http://jhs.sagepub.com/Journal of Hand Surgery (European Volume)

http://jhs.sagepub.com/content/33/2/223.1The online version of this article can be found at:

 DOI: 10.1177/1753193408087110

2008 33: 223J Hand Surg Eur VolPhilippe Pelissier, Elias Sawaya and Ebaa Sabri

Re: ''Inside screw'' wire-frame for internal fixation of intraarticular fracture  

Published by:

http://www.sagepublications.com

On behalf of: 

British Society for Surgery of the Hand

Federation of the European Societies for Surgery of the Hand

can be found at:Journal of Hand Surgery (European Volume)Additional services and information for     

  http://jhs.sagepub.com/cgi/alertsEmail Alerts:

 

http://jhs.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

at HINARI on July 26, 2011jhs.sagepub.comDownloaded from

Re: A carpal boss leading to extensor tendon ruptures –A case report

Dear Sir,

A 59 year-old left-hand dominant man with no previoushand symptoms reported a sudden spontaneous episode ofpain over the dorsum of his right hand with associated lossof index finger extension. Examination revealed significantswellings over the dorsal aspects of both hands at the baseof the index and middle metacarpals. These were mixedbony and soft tissue masses to palpation, with swelling onthe right hand measuring approximately 20mm indiameter. A 301 index finger extensor lag was noted inthe right hand, with full passive extension and normalflexion. X-rays revealed degenerative change and markeddorsal osteophyte formation of the middle and indexcarpometacarpal joints in both hands. A provisionaldiagnosis was made of attritional rupture of the indexfinger extensor tendons secondary to a carpal boss. Atsurgery, a large carpal boss of the joint between thecapitate and the middle metacarpal base was identified,with overlying ruptures of the extensor indicis propriusand index extensor digitorum communis tendons. Therewas no evidence of intratendinous ganglion or degenera-tion. The tendon defects were greater than 60mm, anddirect repair was not possible. After debridement of thecarpal boss, the distal portion of extensor indicis propriuswas transferred into the middle finger extensor digitorumcommunis tendon using a Pulvertaft weave and Ethibondsuture. The patient made an unremarkable recovery, andreview at 3 months demonstrated full active and passiverange of movement of the affected finger.

The carpal boss is an osteoarthritic spur found on thedorsum of the hand at the base of the second and thirdmetacarpals. There is frequently an associated overlyingganglion. A carpal boss may be asymptomatic, but maycause pain or limitation of movement. There are noprevious reports of patients presenting with rupture ofextensor tendons secondary to a carpal boss, althoughsymptoms of snapping, pain and tenosynovitis have beenreported (Artz and Posch, 1973). The presence ofintratendinous ganglia has also been documented (Chen,1992). The development of tenosynovitis and intratendinousganglia may represent the initial degenerative changessecondary to the tendon attrition, leading ultimately totendon rupture as reported here. Rupture of extensortendons overlying a carpal boss has not previously beenreported. This potential complication should be taken intoconsideration when planning the management of a patientwith a carpal boss and considered in patients presentingwith extensor tendon rupture.

References

Artz TD, Posch JL (1973). The carpometacarpal boss. Journal of Boneand Joint Surgery, 55A: 747–752.

Chen WS (1992). Intratendinous ganglion and carpometacarpal boss.A report of two cases. Italian Journal of Orthopaedic Traumatol-ogy, 18: 421–425.

M. R. Williams, FRCS Ed (Tr and Orth) andS. M. Fullilove, FRCS (Tr and Orth)

Department of Trauma and Orthopaedics, PlymouthHospitals NHS Trust, Derriford Hospital, Plymouth,

Devon PL6 8DH, UKE-mail: mrwilliams@doctors.org.uk

r 2008 The British Society for Surgery of the Hand. Published by SAGE. All rights reserved.doi:10.1177/1753193408087111 available online at http://jhs.sagepub.com

Re: ‘‘Inside screw’’ wire-frame for internal fixation ofintraarticular fracture

Dear Sir,

A 38 year-old male manual worker presented with acomminuted fracture of the base of the proximalphalanx of the thumb (Fig 1A). Fracture reductionwas achieved by axial traction. An attempt at osteo-synthesis with K-wires resulted in unstable fixationand immobilisation with an external fixator wouldhave involved the metacarpophalangeal joint, and sowas not used. Finally, alignment of the joint surfacewas maintained with a transverse cannulated screw andthe metaphyseal fracture was stabilised with a boxloop wire passed around the fracture. Distally, the wireof the loop passed through the bone of the phalangealshaft, while, proximally, it passed through the cannula-tion of the screw (Fig 1B). The fixation was sufficientlystable to allow early mobilisation of the thumb. At 8months, the patient had regained a painless and fullrange of motion of the adjacent metacarpophalangealjoint, although interphalangeal joint flexion was slightlyreduced.

Cannulated screws are known to provide stablefixation of articular fractures (Geissler, 2006) and tensionband wiring is widely used to achieve rigid fixation ofboth transverse shaft fractures of the phalanges (Pehlivanet al., 2004) and fractures around the joints (Chew andChong, 2005). When transverse shaft and intraarticularfractures are associated, a combination of the above-citedprocedures can be useful.

References

Chew WY, Chong AK (2005). Intra-articular loop wire fixationallows joint preservation and early motion in replantationaround the proximal interphalangeal joint. Hand Surgery, 10:187–191.

Geissler WB (2006). Cannulated percutaneous fixation of intra-articular hand fractures. Hand Clinics, 22: 297–305.

LETTERS TO THE EDITOR 223

at HINARI on July 26, 2011jhs.sagepub.comDownloaded from

Pehlivan O, Kiral A, Solakoglu C, Akmaz I, Kaplan H (2004). Tensionband wiring of unstable transverse fractures of the proximal andmiddle phalanges of the hand. Journal of Hand Surgery, 29B:130–134.

Philippe Pelissier, Elias Sawaya and Ebaa SabriService de Chirurgie Plastique, Hopital Pellegrin-Tondu,

33076 Bordeaux, FranceE-mail: philippe.pelissier@chu-bordeaux.fr

r 2008 The British Society for Surgery of the Hand. Published by SAGE. All rights reserved.doi:10.1177/1753193408087110 available online at http://jhs.sagepub.com

Re: Two further uses of surgical gloves in hand surgery

Dear Sir,

Surgical gloves have been used for a variety of purposesother than their designated use as sterile hand cover forsurgeons and theatre staff. We use them to insulatejewellery when it is difficult to remove, and to avoidelectric injury from use of the diathermy during surgicalprocedures. The glove is passed between the jewelleryand the skin and the jewellery rolled in a sleeve ofthe glove material (Figs 1A and B). This avoids theneed to cut the jewellery or remove it with difficultyand, sometimes, avoids discomfort or risk of injury to

the patient. This method is quicker than trying toinsulate jewellery by taping and ensures completeinsulation.

Fig 1 (A) Pre-operative X-ray of a comminuted fracture of the base of the proximal phalanx of the thumb. (B) X-ray 8 months after internal

fixation of the fracture with a cannulated screw and a box loop wire.

Fig 1 (a) A surgical glove passed between a wrist bracelet and the skin

of the wrist. (b) The jewellery secured within the turned-over up

glove and, so, insulated from the skin.

THE JOURNAL OF HAND SURGERY VOL. 33E No. 2 APRIL 2008224

at HINARI on July 26, 2011jhs.sagepub.comDownloaded from