Wrist & Hand

Is it dangerous to operate on the hand outside of the operating theatre?

It is extremely tempting to undertake minor procedures in treatment rooms, or even in the office, and hand surgery can lend itself to this. The number of family doctors undertaking carpal tunnel procedures and other minor surgical procedures is on the rise, as is the number of specialised hand surgeons undertaking percutaneous Dupuytren’s release, and other minor local anaesthetic procedures. It’s certainly convenient, quick and cheap. The question lurking in the back of the mind is: is it safe? Surely the infection rate must be higher in a clean, rather than sterile, environment? Researchers from Oxford (UK) have undertaken this timely review as the push is towards more cost-effective healthcare provision, with the aim of establishing whether the use of the operating theatre conveys any advantage in terms of infection rates.¹ The authors’ search initially identified 1200 studies, however, just 46 full-text articles were reviewed, and only six studies form the basis for this review. Three of the studies did not report any infections after surgery in an office, procedure room or emergency department. The two larger studies reported a combined number of 1962 carpal tunnel releases with a 0.4% infection rate. Their report finds an infection rate of just 0.4% for carpal tunnel release, and no infections in a range of other procedures, performed in the office or procedure room or Emergency Department. It should be borne in mind that the quality of evidence informing this report is really quite poor, with little in the way of evidence on which to make a fairly crucial decision. So, subject to the caveats of the data available and to meticulous procedure and careful audit, there probably should be a trend towards moving these smaller procedures into a less formal environment.

Does decompression still work with a diabetic neuropathy?

As the incidence of diabetes and the age of the average patient increases, there is an increasing number of patients presenting to the clinic with diabetic compressive neuropathies. Deciding exactly what to do with these patients is somewhat more troublesome than with your average patient. The complications of surgery are different in diabetic patients, and the microvascular and neuropathic disease seen with diabetes is likely to affect the recovery. This study team from Shanghai (China) undertook a thorough systematic review and meta-analysis treating diabetic neuropathies in general, rather than focusing on a particular entrapment syndrome.² The study team were able to identify a total of 12 papers reporting the outcomes of 1825 patients, all presenting with diabetic peripheral neuropathy and suitable for inclusion in the final analysis, although only a single randomised controlled trial was reported. Seven papers reported upper-extremity nerve decompression and four reported it in the lower extremity. There was a slightly mixed bag of outcome measures reported, however, papers reported outcomes in terms of the Boston Questionnaire, nerve conduction studies and functional outcomes. Within the limitations of the data available there does appear to be, reassuringly, a favourable outcome for surgical treatment with decompression in diabetic neuropathy, both in terms of relief of neurologic symptoms and sensory deficit.

Thumb metacarpal arthritis: do we really implement the literature?

Is it worth injecting carpal tunnels?

One of the bread and butter cases of even a specialist hand clinic is the patient with carpal tunnel syndrome. In some services, patients are offered carpal tunnel decompression on first presentation; in others, conservative measures are instigated first. Although the success rates of conservative measures are well defined in the first presentation, there are no long-term outcomes reported for patients who have undergone a primary decompression. Surgeons like to operate and we like good results, and carpal tunnel release certainly provides good results. If effective in the long-term, steroid injection might, however, save healthcare resources and minimise the risks and post-operative recovery associated with surgery. A team from Canterbury (UK) set out to establish what the long-term results were in their hands.⁴ Their study included the outcomes of 254 patients initially treated with a steroid injection for their primary carpal tunnel syndrome in 2007. There were 157 patients contactable at eight years of follow-up, and 41% had eventually undergone decompression by final follow-up. Of those having surgery, a mean of 1.9 injections were given prior to surgery. In those not having surgery, a mean of two (and up to 12) injections were given, and the Boston scores were significantly worse than in those who eventually underwent surgery. So here at 360 we think that the jury is still very definitely out as to whether the benefit lies with the “inject and see” camp or the “decompress and be done with it” camp. Certainly, steroid injection is seen here to be an alternative that should be discussed with patients as a potential long-term viable option.

Does knuckle cracking harm the fingers?

Clicky knuckles is perhaps more of a social problem than a hand surgical one, but it is a problem that garners a fair bit of attention in both social and medical circles. The rather irritating habit of cracking knuckles is said by some to be innocent and by others to be damaging to the joints. The question posed by a study team from California and South Carolina (USA) is that of harm: is it just socially irritating or a genuinely harmful problem?⁵ The study team identified 30 knuckle crackers, ten of whom did not ‘indulge’ for a thorough evaluation of the hand and finger function. Observers were blinded to the group and volunteers underwent a battery of evaluations including DASH score, ultrasound assessment, range of movement, swelling and grip assessments. They found no evidence of immediate adverse physical examination findings after knuckle cracking. However, they did find a small increase in range of movement among joints that cracked compared with those that did not. It seems that habitual knuckle cracking is just that – a habit with little in the way of measurable clinical adverse effect. It is not clear from this study if a lifetime of knuckle cracking will impact on hand function in the longer term.

Is urgent debridement needed for open hand fractures?

The finger pilon and other injuries

A different approach to the dorsal fracture subluxation

Following directly on from the last report is a case series originating in Villeurbanne (France) of 19 patients with similar injuries.⁸ These patients were all treated with a vastly more complex operation. All of the patients who had more than 40% articular surface involvement underwent hemi hamate osteochondral autografts. Here, though, there are acute (within six weeks, nine patients) and chronic (i.e. delayed treatment > six weeks, ten patients) treatment groups, in contrast to the previous series of all acute fractures. The authors report a follow-up of 24 months, with patients achieving a range of motion of 17° FFD to 86° in the acute fixations, and a remarkably similar result in the chronic group (18° FFD to 81°). The comparison of these two papers is enlightening, with the hemi hamates and its associated big surgical dissection leading to poorer range of movement. In so many areas of orthopaedic trauma surgery, the assumption is that complex and new is better than old – this here seems to be another example that this is not necessarily the case. These are rare injuries so a study with sufficient numbers randomising to techniques is much harder to achieve, however, inferences can be drawn from simple case comparisons such as this one.

Fragment-specific fixation?

It is somewhat curious to read this study from Lund (Sweden).⁹ In light of recent studies from various sources demonstrating that there is no appreciable difference between open reduction and internal fixation and closed k-wires, it is difficult to conceive how a trial with the aim of comparing ‘Fragment-specific fixation versus volar locking plates in primarily non-reducible or secondarily redisplaced distal radius fractures’ would expect to find any form of reasonable difference. Perhaps more confusingly, the authors selected a sample size of just 50 patients randomised to either a volar locking plate or fragment-specific fixation. In both groups, a TriMed plate was used to achieve either volar plating or fragment-specific fixation. Outcomes were assessed at one year with the QuickDASH patient-reported outcome measure (PROM) and a rather basic assessment of ROM/grip. Perhaps unsurprisingly, given the effect size that would be required with this small study in order to find a significant difference, the authors report no outcome measure differences but a small and significantly higher complication rate in the fragment-specific group (which had up to three incisions – dorsally over first and fourth extensor compartments +/- Henry volar approach). This study really is rather a case of putting the cart before the horse. It is to prevent ‘pet questions’ being half-heartedly answered in single-centre studies that the majority of large funders have moved towards a priority setting approach. There is little to gain from these kinds of small underpowered ‘pet studies’ unless they are properly labelled as feasibility or pilot studies from which to power a definitive study.