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Severely comminuted trapezoid fracture which is beyond reconstruction is best managed by carpometacarpal arthrodesis because the motion between the trapezoid and the metacarpal bone is minimal1. However, CT scan was not performed for this patient due to the concern of expected artefact caused by the external fixator. The condition of the trapezoid was not fully visualised prior to the surgery; hence, bone grafting for arthrodesis was not included in the operative plan for this patient. With the experience gained from the current patient, removal of external fixator should be considered in future patients so that CT scan can play a role in the operative planning.
download green 39;s operative hand surgery
Highlights the latest advances and approaches, such as wide-awake local anesthesia no tourniquet (WALANT) hand surgery, nerve transfer techniques, tendon transfer and tendon avulsion repairs, skin grafting techniques, and more.
"There are a limited few "absolute" must-have books for an orthopedic library that are known in orthopedics by the name(s) of the lead author(s): Campbell's, Rockwood and Green, and Green's. Every institution that hosts surgeons who perform hand surgery should have the most recent edition of these titles. Every resident in orthopedic training should have access to Green's and it should be the first book purchased by an orthopedic hand fellow. Active hand surgeons will always need the most up-to-date version."
Studies were identified by searching the electronic databases Medline, AMED, CINAHL and EMBASE. Studies were included if they met the following inclusion criteria: prospective or retrospective, experimental, quasi-experimental or observational studies investigating the effectiveness of static or dynamic splints worn day and/or night-time for at least 6 weeks after surgery and reporting either individual joint or composite finger range of motion and/or hand function. The methodological quality of the selected articles was independently assessed by the two authors using the guidelines for evaluating the quality of intervention studies developed by McDermid.
There is empirical evidence to support the use of low load prolonged stretch through splinting after hand surgery and trauma, however only a few studies have investigated this specifically in Dupuytren's contracture. The low level evidence regarding the effect of post-operative static and dynamic splints on final extension deficit in severe PIP joint contracture (>40) is equivocal, as is the effect of patient adherence on outcome. Whilst total active extension deficit improved in some patients wearing a splint there were also deficits in composite finger flexion and hand function. The lack of data on the magnitude of this effect makes it difficult to interpret whether this is of clinical significance. There is a need for well designed controlled trials with proper randomisation to evaluate the short-term and long-term effectiveness of splinting following Dupuytren's surgery.
A persistent PIP joint contracture is a known complication following Dupuytren's surgery. Such contractures may be due to capsular tightness following prolonged PIP joint flexion from the Dupuytren's disease or due to complications from the operation itself, for example oedema restricting movement. Splinting has been shown to be an effective treatment for both chronic (greater than six months duration) and acute (21 days to six months duration) PIP joint flexion contractures following PIP joint soft tissue injuries[13, 14]. The reasoning for using splints after surgery for DD is that they provide a low-load continuous force which maintains the correction achieved intra-operatively and prevent contracture recurrence. Such splints are normally worn for 3 to 6 months as scar maturation and therefore the splints' effect on remodelling continues for this time period.
A systematic review of the literature was undertaken to evaluate the quantity and quality of evidence regarding the clinical effectiveness of post-operative splinting after surgical release for DC in the hand.
The number of studies evaluating the effectiveness of post-operative splinting is small and the quality of the evidence is low. Two of the evaluation criteria were consistently not met by any of the studies, these were lack of randomisation to groups (question 5) and lack of sample size calculation (question 11). The low scores also reflect a lack of detail in proper reporting of results. Ebscov et al used proportion of patients with contractures and Rives et al only gave percentage improvement. No actual degrees of range of motion were reported making it also difficult to interpret the clinical significance. Glassey reported actual means and standard deviation for range of motion but not for self-reported hand function as measured by the Disabilities of the Arm, Shoulder and Hand Questionnaire (DASH).
This review identified only 4 studies providing low level evidence on the effects of static and dynamic post-operative splinting. None of the studies allocated patients to interventions randomly and therefore systematic differences between groups are likely to have biased results. The quality of the reporting was poor and due to the heterogeneity in splint types, duration of wear, outcomes and follow-up period it was not possible to pool the results. Whilst one study indicates that splinting results in fewer contractures especially when patients are compliant with wearing a splint another study did not support this, favouring the group who did not meet criteria for adequate wear, though follow-up for the latter group was also shorter (9 months). Although improved finger extension is undoubtedly an important outcome of long-term night splinting, composite finger flexion and hand function are also important parameters of the effect of splinting. Only one study included these as outcomes and the results indicate that patients allocated to wear a splint had lower total finger flexion and higher DASH scores (greater disability) at 3 months. These 'negative' effects may well disappear at 6 month or 1 year but no study to date has examined this.
Whilst the value of splints in delivering a low-load prolonged stretch to healing tissues after hand trauma and hand surgery has been well argued its effect on the diseased fascia in DD even after surgical excision remains unknown. Post-operative splinting is widely used and like many interventions in hand rehabilitation supported only by clinical reasoning and anecdotal evidence. The clinical effectiveness of long-term static night splinting on finger movement and hand function remains unproven and a properly randomized controlled trial is needed with a sufficient sample size to confer adequate power for detecting clinically important differences. The effect of different types of splints, duration and patient adherence need to be factored into future trials. Further work is also needed to establish the most appropriate primary and secondary outcomes and follow-up time in future studies of effectiveness.
Clinical appearance on initial presentation to the hand surgery service The patient had wasting of the ulnar innervated intrinsic muscles of the hand between the metacarpals. a The patient also had an ulnar claw hand deformity. When the ulnar innervated intrinsic muscles cannot fire, there is extension at the metacarpalphalangeal (MCP) joints and flexion at both the proximal and distal interphalangeal (IP) joints in the ring and small fingers (b)