Hand Deformities Research Articles

Nonsyndromic Split Hand/ Foot Malformation: Ectrodactyly

The CaseA three year old girl came to our OPD with deformity of left hand called ectrodactyly. She had no other deformities, dysmorphic features and was developmentally appropriate. The X-ray of the hand showed normal radius, ulna and metacarpals but absence of phalanges of the middle three fingers of left hand. She was examined in detail for any ectodermal anomaly, clefting of lip or palate. USG abdomen, kidney and urinary tract was done to rule out any urinary tract malformation. She was finally referred to higher centre for reconstructive surgery for ectrodactyly.J Nepal Paediatr Soc 2016;36(1):103-104

Distal arthrogryposis with variable clinical expression caused by TNNI2 mutation.

Distal arthrogryposis (DA) is a clinically and genetically heterogeneous disorder with multiple joint contractures. We describe a female DA patient with hand and foot deformities, and right-sided torticollis. Using exome sequencing, we identified a novel TNNI2 mutation (c.485>A, p.Arg162Lys) in the patient and her father. The father has no typical DA but hip dysplasia. This may explain the clinical features of DA2B in this family, but with variable clinical expression.

Presentation and Treatment of Poland Anomaly.

Background: Poland anomaly is a sporadic, phenotypically variable congenital condition usually characterized by unilateral pectoral muscle agenesis and ipsilateral hand deformity. Methods: A comprehensive review of the medical literature on Poland anomaly was performed using a Medline search. Results: Poland anomaly is a sporadic, phenotypically variable congenital condition usually characterized by unilateral, simple syndactyly with ipsilateral limb hypoplasia and pectoralis muscle agenesis. Operative management of syndactyly in Poland anomaly is determined by the severity of hand involvement and the resulting anatomical dysfunction. Syndactyly reconstruction is recommended in all but the mildest cases because most patients with Poland anomaly have notable brachydactyly, and digital separation can improve functional length. Conclusions: Improved understanding the etiology and presentation of Poland anomaly can improve clinician recognition and management of this rare congenital condition.

Evidence-based physical therapy of rheumatic diseases

New studies increase the evidence, that different applications of physical therapy are effective. In patients with rheumatoid arthritis (RA) physiotherapy of the hands improve strength, joint mobility and activity without increased risk of pain nor inflammation. A theory-based physiotherapy of the hands shows clinical effectiveness and cost-utility. In patients with spondyloarthritides supervised group exercise training is more effective than home exercise programs. Compared with biologics only combined exercise training and tumour necrosis factor alpha inhibitor therapy improve mobility and disease activity more effectively. Aerobic exercise training reduces fatigue in RA. Working wrist splints and static resting splints improve pain and grip strength. Static resting splints reduce the risk of hand deformities. Local and whole body cryotherapy show short term improvement of pain and inflammatory activity. German S3-guidelines recommend enhanced utilisation of physical therapy as well as coordinated multiprofessional team care and rehabilitation.

Modificación simplificada de la técnica de Zancolli para la corrección de la garra cubital

ObjectivesThe objective of this paper is to study the results obtained with the Chevallard technique (simplified version of the Zancolli technique), to correct claw hand deformity, secondary to ulnar nerve palsy. Materials and methodRetrospective study conducted on 16 patients (16 hands) who underwent claw hand correction (January 2006-December 2013), and were evaluated at the 6 weeks, 3 months, 6 months and one year. ResultsAt one year later, an objective assessment (Brand criteria) showed excellent results in 18.75% (3 patients), good in 75% (12 patients), and poor in 6.25% (1 patient). The latter required a new intervention to solve the recurrence of the claw. ConclusionThe simplified of Zancolli technique or technique of Chevallard allows to easily correct the ulnar claw hand deformity, not ruling out a further intervention in the case of recurrence.

The Use of Acellular Dermal Matrix in Treatment of Mitten Hand in Epidermolysis Bullosa Patients

Dear Sir, Epidermolysis Bullosa (EB) is a group of rare disorders, in which patients frequently present with fragile skin and mucosal surfaces that blister following minor trauma [1]. Hand deformities include web space adduction contractures, pseudo-syndactyly, and flexion contractures of the joints, known altogether as the mitten-hand deformity [2]. Reconstruction of the defects created by releasing of the pseudo-syndactylys or just the flexion contractures of the hands requires use of skin grafts; which make the surgical treatment troublesome for two main reasons: the donor skin graft areas become potential full thickness non-healing regions, and the skin graft harvested will not be a healthy skin, with a defective dermoepidermal structure that will eventually result in recurrence of the syndactyly with any minimal trauma. We present here an 8-year-old female who referred to our clinic for bilateral pseudo-syndactylys of the hands. The medical history revealed diagnosed recessive dystrophic EB that has been managed meanwhile only with palliative topical medication. Physical examination showed multiple bullae and vesicles that were spread generally all over the body with the hands and the legs involved most severely. The left hand revealed adduction contracture of the first web space, incomplete syndactyly of all the web spaces and flexion contractures in all the digits, with the fingernails absent. The right hand revealed incomplete syndactylys of all the webs, with joint contractures of the thumb MCP and IP as well as flexion contractures in all fingers. The surgical treatment was planned for the non-dominant left hand first, which required definite use of skin grafts, for coverage of full thickness skin defects created by the contracture release. The possibility of unsuccessful graft take was discussed with the patient in addition to the possibility of non-healing graft donor sites. The alternative use of acellular dermal matrix without further skin grafting was suggested and the treatment plan consisting of AlloDerm-GBR one-step repair was presented and accepted by the patient. The patient was operated under general anesthesia without application of a tourniquet to prevent trauma. The syndactylys and contractures were released full-thickness and the defects were covered with two pieces of 0.5–0.9 mm thickness sheets of AlloDerm GBR. (Figure 1a) No autologous skin grafts were used. The hands were kept in the appropriate splinted position for 15 days and the dressing was renewed every 3 days. An atraumatic night splint was then used for 2 months to prevent recurrence. The postoperative results revealed epithelization onto the AlloDerm grafts within 2 weeks with the exception of a few areas that were epithelized in 3 weeks (Fig. 1b). Fig. 1 a Intraoperative view showing release of the contractures and application of Alloderm in areas of skin defect and b 60 days postoperatively showing the Allograft take The defects created while releasing the hand pseudo-syndactylys and contractures require use of split-thickness or full-thickness skin grafts, which may not always be possible in these patients because of donor-site morbidity or availability [3, 4]. The use of acellular dermal allograft in EB patients not only makes the need for autologous skin graft redundant, but can also be of great assistance in epithelization. This is of major importance in these patients for which the autologous graft donor site can become a reconstructive challenge on its own, as it is in our case with bilateral hand and body involvement. Recurrence usually occurs within 2 to 5 years in patients with EB. Meticulous skin care and the use of well-fitted splints are essential in the treatment plan of these patients. The transfer of a dermal support, throughout a healthy tissue creating a “thick” new dermis via the acellular dermal matrix can hence possibly prevent recurrence of the pseudo-syndactyly of the hand in the long term. We believe the use of acellular dermal allograft in dystrophic EB patients with hand deformities should be included in the routine surgical treatment protocol of EB, especially in cases with bilateral involvement.

Seven Year Outcomes of the Silicone Arthroplasty in Rheumatoid Arthritis (SARA) Study: Level 2 Evidence

Grant received from: National Institute of Arthritis and Musculoskeletal and Skin Diseases - 2R01 AR047328-06 - An Outcome Study of Rheumatoid Hand Arthroplasty There is no financial information to disclose. Rheumatoid arthritis (RA) often causes debilitating deformities of the hand. Silicone metacarpophalangeal joint arthroplasty (SMPA) has been used for over 50 years to correct hand deformities, but high level evidence for effectiveness is lacking. The SARA study is an NIH-funded, multicenter study following a large cohort of RA patients with severe hand deformities. The purpose of this paper is to compare outcomes for a surgical and a non-surgical cohort of rheumatoid arthritis patients after 7 years of follow-up. RA patients with a defined level of deformity were enrolled from 1 of 3 study sites. Patients were not randomized owing to strong patient preference and chose whether to undergo SMPA or not. Patients were assessed at 6 months and then yearly for up to 7 years. Outcomes included the Michigan Hand Outcomes Questionnaire (MHQ), Arthritis Impact Measurement Scales (AIMS2), and functional measures (grip/pinch strength, Jebson-Taylor test, and ulnar drift, extensor lag and arc of motion measurements at the metacarpophalangeal (MCP) joints. A total of 73 SMPA and 97 non-SMPA subjects were enrolled at baseline. Because of withdrawals, deaths, and loss to follow-up, 25 SMPA and 52 non-SMPA patients had data at 7 years follow-up. Although nonsurgical subjects had better mean MHQ scores at baseline, the surgical subjects had improved scores over time. After adjusting for baseline differences, surgical patients had significantly better outcomes for overall MHQ score and the function, aesthetics and satisfaction domains. Additionally, SMPA subjects had significantly better measures for ulnar drift, extensor lag and MCP joint arc of motion at 7 years after adjusting for baseline covariates. No significant improvements in grip or pinch strength were observed in either group. •The benefits of SMPA reported at earlier assessments were maintained at the 7 year postoperative follow-up.•Non-surgical subjects remained stable in hand function over time.•SMPA subjects reported substantial improvements in ulnar drift and extensor lag, their ability to perform activities of daily living, and decreased pain.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

The clinical treatment and pathogenic gene analysis of a Chinese family with synpolydactyly

Objective To screen and identify disease genes of the propositus of the synpolydactyly family in order to determine whether there was mutation of candidate genes in the family and its loci. Methods Base on family history, clinical signs, and clinical phenotype, diagnosis of familial synpolydactyly was made. The propositus underwent surgical treatment and postoperative functional exercises. Peripheral blood samples of family members were collected to extract genomic DNA. Polymerase chain reaction and direct sequencing technology were applied to screen candidate genes of the family members and determine gene mutations. Results Active treatment of the propositus in the family improved the function and appearance of the hand. The clinical results were satisfactory. Mutations of the HOXD13 gene were found in two family members with the same mutation loci. No mutations of the GJA1, LMBR1 and SHH genes were found. No mutations in HOXD13, GJA1, LMBR1 and SHH genes were found in the control group. Conclusion Synpolydactyly patients need proactive surgical treatment. HOXD13 is the mutant gene in the family. Key words: Hand deformities, congenital; Surgical procedures, operative; Gene mutation; HOXD13

Developmental characteristics of various types of hand bones of Poland's syndrome

To explore development status in different types of the hand bone and its developmental characteristics with Poland syndrome. There were 32 cases with Poland's syndrome who accepted bilateral hand X-ray examination in Department of Hand Surgery, Beijing Jishuitan Hospital from February 2013 to August 2014.There were 24 male and 8 female patients aged from 1.0 to 15.0 years with median age of 2.4 years. Right hand deformity was 23 cases and left hand deformity was 9 cases. According to Tanner-Whitehouse skeletal age scoring system, 20 bones (radius and ulna, 7 carpal bones, 11 metacarpal and phalangeal bones) selected from the affected and contralateral limb respectively, were evaluated. Besides, hand deformity of the cases was classified into 5 types based on relevant literature. Each bone was given an individual age using the references of Greulich-Pyle chart. The average of all individual ages was taken as gross bone age, the average of individual ages of radius and ulna was taken as bone age of long bones, the average of individual ages of carpal bone was taken as bone age of carpal bones, and the average of individual age of metacarpal and phalangeal bones was taken as bone age of short bones.The delay of bone age was evaluated by correlation test, while the curve of cubic equation was used for analyzing the variance of skeletal development with age. The delay of long bone age of patients with Poland's syndrome in this study were 0-1.9 years ((0.5±0.5) years), 0-2.2 years ((0.7±0.5)years) for carpal bone, 0.5-2.0 years((0.6±0.4) years)for short bone and 0.1-1.7 years((0.6±0.4)years) for gross bone.Twelve cases in type Ⅱ hand deformity, 15 cases in type Ⅲ and 5 cases in type Ⅳ. The delay of bone ages, including long bone age, carpal bone age, short bone age and gross bone age, was not related with gender and side(all P>0.05), but related with degree of deformity(F=3.663-12.971, P=0.000-0.038). Compared with normal upper limb, the bone age in the affected limb in Poland's syndrome is delayed and it is correlated with gender, age and the extent of hand deformity and negative with side.

Analysis of the functional consequences of targeted exon deletion in COL7A1 reveals prospects for dystrophic epidermolysis bullosa therapy.

Genetically evoked deficiency of collagen VII causes dystrophic epidermolysis bullosa (DEB)-a debilitating disease characterized by chronic skin fragility and progressive fibrosis. Removal of exons carrying frame-disrupting mutations can reinstate protein expression in genetic diseases. The therapeutic potential of this approach is critically dependent on gene, protein, and disease intrinsic factors. Naturally occurring exon skipping in COL7A1, translating collagen VII, suggests that skipping of exons containing disease-causing mutations may be feasible for the treatment of DEB. However, despite a primarily in-frame arrangement of exons in the COL7A1 gene, no general conclusion of the aptitude of exon skipping for DEB can be drawn, since regulation of collagen VII functionality is complex involving folding, intra- and intermolecular interactions. To directly address this, we deleted two conceptually important exons located at both ends of COL7A1, exon 13, containing recurrent mutations, and exon 105, predicted to impact folding. The resulting recombinantly expressed proteins showed conserved functionality in biochemical and in vitro assays. Injected into DEB mice, the proteins promoted skin stability. By demonstrating functionality of internally deleted collagen VII variants, our study provides support of targeted exon deletion or skipping as a potential therapy to treat a large number of individuals with DEB.

Effectiveness of basic fibroblast growth factor for pediatric hand burns

Aim of the studyPediatric hand deep dermal and deep burns may lead to serious hand deformity with functional impairment and result in an esthetically unfavorable outcome. Since there is no guideline regarding the use of growth factors for pediatric hand burns, we sought to investigate the effectiveness of an angiogenic and regenerative growth factor, basic fibroblast growth factor (bFGF). MethodsConsecutive series of second degree or third degree palmer burns at less than 3 years of age seen from January 2010 to June 2014 were included for evaluation at 6 months post-wound healing. The bFGF treatment started from just after injury and continued up to 21 days. Each patient had their scars scored using the Vancouver Scar Scale (VSS) at 6 months after wound healing. ResultsThere were 34 children with 49 acute palmar burns. The mean healing period was 13.5 ± 4.3 days (7–44 days) and 43 wounds healed within 21 days. There was no need of additional surgery in the 43 wounds, healed within 21 days. In comparison to the wounds for which healing took more than 21 days, the wounds that healed within 21 days demonstrated significantly better pigmentation, pliability, and height according to the VSS (p < 0.05), as well as no scar contracture or hypertrophic scars. ConclusionbFGF treatment was effective in cases that healed within 21 days, avoiding scar contractures and hypertrophic scars. Our methods using bFGF to complete wound healing are less invasive and produce better results in pediatric palmer burns.

Neurovascular island flap for pulp and nail augmentation in thumb duplication reconstruction

Objective To introduce a neurovascular island flap for pulp and nail augmentation, and combined with a dorsally based skin flap approach, to improve the esthetic result in thumb duplication reconstruction. Methods Eight cases of thumb duplication, including 1 Wassel type Ⅱ, 1 type Ⅲ and 6 type Ⅳ, were treated with modified Bilhaut-Cloquet procedure between December 2002 and November 2010. All the patients had significant hypoplasia and asymmetry of the pulp and nail of the duplicated thumbs. Nail and pulp flaps were dissected from the thumb to be excised and transferred to the thumb to be retained. All the patients were follow-up to monitor the esthetic, functional and radiological outcomes. The average follow-up was 80 months (range, 25 to 120 months). An esthetic scoring system was proposed to assess the cosmetic results of thumb duplication reconstruction. Results All the flaps survived. There was no visible surgical scar on the dorsal aspect of the thumb. Pulp and nail fold symmetry was improved in all cases. Nail width and pulp circumference were close to those on the normal side. The proposed esthetic scoring system was able to assess and highlight the cosmetic aspect of the outcome, which was well correlated to the parents’ satisfaction. Conclusion In selected case of thumb duplication with significant hypoplasia and pulp and nail asymmetry, the neurovascular pulp and nail island flap is a safe and effective approach to restore symmetry for esthetic improvement. Key words: Hand deformities, congenital; Surgical flaps; Esthetics

'Epidemic' of hand deformities in the French Renaissance paintings of Jean and François Clouet.

This article analyses the nature of the multiple finger anomalies found in portraits by the French Renaissance artistic dynasty, the Clouets. The multiplicity of finger anomalies could be either innocent congenital variants, or pathological and traumatic deformities. In view of the presence of such `beautifying variations' in the works of other Renaissance artists, the authors decided that these features were not the result of an epidemic of deformities, but instead represented a stylistic approach in paintings of this period at the French Court.

Minimising impairment: Protocol for a multicentre randomised controlled trial of upper limb orthoses for children with cerebral palsy.

BackgroundUpper limb orthoses are frequently prescribed for children with cerebral palsy (CP) who have muscle overactivity predominantly due to spasticity, with little evidence of long-term effectiveness. Clinical consensus is that orthoses help to preserve range of movement: nevertheless, they can be complex to construct, expensive, uncomfortable and require commitment from parents and children to wear. This protocol paper describes a randomised controlled trial to evaluate whether long-term use of rigid wrist/hand orthoses (WHO) in children with CP, combined with usual multidisciplinary care, can prevent or reduce musculoskeletal impairments, including muscle stiffness/tone and loss of movement range, compared to usual multidisciplinary care alone.Methods/designThis pragmatic, multicentre, assessor-blinded randomised controlled trial with economic analysis will recruit 194 children with CP, aged 5–15 years, who present with flexor muscle stiffness of the wrist and/or fingers/thumb (Modified Ashworth Scale score ≥1). Children, recruited from treatment centres in Victoria, New South Wales and Western Australia, will be randomised to groups (1:1 allocation) using concealed procedures. All children will receive care typically provided by their treating organisation. The treatment group will receive a custom-made serially adjustable rigid WHO, prescribed for 6 h nightly (or daily) to wear for 3 years. An application developed for mobile devices will monitor WHO wearing time and adverse events. The control group will not receive a WHO, and will cease wearing one if previously prescribed. Outcomes will be measured 6 monthly over a period of 3 years. The primary outcome is passive range of wrist extension, measured with fingers extended using a goniometer at 3 years. Secondary outcomes include muscle stiffness, spasticity, pain, grip strength and hand deformity. Activity, participation, quality of life, cost and cost-effectiveness will also be assessed.DiscussionThis study will provide evidence to inform clinicians, services, funding agencies and parents/carers of children with CP whether the provision of a rigid WHO to reduce upper limb impairment, in combination with usual multidisciplinary care, is worth the effort and costs.Trial registrationANZ Clinical Trials Registry: U1111-1164-0572.

Severe deformans tophaceous gouty arthritis

A 61-year-old man with a 20-year history of gout with severe functional disability was evaluated in our service. He received alopurinol and colchicine without response. Physical examination revealed bilateral great deformity, multiple tophi and edema of hands (Fig. 1), feet and knees. Serum uric acid was elevated: 11.2 mg/dL (reference value: 3.4–7.0 mg/dL). Hands X-ray AP view demonstrated, in both hands (Fig. 2A [left] and B [right]), conserved bone mineralization with severe soft-tissue swelling, extensive erosions with sclerotic borders (white arrows), precipitation of calcium with urate crystals giving density to the tophi (head arrows), bone spiculations (black arrows) and osteolytic expansive lesions in multiple heads of metacarpophalangic joint (double-head arrows).

ANTERIOR SUBCUTANEOUS TRANSPOSITION OF ULNAR NERVE AND HAND INTRINSIC MUSCLES FUNCTION RECONSTRUCTION FOR SEVERE CUBITAL TUNNEL SYNDROME

To study the effectiveness of anterior subcutaneous transposition of ulnar nerve with reconstruction of hand intrinsic muscle in the treatment of severe cubital tunnel syndrome. Between March 2006 and May 2015, 22 cases (23 hands) of severe cubital tunnel syndrome were treated by use of anterior subcutaneous transposition of ulnar nerve with reconstruction of hand intrinsic muscle. There were 15 males and 7 females, aged 45-60 years (mean, 55 years). The causes were valgus deformity of elbow joint in 12 cases, ulnar nerve subluxation in 4 cases, and osteoarthritis in 6 cases. The disease duration was 10 months to 3 years (mean, 17 months). According to Akahori classification, 14 cases were rated as type 4 and 9 cases as type 5. The ring/little finger's numbness, hand intrinsic muscle atrophy, recovery of thumb adduction function, and improvement of claw hand deformity were observed after operation. Thumb and index finger's pinch strength was measured by use of pinch device; postoperative hand function was evaluated by the standards of Chinese Medical Society of Hand Surgery of upper limb assessment protocol. All incisions healed well and all cases were successfully followed up 8 to 24 months (mean, 14 months). Numbness of ring/little finger was significantly reduced at 1 day after operation in 10 hands; numbness disappeared completely at 1 month after operation in 12 hands; mild numbness remained at 14 months after operation in 11 hands. At last follow-up, hand intrinsic muscle atrophy partially improved (+++) in 1 hand, no improvement in 22 hands; improvement of claw hand deformity was achieved in 17 hands, no improvement in 6 hands; pinch strength of thumb and index finger was significantly improved to (5.07±1.11) kg from preoperative (2.91±0.63) kg (t=-12.340, P=0.032). At last follow-up, the results were excellent in 11 hands, good in 8 hands, fair in 3 hands, and poor in 1 hand, and the excellent and good rate was 82.6%. Anterior subcutaneous transposition of ulnar nerve with reconstruction of hand intrinsic muscle is a simple, effective, and reliable surgical treatment for severe cubital tunnel syndrome.

Predictors of musculoskeletal flares and Jaccoud׳s arthropathy in patients with systemic lupus erythematosus: A 5-year prospective study.

To investigate the prognostic value of US in predicting musculoskeletal flares and Jaccoud׳s arthropathy (JA) in systemic lupus erythematosus (SLE). A total of 80 out of 94 patients (76 female; age 45.5 ± 13.2 years) with non-deforming non-erosive (NDNE) arthritis and 48/60 healthy controls (42 female; age 49.6 ± 11.6 years) completed the 5-year follow-up study. Each patient was prospectively assessed for the occurrence of musculoskeletal flares using BILAG2004 and hand deformities according to Jaccoud׳s articular index. Baseline clinical, serological, semi-quantitative (0-3 scale) ultrasound (US) findings, PD-synovitis and PD-tenosynovitis scores were used as covariates to identify predictors of study outcomes. Short Form 36 v2 (SF36v2) health survey questionnaire was administered. Overall, 12 MS flares in 10 (12.5%) patients were recorded and the incidence rate was 3.0 per 100 patient-year. Baseline PD-synovitis score independently predicted MS flare (p < 0.001; RR = 2.0; 95% CI: 1.4-3.0) within 2 years since US examination. In all, 5 (6.2%) patients developed JA whose incidence rate was 1.25 per 100 patient-year. Independent risk factors for development of JA were higher longitudinal BILAG score in the musculoskeletal domain (p = 0.005; RR = 2.4; 95% CI: 1.3-4.6) and longer disease duration (p = 0.013; RR 1.2; 95% CI: 1.1-1.3). JA and active musculoskeletal inflammation (BILAG ≥ C), but not US erosions, were associated with lower results in SF36v2 physical and mental summary components. Performing musculoskeletal US can be useful in order to predict MS flares. Jaccoud׳s deformities may arise in patients with long-standing SLE and prolonged, even subclinical, joint and tendon inflammation.

The Effect of n‐Acetylcysteine on the Migration of Myofibroblasts

Dupuytren's contractures are hand deformities that affect more than 200,000 cases in the US per year and are typically cured by invasive procedures that remove the nodules that form on the affected hand. Our goal is to study chemical inhibition of myofibroblasts, cells associated with Dupuytren's contracture, to provide insight for a noninvasive treatment of Dupuytren's contractures. Myofibroblasts use migration as part of their pathologic activities. This study examined the migration of myofibroblasts, using varying amounts of the amino acid n‐acetylcysteine (NAC), previously shown to inhibit myofibroblast differentiation. The methods used were an elastomer plug migration assay and this determined the myofibroblast migration. Our results demonstrated NAC increased the speed of migration when used in concentrations of 1–5μM and NAC inhibited the migration when used in concentrations of 10–20μM. In a complex tissue, this biphasic result may have unintended consequences. Our future goal is to study the mechanism of this biphasic migration effect.Support or Funding InformationUCO Office of Research and Grants

Active range of motion outcomes after reconstruction of burned wrist and hand deformities

This works aim is to evaluate the efficacy of skin grafts and flaps in reconstruction of post-burn hand and wrist deformities. A prospective study of 57 burn contractures of the wrist and dorsum of the hand was performed. Flaps were used only if there was a non-vascularized structure after contracture release, otherwise a skin graft was used. Active range of motion (ROM) was used to assess hand function. The extension deformity cohort uniformly underwent skin graft following contracture release with a mean improvement of 71 degrees (p<0.0001). The flexion deformity cohort was treated with either skin grafts (8 patients) or flaps (9 patients) with a mean improvement of 44 degrees (p<0.0001). Skin grafts suffice for dorsal hand contractures to restore functional wrist ROM. For flexion contractures, flaps were more likely for contractures >6 months. Early release of burn contracture is advisable to avoid deep structure contracture.

Treatment of Peripheral Neuropathy in Leprosy: The Case for Nerve Decompression.

Plastic surgery has a tradition of caring for patients with facial deformity and hand deformity related to leprosy. The approach, however, to the progressive deformity and disability related to chronic nerve compression is underappreciated in the world today. A cohort of patients with leprous neuropathy from an indigenous area of leprosy in Ecuador was evaluated for the presence of chronic peripheral nerve compression, and 12 patients were chosen for simultaneous upper and lower extremity, unilateral, nerve decompression at multiple levels along the course of each nerve. The results at 1 year of follow-up show that 6 patients improved into the excellent category and 4 patients improved into the good category for improved function. Based on the early results in this small cohort of patients with leprous neuropathy, an approach to peripheral nerve decompression, encompassing the concept of multiple crush at multiple levels of each nerve, seems to offer optimism to improve upper and lower extremity limb function. Long-term studies with quality-of-life outcomes would be welcome.