Hand Cases to Consider.
Last updated Friday, February 11, 2005
Case 1History A 36 year old white male presented with symptoms of right hand pain. He
has had this pain for several years. He also notes increasing stiffness
in his fingers, specially the thumb. Recently he has developed
increasing thickness of the skin on the dorsum of his hand. His family
history is negative.X-ray Please click on the x-ray to get a more detailed view.
What is your diagnosis? Diagnosis: Melorheostosis Melorheostosis was first described by Leri and Joanny in 1922. They
reported on a patient with "flowing hyperostosis" x-ray changes
resembling melting wax dripping down one side of a candle. Since then
many more cases have been reported, but the condition can still be
called uncommon.
The etiology of melorheostosis is unknown. It is not a hereditary
disease, but it appears to be congenital. The disease often manifests
itself in early childhood and is progressive. The changes are most
commonly seen in the lower limbs, but are also seen in the upper limbs.
Initial symptoms are pain, joint stiffness, fibrosis of skin and
deformities. Many of the children are first diagnosed as some form of
arthrogryposis because of the contractures and because the typical
skeletal changes often appear later. The disease is slowly progressive
with thickening of the cortex of the affected long bones, osteophyte
formation and secondary joint involvement. There does not appear to be
an increased risk of fracture and there are no reports of this
condition being premalignant.
The histological characteristics of melorheostosis is similar to
that of hyperostotic bone in other conditions such as osteopoikilosis.
There is a sclerotic, thickened and somewhat irregular laminae
surrounding the Haversian systems. The Haversian canals are of unequal
diameter. Inflammatory vascular changes have been reported.
Treatment of this rare disease is mostly conservative treatment of
symptoms. Surgical treatment is sometimes necessary for the joint
affection. Because the soft tissue changes frequently precede the
hyperostosis changes, specially in children, these patients are often
initially incorrectly diagnosed. References Campbell CJ, Papademetriou T, Bonfiglio M,: Melorheostosis: a case
report of the clinical, roentgenographic and pathological findings in
fourteen cases. J Bone Joint Surg 1968;50A:1281-304
Azuma H, Sakada T, Tanabe H, Handa M,: Melorheostosis of the hand: A report of two cases. J Hand Surg, 1992;17A:1076-8
What is your diagnosis? Suggestions for treatment?
Please click on the image to get a more detailed view.
Diagnosis: Bowstringing of the flexor tendon In the fingers, the flexor tendons are enclosed in a fibrous sheath.
This pulley system is necessary for normal flexion of the fingers. The
sheath is divided into 5 annular (A1-5) and 3 crusiform pulleys (C 1-3).
In open injuries to the flexor tendons these pulleys can get damage
and can result in a condition called bowstringing. This condition
results in the flexor tendon being displaced volar on flexion. If there
is need for tendon repair as well as extensive pulley reconstruction,
then a staged tendon procedure is indicated.
Some methods for reconstruction of the pulley system include:
- Using part of the FDS. The distal incertion is left intact and the
free end is brought over to the other side of the FDP (or rod).
- Tendon graft encircling the phalanx. This tendon graft is brought
superficial to the extensor tendon around the middle phalanx and deep
to the extensor tendon around the proximal phalanx.
- Using segment of the extensor retinaculum from the dorsum of the
wrist. This is passed around the phalanx similar to the tendon graft.
- Artificial material.
References Operative Hand Surgery (3th edition), edited by David P. Green, M.D.
A 27 year old male suffered this fracture while playing basketball.
What is your diagnosis? How would you classify the fracture?
Suggestions for treatment?
Please click on the image to get a more detailed view. Diagnosis: Unicondylar phalanx fracture Condylar phalanx fractures are frequently associated with sporting activities, as in this case.
In 1971 London classified these fractures into 3 groups:
- Type I Nondisplaced stable fractures
- Type II Unicondylar unstable fractures
- Type III Bicondylar
Some argued that in reality there were very few type I fractures and
that condylar fractures should be regarded as unstable. In 1993 Weiss
and Hastings reported on 38 unicondylar fractures. They proposed the
following classification:
- Class I Oblique palmar pattern. The plane of the fracture resides
in neither the sagittal nor the coronal planes. The distal fracture
fragment lies palmar to the proximal phalangeal shaft
- Class II Long oblique fracture line with the plane of the fracture sagittally oriented
- Class III Dorsal coronal fragment
- Class IV Palmar coronal fragment
In their patient group they had 7 nondisplaced fractures that were
treated initially with splinting. 5 of these later displaced and needed
surgical treatment. 4 of 10 fractures treated with a single k-wire
fixation displaced. The authors recommended treatment was multible
k-wires or miniscrew fixation.
Our case is a class I unicondylar fracture (see image with arrow at
the proximal fracture line). He was treated with an open reduction and
a single miniscrew (see image). We will usually try to reduce the
fracture closed and pin it with k-wires. After getting 2 k-wires across
the fracture, then one k-wire is changed over to a miniscrew. Here is a
conversion table for k-wires to miniscrew:
| K-wire |
Drill |
Miniscrew |
| 0.045 |
1.1 mm |
1.5 mm |
| 0.062 |
1.5 mm |
2.0 mm |
References London PS: Sprains and fractures involving the interphalangeal joints. Hand 3:15-8, 1971
Weiss AC, Hastings II H: Distal unicondylar fractures of the proximal phalanx. J Hand Surg 18A:594-9, 1993.
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