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The palmar triangle is an area vascularized by perforator arteries arising from the common digital palmar arteries. The aim of this article was to perform an anatomical study of common digital palmar arteries perforators. Twelve injected specimens were included in this study. The purpose was to quantify the number of perforator arteries of each common digital palmar arteries in the 2nd, 3rd, and 4th intermetacarpal space, measure distances between them, between the distal perforator and corresponding commissure, and the distance between the proximal perforator and the superficial palmar arch. Four to eight perforators were arising from common digital palmar arteries of the 2nd, 3rd, and 4th intermetacarpal space. The average distance between perforator arteries was 6.5 mm, between superficial palmar arch and proximal perforator artery - 8.2 mm, between the distal perforator artery and corresponding commissure - 6.3 mm., (© The Author(s) 2014.)

Objectives: To investigate median nerve structure in patients with recurrent carpal tunnel syndrome (CTS) using diffusion tensor imaging (DTI) and to relate DTI changes to anatomical MRI and to measures of median nerve function., Methods: Median nerve structure was quantified according to DTI in patients with recurrent CTS and in healthy controls of similar age. Anatomical MRI was used to identify the presence of nerve compression and fibrosis. Median nerve function was measured using electromyography, a force-tracking task (accuracy of precision grip control) and clinical measures., Results: Patients showed reduced apparent diffusion coefficient (ADC), reduced axial diffusivity (AD) and radial diffusivity (RD) along the median nerve compared with controls (P < 0.001). Patients with endoneural fibrosis had the greatest reductions in ADC and in RD. ADC and AD correlated positively with nerve conduction velocity (R = 0.54 and R = 0.68, respectively) and fractional anisotropy correlated negatively with error during force-tracking (R = -0.58)., Conclusions: A specific pattern of DTI changes in the median nerve was identified in patients with recurrent CTS. Fibrosis may be underlying these structural changes. The correlations with nerve conduction velocity and accuracy of force control suggest that DTI is a promising technique in the study of median nerve structure in recurrent CTS., Key Points: • Diffusion tensor imaging (DTI) offers further possibilities in musculoskeletal magnetic resonance imaging. • DTI reveals median nerve changes in recurrent carpal tunnel syndrome. • DTI changes were greater with signs of median nerve fibrosis. • DTI parameters correlated with nerve conduction and force control measures. • DTI is a promising technique in recurrent carpal tunnel syndrome.

Purpose: We report a series of 5 patients (mean age, 41 y) presenting with ulnar styloid impingement syndrome (USIS) and treated by an oblique ulnar styloid osteotomy. The purpose of the study was to determine whether the osteotomy is an effective method for treating USIS., Methods: The diagnosis of USIS was made based on a history of ulnar-sided wrist pain supported by clinical and radiological findings. Clinical assessment included provocative tests to differentiate USIS from pain associated with ulnocarpal impaction syndrome. The ulnar styloid length was assessed with a posteroanterior X-ray using the methods of Garcia-Elias and Biyani. The ulnar styloid was deemed excessively long if the ulnar styloid process index was greater than 0.21 or if the overall styloid length was greater than 6 mm. Ulnar variance was recorded. All wrists were assessed by computed tomography arthrography and magnetic resonance imaging studies to rule out any associated soft tissue abnormalities, including ligamentous injuries. Preoperative and postoperative pain levels were recorded using a pain scoring system., Results: Patients were followed up for a mean of 46 months. Before surgery, the mean styloid length was 10 mm, and the ulnar styloid process index was 0.32. The reported pain score was significantly reduced following surgery and all patients, except one, returned to premorbid levels of activity., Conclusions: Oblique ulnar styloid osteotomy is an effective means of relieving impaction of the ulnar styloid while preserving the integrity of the intrinsic ulnar styloid ligaments., Type of Study/level of Evidence: Therapeutic IV., (Copyright © 2011 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Objective: The purpose of this study was to retrospectively determine the accuracy of MRI in identification of the morphologic features of median nerve dysfunction after surgical release of the median nerve for carpal tunnel syndrome., Materials and Methods: Two blinded readers independently evaluated axial 1.5-T MR images for retinacular regrowth, morphologic characteristics of the median nerve, and presence of mass effect, fibrosis, and carpal tunnel decompression. All 47 patients (11 men, 36 women; mean age, 55 years; range, 27-81 years) had undergone open surgical release of the median nerve for carpal tunnel syndrome. Thirty-five patients had electromyographic evidence of recurrent carpal tunnel syndrome. The other 12 patients did not have electrophysiologic evidence of recurrent carpal tunnel syndrome and were the control group., Results: A statistically significant difference between the recurrent carpal tunnel syndrome and control groups was found for fibrosis (p = 0.009), nerve enhancement (p = 0.04), and median nerve width (p = 0.008) and ratio (p = 0.01) at the pisiform level., Conclusion: MRI may be used in association with electromyography for accurate postoperative evaluation of the carpal tunnel.

We report a case of unilateral congenital aplasia of the carpal scaphoid bone discovered in adulthood, which probably caused a severe painful intercarpal degenerative arthritis. This case was not associated with hypoplasia or aplasia of thenar and forearm muscles, abnormality of the skeleton of the thumb ray, absence of the sesamoid bones, hypoplasia of the forearm bones, as in cases reported in the literature; the only additional anatomic abnormality was a mild hypoplasia of the radial styloid. A surgical treatment (4-bone arthrodesis) has been performed to treat the advanced carpal collapse and the arthritis.

The vascular malformations are not uncommon on the hand and offer diagnostic and therapeutic challenges. Enjolras and Mulliken's classification is exposed. Their depiction and pretreatment assessment may benefit from non-invasive imaging as color-Doppler ultrasound and MRI combined with magnetic resonance angiography (MRA). Some chronic traumatic vascular injuries as the hypothenar hammer syndrome may also take advantage of these imaging modalities.

Objective: To report the MR imaging findings of painful injured metacarpophalangeal (MCP) joints of the fingers., Design and Patients: MR imaging of 39 injured MCP joints in 38 patients was performed after a mean delay of 8.8 months. The MR images were obtained with the fingers in extended and flexed positions using T2-weighted and T1-weighted sequences before and after intravenous injection of a gadolinium compound. Ten patients were treated surgically. Mean clinical follow-up was 1.8 years., Results: Tears of the collateral ligaments were the most common lesion (30/39), most being radial in location. Contrast-enhanced axial T1-weighted images with the MCP joint in a flexed position showed these lesions optimally. Ten tears were partial and 20 were complete. In 13 patients, MR images showed 17 associated lesions including injuries of the extensor hood (10/17), interosseous tendon (3/17), palmar plate (3/17), and an osteochondral lesion (1/17). Sagittal MR images were essential to highlight palmar plate tears., Conclusion: Partial or complete tears of the collateral ligaments are prevalent MR imaging findings in patients with chronic disability resulting from injuries to the MCP joints. Although conservative treatment generally is sufficient for isolated injuries of the collateral ligaments, surgical repair is often required in cases of more extensive injuries. MR imaging may clearly delineate associated lesions of and about the MCP joints.

Congenital coalition of pisiform and hamate is rare and had been considered asymptomatic in the first reports. The authors report a case of bilateral pisiform-hamate coalition in a young patient, causing symptoms of median nerve compression in the carpal tunnel and attritional changes on digital flexor tendons. This type of coalition had not previously been related to such symptoms. Additionally, the morphology of the coalition on the right side is unique among published cases. Surgical treatment with bilateral excision of the coalition resulted in the resolution of symptoms.

Purpose: To determine the magnetic resonance (MR) imaging findings in recurrent glomus tumors of the fingertips., Materials and Methods: Twenty-four consecutive patients with recurrent pain after previous excision of a glomus tumor of the fingertip underwent MR imaging studies and surgery. T1-weighted spin-echo MR images were obtained in each patient before and after intravenous injection of contrast material; T2-weighted spin-echo and three-dimensional gradient-recalled echo images were also obtained. MR angiography was performed in four patients. Postsurgical histopathologic analysis revealed recurrent glomus tumors in 22 patients. Signal intensity, enhancement, and margins of the scar tissue and the recurrent tumors at MR were assessed., Results: The postsurgical scars were depicted in 21 (88%) of 24 patients with all sequences but were best demonstrated on gradient-recalled echo MR images. Seven patients had undergone multiple surgical procedures and had extensive scar tissue and, in one case, a neuroma. In all patients, MR imaging revealed a nodule compatible with the diagnosis of a recurrent glomus tumor. In 13 (54%) of 24 patients, the nodule had typical features of a glomus tumor. In eight (33%) of 24 patients, the tumors had low signal intensity or isointensity compared with the nail bed on T2-weighted images. In six (25%) of 24 patients, the tumors had faint enhancement after intravenous gadolinium chelate administration. The margins of the tumors were blurred by scar tissue in nine of 24 cases., Conclusion: MR imaging can aid in the evaluation of recurrent glomus tumors.

We report a complication following trapeziectomy and tendon interposition. Subcutaneous herniation of the tendon interposition occurred in 3 of 412 cases in which trapeziectomy, ligament reconstruction, and tendon interposition were performed. This herniation occurred posterolaterally in the early postoperative period and resulted in dorsal swelling and superficial pain. Magnetic resonance imaging was helpful in confirming the diagnosis and excision of the herniated interposition material resulted in satisfactory pain relief and functional outcome as long as metacarpal stability was present.

The occurrence of an osteochondroma in the carpus is very rare and its excision is indicated in the case of significant symptoms or change in its appearance. The diagnosis is often made in adulthood due to the onset of a functional problem even though development of the tumour occurs during skeletal growth. We report the case of a 38 year old patient, with no antecedent trauma, who presents with simultaneous exostoses on the dorsal and palmar surfaces of the capitate, which has not been previously described in the literature. The existence of a bipolar lesion extending anteriorly and posteriorly in the carpus is a possibility which may not be apparent and renders plain radiograph insufficient in the investigation of such a lesion. CT scan and MRI scan are indispensable in the investigation of this kind of carpal lesions, allowing better visualization of the base of the tumour, the expansion of the tumour and relation to the neighbouring soft tissues and the presence of malignant degeneration.

Objectives: To define the characteristics of synovial osteochondromatosis of the hand and wrist., Patients and Methods: Retrospective study of 21 patients, including 11 with intraarticular and 10 with tenosynovial disease. Cases secondary to degenerative joint disease were excluded. Surgery consisted in removal of the osteocartilaginous bodies and of the adjacent synovial membrane. Mean follow-up was seven years (range, three to 18 years). The relevant literature was reviewed in part., Results: Recurrence was seen in four patients and was multiple in two of these four. Most recurrences occurred within five to ten years after surgery. All four patients with recurrences had intraarticular disease. No cases of malignant transformation were seen. The characteristics of synovial osteochondromatosis at the hand and wrist are reviewed., Conclusion: Detailed preoperative investigations including computed arthrotomography and magnetic resonance imaging should be performed to increase the likelihood of complete excision.

Resection arthroplasties were performed through a carpal tunnel incision in 72 hands of 57 patients with trapeziometacarpal joint arthritis and coexistent pathology of the anterior hand or wrist. Sixty-nine hands were followed for an average of 44 (range, 12-74 months). Pain relief was excellent in 60 hands, good in 7, and fair in 2, and thumb motion was satisfactory in 64 hands. Mean strength increase was 30%. Scaphometacarpal space loss was 0.5 mm each year, and residual space averaged 3.1 mm at 60 months. There were two failures. The study corroborated the frequent coexistence of other pathology of the anterior area of the hand and wrist, specifically, carpal tunnel syndrome and flexor carpi radialis tenosynovitis. Furthermore it demonstrated the possibility of an anterior approach to treat these conditions via the same incision. After 5 years, functional results remained good despite progressive collapse of the scaphometacarpal space.

Fracture and luxation of the long fingers are particularly frequent in hand trauma. Untreated or poorly treated, they may leave highly disabling sequelae. The aim of treatment is two-fold: to repair the anatomical lesion and to obtain movement as rapidly as possible, the only means of avoiding joint stiffening. It is important to underline that the metacarpo-phalangeal joints usually stiffen in extension and that the proximal interphalangeal joints on the contrary stiffen in flexion. Thus, in case of immobilisation of the hand, an attempt should be made to obtain an "intrinsec plus" immobilisation, that is, with the metacarpo-phalangeal joints in flexion and the interphalangeal joints in extension.

To permit a smooth entry into the water, platform divers assume a special position with their hands. An older method consists of hitting the water with both fists closed while holding one thumb in the palm of the other hand. In a newer technique fingers and wrists are hyperextended, the forearms pronated, and the hands overlapped. In this series of 21 divers, the injuries included 2 fractures and 5 sprains treated by conservative methods. Two divers required surgery: one with loose bodies in the radiocarpal articulation, the other with chronic rupture of the trapeziometacarpal ligament and synovitis of both extensor pollicis brevis and longus. Eighteen divers complained of pain caused by the impact of the hand with the water. A kinetic analysis with a video imaging system explains the mechanism and forces of water penetration.

The authors report on a study of 53 patients suffering from resectable nerve tumors of the peripheral nerves, representing a total of 73 tumors. This concerns a round, hard swelling, with slight transversal movement, located along the course of a nerve. This swelling was painful and percussion led to lancinating pains along the course of the nerve. The same surgeon operated on all of these patients. The surgical treatment of the 46 patients undergoing surgery for the first time always consisted in a simple enucleation after opening of the epineurium with good results. Seven cases were seen in the stage of sequelae and five were clearly improved by a second operation. The principal surgical procedures are given. The maximum time of follow-up was 14 years and the minimum 12 months, with an average of 52 months. Our study included 34 women and 19 men suffering from one or more nerve tumors. The average age was 50.7 years, ranging from 17 years to 88 years. 39 patients had schwannomas, 1 lymphoma of the sciatic nerve, 2 hemangiomas of the sheath of Schwann, 6 intraneural cysts and 5 fibrolipomas. The authors analyse the diagnosis difficulties, the additional examinations and particularly RMI which has been perform on 7 patients and revealed to be very sensitive and of a great liability.

Ten cases of nonunion of the hook of the hamate were observed, eight of which had occurred during athletic activity. The mean age was 31.1 years and the mean length of time between the accident and diagnosis was 8.8 months. Diagnosis was most often confirmed by CT scanning, which, represents the examination of choice. In all cases, surgical treatment was applied using the same technique and the same surgeon. Results were evaluated according to resolution of pain, movement, strength of grip and return to former level of athletic activity. Results were very good in six patients and good in two others who returned to previous activity. One patient had only a fair result with resolution of pain. One case was a failure with persistence of pain and ulnar paralysis.

The authors report five cases of ulnar dislocation of the Extensor pollicis longus caused by rupture of the hood at the metacarpophalangeal of joint the thumb. This rarely described lesion is well known in long fingers but seems to be less common in the thumb and no previous series can be found in the literature. This dislocation gives a deficit on active extension of the metacarpophalangeal joint of the thumb. During trauma of MP, the expansion of abductor pollicis brevis cans be damaged which provokes ulnar dislocation of EPL. An anatomical study of this region is reported by the authors. 10 dissections on fresh or prepared cadavers were performed with two series of slices of all of the extensor apparatus on the MCP. The hood of the MCP has two superposed planes: one is superficial with transverse fibers which run over the joint from the Abductor to the adductor with the EPL getting through it and a deep plane composed of the EPB and the capsule. Diagnosis is made on clinical observation. The patient has partial deficit of extension of the MCP with a history of old thumb trauma. EPL is active and palpable under the skin. On the MCP it is ulnarly dislocated and lesion front of the rotation center. Dislocation can be reduced manually by a skin pinch on the dorsal part of the MCP. Extension is then possible and complete. This lesion is rare, as we have found only five patients reported between 1984 and 1991. Two patients presented an isolated dislocation of the EPL due to a lesion of the superficial plane.(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report 62 cases of De Quervain tenosynovitis treated from 1983 to 1990 by the same surgeon. The de Quervain's tenosynovitis is an inadequation between the volume of the abductor pollicis longus and the extensor pollicis brevis and their tunnel above the radial styloid process producing a mechanical tenosynovitis. This disease occurs mostly in women with an average age of 47 and almost never before the age of 30. Clinically the patients have pain and swelling above the radial styloid process. Most of the surgeons know today this disease, nevertheless complications may occur (Abductor pollicis longus luxation, disgratious enlargement and adhesion of the scar). The transversal incision provides a less disgracious scar. As the tendinous pulley is opened frequent anatomical variations of the tendons are found. A ventral capsular flap fixation with a subcuticular continuous suture is made. This fixation prevents any ventral luxation. Radial nerve neuromas or neuritis is constantly looked for. The authors expose and analyse the statistical data of this intervention's results with a 6 month minimal and 7 years maximal follow up.

The retrospective study of this homogeneous series of 110 carpal tunnel syndromes in 70 patients on hemodialysis shows the usual severity of symptoms (right thenar amyotrophy in 56% of cases, advanced nerve lesions in 66%). Synovitis plays a major role, as demonstrated by the frequency of clicking fingers (45%), and requires synovectomy that allows thoroughly exploring the carpal tunnel and removing a highly aggressive element against tendons. In this study, fisculae do not seem to have the generally admitted importance, but it requires surgical caution. Two thirds of patients were followed up for an average of 3 years. Apart from 3 recurrences, the control of pain is good but sensorimotor recovery is long and often incomplete, which is in favor of earlier surgery.

Dislocation of the extensor tendon over the MP joint as a result of trauma is a rare and unrecognized injury as our six patients were only operated subsequently. The diagnosis is simple: flexion is possible, while extension is not. The patient is able to hold the extension despie resistance if the dislocation is reduced by artificial extension. X-rays eliminate any possible fracture. Six cases have revealed two different assumptions: either the two tendons (extensor digitorum communis and extensor digiti quinti proprius) are simultaneously dislocated together on the ulnar side, or they are dislocated on either sides of the joint. In the first assumption, the injury occurred ulnar-wise tearing the sagittal band. This case concerns the three older patients. The dislocation was reduced and stabilized by the Michon surgery method. The second assumption concerns the three youngest patients who suffered from a direct axial shock. This separation was reduced by suture of the two tendons on the dorsal base of the joint. The postoperative care was ensured in all cases by a splint attached to the palm, keeping the MP joint in extension and enabling immediate web-fingered reeducation. This therapeutic technique has given satisfactory results as over an average period of six years no recurrence of stiffness has been observed.

The author reports about an original technique of release of the ulnar nerve in the elbow by frontal partial epicondylectomy. In our opinion, this technique has the advantage of leaving a natural protection for the ulnar nerve when leaning on the internal aspect of the elbow. After summing up the various elements of ulnar nerve compression in the elbow and the various surgical techniques to remove compression, we describe in detail the surgical technique that we propose. The series is reported and the results are presented. These results are comparable to those of other published series and seem to depend mainly on the stage of nerve compression.

The author presents an original technique of transposition of the fifth ray by intracarpal osteotomy. After a review of the different techniques and their inconvenience, the author describes the principles of this procedures. It includes a resection of the whole fourth ray, and a translocation of the fifth ray following a wedge-shaped osteotomy of the lateral aspect of the hamate and an arthrodesis between the capitate and the hamate. The details of this intervention are presented. 17 cases are reported with a follow-up ranging from 17 months to 34 months, and the results of which are analysed.

The consequences of the division of the pulley of the flexor hallucis longus are described. This division may be necessary for the repair of tendon or in the treatment of trigger thumb. After division, the pulley cannot be sutured and the flexor tendon remains displaced anteriorly. The authors describe a technique of repair using a flap detached from the tendon of the adductor pollicis. 6 cases have been operated on with good results.