Transverse Metacarpal Ligament Research Articles

Anatomic Relationship of Hand Intrinsic Tendons at the Metacarpal Head as It Relates to the Diagnosis of Saddle Syndrome: A Cadaveric Study

The purpose of this cadaveric study was to investigate the intrinsic anatomy surrounding the metacarpal head and the relationship between the interosseous-lumbrical junction (ILJ) and transverse metacarpal ligament (TML) as it pertains to saddle deformity-posttraumatic adhesions at the ILJ that cause impingement during intrinsic activation. Ten fresh frozen cadaveric arms underwent dissections, identifying the intrinsic musculature within the second through fourth webspaces. The TML and ILJ, or "true tendon," were identified. A separate area of nontendinous fibrous tissue identified proximal to the ILJ was referred to as "pseudotendon." Measurements were made within each webspace to identify distances between these structures in full finger extension and intrinsic plus position to assess for changes during simulated motion. The true tendon to TML distance progressively decreased toward the ulnar digits. In the intrinsic plus position, the pseudotendon to TML distance was 0 mm at all webspaces for each specimen. When moving from neutral to intrinsic plus, the true tendon to TML distance decreased the most in the third and fourth webspaces compared with the second, consistent with the trend toward a smaller ILJ to TML gap in the ulnar digits. There is a fibrous pseudotendinous region proximal to the ILJ that abuts the TML in the intrinsic plus position, which may cause impingement when inflamed in the setting of saddle syndrome. Furthermore, a decreased ILJ to TML gap in the ulnar digits may be related to an increased predilection for saddle deformity in those areas. These results suggest that there is a fibrous region present proximal to the ILJ that may be implicated in the pathology of saddle deformity. Furthermore, decreased distances found between the ILJ and TML invivo may be an explanation for increased occurrence of saddle syndrome in the third and fourth webspaces in clinical practice.

Nonsurgical treatment of deep transverse metacarpal ligament injuries

The deep transverse metacarpal ligament (DTML) is a structure that extends between the head of the second to fifth metacarpal to maintain the stability of the transverse metacarpal arch. Injuries of this ligament due to blunt trauma produce DTML injury and present with pain, decreased grip strength, deflection and diastasis of the affected fingers. Several surgical techniques for its reconstruction have been described. However, we evaluated the evolution of two patients who presented this injury diagnosed in acute and treated conservatively. Immobilization with forearm plaster in the intrinsic plus position and syndactyly to the adjacent finger was performed for 4 weeks. At one year of follow-up, they presented no pain (VAS 0/10) and showed hand function with comparable mobility to the contralateral hand and no diastasis between the fingers. We consider that in the face of DTML lesions evaluated in the acute period, diagnosis through clinical and radiological evaluation, as well as nonsurgical treatment, are usually sufficient.

Cleft Hand-Our Experience of Five Cases.

Introduction Hand helps us perform our work and express ourselves. Cleft hand is an aesthetic deformity rather than functional. We document our experience in five such cases from the ages of 3 to 5 years who underwent reconstruction under general anesthesia. Materials and Methods Three patients underwent Snow-Littler procedure, one underwent osteotomy for angled metacarpal and transverse metacarpal ligament reconstruction, and one underwent removal of transverse bone and transverse metacarpal ligament reconstruction. Splintage was done for 6 to 8 weeks and physiotherapy started. Function was assessed at 6 months. Results The operating time ranged from 2 to 3 hours. No major postoperative complications were noted. The parents' satisfaction was excellent at 6 months. None of the patients needed revision surgery for recurrence or first web space widening. Conclusion Cleft hand needs to be analyzed for the adequacy of first web space. The reconstruction is aimed at functional first web space and cleft closure for providing better aesthetic results.

Knotless Webspace Reconstruction Technique for Central Metacarpal Ray Resections.

Ray amputations of the hand are procedures performed for traumatic injuries, infection, neoplasm, and certain deformities. When performed for the central digits, the gap created between the remaining digits can significantly impact hand function. Multiple deep transverse metacarpal ligament reconstruction techniques and bone transposition have been described to address this issue. The purpose of this case series is to describe a novel technique utilizing a knotless suture anchor reconstruction of the deep transverse metacarpal ligament after central digit ray amputation. We present a novel knotless suture anchor reconstruction technique through a single incision which allowed for an immediate range of motion. We present 2 cases where this technique was utilized with satisfactory cosmetic and functional outcomes. Knotless webspace reconstruction for central metacarpal ray resection reconstruction is technically simple and allowed for immediate motion with satisfactory cosmetic and functional patient outcomes. Level of Evidence: Level IV-therapeutic.

Interosseous-lumbrical adhesions – a rare condition? A series of five cases

Adhesions between the interosseous and lumbrical muscles involving the deep transverse metacarpal ligament (dTML) can be a cause of chronic pain and reduced range of motion. New reports on this condition are rare. We identified five patients experiencing pain, swelling and decreased range of motion in the metacarpophalangeal (MCP) joints during manual load. The condition was caused by a direct trauma. After not responding to conservative treatment, patients underwent surgery. Time between trauma and surgery was on average 16 months and the mean postoperative follow-up was 8 months. The lumbrical–interosseus junction was exposed by volar or dorsal incision, adhesions were widely released and the distal third of the dTML was resected. This resulted in normal passive excursion of the muscles and the tendon junction. At the mean follow-up time 8.2 months (3–18) after surgery, all patients were pain-free and had gained near normal range of motion in the MCP joints. Interosseous-lumbrical adhesions may be more common than reflected by the literature. Hand surgeons should keep this condition in mind in cases with chronic inter-metacarpal pain after trauma or infection. Surgical exploration is relatively straight forward and tends to lead to gratifying results. Level of Evidence: IV (therapeutic)

Results of central ray metacarpal resection after failure of digit replantation in children

Central ray amputation results severe esthetic blemish and functional and psychological sequelae. Three main reconstruction procedures have been reported in adults: digital translocation, intracarpal osteotomy, and metacarpal resection; none of these, however, have been studied in children. The aim of this study was to report medium-term results for treatment of central ray amputation by proximal metacarpal resection following failure of digit replantation in children (i.e., skeletally immature patients). All children consecutively operated on by metacarpal resection after failure of digit replantation for complete central ray amputation between 2012 and December 2017 were retrospectively included. The surgical procedure consisted in metacarpal resection through a palmar approach, with deep transverse metacarpal ligament reconstruction. At last follow-up, adjacent finger range of motion, pain, rotational deformity and grip strength were evaluated, as well as metacarpal laxity. Metacarpal migration index and metacarpal divergence were measured on standard X-ray. Eleven children with a mean age of 11 ± 8 years were included. At mean 18 ± 3 months’ follow-up, range of motion in adjacent digits was conserved in all cases, with no intermetacarpal laxity. Grip strength was 28% lower than for the contralateral side. Two patients showed rotational malalignment in extension, without functional impairment. In 4th ray amputation (n = 8), metacarpal migration index was decreased by 65% due to radial migration of the 5th metacarpal, but metacarpal divergence was conserved in all cases. Isolated metacarpal resection of the central ray for replantation failure is a reliable and safe procedure with good radiological and functional results in skeletally immature children.

Lumbrical Muscles Neural Branching Patterns: A Cadaveric Study With Potential Clinical Implications.

Lumbrical muscles originate in the palm from the 4 tendons of the flexor digitorum profundus and course distally along the radial side of the corresponding metacarpophalangeal joints, in front of the deep transverse metacarpal ligament. The first and second lumbrical muscles are typically innervated by the median nerve, and third and fourth by the ulnar nerve. A plethora of lumbrical muscle variants has been described, ranging from muscles' absence to reduction in their number or presence of accessory slips. The current cadaveric study highlights typical and variable neural supply of lumbrical muscles. Eight (3 right and 5 left) fresh frozen cadaveric hands of 3 males and 5 females of unknown age were dissected. From the palmar wrist crease, the median and ulnar nerve followed distally to their terminal branches. The ulnar nerve deep branch was dissected and lumbrical muscle innervation patterns were noted. The frequency of typical innervations of lumbrical muscles is confirmed. The second lumbrical nerve had a double composition from both the median and ulnar nerves, in 12.5% of the hands. The thickest branch (1.38 mm) originated from the ulnar nerve and supplied the third lumbrical muscle, and the thinnest one (0.67 mm) from the ulnar nerve and supplied the fourth lumbrical muscle. In 54.5%, lumbrical nerve bifurcation was identified. The complex innervation pattern and the peculiar anatomy of branching to different thirds of the muscle bellies are pointed out. These findings are important in dealing with complex and deep injuries in the palmar region, including transmetacarpal amputations.

Results following isolated fourth ray resection

After partial resection of the fourth finger ray, many hand surgeons perform a transposition of the fifth ray to the position of the fourth ray. Others, us included, resect the fourth ray in total through exarticulation in the carpometacarpal joint and tightly readapt the deep transverse metacarpal ligament, assuming that the gap between the third and fifth metacarpal bones will be sufficiently reduced through spontaneous radial translocation of the fifth ray. The aim of this retrospective study was to examine the clinical, radiological and patient-reported results after total resection of the fourth ray with adaption of the deep transverse metacarpal ligament. Seven patients (three women, four men) with a mean age of 50 (26-62) years were reached for a follow-up examination after a mean of 43 (2-174) months. Parameters assessed included finger movement, hand strength, sensitivity (Tinel sign, Semmes-Weinstein monofilament), dexterity (nine-hole peg test), pain (at rest and during stress, phantom pain, weather sensitivity) and patient-reported functional and cosmetic outcome. Radiological assessment included measurement of the distance between the heads and bases of metacarpal bones III and V before and directly after surgery and at follow-up. The only complication encountered was a mild wound healing disorder in one patient, which was controlled conservatively. Sensitivity was not impaired in any patient and no patient showed signs of neuromas. Finger movement for both flexion and extension was slightly impaired in two patients. Mean grip and pinch strength was 61 (54-78) % and 65 (35-122) % compared with the unaffected hand. The mean DASH score was reduced from 42.2 preoperatively to 27.5. Dexterity was slightly reduced with a nine-hole peg test prolonged by 23 % compared with the unaffected hand. At follow-up, the intermetacarpal gap was reduced by a mean of 67 % between the bases and by 50 % between the heads of metacarpal bones III and V. Patients rated the cosmetic appearance of the hand as very good. Total resection of the fourth finger ray with soft tissue adaption enables a sufficient closure of the intermetacarpal gap without rotational malalignment and results in good to very good functional and cosmetic outcomes and a low complication rate.

A Reconstructive Extensor Tendon Centralization Technique for Sagittal Band Disruption.

Sagittal band injuries may result in extensor digitorum communis (EDC) tendon instability and may require operative treatment for symptomatic loss of extension, pain, and snapping at the metacarpophalangeal joint (MCPJ). Operative methods vary according to the source of donor tissue, as well as the anchor point of attachment. We present a surgical technique that diminishes tension of the repair with MCPJ flexion. Twenty-two EDC tendon stabilization procedures were performed between 2006 and 2017 using a tendon flap method. The selection criteria for this group of patients included completely dislocating extensor tendons with persistent complaints of pain and decrease in finger extension despite at least a 6-week conservative treatment attempt. All subjects underwent surgical treatment for tendon centralization using a distally based tendinous flap from the EDC sutured to the adjacent finger volar plate. A mathematical model was developed to analyze repair tension at 30, 60, and 90 degrees of MCPJ flexion calculating the flap length difference of 2 attachment points: deep transverse metacarpal ligament versus adjacent volar plate. Centralization was maintained in all digits with no evidence of subluxation at final postoperative evaluation. Clinical symptoms of pain and weakness resolved in all patients. Mathematical modeling provided evidence that translation of the anchor point of reconstructed flap to the volar plate of the adjacent finger resulted in lower tensile forces when compared with attachment at the intermetacarpal ligament. This optimized forces on reconstructed tendon flap experienced during MCPJ flexion.Level of Evidence: Level IV-therapeutic, case series.

Deep Transverse Metacarpal Ligament Reconstruction Using Suture Button and A1 Pulley.

Rupture of the deep transverse metacarpal ligament (DTML) can result in pain, impaired grip strength, and undermine functional performance of the hand. We describe the case of a patient whose right hand came into contact with a boat propeller. He sustained a complete disruption of the DTML between the second and third ray in addition to soft tissue injury and open metacarpal fractures. Although other techniques describe a reconstruction of the DTML, our technique describes an adjunctive technique that strongly augments the A1 pulley reconstruction and nullifies the requirements of palmaris longus graft.

The outcome of conservative treatment of spiral metacarpal fractures and the role of the deep transverse metacarpal ligaments in stabilizing these injuries.

We carried out a prospective study to assess the outcome of spiral metacarpal fractures treated with early mobilization even in the presence of malrotation. We treated 30 patients of whom we assessed 25. Of these, 23 had an excellent outcome and two had good outcomes. Objectively all the fractures united with some shortening of between 2-5 mm. Only two cases reported mild dysfunction: one patient had a residual malrotation of 5° and one had some discomfort when boxing. We also carried out simple biomechanical studies on a cadaver and two patients undergoing ray amputations. These showed that, as the distal fracture fragment migrates proximally, any malrotation in a closed injury with intact deep transverse metacarpal ligaments corrects with flexion, which also helps to limit the shortening. Spiral metacarpal fractures, whether central or border, whether single or multiple, can usually be treated reliably with early mobilization as any malrotation corrects with flexion and the degree of shortening is limited.

A technique to reconstruct the deep transverse metacarpal ligament

A technique to reconstruct the deep transverse metacarpal ligament

Deep transverse metacarpal ligament: a cadaveric study

The transversely running Deep transverse metacarpal ligament connects the metacarpal head of the index finger to little finger by attachment of volar plate. Sixty cadaveric hands, irrespective of sex, from the department of Anatomy were dissected to study the anatomical features and variation in the attachments of hypothenar muscles. In four out of sixty hands (6.66%), there was abrupt transition between the volar plate and the fibers of deep transverse metacarpal ligament. While in the rest fifty-six (93.33%) the transition was smooth. The collateral ligaments were noted on both the sides of the metacarpo phalangeal joints. Insertion of Abductor digiti minimi, flexor digiti minimi brevis in majority cases and opponence digiti minimi in few cases was observed into medial side of the deep transverse metacarpal ligament.

A Cadaver Model That Investigates Irreducible Metacarpophalangeal Joint Dislocation

Controversy exists over the pathologic anatomy of irreducible dorsal metacarpophalangeal (MCP) dislocation. The aim of this work is to develop a cadaveric model of MCP joint dislocation that closely simulates the clinical situation and to study the structures around the MCP joint and their contribution to irreducibility of the dislocation. Nine fresh-frozen cadaveric specimens were amputated at the radiocarpal joint and stabilized in a specially formulated fixture. The dislocation was created by an impact load delivered by a servohydraulic testing machine, at a displacement rate of 1000 mm/s and with a maximum displacement of 60 mm. An irreducible dislocation was successfully created in 6 index fingers. An attempt at closed reduction was followed by a dissection of the dislocated joint. In the 6 examined specimens, the flexor tendons were ulnar to the joint in all cases, the radial digital nerve was superficial (5 cases) or radial (5 cases) to the metacarpal head, and the lumbrical was usually radial (5 of 6 cases) to the joint. Division of the superficial transverse metacarpal ligaments, natatory ligaments, flexor tendons, or lumbricals does not aid reduction of the dislocation. Division of the volar plate was necessary for reduction of the dislocation in all 6 cases, whereas division of the deep transverse metacarpal ligaments does not allow reduction of the dislocation. We present a model for creating an irreducible MCP joint dislocation using an impact load that simulates the clinical situation. The volar plate is the primary structure preventing reduction of the dislocation. Division of the deep transverse metacarpal ligament is not effective in reducing the dislocation. The flexor tendons, lumbricals, superficial transverse metacarpal ligament and natatory ligaments do not contribute to irreducibility. The anatomy of the structures surrounding the MCP joint is variable, and careful dissection to prevent iatrogenic injuries is mandatory.

Digital Neuropathy of the Median and Ulnar Nerves Caused by Dupuytren's Contracture

Digital neuropathy is a pure sensory neuropathy of a digital nerve. It may be caused by acute or chronic local trauma or pressure, or accompany systemic illnesses such as rheumatoid disease, leprosy, Raynaud disease, dysproteinemia, or diabetes mellitus. We describe an extraordinary case of digital neuropathy of the median and ulnar nerves caused by Dupuytren contracture. A 56-year-old right-handed man was presented with numbness and tingling of the little finger of the right and ring finger of the left hand. The clinical and EMG findings in this patient were consistent with a lesion of the median and ulnar palmar digital nerves of the right and left ring and little fingers. Dupuytren tissue usually affects the palmar fascia, superficial to the digital nerves, and it may rarely affect the spiral cord in the digits. A spiral cord may cause sensory loss due to impingement of digital nerves or Dupuytren tissue may have been compressing the palmar digital nerves against the relatively inelastic deep transverse metacarpal ligament. As a result, digital neuropathy can develop in those with Dupuytren's contracture, and nerve conduction studies should also be performed to determine the condition. New studies are needed to provide better diagnostic criteria for the condition.

Metacarpophalangeal Joint Dislocation

Traumatic dislocation of the metacarpophalangeal joint is a relatively uncommon injury. The dislocation may be easily reducible (ie, simple) or require surgical intervention (ie, complex). The flexor tendons, lumbrical muscle, natatory ligament, and superficial transverse metacarpal ligament combine with the displaced volar plate to create a tight noose, preventing reduction. Surgical approach may be dorsal or volar; however, the radial digital nerve to the index finger is especially at risk through the volar approach. Reported complications include stiffness, arthritis, osteonecrosis of the metacarpal head, and even premature closure of the physis.

The additional value of magnetic resonance imaging in suspected saddle deformity

Symptomatic adhesions of the interosseous–lumbrical tendons have been termed saddle deformity [Watson HK, Ritland GD, Chung EK. Post-traumatic interosseus–lumbrical adhesions. A cause of pain and disability in the hand. J Bone Joint Surg Am 1974;56(1):79–84]. These adhesions produce intermetacarpal pain during intrinsic contraction by impingement on the deep transverse metacarpal ligament (dTML). Traumatic injuries of the hand have been described as a cause of saddle deformity. In this case report a patient with clinical symptoms of saddle deformity is presented after an episode of reflex sympathetic dystrophy. MR imaging highly suggested this diagnosis with a differential diagnosis of an inflammatory process, and therapy effect of steroid injection could be evaluated.

LIPOBLASTOMA OF THE HAND TREATED WITH EXCISION AND LIGAMENT RECONSTRUCTION: A CASE REPORT

Lipoblastoma of the hand is a rare benign tumour of infancy. Although benign, the tumour can present as a large mass. We present a case of a two-year-old female with a large, slowly growing soft tissue mass between the second and third metacarpal of the right hand. After excision of the mass, the deep transverse metacarpal ligament (DTML) was reconstructed using a free tendon graft from the extensor indicis propius (EIP).

Reconstruction of disruptions of the deep transverse metacarpal ligament of the ring finger using the A1 pulleys

There is little information in the literature regarding the clinical features, investigation, diagnosis and treatment of closed rupture of the deep transverse metacarpal ligament. We demonstrate a case with previously undescribed features and describe the surgical management.

Morphological and functional interface between palmar plates of metacarpophalangeal joints and intrinsic muscles of the hand

Summary. After a ten-year period of intensively dealing with the hand as a Medical Artist, it became quite obvious that the palmar section of MP joints is described in the literature partly different from what we found in our cadaver studies. This especially applies to the proximal continuation and fixation of palmar plates and the deep transverse metacarpal ligament. Thus we tried to understand and explain the complex character of interaction between locomotion apparatus and structures of the hand's "connective-tissue body". Cadaveric operation microscope-assisted dissection of the palmar ligament (plate), deep transverse metacarpal ligament, interosseous muscles as well as mechanically stable sections of the "connective tissue body" and fascia allowed a clear view of morphology, interaction, and character of these structures during passive finger motion. 1. Proximally, the palmar ligament (plate) of a metacarpophalangeal joint ranges to the tendinous sheets of origin of the interosseous muscles and in extension of these it is attached to the palmar carpal ligaments. In the following, these tendinous structures will be referred to as "deep longitudinal metacarpal fibres". This highly sophisticated proximal attachment is formed bilaterally from each palmar plate in several cascades. Thus, a widely ranging distribution of forces implied by MP-extension is guaranteed. The deep transverse metacarpal ligament executes the function of a "force dissipating center": Extension strain is passed on from the fingers via the "lateral digital sheet" and the "spiral ligament" to the palmar fascia and further on into a proximal and "deep" direction by the vertical sheets (Legueu and Juvara 1892/1974). On the next central level, a similar flow of forces reaches the palmar carpal ligaments from the osseous phalangeal base via the phalangoglenoidal ligaments and the palmar plate. Junction of these forces is the "soft tissue confluence" (Zancolli 1992), whereas the described "deep longitudinal metacarpal fibres" can be understood as a final common route. Overstretching forces at the index finger are transferred to the palmar carpal ligaments by a ligamentous "Arcus adductorius".2. Contrary to published reports, the palmar ligament (plate) does not have a determined and constant length but does adapt its extension in longitudinal direction to the joints' excursions, more than doubling in length in extended position compared to its minimal length in a maximally flexed MP joint. This is performed by criss-crossing fibers throughout the palmar ligament.3. Distally, the palmar ligament is attached to the base of the proximal phalanx on both sides with no mechanically relevant fixation in the middle. This predominant lateral attachment is additionally stabilized by the proximal section of the phalangoglenoidal ligaments, thus extending the area of osseous fixation. The biomechanical principle of restraining extension in the MP joints can be compared to the architecture of Gothic cathedrals or modern bridges. Here too, simple algorithms create complex systems. One major force (extension of MP joint) is split up into many single components to spread out the strain over a wide area. This allows high endurance with minimal expension of materials and simultaneously a well-distinguished mobility of the fingers. Operative treatment in this area (Zancolli's capsuloplasty for treatment of paralytic claw fingers) could be modified by considering these functional and morphological criteria, thus lowering frequency of relapse in palmar plate surgery.