Wrist Crease Research Articles

Pseudoaneurysm of Ulnar Artery after Endoscopic Carpal Tunnel Release

The authors present an extremely rare case of a pseudoaneurysm of the ulnar artery as a complication of a two-portal endoscopic carpal tunnel release (ECTR). A 70-year-old man with chronic renal failure and on maintenance hemodialysis with a left arteriovenous fistula presented with paresthesia of his right hand. A clinical diagnosis of right carpal tunnel syndrome was confirmed by ultrasonography and an electrophysiologic study. He underwent two-portal ECTR, and the paresthesia was much improved. However, he presented to us one month after operation with severe pain, a tender mass distal to the right wrist crease and more aggravation of the paresthesia in the ulnar nerve distribution. Doppler ultrasound was performed and revealed a hypoechoic lesion 20 mm in diameter in the right palm, with arterial Doppler flow inside connected to the palmar segment of the ulnar artery. An ulnar artery pseudoaneurysm was diagnosed and treated by ultrasound-guided percutaneous thrombin injection. Transverse color Doppler ultrasound image showed complete thrombosis of the pseudoaneurysm and flow cessation after a total injection of 500 units of thrombin. The symptoms were also improved.

Anomaly of Flexor Digitorum Superficialis Penetrating Through the Median Nerve: Case Report

The median nerve displays frequent anatomic variation. Here, we report an unusual anatomic variation consisting of a penetrated median nerve and the tendon of the flexor digitorum superficialis to the index finger passing through it approximately 4 cm proximal to the wrist crease.

Técnica de microincisão na cirurgia do túnel do carpo

Resumo Contexto: O tratamento proposto para síndrome do túnel do carpo é dividido em conservador e cirúrgico. O tratamento conservador versa em fisioterapia e uso de medicamentos. A cirurgia para liberação do túnel do carpo é um assunto corrente na literatura, motivo de diversas publicações, principalmente a partir dos anos 1950. Na liberação tradicional, o cirurgião faz uma incisão de 5 cm a 6 cm, estendida longitudinalmente em relação à prega formada pelo punho, e realiza a liberação do ligamento transverso do carpo sob visualização direta. Objetivo: Apresentar a técnica cirúrgica desenvolvida por nós, que consiste em uma microincisão de 1 cm na linha média da prega do punho e recortar os bordos do retináculo dos flexores, e demonstrar as vantagens dessa técnica, perante a vigente. Casuística: A técnica foi utilizada em 40 pacientes de ambos os gêneros, das mais variadas faixas etárias, atendidos e acompanhados no Hospital Antônio Targino e na Clínica de Neurologia e Neurocirurgia Domício Holanda, (ambos situados na cidade de Campina Grande, PB) com síndrome do túnel do carpo no período de janeiro de 1993 a dezembro de 2008. Resultados: Verificou-se que houve diminuição da dor, a técnica proporcionou melhor efeito estético, uma vez que, pela microincisão na linha da prega palmar, pouco tempo após o procedimento a cicatriz perdia-se entre as pregas palmares; em nenhum dos pacientes acompanhados após a cirurgia houve recidiva, constituindo uma vantagem sobre a técnica vigente; quanto à cicatrização, não houve formação de queloides em nenhum dos pacientes, ratificando-se melhor reposta cicatrizante; melhor exequibilidade ao cirurgião e menor tempo cirúrgico. Conclusão: A técnica apresentada oferece resultados extraordinários, diminuindo a chance de recidivas, trazendo melhor exequibilidade ao cirurgião e levando maior satisfação aos pacientes.

Inter- und Intraobserverreliabilität definierter Messpunkte zur sonografischen Diagnostik des Karpaltunnelsyndroms – eine Validierungsstudie an gesunden Probanden

High-resolution ultrasound is becoming increasingly important in the diagnosis of carpal tunnel syndrome (CTS). Most studies define cut-off values of the cross-sectional area (CSA) of the median nerve in different locations. The individual range of nerve swelling, the size of the nerve, and its CSA are not addressed. The aim of the study is to define the intra- and interobserver reliability of diagnostic ultrasound using two different cross-sectional areas of the median nerve at the carpal tunnel in predefined locations. Two observers using high-resolution ultrasound examined 50 wrists of healthy volunteers independently. The CSA of the median nerve was measured at the entrance of the carpal tunnel and 2 cm proximal to the palmar wrist crease. The height and width of the carpal tunnel were determined using anatomical landmarks. The intra- and interobserver reliability was determined using Cronbach's alpha. Depending on the observer, the mean width of the carpal tunnel ranged from 3.37 to 3.43 cm with the height ranging from 1.18 and 1.19 cm. The CSA of the nerve was measured with values of 8.43 and 9.05 mm (2) on the pisiform level and 9.37 and 9.68 mm (2) on the proximal level. Cronbach's alpha ranged from 0.754 to 0.940 for the interobserver reliability and from 0.924 to 0.996 for the intraobserver reliability. To use high-resolution ultrasound for the diagnosis of carpal tunnel syndrome, the reproducibility of this method has to be evaluated. Our study confirms examiner-independent reproducibility of two predefined diagnostic cross-sectional areas resulting in good alpha values.

The Glabrous Palmar Flap

We devised a new flap using the palmar cutaneous branch of the superficial radial artery proximally and anastomosed with a cutaneous perforator of the superficial palmar arch distally. We named our flap "the volar glabrous palmar flap." The flap was used both as a free flap and as a reverse-flow island flap. Thirty-six patients with volar hand defects (24 digits, 7 palms, and 5 first web space) were reconstructed with this flap. The flap was used as a proximally based free flap in 15 patients and was used as a reverse-flow island flap based on distal communication in the remaining 21 patients. Free flaps were supplied by the palmar branch of the superficial radial artery and its fasciocutaneous extensions; reverse-flow island flaps were supplied by one of the perforating branches of the superficial palmar arch, which is connected to the proximal fasciocutaneous branches. Flaps extended from the wrist crease to the proximal palmar crease and were designed medially on the thenar crease, extending 2 to 2.5 cm laterally. Flap sizes ranged from 1.5 x 2.2 cm to 2.5 x 10 cm. The palmar cutaneous branch of the median nerve within the flap area was identified and then was sutured to the divided digital nerve in 6 cases of finger pulp defect. The donor sites were closed and repaired primarily in most cases. The postoperative course was uneventful, and all the flaps survived without major complications. Follow-up (minimum 6 mo, mean 24 mo) showed excellent functional and cosmetic results. Satisfactory sensory reinnervation was achieved in patients who underwent sensory flap transfer for pulp defects. At the same time, we studied 6 cadaver hands to understand the vascular anatomy of the thenar area of the hand. We also revised several published anatomic papers to obtain a refined and scrutinized understanding of the palmar anatomy.

Use of Wolfe Graft for the Treatment of Mucous Cysts

Many surgical procedures have been described for the treatment of mucous cysts. We report a case series of a surgical technique that excises the cyst along with overlying skin and reconstructs the defect using a Wolfe graft harvested from the wrist crease. This technique can be applied to cysts in all locations, even those adjacent to the nail. The procedure has been performed on 51 mucous cysts with satisfactory results, a very low recurrence rate (4%) and negligible complications.

Using Acupoint Heart 7: An Anatomical Approach

Abstract Acupuncture point Heart (HT) 7 can be used for a wide variety of cardiovascular conditions. It is usually located at the medial end of the most distal wrist crease, on the medial aspect of the wrist. HT 7 is a source of healing energy specific to cardiovascular illnesses and can be needled on an empirical basis in any condition particular to that system. This article discusses a scientific approach to the location of HT 7, allowing for precise needling.

Comparison of Needle Position Proximity to the Median Nerve in 2 Carpal Tunnel Injection Methods: A Cadaveric Study

Steroid injections are commonly performed by hand surgeons for relief of symptoms associated with carpal tunnel syndrome. The purpose of this study is to examine the relationship of the needle to the median nerve within the carpal tunnel and to the palmar cutaneous branch, using 2 injection techniques. Simulated carpal tunnel injections were performed on 15 cadaveric arms using 2 methods. The first injection used a widely accepted approach in which the needle is inserted at the wrist crease, just ulnar to the palmaris longus, and directed at a 30 degrees angle to the horizontal. In the second method, the needle is positioned just ulnar to the palpable ulnar border of flexor carpi radialis and angled 30 degrees to the horizontal. Specimens were dissected using an open carpal tunnel release. Calipers measured the distance from each needle to the median nerve within the carpal tunnel and to the palmar cutaneous branch. Using the first injection method, the needle pierced the median nerve in 4 specimens, and its mean distance from the nerve measured 1.34 mm +/- 1.83 mm. With the second injection method, the median nerve was pierced in 1 specimen, and the needle averaged a distance of 4.79 mm +/- 3.96 mm from the nerve. In the first approach, the needle averaged 9.47 mm +/- 4.11 mm from the palmar cutaneous branch, compared to 1.74 mm +/- 1.59 mm with the second technique. Physicians must exercise caution when performing carpal tunnel injections to avoid intraneural injection. The needle was a statistically significant shorter distance to the median nerve with the traditional injection method; however, the alterative method risks injury to the palmar cutaneous branch of the median nerve.

Use of Wolfe Graft for the Treatment of Mucous Cysts

Many surgical procedures have been described for the treatment of mucous cysts. We report a case series of a surgical technique that excises the cyst along with overlying skin and reconstructs the defect using a Wolfe graft harvested from the wrist crease. This technique can be applied to cysts in all locations, even those adjacent to the nail. The procedure has been performed on 51 mucous cysts with satisfactory results, a very low recurrence rate (4%) and negligible complications.

Free Flap From the Superficial Palmar Branch of the Radial Artery (SPBRA Flap) for Finger Reconstruction

Functional reconstruction after a severe hand injury is best achieved by obtaining primary, stable soft tissue coverage to avoid delayed wound healing, prolonged immobilization, and joint stiffness. A wide range of procedures from spontaneous healing to local flaps has been proposed to treat soft tissue defects in appropriate circumstances. However, these pedicled flaps are insufficient in covering larger finger defects, so we used flaps from the free superficial palmar branch of the radial artery (SPBRA) for such cases. Between June 2003 and May 2007, 11 people with traumatic finger injury were treated with SPBRA flaps. The blood supply of the flap is derived from the SPBRA, which can be palpated and confirmed by Doppler flowmetry 18 mm proximal to the palmar wrist crease. Anastomoses of vessels were performed under a microscope, linking the SPBRA to the digital artery and the concomitant vein to the digital dorsal vein. The defects were located at the fingertip in seven patients, in the dorsum of the proximal phalanx in two, and at the interphalangeal joint in two. The average flap size was 8.4 cm with the largest flap being 12.5 cm2 (50 mm x 25 mm). All the flaps survived completely and the wound healed satisfactorily, except for one partial necrosis. All the donor sites were closed primarily without complications or obvious scarring. Most of the fingers involved achieved a full range of motion and showed a good contour. Two-point spatial sensory discrimination was recorded for six patients and adequate protective sensation was attained. The SPBRA flap provides a thin, pliable, reliable, and good glabrous skin flap for covering medium to large finger defects. Only one operative field is required and the major vessels are preserved. This approach can add to the armamentarium of the plastic surgeon for covering large defects of the finger.

Lipofibromatous hamartoma of the median nerve: A case report and review of the literature

A case of lipofibromatous hamartoma of the median nerve in an adult is described in this article. A 33-year-old male presented with tingling, numbness and swelling in the palm of the left non dominant hand that had been present for a few months. Examination revealed that there was fullness in the volar aspect of the wrist and in the inter-thenar area. Another mass was present at the base of the index finger, which appeared to be involving subcutaneous tissues. The clinical diagnosis was carpal tunnel syndrome due to a space occupying tumor mass in the carpal tunnel. On exploration of the carpal tunnel, a large median nerve was seen 4 cm proximal to the wrist crease line and extending distally until it divided into its branches. Another mass was present at the base of the index finger, which was adherent to the skin. The radial digital nerve of the index finger was normal in size. For the enlarged nerve, an epineurotomy was performed and a biopsy was taken. Another biopsy was taken from the distal mass. His postoperative period was uneventful. In July 2004, at the end of 5 years, the patient had no symptoms and the size of the tumor had not increased.

Intraneural Lipoma of the Ulnar Nerve

Sir: A 9-year-old girl presented with exertional discomfort of the right hand due to two slowly enlarging masses. There was no history of trauma, paresthesias, numbness, or weakness. Clinical examination revealed two discrete masses, one proximal to the flexor wrist crease measuring 5 × 1.5 × 0.5 cm and a second measuring 7 × 4 × 2 cm in the hypothenar eminence (Fig. 1). The masses were soft and mobile, with well-defined borders and no overlying skin changes. The Tinel sign was absent. An Allen's test demonstrated the ulnar artery of the hand to be patent, but with delayed filling.Fig. 1.: Gross appearance of the right wrist and hypothenar eminence masses of the right hand, measuring 5 × 1.5 × 0.5 cm and 7 × 4 × 2 cm, respectively. Intraoperative markings demonstrate the location and extent of the lesion. A single incision was made directly over the lesion and crossing the flexor wrist crease, as shown.Magnetic resonance imaging was consistent with a lipoma in the volar aspect of the right wrist and hand with displacement of the flexor digitorum superficialis tendons. Magnetic resonance angiography revealed radial displacement of the ulnar artery. At exploration, the mass appeared to be a large, multilobulated lipoma originating from within the ulnar nerve, with splaying of fascicles and attenuation of the hypothenar musculature. The ulnar artery was displaced radially. Resection yielded a 14-cm multilobulated mass with no residual lesion (Fig. 2). All nerve and fascicle groups, the ulnar artery, and the palmar arch were left intact.Fig. 2.: With the mass completely removed, the splayed, intact fascicles of the ulnar nerve are visible. The incision was closed directly without removing excess skin.Gross pathologic examination revealed an encapsulated, lobulated mass of homogeneous adipose tissue. Microscopic findings showed mature fibroadipose tissue consistent with the diagnosis of a benign intraneural lipoma. Postoperative evaluation at 2 weeks showed normal median and ulnar nerve function, with only mild weakness of the abductor digiti minimi. Follow-up at 1 month showed increased range of motion, improved ulnar sensation, and persistent, mild, residual small-finger weakness on abduction. Masses originating in the median and ulnar nerves are exceedingly rare.1,2 The nomenclature for such masses has been based primarily on pathologic descriptions, such as lipoma, intraneural lipoma, lipofibromatous hamartoma, fibrofatty proliferation, and fatty infiltration.1,3,4 Intraneural lipofibromas have been divided into three major entities based on pathologic descriptions and clinical/anatomical behavior: true intraneural lipomas, lipofibromas, and peripheral nerve hamartomas with marcrodactyly.3 True lipomas are soft, noninvasive, encapsulated tumors that displace adjacent structures. These lesions can be readily dissected from surrounding tissues and histologically contain fibrous and fatty tissue, but lack neural elements. Distinct from true lipomas, lipofibromas contain fibrous, fatty, and neural elements. Confined within the nerve sheath, lipofibromas are often impossible to separate from nerves without extensive interfascicular dissection or complete nerve resection. Nomenclature varies and includes the pseudonyms fibrofatty proliferation, intraneural lipoma, and lipomatous hamartoma. Hamartomas represent a third entity of benign tumors, similar to lipofibromas histologically in that they both contain fibrous, fatty, and neural elements. Some authors propose nomenclature that combines associations with macrodactyly: lipofibromatous hamartoma with or without macrodactyly.1,2 Patients present in childhood with swelling of the wrist or hand and varying degrees of compressive symptomatology. Magnetic resonance imaging is typically diagnostic but cannot delineate the degree of fascicular involvement.5 Operative exploration is indicated for progressive mass enlargement, overt compressive symptoms, and histopathologic confirmation. Depending on the anatomical relationship of the lesion, surgical treatment may involve biopsy and ligamentous decompression, limited interfascicular dissection, complete resection with nerve grafting, complete resection, and, occasionally, compensatory tendon transfer. In summary, benign, fibrofatty tumors of the hand and wrist are indeed rare. Associated symptoms are directly related to tumor size and anatomic location. The natural history is continued growth and potential exacerbation of symptoms without spontaneous regression.4 Surgical intervention should be considered in patients with large or indeterminate masses. Treatment by excision should be considered early in the disease process. Laura A. Bonneau, Stephen J. Delatte, M.D. Michael L. Bentz, M.D. Division of Plastic Surgery Department of Surgery University of Wisconsin-Madison Madison, Wis.

A modified hand anatomic index to assesss hand deformity in scleroderma

We recently described a hand anatomic index (HAI, a simple and reliable quantitative measure of hand deformity) in scleroderma and showed that it clearly distinguished patients with increasing hand deformity and separated patients with diVuse scleroderma from those with limited scleroderma [1]. Furthermore, the HAI correlated signiWcantly with measures of functional impairment. We now wish to report a modiWed HAI (mHAI) which appears to be more informative than the original HAI. This new mHAI additionally incorporates a measure of the severity of the Xexion deformity of the third digit into the original HAI. The new index is derived from the equation (maximal lateral hand height/extended hand span) £ (distance of volar arch of third digit (from distal wrist crease to tip of Wnger)/direct volar distance of third digit) £ 10. It can be quickly and simply measured in the clinic setting and a normal range has been determined. The mHAI was measured in 19 scleroderma patients registered on the South Australian Scleroderma Register [2] and compared with a qualitative measure of structural hand deformity (as assessed by two independent rheumatologists [1]) and with the validated Cochin Hand Functional Scale (CHFS), an 18 point questionnaire that accurately reXects hand function and has good construct validity [3]. The mHAI was signiWcantly elevated in patients with scleroderma, separated patients with limited disease from diVuse disease (Fig. 1) and correlated signiWcantly with the measure of structural hand deformity (r = 0.94, P = 0.00001) and with the CHFS (r = 0.69, P = 0.003). The mHAI with stronger correlation coeYcients appears to be more informative than the original HAI. We conclude that the measurement of the mHAI in scleroderma produces a reliable and objective measure reXecting the degree of hand deformity and functional impairment, and might provide a valid clinical outcome

Reply

Sir: We are pleased that Tubbs et al. found our research project and article1 interesting. These authors have added noteworthy qualitative reports of the position of the palmar arches. The purpose of our study was to identify the location of the palmar arches in relation to surface and bony landmarks. Our article significantly augmented previous reports of palmar arch locations by providing practical quantifiable data. In particular, we found the distal wrist crease to be a reliable surface landmark for both the superficial and deep palmar arches, given its clear delineation and the consistency in measurements in our cadaver dissection. We feel that our study significantly enhances past anatomical reports by providing clinically applicable information to ease surgical dissection and interpretation of abnormal arteriograms. Kia M. McLean, M.D. Justin M. Sacks, M.D. Yur-Ren Kuo, M.D., Ph.D. Ronit Wollstein, M.D. J. Peter Rubin, M.D. W. P. Andrew Lee, M.D. Division of Plastic and Reconstructive Surgery University of Pittsburgh Pittsburgh, Pa.

A new tool for mini-open carpal tunnel release – the PSU retractor

BackgroundMini-open carpal tunnel release has become increasingly popular for the treatment of carpal tunnel surgery. The main advantages are shortening recovery time and return-to-work time. However, the risk of neurovascular injury still remains worrisome.MethodsIn this study, we developed a new retractor (herein called the PSU retractor) modified from the widely used Senn retractor, with the aim of decreasing the risk of neurovascular problems from normal procedure. 3-Dimensional computer design software (SolidWorks® Office Premium 2007 SP3.1) was used to construct a 3-D PSU retractor prototype. An amputated arm from a 30-year-old woman diagnosed as synovial sarcoma at the shoulder was used to test the maximal visual length. A mini-surgical incision was performed at 3 cm distal to the transverse wrist crease and a tiny flexible ruler was inserted through the tunnel beneath the skin to measure the maximal visual length.ResultsOur new retractor showed significantly better maximal visual length compared to the Senn retractor (47.7(8.1) mm vs. 39.2(6.5) mm). In addition, most assessors expressed a higher satisfaction rate with the PSU retractor than with the Senn retractor (7.3 (1.9) vs. 6.3 (1.1)).ConclusionIn conclusion, we have developed a promising new retractor using a computer design program, which appears to be an improvement on the currently available equipment used for mini-open carpal tunnel surgery. However, further clinical studies are needed to confirm our initial findings.

High-Resolution Sonography of the Palmar Cutaneous Branch of the Median Nerve

The aim of this study was to describe the potential value of high-resolution sonography for evaluation of the palmar cutaneous branch of the median nerve (MN). The volar wrists of 12 healthy volunteers and 22 consecutive patients with sensory deficit in the palmar triangle and thenar eminence suggesting neuropathy of the palmar cutaneous branch of the MN were examined with high-frequency sonography. Nine patients underwent carpal tunnel release, five had a history of penetrating trauma, six had symptoms suggesting concurrent carpal tunnel syndrome, one received surgery for palmaris tendon transfer, and one underwent resection of a ventral carpal ganglion cyst. Correlative 1.5-T MRI was performed in six patients. In 83% of the healthy volunteers, 17-5-MHz sonography was able to identify the palmar cutaneous branch of the MN from its origin down to slightly distal to the wrist crease. In the patient group, sonography allowed detection of nerve abnormalities in 55% of the cases. Focal hypoechoic swelling of the nerve at the fascial crossing was observed in patients who had either concurrent carpal tunnel syndrome (four cases) or previous carpal tunnel release (three cases). Sonography performed after a penetrating trauma revealed nerve encasement by scar tissue (two cases) or complete transection of the nerve ending in a terminal neuroma (one case). Nerve transection secondary to resection of a ventral carpal ganglion cyst (one case) or to carpal tunnel release (one case) was also observed. Sonography can identify the palmar cutaneous branch of the MN and characterize its abnormalities, providing unique information about this small nerve branch.

Endoscopic Revision of Carpal Tunnel Release

Open revision has been the standard approach for treatment of recurrent carpal tunnel syndrome. The authors hypothesized that endoscopic revision would yield results comparable to those with open revision. Forty-one patients with unilateral recurrence were analyzed prospectively before and after endoscopic revision for a period of 1 year. All had clinical signs or symptoms, a positive response to a steroid injection, and electrodiagnostic findings consistent with carpal tunnel syndrome after primary open release and had failed to improve after an average of 16 months. Follow-up evaluations were performed with validated outcome instruments and quantitative measurements of strength and sensation. Thirty-seven of the 41 patients reported improvement after the endoscopic revision. Significant improvement was seen at 3 and 12 months after the procedure in the Carpal Tunnel Syndrome Symptom Severity Score, the Carpal Tunnel Syndrome Functional Status Score, the University of Washington satisfaction score, pinch strength and sensation, and a decrease in scar sensitivity. An improvement in grip strength was measured after 12 months. The satisfaction score was found to be significantly correlated to the Symptom Severity Score and the Functional Status Score. Endoscopic release of recurrent carpal tunnel syndrome may be performed safely using standard technique with good results. The advantage of the procedure is the ability to approach the tunnel while avoiding the scarring related to the previous open approach. This technique is not adequate for cases after several open revisions, suspected nerve injury, or extension of the previous open approach proximal to the wrist crease.

Energy Expenditure During Cane-Assisted Gait in Patients with Knee Osteoarthritis

To compare the energy expenditure in patients with unilateral knee osteoarthritis while walking with canes of different lengths. A quasi-experimental study (single-group) was carried out on thirty patients with unilateral knee osteoarthritis. An adjustable aluminum cane was used, and three different cane lengths were determined for each subject: C1--length from the floor to the greater trochanter; C2--length from the floor to the distal wrist crease; and C3--length obtained by the formula: height x 0.45 + 0.87 m. Resting and walking heart rates were measured with a Polar hear rate meter. Walking speed was calculated by the time required for the patient to walk 10 m. Gait energy cost was estimated using the physiological cost index, and results were compared. The sample consisted of 25 women and five men (average age of 68 years). Statistically significant differences in physiological cost index measurements were observed between unassisted walking and assisted walking with a cane of any length (p<0.001), as well as between walking with a C2-length cane and unassisted walking, and walking with a C1-length cane and walking with a C3-length cane (p=0.001; p = 0.037; p=0.001; respectively). These data demonstrate that small alterations in the length of canes used for weight-bearing ambulation in patients with unilateral knee osteoarthritis increase the energy expenditure measured by the physiological cost index during walking. Further studies are needed for a more precise quantification of the increase in energy expenditure during cane-assisted gait and an assessment of the effectiveness of cane use in relieving pain and improving function in patients with knee osteoarthritis.

Estimation of stature from hand dimensions of north and south Indians

The present study was undertaken to predict the stature of a person using hand length and breadth. The study includes 500 right-hand dominant medical students aged between 20 and 30 years, from northern and southern parts of India, studying in Kasturba medical college, Manipal, India. Hand length was measured ‘between the distal wrist crease and the tip of middle finger (HL-1)’ and ‘between the mid-point of inter-styloid line to the tip of middle finger (HL-2)’. Hand breadth was measured between radial side of the second metacarpophalyngeal joint and ulnar side of the fifth metacarpophalyngeal joint (HB). No significant difference was present in hand dimensions between north and south Indians. When compared between both hands, right-hand dimensions were larger than the left hand, with statistically significant difference in HL-2 and HB. Linear regression equations using hand length is more helpful in estimating stature than the hand breadth. The correlation coefficients ranged from 0.673 to 0.665 and 0.740 to 0.732 in north Indian males and females, respectively. Whereas in south Indians, it ranged from 0.752 to 0.732 and 0.701 to 0.691 in males and females, respectively. Multiple regression equations give better results than linear regression equations. HL-2 gives more accurate results in stature estimation than the HL-1.

Fourteen Cases of Free Thenar Flap

The thenar area was first used for a free vascularized transfer by Tsai who, in 1991, resurfaced and vascularized a traumatized index finger basing the dissection on the radial digital artery of the thumb. Later, Kamei and Omokawa described a similar flap in finger reconstruction, which was supplied either by the radial artery or its volar branch. Between 1997 and 2005 14 free thenar flaps were performed at Chang Gung Memorial Hospital for thumb (3 cases) and digital reconstruction (11 cases). In 6 cases, the pulp was involved whereas in the remaining 8 cases, the lesion was either in the volar (6 cases) or in the dorsal surface (2 cases) of the fingers. In 7 patients, a perforating branch rising about 3 cm proximal to the wrist crease was the main vascular source of the flap. In 8 cases, the volar radial artery provided adequate blood supply to the flap. No sensory nerve was included in the flap dissection. Two patients underwent reexploration for arterial thrombosis and venous congestion, respectively, which resulted in complete survival in this series. Donor site morbidity was inconspicuous and, in all cases, the thenar flap provided a well-padded tissue with glabrous skin. In the 7 patients who came back for a final evaluation, 2PD showed poor recover. The free thenar flap offers a thick skin of similar glabrous texture to that of the digits. This flap is especially indicated in those cases of multiple digital injuries or wide skin defects where homodigital or heterodigital island flaps are unsuitable.