Callus distraction for lengthening of mid-hand and finger stumps in congenital hand abnormalities--personal results and review of the literature

Distraction-lengthening technique is quite useful in a variety of congenital hand deformities with hypoplastic, or primary normal but secondary shortened (constriction ring syndrome) finger rays. It appears that around the age of two years is the earliest practical time to start distraction; certainly distraction and secondary surgical procedures to improve function should be completed before school entry age whenever possible. Between June 1990 and March 1993, nine distraction lengthening procedures (5 thumbs, 1 index, 3 little fingers) in five patients presenting with congenital hand deformities, were carried out. Although restoring length to the finger, lengthening does not provide normal circumference or, of course, interphalangeal joint motion. Amelioration in function seems to be more important than the esthetic gain. Distraction lengthening tolerates only few errors of indication, operative technique, and/or postoperative management. A high compliance of the patient and her/his parents as well as a close follow-up by an experienced surgeon, are mandatory for a good result. A variety of possible complications have been described. Generally, complication risk increases in cases of simultaneous and multiple level lengthening. Provided adequate operative technique and postoperative care, superficial pin infection and fracture in the region of distraction are the major complications. Contrary to adults, sufficient bone formation by distraction is the rule in children. Therefore, the distraction-lengthening technique is preferred to the distraction-interposition technique in the treatment of congenital hand deformities. The latter should only be used as a salvage procedure in the rare cases of insufficient callus formation. Because of the missing growth potential and reduced joint mobility, distraction lengthening is the therapy of second choice when compared to microvascular second toe transplantation.     

Prolonged studies of perfluorocarbon associated gas exchange and of the resumption of conventional mechanical ventilation

We applied functional magnetic resonance imaging (FMRI) to map the somatotopic organization of the primary motor cortex using voluntary movements of the hand, arm, and foot. Eight right-handed healthy subjects performed self-paced, repetitive, flexion/extension movements of the limbs while undergoing echo-planar imaging. Four subjects performed movements of the right fingers and toes, while the remaining subjects performed movements of the right fingers and elbow joint. There was statistically significant functional activity in the left primary motor cortex in all subjects. The pattern of functional activity followed a topographic representation: finger movements resulted in signal intensity changes over the convexity of the left motor cortex, whereas toe movements produced changes either at the interhemispheric fissure or on the dorsolateral surface adjacent to the interhemispheric fissure. Elbow movements overlapped the more medial signal intensity changes observed with finger movements. Functionally active regions were confined to the cortical ribbon and followed the gyral anatomy closely. These findings indicate that FMRI is capable of generating somatotopic maps of the primary motor cortex in individual subjects.     

Total anterior teno-arthrolysis. Report of 72 cases

This report describes a new technique for treatment of the chronically flexed fingers which applies in particular to fingers previously operated on several times and now presenting cutaneous, tendinous and joint problems. It consists in releasing the entire flexor apparatus through a full length lateral digital incision and a sub periosteal dissection. The volar plates of PIP and DIP are released as a whole with the flexor apparatus. The extended finger and flexor apparatus then are allowed to heal in a new relationship. Straightening of the finger is always possible. The range of motion is maintained or increased. This technique can also be used in stiff PIP joints and in certain serious forms of Dupuytren's contracture. 56 cases are reviewed with 78% with good or fair results.     

Donor site morbidity in cross-finger flaps

As relevant literature is scarce, this study was undertaken to assess the donor site morbidity of cross-finger flaps. It included 23 patients who had undergone reconstruction of a finger defect with a cross-finger flap. Any additional trauma to the donor finger was an exclusion criterion. Split thickness skin grafts were employed for donor site closure in 13 cases, full thickness skin grafts were used in 10 cases. Follow-up time averaged 83 months. Active and passive total range of motion of the donor finger and maximal pinch grip strength in kilopascals were measured. Both parameters were compared to the corresponding finger of the other hand. The donor site scar was evaluated for instability and pain in the donor finger was determined subjectively with a visual analogue scale. Cold intolerance and the cosmetic appearance of the donor site were also assessed.Active total range of motion of the donor fingers averaged 156°. Average active total range of motion of the contralateral control fingers was 173.6°. There was a significant difference between the donor fingers and the control fingers (p=0.03) but not between split thickness and full thickness grafted donor sites (p=0.91). Grip strength was significantly impaired in the donor fingers (p=0.03), but there was no significant difference between split thickness and full thickness grafted donor sites. Subjective cosmetic evaluation by the patients revealed significantly better results for full thickness grafted donor sites. Donor finger pain averaged 2.4 with a range of 0–8. Five of the 13 patients with split thickness grafted donor sites and two of the 10 patients with full thickness grafted donor sites mentioned cold intolerance.In conclusion, the cross-finger flap is a secure and valuable option. There is, however, significant donor site morbidity. Our results suggest that alternative solutions should also be considered and if a cross-finger flap is employed, donor sites should be closed with full thickness grafts.     

Lateral digital rotation flaps in the treatment of forms of Dupuytren's contracture. 141 cases

Severe contractures of the little finger can be corrected with a rotation flap. It has been used 141 times in a homogeneous series of 522 Dupuytren diseases. This flap brought to the metacarpophalangeal crease to the proximal phalanx can provide a skin lengthening of about 15 mm. The incision can be extended to the palm in order to remove the other fascial lesions. It was used mainly on the little finger (9 times out of 10). A single flap was usually made, but one may use two flaps from contiguous fingers, and even raise two flaps from the same finger. A comparative study with "Z" plasties was carried out. Out of 131 "Z" plasties with an average lack of extension of 126 degrees, the rate of improvement was 57%. The rotation flap was used in 141 cases with an average lack of extension of 140 degrees, and the rate of improvement was 79%. This flap seems to be an interesting procedure in the surgical treatment of severe Dupuytren contractures and seems more efficient than "Z" plasties.     

Individual finger forces acting on a grasped object during shaking actions

Individual finger grip forces acting on a hand-held object were examined during shaking tasks with a five-finger precision grip. The subjects (n = 13) shook a force transducer-equipped grip object (mass = 400 g) in vertical, horizontal, and mediolateral directions at an average movement speed of 33 cm/s (moderate) and 66 cm/s (fast). In addition, grip forces were examined while the subjects (n = 10) held the object in front of the body and walked or ran in place. It was found that the grip forces for all the fingers changed temporally and spatially coupling with the acceleration of the object resulting from shaking. The results suggest that grip force control is accomplished in an active and anticipatory fashion. Regardless of the shaking direction and speed, among the four fingers the absolute grip force in the index finger was largest, followed by the middle, ring, and little finger forces. The index finger therefore plays a primary role in grip force control during shaking. The percent force contribution by each finger varied depending on the direction of shaking. Contributions of the ring and little fingers were larger when shaken in the horizontal and mediolateral directions than they were in the vertical direction. The results suggest that different finger co-ordination is required in relation to shaking direction. Changes in shaking speed from moderate to fast changed the grip forces for all the fingers. During walking and running, grip force control similar to that during active vertical shaking was required to hold the object safely in the hand.     

Volkmann's ischemic contracture of the upper extremity

Upper extremity deformity of ischemic contracture usually includes elbow flexion, forearm pronation, wrist flexion, thumb flexion and adduction, digital metacarpophalangeal joint extension, and interphalangeal joint flexion. Treatment of mild contractures consists of either nonoperative management with a comprehensive rehabilitation program (to increase range of motion and strenght) or operative management consisting of infarct excision or tendon lengthening. Treatment of moderate-to-severe contractures consists of release of secondary nerve compression, treatment of contractures (with tendon lengthening or recession), tendon or free-tissue transfers to restore lost function, and/or salvage procedures for the severely contracted or neglected extremity.     

Fixed post-traumatic flexion-contractures of digits. Review of thirty-three cases

A fixed post-traumatic flexion contracture of a finger is usually secondary to multiple previous operations. We have observed that a former flexor tendon laceration is not constant and is missing in 18% of our cases. The flexor tendons are, nevertheless, always involved in the contracture. A volar skin contracture was present in all cases, but only in half of them was noted a retraction of the volar components of the PIP joint. This articular involvement has no statistical correlation with the time elapsed from the onset of the contracture. We have reviewed 33 cases of post-traumatic flexions contractures of the digits all secondary to volar trauma. In every case there was at least a flexor tendon adhesion and skin contracture. They have all been submitted to both objective and statistical analysis. Results have been evaluated by comparison between the normal functional range of motion for each digit and the actual post-operative active range of motion. On the basis of our study we conclude that the age of the patient is an important prognostic factor. We obtained 75% satisfactory results in patients younger than 27 years, but only 22% in the older group. Good results are more easily obtained in radial (65%) than ulnar digits (31%). While the authors rated 39% of the results bad, half of the patients in this group were satisfied with the result. A volar PIP joint release has been necessary in half of the cases with no significant secondary joint stiffness. A skin flap is necessary to cover the cutaneous defect secondary to the release. There is no statistically significant advantage to cross finger flaps. Therefore we feel that local flaps are indicated except in the cases where local scar tissues would not make it, feasible. The prognosis is independent of the number of previous operations and of associated nerve lesions. Therefore amputation is not the only solution for a multi-operated finger fixed in flexion.     

Surgical principles and planning for the rheumatoid hand and wrist

Each surgical procedure available for the rheumatoid hand has a score card. The most indicated and necessary procedures include: extensor tenosynovectomy and Darrach for the impending or already ruptured extensor tendons; flexor tenosynovectomy and carpal tunnel release for the patient with impaired median nerve function; stabilization of the deformed unstable thumb with MP or IP arthrodesis; and flexor tenosynovectomy in the palm and finger of a motivated patient with significant disparity between active and passive motion. Relative indications for surgery include arthrodesis for the unstable wrist; MP arthroplasty for the fixed MP volar and ulnar subluxation with inability to open the hand; synovectomy for the occasional patient with painful boggy synovitis of the MP or PIP joint; and reconstruction of the fixed swan neck deformity with relatively good PIP joints. Both MP and PIP joints can and should be operated on at the same time. Extensive wrist surgery, that is, tenosynovectomy and Darrach or arthrodesis, should not be performed at the same time as MP arthroplasty. Try to do the "winner operations" first.     

How similar are motor imagery and movement?

It has been suggested that motor imagery (MI) has the basic components of real motion. This possibility was tested here in 17 healthy volunteers studied while performing or imaging a fast sequence of finger movements of progressive complexity, a fast and precise extension of the arm to touch a small circle with the tip of a pencil, a periodic repetitive flexion-extension of the index finger at a specified rate, and a velocity-regulated continuous rotary movement of the right hand. Motor sequences of 4 to 5 fingers showed a real-virtual congruency similar to that previously reported with other equivalent tests, but it decreased in the simplest sequences performed with 1 to 2 fingers. A more marked decrease of real-virtual congruency was found in the experimental paradigm aimed at producing movements with a pre-specified velocity, which was low for rhythmic movements of the index finger and practically absent in the continuous rotary movements of the hand. Present data show that the ability of MI to produce "realistic" simulations of motion is not the same for all motor tasks. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Heterotopic replantation

In multidigital amputations, it is sometimes better to replant an amputated finger to a different proximal part if a better function can be expected in this position. In our clinical material between October 1991 and March 1994, heterotopic replantation was performed in twelve digits in eleven patients. Three fingers were replanted to the thumb, three to the index, four to the middle, and two to the ring fingers. The functional results were satisfying. The total active range of motion was on an average 24% of a normal finger. Static two-point discrimination was 8.5 mm on an average, and the values for the Semmes-Weinstein test ranged between 3.61 and 6.5. A heterotopic replantation is of special value for primary thumb reconstruction.     

Evaluation of the two-stage flexor-tendon reconstruction in severely damaged digits

From July 1971 to July 1974, the two-stage tendon-grafting procedure of Hunter and Salisbury was performed in thirty-two severely damaged digits in twenty-five patients. Of these digits, twenty-three fingers and five thumbs could be evaluated for gain in total active flexion (expressed as per cent of preoperative passive flexion) and for gain in total active motion (expressed as per cent of total preoperative passive motion) after follow-ups ranging from six to fifty months. The results for total active flexion were 60.9 per cent good, 21.7 per cent fair, and 17.4 per cent poor, and for total active motion 21.7 per cent good, 56.5 per cent fair, and 21.7 per cent poor. Complications were frequent after both stages and included infection, migration of the rod, and adhesions within the proximal end of the newly formed sheath. Flexion contractures were a significant problem.     

Ser-311-Cys polymorphism of the dopamine D2 receptor gene and schizophrenia--an analysis of schizophrenic patients in Fukuoka

Functional brain imaging studies have indicated that several cortical and subcortical areas active during actual motor performance are also active during imagination or mental rehearsal of movements. Recent evidence shows that the primary motor cortex may also be involved in motor imagery. Using whole-scalp magnetoencephalography, we monitored spontaneous and evoked activity of the somatomotor cortex after right median nerve stimuli in seven healthy right-handed subjects while they kinesthetically imagined or actually executed continuous finger movements. Manipulatory finger movements abolished the poststimulus 20-Hz activity of the motor cortex and markedly affected the somatosensory evoked response. Imagination of manipulatory finger movements attenuated the 20-Hz activity by 27% with respect to the rest level but had no effect on the somatosensory response. Slight constant stretching of the fingers suppressed the 20-Hz activity less than motor imagery. The smallest possible, kinesthetically just perceivable finger movements resulted in slightly stronger attenuation of 20-Hz activity than motor imagery did. The effects were observed in both hemispheres but predominantly contralateral to the performing hand. The attempt to execute manipulatory finger movements under experimentally induced ischemia causing paralysis of the hand also strongly suppressed 20-Hz activity but did not affect the somatosensory evoked response. The results indicate that the primary motor cortex is involved in motor imagery. Both imaginative and executive motor tasks appear to utilize the cortical circuitry generating the somatomotor 20-Hz signal.     

Modulation of cerebral somatosensory evoked potentials arising from tibial and sural nerve stimulation during rhythmic active and passive movements of the human lower limb

The magnitudes of cerebral somatosensory evoked potentials (SEPs), following stimulation of cutaneous or muscle afferents in the upper limb, are reduced during active and passive movements of the fingers. The generalizability of such a movement effect was tested for lower limb events. We measured SEP magnitudes following activation of cutaneous (sural) and mixed (tibial) nerves during the flexion phase of active and passive rhythmic movements of the human lower limb. In eight volunteers, 150 SEPs per condition were recorded from Cz' referenced to Fpz'. Compared to stationary controls, both active and passive movements significantly depressed the early SEP components (P1-N1) [mean values, to 12.8%, 9.9% respectively for tibial nerve and to 29.6%, 25.6% for sural nerve stimulation, p < 0.05]. The attenuation was still observed when only one leg was moved and with stimulation at an earlier point in the flexion phase of movement. Visual fixation did not significantly affect P1-N1 amplitudes, compared to eyes closed. As previously shown, soleus H reflexes with stable M waves were significantly depressed during the movements (p < 0.05). The general construct may be that centripetal flow initiated from somatosensory receptors during limb movement leads to modulation of both spinal and cortical responses following large diameter cutaneous or muscle afferent activation.     

Multifinger tapping performance as a function of the direction of tapping movements.

What can the study of finger movements in typing, especially with respect to directional aspects, tell us about the way in which office and data-processing machine keying operations can be improved? "Five male Ss were given 3-minute trials at each of five keyboard positions for 20 consecutive days. The keyboard, consisting of the eight keys of the starting position of a typewriter, was hinged in the middle, so that the direction of tapping movements, could be varied from horizontal to vertical. The task was a simple alternation of both fingers and hands." Relatively poor performance with the standard horizontal keyboard and other findings suggest the possibility of much improved keyboards. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The "callus-thenics" of touching.

Studied 8 undergraduates to provide an experimental test of the skin deformation model of tactile roughness and to examine the relative effectiveness of various tactile exploration strategies. Ss made magnitude estimates of the roughness of grooved aluminum plates presented at 2 different forces, using the 3 middle fingers of their writing hand, 1 at a time. Perceived roughness increased as a function of increasing groove width, increasing force, and finger (in the order index, middle, and ring). The effect of finger was predicted on the basis of differential callus thickness on the fingertip, and provided support for the skin deformation model proposed by M. M. Taylor and S. J. Lederman (see record 1975-10788-001). Discrimination with the index finger was better than when either the middle or ring finger was used, although there were no differences in the reliability of the judgments. The finding that the index finger was the most discriminating and likely to be the most highly calloused argues against a simple reduced sensitivity explanation of the effect of increased callus on perceived roughness. The merits of both perceptual learning and sensory explanations for the finger discrimination differences are discussed. Implications for procedures used to improve texture discrimination in young blind children are considered. (French summary) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

New contributions to clinical hypertension from molecular biology

The authors constructed a new dynamic guiding splint assisting the active mobilisation after flexor tendon repair distal to the wrist. In these cases, the "inverse" wrist position seems to be the best position for mobilisation. This means that finger flexion should be carried out during wrist extension, and finger extension during wrist flexion. The splint guides and co-ordinates the movements of the wrist and the fingers, and it limits the free usage of the hand.     

Distraction effects on muscle. Leg lengthening studied in rabbits

We investigated changes in the anterior tibial muscle during lengthening of the lower leg in rabbits. In 37 rabbits, an osteotomy of the right middle tibia was performed and was fixed by a unilateral external fixator. The rabbits were randomized into 6 groups. In groups 1, 2, and 3 the tibiae were distracted 0.5 mm/day. In groups 1 and 2, the rabbits were killed after 14 and 28 days of distraction, respectively, and in group 3 after 28 days of distraction, followed by 14 days of rest. Groups 1a, 2a, and 3a served as controls. They were treated similarly as groups 1, 2, and 3, but no distraction was performed. Proliferating cell nuclei were labeled with 5-bromo-2-deoxyuridine and were identified by immunohistochemical staining. The weight of the muscle was measured. During bone lengthening the muscle showed signs of growth, as indicated by increasing weight and number of proliferating cell nuclei. This was observed only during lengthening and it ceased when the lengthening was stopped.     

The effect of peritoneal air exposure on postoperative tumor growth

Botulinum toxin A has been used to treat wrist and finger spasticity mainly through injection of the forearm flexor muscles. This case study describes its first reported use in managing spastic lumbricals of the hand. A 19-year-old male had significant flexion deformity and hypertonicity of the left wrist and hand, particularly the second through fifth metacarpophalangeal joints, after traumatic brain injury. By using the 0-4 Ashworth scale, spasticity of the lumbricals across the second to fourth metacarpophalangeal joints was rated 2, with persistent clonus of the finger flexors as confirmed by electromyography to the middle and ring fingers, even after botulinum toxin A injection of the flexor digitorum sublimis and profundus muscles. By using the electromyography-guided technique, botulinum toxin A was injected into the first lumbrical of the index finger (12 units), second and third lumbricals of the middle and ring fingers, respectively (15 units each), and fourth lumbrical of the little finger (10 units). At follow-up, clinical and electromyographic examination revealed a significant reduction in tone and clonus of the injected lumbricals. Ashworth scores of the lumbricals from the index to little finger improved to 1. Botulinum toxin A injection of the lumbricals can be beneficial in managing spasticity of these muscles. It is well tolerated and effective at doses of 10 to 15 units. Lumbrical injection of botulinum toxin A is a useful adjunct in our percutaneous armamentarium for managing the spastic hand.     

Proprioception acts as the main source of input in human S-I activation experiments: a functional MRI study

During tactile exploration cells in human somatosensory cortex S-I receive input from skin receptors and from proprioceptive feedback. To study the extent to which these sources contribute to cell activation we used functional magnetic resonance imaging (fMRI) in order to visualize the spatial extent and amplitude of activation in S-I during active finger movement and passive stimulation of finger tips. In all subjects (n = 6) we measured activation elicited by unilateral single finger tapping (active task) and mechanical stimulation of the palm of the index finger (passive task). In the finger tapping condition all subjects showed a strict contralateral activation of somatosensory cortex S-I and motor cortex M-I. In the passive stimulation experiment we found activation of the contralateral somatosensory cortex S-I only. Although subjects were trained to perform the finger movement with the same frequency and pressure in comparison to the passive stimulation, the activation within S-I induced by finger movements was always significantly larger than that induced by passive stimulation. This result implies that activation of somatosensory cortex originates to a large extent from proprioception while tactile input plays a minor role in S-I excitation.