Distal Crease Research Articles

Prospective Study on Effectiveness of Belfast Regime on Flexion Tendon Injury Zone V Using Tam Scoring

About 20% of injuries presented in the emergency room that require surgical repair involve the hand. Most of these injuries result from sharp objects such as glass and knives, and blades in case of suicide. In Pakistan, the most common injuries occur at the junction between the transverse distal crease on the wrist and the forearm muscles (zone 5). Wrist injuries are difficult to repair since they result in the tendon, ulnar and median nerve and arteries abrasion. In addition, an inadequate approach could damage abrasion and swelling of the flexor muscles, risking the functioning of the hand. A good outcome necessitates prioritizing the flexor muscles to avoid swelling and hand dysfunction. The objective of this study is to investigate the effectiveness of Belfast rehabilitation in the treatment of flexion tendon injury. The process of rehabilitation was carried out for a period of 2 years. Using the Belfast regime as a post-rehabilitation regime ensures no adhesion formation, swelling, or delayed healing.

Palmar Resurfacing of the Hand With Porcine Urinary Bladder Extracellular Matrix Following Traumatic Injury

Complex wounds of the hand often result in soft tissue defects that are not amenable to primary closure, vacuum-assisted closure, or tissue expansion. Injuries presenting with large defects involving multiple levels of tissue must be addressed by using techniques at higher rungs on the reconstructive ladder, such as split-thickness grafting, pedicled flaps, or free flaps. When repairing palmar tissue, these techniques fall short due to their failure to approximate structure and function of specialized skin. More recently, dermal substitutes containing a decellularized extracellular matrix (ECM) have been used in reconstruction of soft tissue defects, acting as a structural scaffold for the regrowth of native cells. Extracellular matrix products have been shown to improve functional and sensory outcomes in areas requiring highly specialized skin. Urinary bladder matrix (UBM), a porcine ECM scaffold, is unique in that it contains an intact epithelial basement membrane that promotes more organized regrowth through layered structure. This case presents a novel use of this product in resurfacing 80% of a palm after postoperative necrosis following a table saw injury to the right volar palm at the distal crease. The patient had intact sensation and near normal functional outcomes at most recent follow up. The UBM may be a valuable adjunct to achieve soft tissue coverage in large, complex hand wounds, particularly those involving the palmar surfaces.

Determination of the Minimum Detectable Change in the Total and Segmental Volumes of the Upper Limb, Evaluated by Perimeter Measurements.

Among female breast cancer survivors, there is a high prevalence of lymphedema subsequent to axillary lymph node dissection and axillary radiation therapy. There are many methodologies available for the screening, diagnosis and follow-up of breast cancer survivors with or without lymphedema, the most common of which is the measurement of patients’ arm circumference. The purpose of this study was to determine the intra-rater minimal detectable change (MDC) in the volume of the upper limb, both segmentally and globally, using circumference measurements for the evaluation of upper limb volume. In this study, 25 women who had received a unilateral mastectomy for breast cancer stage II or III participated. On two occasions separated by 15 min, the same researcher determined 11 perimeters for each arm at 4 cm intervals from the distal crease of the wrist in the direction of the armpit. The MDC at the segmental level ranged from 3.37% to 7.57% (2.7 to 14.6 mL, respectively) and was 2.39% (42.9 mL) at the global level of the arm; thus, minor changes in this value result in a high level of uncertainty in the interpretation of the results associated with the diagnosis of lymphedema and follow-up for presenting patients.

Reconstruction of Defects of the Lower Third of the Leg and Foot With a Reverse Sural Island Flap

Background: Closure of lower limb defects asks for thorough knowledge of all the reconstructive options, starting with the use of local tissues. The scarce availability of such, makes this task difficult and demanding. Unique nature of blood supply to the leg, complicates this issue even more. Reverse sural island flap is what we found handy in solving the problem for defects of small to moderate size, on the lower leg and foot. Objectives: The aim of this study is to report our experience with the use of the reverse sural island flap in the reconstruction of complex soft tissue defects of the lower leg and the foot. Materials and methods: Following institutional review board approval, a database search was completed to identify all patients who underwent reconstruction of distal lower extremity and foot defects with a reverse sural island flap between 2011-2019. Data were collected from the medical records of patients, as regards: demographics, history of trauma or nature of the wound, personal medical history (accompanying diseases, smoking status), location of the defect, dimensions of the flap after being elevated, pedicle length etc. Results: 15 cases received a reverse sural island flap, all the cases except one, being acute trauma. The remaining one was a chronic wound after a previous burn. In one of the cases the flap was delayed. In three of them flap it was used to cover defects of the dorsum of the foot. Flap dimension varied from 7 × 4 cm to 15 × 12 cm, length of the pedicle from 6 to 16 cm, two of the flaps were very close to the distal popliteal crease. In all of the cases, except one, donor area of the flap needed be skin grafted. Only two of the flaps were complicated: one by a partial necrosis, the other by a venous stasis, which in the end were both treated successfully. In none of the patients a detailed examination of vascular supply of the area was needed, all of them being nondiabetic and nonischemic legs. Conclusions: Reverse sural island flap is a very useful tool for the reconstruction of small to moderate defects of the lower leg and foot, relatively easy to be raised, with no special needs for complicated vascular preoperative workup, and with a low rate of failure and complications in carefully selected patients.

New technique of ultrasound-guided injection in the carpal tunnel syndrome

In conventional ultrasound-guided corticosteroid injection in carpal tunnel syndrome (CTS), the entry point is usually at the distal crease of the wrist. However, actual pathology of CTS is caused by thickening of the transverse carpal ligament (TCL). Injection of corticosteroid can reduce inflammation and ameliorate the symptoms, but it cannot reduce the thickness of TCL. If we change the entry point to just 10 mm below the distal crease rather than at the distal crease, we can inject corticosteroid around the median nerve and into the TCL. Five patients with CTS treated with ultrasound-guided corticosteroid injection around median nerve and into the TCL. The diagnosis of CTS was made by history, physical examination, sonographic evaluation, and electrophysiologic confirmation. Sonographic examinations were performed by one physiatrist using Samsung scanner with a 5–12 MHz linear transducer. Standard 23-gauge needles were used for administration of local anesthetics and triamcinolone mixture (total 1 cm 3 ). After transverse view and longitudinal view, the entry point was determined. The entry point was below the distal crease, where the needle could easily introduce the injection material into the thickened TCL. The direction of the needle entry point was from lateral to ulnar side. Total of five female patients with CTS were included. The mean age was 55.4 ± 3.6 years. The mean duration of disease was 4.6 (range 3–8 mo) months. The results were good to excellent in all patients. There were no complications during the procedure. Ultrasound-guided corticosteroid injection in CTS, combined with injection at the thickened TCL may be a good method and further research is needed to confirm the usability.

Topographic anatomical landmarks for pulley system of the thumb.

Knowledge of anatomical landmark to pulley system of the thumb is essential in successful treatment of trigger thumb release either by percutaneous or by minimally invasive technique. Though surgical release of trigger thumb is done commonly, there is paucity of data in the literature regarding its surface landmarks. The purpose of this study is to identify palmar surface anatomical landmarks to the pulley system of the thumb. Dissection was performed on 55 fresh frozen adult cadaveric thumbs. The palmar thumb creases were given names as the proximal-proximal crease (PPC) present at the metacarpophalangeal joint, the distal-proximal crease (DPC) over the middle of the proximal phalanx and the distal crease (DC) at interphalangeal joint. The distance between the proximal edges of each pulley to the three thumb creases and longitudinal length of A1, A2, oblique and Av pulley was measured using digital vernier caliper and was expressed in mean and standard deviation. The proximal edge of A1 pulley was 1.98 ± 1.61mm proximal to the PPC. The mean longitudinal length of the A1 pulley was measured to be 5.06 ± 0.87mm, so the distal edge of the A1 pulley was calculated to lie 3.08mm distal to PPC. The proximal edge of Av and oblique pulley was situated 7.78 ± 2.5 and 15.72 ± 3.22mm distal to PPC, respectively. The proximal edge of A2 pulley was very nearer and 2.88 ± 1.79mm proximal to DC. The knowledge of anatomical skin surface landmarks is helpful in the percutaneous release or minimally invasive procedure. The PPC serves as a definite landmark for A1, Av and oblique pulley whereas it is the DC for A2 pulley.

ROLE OF ULTRASONOGRAPHY IN THE DIAGNOSIS OF CARPAL TUNNEL SYNDROME

Background: Carpal tunnel syndrome (CTS) is the most common form of peripheral entrapment neuropathy. The use of sonography for investigation and diagnosis of musculoskeletal conditions has been rapidly increasing over the past few decades. Recent studies have demonstrated advantages of sonographic techniques in the diagnosis of carpal tunnel syndrome (CTS). Objective: Assessing the utility of ultrasonography in the diagnosis of carpal tunnel syndrome (CTS) and grading its severity. Patients and Methods : Sixty hands in 46 patients with clinically and electro-physiologically confirmed carpal tunnel syndrome, and sixty asymptomatic hands in 34 healthy individuals as control group were included in the study and underwent high-resolution ultrasonography of the wrists. In ultrasonographic assessment the cross-sectional area (CSA) of the median nerve at the distal crease of the wrist and flattening ratio (FR) of the median nerve in the carpal tunnel as well as palmar bowing (PB) of the flexor retinaculum were measured. Ultrasonographic Data from the patients group and control group were compared to determine the statistical significance. The accuracy of the ultrasonographic diagnostic criteria for carpal tunnel syndrome was evaluated using receiver-operating characteristic (ROC) curve analysis. Sensitivity and specificity of ultrasonographic measurements were evaluated. Ultrasonographic measurements were correlated with severity of CTS according to nerve conduction studies (NCS). Results: The CSA of the median nerve and PB of the flexor retinaculum were significantly larger in the CTS hands compared to the normal control hands. However, FR of the median nerve showed no significant difference between both groups. Increased cross-sectional area of the median nerve was the most predictive measurement of carpal tunnel syndrome. Using the ROC curve, a CSA cut-off value of 10 mm² provided a diagnostic sensitivity of 93.3 % and specificity of 98.3 % and PB cut-off value of 3.3 mm provided a diagnostic sensitivity of 90 % and specificity of 85 %. No significant differences in CSA and PB were found among patients with mild, moderate and severe carpal tunnel syndrome so that CSA and PB did not reflect the severity of the condition. Conclusion: Ultrasonography is a useful non-invasive method for the diagnosis of carpal tunnel syndrome but not assessing its severity.

Finger tapping impairments are highly sensitive for evaluating upper motor neuron lesions

BackgroundIdentifying highly sensitive and reliable neurological exam components are crucial in recognizing clinical deficiencies. This study aimed to investigate finger tapping performance differences between patients with CNS demyelinating lesions and healthy control subjects.MethodsTwenty-three patients with multiple sclerosis or clinically isolated syndrome with infratentorial and/or cervical cord lesions on MRI, and 12 healthy controls were videotaped while tapping the tip of the index finger against the tip and distal crease of the thumb using both the dominant and non-dominant hand. Videos were assessed independently by 10 evaluators (three MS neurologists, four neurology residents, three advanced practice providers). Sensitivity and inter-evaluator reliability of finger tapping interpretations were calculated.ResultsA total of 1400 evaluations (four videos per each of the 35 subjects evaluated by 10 independent providers) were obtained. Impairments in finger tapping against the distal thumb crease of the non-dominant hand, identified by neurologists, had the greatest sensitivity (84%, p < 0.001) for detecting impairment. Finger tapping against the thumb crease was more sensitive than the thumb tip across all categories of providers. The best inter-evaluator reliability was associated with neurologists’ evaluations for the thumb crease of the non-dominant hand (kappa = 0.83, p < 0.001).ConclusionsImpaired finger tapping against the distal thumb crease of the non-dominant hand was a more sensitive technique for detecting impairments related to CNS demyelinating lesions. Our findings highlight the importance of precise examinations of the non-dominant side where impaired fine motor control secondary to an upper motor injury might be detectable earlier than the dominant side.

CRESCENT FLAP FOR FINGERTIP RECONSTRUCTION

A volar advancement flap based on V-Y concept for fingertip reconstruction is described. The crescent flap utilises curved incision to preserve fingertip contour and distal digital crease. Satisfactory outcome was achieved in two patients who underwent fingertip reconstruction using this technique. Its advantages are technical simplicity, minimal donor morbidity, and may be used in situation where conventional V-Y incision is unsuitable.

Transverse Anatomic Landmarks for the A1 Pulley of the Thumb

Triggering of the thumb is a common entity resulting in pain and disability. Operative management requires accurate knowledge of the pulley system for proper release of the A1 pulley. The purpose of this study was to predict the location of the A1 pulley with surface anatomic landmarks while avoiding injury to the neurovascular bundles and the critical oblique pulley. Thirteen fresh cadaveric thumbs were dissected while the volar digital creases of the thumb served as our potential anatomic landmarks for the A1 pulley. These included the distal crease and the two identifiable proximal creases. Measurements from the proximal edge of the A1 pulley to the surface landmarks were obtained. The pulley system was also inspected for variability, and the length of the A1 pulley was measured. Of the three volar creases in the thumb, the proximal-proximal crease (PPC) corresponded anatomically to the A1 pulley and demonstrated minimal variability compared to the other landmarks. It measured 0.10 ± 0.15cm distal to the proximal edge of the A1 pulley. The average length of the thumb A1 pulley measured 0.61 ± 0.17cm. Therefore, the distal edge of the A1 pulley is predicted to be located 0.51cm distal to the PPC. Hand surface landmarks can be used reliably to predict the location of the thumb A1 pulley, thus avoiding injury to adjacent structures such as the critical oblique pulley.

Effects of fusion angle on functional results following non-operative treatment for fracture of the neck of the fifth metacarpal

To investigate in fractures of the fifth metacarpal neck whether there is any difference in functional results of non-operative treatments with dorsal angulation either below or above 30 degrees. After closed reduction, fractures were treated with plaster splints for 5 weeks. Cases were divided into two groups, with dorsal angulation either below (group 1) or above (group 2) 30 degrees, according to oblique radiography, and were evaluated at 6 months. Grip strength, range of passive joint movement and distance from fingertip to distal crease were measured and compared. A scoring system assessed function, and occupational adequacy, patient satisfaction and presence of pain were recorded. Functional outcome was good or very good in both groups and occupational adequacy was not reduced in any case. Full patient satisfaction was achieved except for one person in group 1 and two people in group 2, regarding cosmetic results. There was no statistically significant difference between the two hands in either group except for one man from group 2, who had mild pain during coercive use of the injured hand. With non-operative treatment of fractures of the neck of the fifth metacarpal, similar results were achieved with dorsal angulation either above or below 30 degrees. A dorsal angulation less than 45 degrees may be treated conservatively.

Profile of fisting in term newborns

Persistence of fisting of hands and cortical thumb is a predictor of abnormalities in development and dysfunction of the central nervous system, though this may be a normal finding in the immediate newborn period. To study the profile of fisting in early neonatal period. Five hundred and fifty healthy term neonates were studied. Hand position was examined by a single observer between 24-48h of birth when the baby was awake and quiet. Complete fisting was defined as flexed fingers covering both proximal and distal palmer creases. If only the distal crease was covered, it was defined as incomplete fisting. Thumb position was observed as thumb by the side of the fingers, under the fingers and above the fingers. Of the total 550 babies, 338 (61.45%) had bilateral, 39 (7.09%) had right sided and 38 (6.91%) had left sided fisting and 135 (24.55%) had open hands. Of the 1100 hands, 669 hands (60.8%) had complete and 84 (7.63%) had incomplete fisting. "Cortical thumb" was found in 57% of fisted hands. There was no significant difference (p>0.05) in fisting according to the sex and weight of the babies. Fisting was a predominant hand posture among the babies (75.45%) but cortical thumb with bilateral fisting was seen in only 30% of babies.

Embryological development and prevalence of digital flexion creases

The embryological development and morphology of digital flexion creases were studied in 178 human embryos and fetuses 6-20 weeks of gestational age. The results suggest the existence of two types of digital flexion creases, that differ from each other in their development. The regular creases, with the exception of the distal crease of the proximal interphalangeal creases, and the oblique and extra creases of the irregular creases, develop concurrently with the appearance of the digital pads by about 11 weeks of gestation. The remaining creases, i.e., the distal crease of the proximal interphalangeal creases and the accessory crease develop later unrelated to the pads but, apparently, secondary to the flexion movements of the hand. Our observations further suggest that, because of their high frequencies, the oblique creases on the ulnar side of digits I and II and on the radial side of digit V and the extra creases on the proximal phalanx of digits I, III, and IV should be considered as "regular" creases. Previously unreported pads were also found on the middle phalanges at about 11 weeks of gestation. Unlike the single, large pads with high elevation, typically found on the distal phalanges, those on the middle phalanges are multiple, small, and only slightly elevated. This observation provides further support to the concept of the relationship between the fetal digital pads and the development of the epidermal ridge patterns.

The genetics of plamar creases: A study in the inheritance of liability estimated from the incidence among relatives

Six-hundred and fifty-nine Chinese children and 613 first degree relatives were studied with regard to four variations in the palmar creases: the simian crease, the Sydney line, the radial border termination of the thenar crease, and the distal border termination of the distal crease. With the exception of the Sydney line, these palmar crease variations were found to occur with significantly increased frequency in the parents of the propositi compared with 400 controls, indicating the presence of genetic factors in their embryogenesis. If the polygenic hypothesis is accepted, the very high heritability of liability (100%) to the radial border termination of the thenar crease is a further demonstration of the importance of the genetic contribution. Variations in the palmar creases thus cannot be totally explained away by early flexional folding in the skin of the developing hand.

Flexor tendon grafts in the fingers and thumb

A sutdy of the end results in a series of flexor-tendon grafts in the fingers and thumb, inserted because of damage to the tendons in the critical zone, shows that the influencing factors, in order of importance, are cicatrix from injury or infection, stiffened joints, trophic changes, and damage to more than one digit. Improvement in results has followed the use of Bunnell-type of stainless-steel wire sutures in place of silk, combined with meticulous excision of scar and thickened sheath tissue. The use of the palmaris longus tendon as a graft has given better results than use of other tendons. In the thumb, a graft from the musculotendinous origin to the insertion is preferred. It has been shown that, under ideal conditions, the results of digital flexor-tendon grafts are as follows: In 25 per cent. of the cases flexion is complete, so that the pulp of the finger reaches the distal crease of the palm; in 50 per cent., the pulp reaches to within one-half inch of the distal crease of the palm.

Twin Pair Analysis of Some Palm Indexes

SummaryThe heritability of two main line indexes (DLI and TLI), a palm crease index (API), and an ulnarity index (UI) were investigated by using twin pair methodology for quantitative traits.The analyses of the data allow to conclude that both DLI and API, which have been used to evaluate the obliquity of the main lines and the distal crease of the palm, should not be considered as depending upon an important genetic component. Otherwise, data on TLI and UI, while showing inconsistencies with the theoretical expectations, may be considered as genetic traits.

Genesis and Significance of Palmar and Digital Creases

Our studies of skin creases in the early developing hand and in a variety of malformed hands show that these creases, which develop between 7 and 14 weeks of fetal life, are secondard to the early flexion planes in the developing hand. Thus with lack of development or flexion of a digital joint no underlying digital crease was found of a digital joint no underlying digital crease was found; and with lack of formations or oppositional function of the thumb there was no thenar palmar crease. The normal distal palmar sloping crease was found to be related to the sloping flexional plane of the 3rd, 4th, and 5th metacarpal-phalangeal joints and the usual mid-palmar crease represents the plane of skin folding between the sloping distal crease and the thenar crease. The occurrence of a single horizontal palmar crease, the simian crease, was found by roentogenographic studies to be related to a diminished slope of the 3rd, 4th, and 5th metacarpal-phalangeal joints such that only a single early horizontal plane of flexion existed in the skin of the upper palm. Thus hand creases provide a record of the early flexional planes of function in the developing hand and any crease abnormality should always be interpreted as an indication of a more primary defeat in form and/ or function of the early developing hand.

Incisions and technics in tendon grafting

W HEN STUDYmO the technics of different surgeons of great experience who perform tendon grafting, it is amazing to note the diversitv of technics they use. Many principles are not accepted unanimously. For instance, incisions are different; the amount of sheath removed is variable; usually the flexor profundus is reconstituted, but reconstitution of the superfieialis is sometimes advantageous; the sources of grafts are numerous. Some surgeons use long incisions to obtain grafts and insist on the value of the paratendon while others utilize a stripper or even intrasynovial tendons; junctures and sutures are various; as far as the suture material is concerned, every one admits that i thas to be thin, resistant, nonirritating, b u t some prefer silk, others wire or nylon. The duration of'immobilization after surgery has also been very controversial and Pulvertaft [2] has noticed, by comparison, that his results were not affected by either early mobilization or three weeks' immobilization. What principles are accepted by all the specialists in this surgery?They are not numerous but they are important [5]:(1) Only one graft of flexor tendon is placed in one finger. Because of fear of adhesion, noonehas, t o m y knowledge, a t tempted to reconstitute tt~e normal anatomy, namely, by two grafts. I t is sometimes possible in selected eases to substitute a graft for the profundus when thesuperfieialis is intact but intact superficialiS is never to be sacrificed. (2) The graft, taken fr0m the patient, is placed in the hand without delay. (3) The graft should be of Small ealiberand its extremities should be fixed Carefully, far from the fibrous sheath. (4 ) I t is preferable to spare at least one pulley to prevent bowstringing, (5) The tension of the graft must be calculated in each case. (6) There is one additional point common to all surgeons who perform this surgery with any success: patience and attention to minutiae. Atraumatic surgery, gentleness and careful suturing are essential for a good prognosis. The technic we use is not original. I t has been borrowed from the leading specialists of this surgery, mainly, Boyes [1 ], Pulvertaft [2] and Littler [3]. With experience wehave modified a few details. We will consider primarily the incisionsand the exposure of the lesions. Normally, the tissues of the fingers are rich in blood supply. This i vaseularization :depends mainly upon: thei: two proper: digital: arteries which are oftenwounded With the tendons: The skin o f t h ~ palm isSupplied: bysmal l vertical arteries whiehperforate the:fasciato nourish it. Conway and Stark i[4]~::: by vascular injection, have : ~lemonstrated: tlire~: i Well ~ V~cularized areas in:the palm:These are atlthelevel of the thenar and hypothenar skin and in the: palmar tissues distal: to:i the ~ transverse distal crease. They poorly mining sharp angles must be avoided. Sensation is imp¢ essential a t the level for ~exposure i Should digital nerves to the ineisein the usual zones of prehension or of pressure.