (30° Extension/10° RD) to Dart-Throw Motion Flexion (50° Flexion/20° UD), in both neutral and pronated forearm have been analyzed. Quantification analyses were done by measuring the changes in the network thread length, as well as determining the correlation between the threads at different wrist positions. We observed similarities in the kinematic web-network patterns across all specimens, and the interactions between the network threads were aligned to the carpal bones' kinematic behaviour. Furthermore, analyzing the relative changes in the wrist web network has the potential to address the heterogeneity challenges and further facilitate the development of a 3D wrist biomechanics quantitative tool., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Various studies have examined occlusive dressings in fingertip amputations and reported good outcomes. Occlusive dressing preserves appropriate pH, cell accumulation and moisture for healing, thereby limiting scar formation and deformity. To our knowledge, no study was performed in tropical Asia. This study aims to demonstrate the viability of healing fingertip amputations through secondary intention using an effective dressing technique, even in warm tropical climates. Methods: All patients who presented to our institution with fingertip amputations from 1 July 2020 to 31 July 2022 were analysed retrospectively. Seventeen patients (15 male, 2 female) of mean age 37.2 ± 9.4 years old with 18 injured digits were retrospectively analysed. Twelve (66.7%) were Allen Type III injuries, and one patient required distal phalangeal K-wire fixation. During the patient's final review, static 2-point discrimination, pulp sensation, fingertip contour and nail deformities alongside the last measured range of motion (ROM) of the injured finger was recorded. Treatment duration and days of leave taken were also summed and assessed. Results: Patients were dressed with semi-occlusive dressing for an average of 20.1 ± 6.83 days. The average total duration of dressing is 36.78 ± 18.88 days over an average of 7.18 ± 4.03 dressing visits. Mean duration of follow-up was 108 ± 63.46 days. Good outcome measures in sensation, pulp contour, nail deformity and ROM similar to existing literature were reported. Conclusions: Occlusive dressing remains a viable and feasible treatment option for fingertip amputation even in a tropical climate. While this simple treatment method may require more effort from patient, wound healing was attained after 36.8 ± 18.9 days of dressing. Level of Evidence: Level IV (Therapeutic).

Septic arthritis of the metacarpophalangeal joint (MCPJ) compromises 9% of hand infections in Singapore. Common surgical treatment is open arthrotomy and joint washout. The wound is often left open for drainage postoperatively. Repeated debridement and secondary closure are frequently needed after the index surgery. We describe a method of continuous catheter irrigation of septic MCPJ joint using an infant feeding catheter. This method provides great infection clearance to avoid repeated debridement and allows primary closure of the wound to avoid secondary closure. This method also significantly reduces postoperative pain so that to facilitate early mobilization of the joint, which is crucial for functional recovery. We illustrate the techniques of this procedure and key points of postoperative management in the ward with case examples to demonstrate its simplicity, safety, and efficacy in treating MCPJ septic arthritis., Competing Interests: Conflicts of Interest and Source of Funding: The authors report no conflicts of interest and no source of funding., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Concepts of tissue damage from sepsis are rooted in the works of Pasteur regarding colonization by microorganisms, and Lister's observation of avoiding suppuration by their exclusion. The reactive inflammation has been considered a beneficial defence mechanism. A more complex biology is now unfolding of pathogenic mechanisms with toxins produced by the organisms now being placed in a broad category of virulence factors. Neutrophils are key cells in providing innate immunity and their trafficking to sites of infection results in entry to the extracellular space where they attack pathogens by release of the contents of neutrophil granules and neutrophil extracellular traps. There is now considerable evidence that much of the tissue damage in infection is due to excessive host innate immunological reaction; a hyperinflammatory response, whether localized or systemic. In addition to traditional surgical methods of drainage and decompression there is now a focus on dilution of inflammatory mediators. This emerging knowledge can potentially alter the way we approach hand infections., Competing Interests: Declaration of conflicting interestsThe author declares no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study aimed to compare the torsional resistance of three fixation techniques for spiral metacarpal fractures: screw-only fixation, screw plus neutralization plate fixation, and a locking plate construct. A spiral fracture was created on 18 cadaveric metacarpal bones by applying an axial and torsional loading force using an Instron 3343 mechanical tester. The failure strength was defined as the native torque strength. The fractures were divided into three groups and fixed using each of the three techniques. The repaired bones were loaded to failure to determine the post-repair strength. The neutralization plate group conferred a post-repair torque (278.6 Nmm) that was similar to the native torque (292 Nmm) with a diminution of only 4.5% and appeared to provide the best resistance to torsion., Competing Interests: Declaration of conflicting interestsThe authors declare no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

This study investigated the contribution of different forearm muscles, namely the flexor carpi ulnaris, extensor carpi radialis longus and brevis, extensor carpi ulnaris and flexor carpi radialis, during the dart thrower's motion. Thirteen healthy participants were recruited. The forearm muscle activation patterns during the dart thrower's motion were measured using surface electromyography. The average root mean square for the extensor carpi ulnaris was found to be the highest during the dart thrower's motion. Muscle activations during the dart thrower's motion were heterogeneous among the participants. The results suggest the rehabilitation protocol for patients with wrist injuries should be reconsidered.

Understanding the stresses on the scapholunate interosseous ligament (SLIL) and its interaction with synovial fluid pressure could be vital to improve wrist treatment for various wrist conditions such as arthritis, sprains and tendonitis. This study investigated the interaction between the intra-articular pressure, specifically the synovial fluid pressure change and the SLIL stresses in a computational model during wrist radioulnar deviation (RUD). Magnetic resonance imaging (MRI) scans were used to acquire the anatomical model of the carpal bones and ligament, while the kinematics of scaphoid and lunate were obtained through dynamic computerized tomography (CT) scans. A two-way fluid-structure interaction (FSI) was used to model the dynamics between the scaphoid and lunate, the SLIL, and the synovial fluid. The synovial fluid pressure change was found to be small (-4.86 to 3.23 Pa) and close to that simulated in a previous work without the SLIL (-1.68 to 2.64 Pa). Furthermore, peaks of maximum fluid pressure were found to trail the peaks of ligament stress. Therefore, it is suggested that the influence of synovial fluid pressure on the ligament in the SLIL model is negligible and simulations of the scapholunate joint could forego fluid-structure interactions. Future studies can instead explore other structures in the carpus that can possibly contribute to the ligament stresses. Clinically, treatments can be targeted at these areas to help prevent or slow the progression of ligament injuries into serious consequences like the degenerative joint disease.

Purpose: The first dorsal interosseous (FDI) muscle, when impaired due to traumatic injuries or degenerative conditions, can be reanimated in various ways to restore pinch grip. These reconstructive techniques are planned based on a precise anatomical understanding of the FDI muscle. However, a review of the existing literature has brought to light controversy regarding its insertions. A systematic review of these descriptions is presented to appreciate these variations., Methods: An electronic database search without exclusion by publication year and language was performed according to the Checklist for Anatomical Reviews and Meta-Analyses (CARMA) guidelines, using the PubMed, Scopus, Web of Science and Embase databases. An assessment of the methodological quality was performed., Results: Thirteen studies were included in this article. There is general agreement that the FDI muscle contains two bellies and a bony insertion into the index finger proximal phalanx base. However, due to wide anatomic variation, differences were reported on whether there is a soft tissue insertion. When this was found, the included studies differed on how commonly this occurs (between 1.4% and 78%), where it inserts. Other sites of distal insertions reported include the metacarpophalangeal capsule, the interosseous hood and an assemblage nucleus on the volar plate., Conclusions: Our systematic review, focusing on the insertion of the FDI muscle, summarizes the existing knowledge on its anatomy and variations, thereby facilitating better understanding of its function and surgical planning for reconstruction., (© 2023. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Background: This review aims to identify publications on quantitative biomechanical testing of surgical knot security and the physical factors that determine knot security and failure., Materials and Methods: An electronic literature search was performed in accordance with PRISMA guidelines in January 2022 utilizing the PubMed and Google Scholar databases to look for objective biomechanical studies on knot security in surgery using the primary terms 'knot security' and 'biomechanical testing'., Results: Thirty-six articles were included. Twenty-four configurations of surface, laparoscopic, and arthroscopic knots were studied. Biomechanical tensile testing was used to evaluate knot security in vitro . Load to failure (N) and elongation at knot failure (mm) were quantified by static and cyclic testing to evaluate the knot holding capacity and failure mechanism of slippage or rupture., Conclusion: This review reassures that the knot configuration, suture materials, suture sizes, and number of throws are key factors in determining the knot's security. Knot configuration has to be simple for laparoscopic and arthroscopic knots due to the confined space of the operating site. With the advent of stronger suture materials for high-tension surgical reconstructive procedures, there is an unmet need to understand the physical behavior of the knot and the factors that determine its resistance to slippage or rupture.Level of Evidence: Level IV., (Copyright © 2023 The Author(s). Published by Wolters Kluwer Health, Inc.)

Purpose: Peripheral vein thrombophlebitis has a reported overall incidence ranging from 20% to 80%. Thrombophlebitis can progress despite antibiotic therapy to become a challenging clinical problem requiring surgical intervention. There is currently no consensus on its optimal management. We reviewed our experience of surgical intervention with analyses of the indications for intervention, descriptions of the surgical procedures, and outcomes. We aimed to provide guidance on the management of this potentially serious complication., Methods: This is a retrospective review of 51 patients with thrombophlebitis refractory to conservative management between January 2017 and August 2020., Results: Analyses revealed a high prevalence of comorbidities, including diabetes mellitus, malignancy, and chronic kidney disease. A total of 60% of patients had concurrent bacteremia, and the decision to operate had a low threshold in the presence of these factors. On exploration, 80% of patients had intraluminal thrombus, 47% had intraluminal pus, and 29% had pus beyond the veins or extending proximally. The surgical approach employed in 98% of patients involved an extensile incision in those with several morbidity factors (diabetes mellitus, chronic kidney disease, or bacteremia). One patient presented with severe clinical signs of local infection, and on exploration, there was intraluminal pus and thrombus up to 10 cm. A novel technique of a minimally invasive approach of intermittent stab incisions was employed in a young and healthy patient without comorbidities., Conclusions: We developed an algorithm to guide the indications for intervention and surgical approach to thrombophlebitis. The threshold for intervening surgically should be lowered by the presence of comorbidities. The failure of antibiotics to resolve the clinical signs of infection or the suspicion of abscess formation should mandate intervention. Thrombosed sections of the vein should be ligated proximally and distally and excised and surrounding collections of pus drained. Delayed secondary wound closure is usual. Stab incisions may limit surgical dissection and subsequent scarring in less severe cases., Type of Study/level of Evidence: Prognostic IV., (© 2022 The Authors.)

Background: Massachusetts General Hospital (MGH) repair is one of the widely used 4-strand flexor tendon repair techniques. However, it uses two single strand sutures that are each passed twice across the repair site. This is time consuming and may cause imbalance of the load across the repair. We modified the MGH repair by using a looped suture and call it the looped MGH repair. The aim of this study is to compare the strength of the looped MGH repair performed with three different looped sutures against the strength of original MGH repair. Methods: Forty porcine flexors were used for the study. The original MGH repair was performed with Prolene ® 4-0. Looped MGH repair was performed with three different loop sutures, Supramid ® 4-0, Tendo-Loop ® 4-0 and FiberLoop ® 4-0. Mechanism of failure, ultimate tensile strength, stiffness, load to 2-mm gap formation and repair time were recorded for comparison. Results: There was no significant difference between the original MGH repair and the looped repair using Supramid ® regarding their biomechanical performance. Looped MGH repair using Tendo-Loop ® and FiberLoop ® showed significantly higher ultimate tensile strength and FiberLoop ® had highest 2-mm gap force. All looped MGH repairs required significant less time compared to original MGH repair. Conclusions: Our modification of the MGH repair using a looped Supramid ® 4-0 suture took significantly lesser time to perform while providing the same strength as the original MGH repair using Prolene ® 4-0. The use of the FiberLoop ® 4-0 provided significantly greater strength while taking lesser time.

Injuries within the peripheral nervous system (PNS) lead to sensory and motor deficits, as well as neuropathic pain, which strongly impair the life quality of patients. Although most current PNS injury treatment approaches focus on using growth factors/small molecules to stimulate the regrowth of the injured nerves, these methods neglect another important factor that strongly hinders axon regeneration-the presence of axonal inhibitory molecules. Therefore, this work sought to explore the potential of pathway inhibition in promoting sciatic nerve regeneration. Additionally, the therapeutic window for using pathway inhibitors was uncovered so as to achieve the desired regeneration outcomes. Specifically, we explored the role of Wnt signaling inhibition on PNS regeneration by delivering Wnt inhibitors, sFRP2 and WIF1, after sciatic nerve transection and sciatic nerve crush injuries. Our results demonstrate that WIF1 promoted nerve regeneration ( p  < 0.05) after sciatic nerve crush injury. More importantly, we revealed the therapeutic window for the treatment of Wnt inhibitors, which is 1 week post sciatic nerve crush when the non-canonical receptor tyrosine kinase (Ryk) is significantly upregulated., Competing Interests: Declaration of conflicting interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)

We performed a detailed dynamic high-resolution ultrasound examination of the flexor tendons in trigger fingers and compared this with normal contralateral digits. There was a loss of defined linear tendon margins and/or traction of the flexor tendons on the surrounding soft tissue during passive flexion of the distal interphalangeal joint in 17 out of 20 trigger fingers, which indicated adherence to the surrounding tissues. The differential motion between the flexor digitorum profundus tendon and the flexor digitorum superficialis tendons was also lost in ten trigger fingers, which suggested adherence between the tendons. No signs of peritendinous or intertendinous adhesions were found in the healthy control fingers. We conclude that tendon adhesions are present in the majority of trigger fingers. We could not determine a relationship between the severity of triggering and the presence of adherence due to limited sample size. Level of evidence: II.

We tested the tensile strength of the proximal juncture of tendon grafts with Pulvertaft tendon repairs in 18 cadaveric digital flexor tendons. These tendons were divided into three groups of six: single, two, or three weaves. Each of the interlacing weaves was secured with eight anchoring sutures. The specimens were loaded in a biomechanical tester until failure. The ultimate tensile strength did not show any significant differences across all three groups with statistical power of 0.77. The mean tendon elongation before repair failure showed significant difference at 10 mm (standard deviation (SD) 2), 16 mm (SD 3), and 15 mm (SD 3), respectively. All specimens failed by intra-tendinous pull-out of the weaves. We conclude that the two-weave Pulvertaft construct demonstrated comparable tensile strength to three weaves and tendon elongation was similar when two or three weaves were used.

Background: The acceptable incidence of thrombophlebitis following intravenous cannulation is 5%, as recommended by the Intravenous Nurses Society guidelines, but publications have reported startling figures of 20% to 80%. Given the frequency of intravenous lines, this presents a potential clinical problem. We aimed to determine the predisposing patient, catheter, and health care-related factors of peripheral vein thrombophlebitis in the upper extremity., Methods: In this systematic review, we used a comprehensive search strategy to identify risk factors of thrombophlebitis from inception to May 20, 2019. Studies reporting risk factors of peripheral vein thrombophlebitis of adult patients admitted to the hospital and receiving an intravenous cannulation were included. The Quality of Prognostic Studies tool was used in the assessment for risk of bias to determine the study quality., Results: Of the 6910 studies initially identified, 25 were eligible for inclusion. Qualitative syntheses revealed that patient-related factors that confer a higher risk included intercurrent illness, immunocompromised state, comorbidities such as diabetes mellitus, malignancy, previous thrombophlebitis, burns, and higher hemoglobin levels. Catheter-related risk factors included catheter size, duration, and site of insertion. Intravenous antibiotics and potassium chloride predisposed to thrombophlebitis. Cannulation by an intravenous therapy team and more nursing care were associated with a decreased risk. A P-value < .5 was considered to be statistically significant., Conclusion: Recognition of the predisposing factors would allow for targeted strategies to aid in the prevention of this iatrogenic infection, which may include closer monitoring of patients who are identified to be vulnerable. Based on this systematic review, we developed an algorithm to guide clinical management. Further research is warranted to validate this algorithm., (Copyright © 2019. Published by Elsevier Inc.)

Septic arthritis of the small joints of the hand usually occurs secondary to bacterial inoculation through penetrating injury to the joint, or direct spread of infection from paronychia, felon, or pyogenic flexor tenosynovitis. Surgical treatment involves drainage and irrigation and may involve debridement if there is an open wound. We describe a method of continuous irrigation of septic joints of the hand postoperatively in the ward setting using an intravenous cannula placed within the joint and connected to an intravenous giving set with delivery of physiological fluid using a pump driver. Modifications of the technique are described for distal interphalangeal, proximal interphalangeal, and metacarpophalangeal joints and illustrated in each joint by 3 case studies. In addition to the irrigation, intravenous antibiotics were administered. All patients healed well with a full return of joint motion, no radiologic change, and a mean QuickDASH score of 4.8 at a mean follow-up duration of 3.6 months. This is a safe and simple technique that can be performed in patients with suspected or confirmed septic arthritis and carries minimal morbidity.

Background: When closed ruptures of flexor tendons of fingers occur, there is often an identifiable pathology, which should be addressed in the same surgical setting as the tendon repair. The concept of "spontaneous" tendon rupture, occurring in the absence of identified pathology, however, has also been reported in a significant number of papers. This controversy has prompted us to do a review of the existing literature. Methods: We did a review of cases of closed ruptures of the flexor digitorum profundus (FDP) of the little finger in existing literature. Fifty-three publications were retrieved by searching "FDP tendon rupture" and "little finger" using PubMed database. We analyzed data such as the zone of rupture noted intra-operatively; and any precipitating factors, pathology or trauma. We also conducted a review on papers which discussed the concept of "spontaneous rupture". Results: Fifty-three publications were retrieved. There were 8 cases of ruptures in Zone I; 2 in Zone II; 30 in Zone III; 59 in Zone IV and 5 in Zone V. Majority of cases were associated with an element of trauma of varying severity, or pathology. A precipitating cause was not documented in 12 cases. Amongst all 36 cases of ruptures labelled as "spontaneous", only 1 case was truly "spontaneous" without any associated trauma or pathology. Conclusions: Most reports labeled as spontaneous rupture occurred in Zone III, where tendon ruptures are rare. There are documented pathological causes or evidence of trauma to most of these cases. We conclude these ruptures may have been mislabeled as spontaneous ruptures. Bearing in mind the propensity for tendon excursion, we suspect the lack of documentation of exploration in proximal zones contributed to this mislabeling. Understanding this concept of non-spontaneity to most tendon ruptures and the common sites of rupture or pathology is crucial for a surgeon to make strategic incisions and minimize future recurrence.

Background: Crush injury of nerves is a common condition but the biomechanical integrity of the human peripheral nerve after crushing is unknown. This study aims to investigate the impact of crush injury on human digital nerves based on different compressive forces., Materials and Methods: Twenty digital nerves were harvested from three fresh-frozen cadaver hands. The original diameters of proximal, middle and distal end of nerve segment were measured. The midst of each digital nerve was compressed by a customized mechanical system, at 1N, 3N and 5N for 30sec. The diameters were measured again within 1 minute after the nerve crush test was performed. The digital nerve was then subjected to biomechanical test to measure its ultimate tensile strength, stiffness, maximum stress and strain. Deformity of digital nerve was computed based on the diameter of middle nerve segment before and after crush test., Results: No significant difference was found in between groups for ultimate tensile strength ( p =0.598), stiffness ( p =0.593), maximum stress ( p =0.7) and strain ( p =0.666). The deformity of nerves under the compression of 1N, 3N and 5N was computed at 72.1%, 54.2% and 45.9%. The effect of compression on the deformity of nerves was statistically significant ( p <0.001)., Conclusions: It was found that the compressive forces have no impact on the biomechanical integrity of peripheral nerves but the deformity of nerves could be severely caused by low compressive force. It is suggested that the management of nerve crush injury shall be taken immediately and focus on neurophysiological function and degeneration of nerves for a crush with low compressive force and short duration.

Purpose: Grayson ligament has been described as a common pathway for digital contracture in Dupuytren disease. Its anatomical descriptions in the literature are, however, inconsistent., Methods: We have performed a microsurgical dissection study in 20 fresh-frozen and thawed digits to revisit the anatomy of Grayson ligaments. We also performed dissections in Thiel-preserved hands to be able to study the changes in tension of the ligaments during flexion and extension of the finger., Results: We found the ligaments originally described by Grayson to be the best developed part of a trabecular network of fibers, originating in continuity with the outer adventitial layer of the flexor tendon sheath and running toward their insertions into the skin in multiple planes, all volar to the neurovascular bundle. The most dorsal fibers, which cover the neurovascular bundles, form a chevron shape with its midline apex pointing distally in an extended finger. During flexion, the fibers become more transversely oriented., Conclusions: We found Grayson ligament comprises a trabecular network of fibers, instead of a ligament, with a dynamic fiber orientation on the volar side of the finger. The main function of this network of fibers seems to be the stabilization of the skin and fat pad in digit extension while the relaxation in flexion allows the skin and volar fat pad to adapt optimally to the form of the object that is held., Clinical Relevance: The new insights in the anatomy of Grayson trabecular network of fibers may be of importance in the understanding of the pathological anatomy of Dupuytren disease., (Copyright © 2019 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)