December, 1959 P H Y S I O T H E R A P Y Page 3 Some Contributions to Surgery of the Hand* B y W IL L IA M G IR D W O O D , B.Sc. (M ed.), M .C h .(R a n d ), F .R .C .S .(E d in .), F .R .C .S .(E n g .), Johannesburg. {Reproduced b y k in d permission I M A K E n o a p o lo g y fo r discussing a subject as h um ble as the h a n d s ; m u ch o riginal th o u g h t a n d genuine progress have com e fro m th e a p p lic a tio n o f sincere stu d y a n d a cc u rate o b servations on th e m eanest p roblem s. M oreover, because o f its im p o rta n c e to m a n k in d , th e h a n d h as a ttra c te d the a tte n tio n o f surg eo n s th ro u g h o u t th e years. Jo h a n n e sb u rg — a n d the U n iv e rsity o f the W itw a tersra n d — has re a so n to be p ro u d o f its c o n trib u tio n s to th e a n a to m y and surgery o f th e h a n d . F o u r theses have been w ritte n by its sons, n am ely, M r. Ja c k A llen, M r. T re v o r Jones, M r. H . G aylis a n d myself. M r. L ee M c G re g o r’s Synopsis o f A n a to m y has fu rth e r c o n trib u te d to th e a n a to m y o f the hand. M u ch o f the w o rk to be discussed in this p a p e r w as d o n e J8 years ago. A t t h a t tim e, K a n a v e l a n d S h a w ’s valuable "c ontributions o n th e h a n d h a d been p u b lished a lm o st as long ag ain b efore. T h e c h a ra c te r o f a n an im a l is reflected in th e stru c tu re o f the u p p e r lim b. T h e activities o f civilised m an a n d his pursuits as w o rk m a n o r a rtist a re reflected in the close brain-eye-hand c o rre la tio n th a t is m a n ’s c h ie f c h ara cte ristic. T he d istal a rtic u la r surface o f th e m eta c a rp o -p h a la n g e a l jo in t, in p a rtic u la r, is different in m an as c o m p a re d w ith apes; so, to o , a re th e m e ta c a rp a l h e ad s. A p a rt fro m th e m ore pow erful o p p o sa b le th u m b o f m a n , th e m ain difference betw een the h and o f m an a n d a p e a re to be seen in the m eta ca rp o -p h alan g e a l jo in ts. T h e h u m a n b e ing has m o re side m ovem ent in flexion th a n th e lim ited u p -a n d -d o w n m ovem ent in apes, to fa v o u r th u m b -in d e x sensory a nd m o to r a p p ro x im a tio n a n d th e fo rm a tio n o f a fist. I t behoves surg eo n s to be in terested in h a n d surgery. T o d ay th ere is a v a st a m o u n t o f in d u stria l W .C .A . h a n d surgery th a t re q u ire d tre a tm e n t a c c o rd in g to the highest tenets o f o u r profession. I t is on ly th ro u g h th e surgical teachers th a t basic know ledge co n ce rn in g h a n d surgery is handed on to o u r stu d e n ts. H a n d surgery has becom e a casualty pro b lem , a n d surg eo n s w h o p ra ctised in the ‘golden era ’ o f h and surgery, w hen a t lea st 2 0 % o f h o sp ital beds in surgical w a rd s w ere occupied by h a n d cases, m u st realise th at a low e b b has been re ac h ed in th e tea ch in g o f h a n d surgery. . H a n d surgery is th e m eeting p lac e fo r m an y bran ch es o f m edicine. H e re th e general p ra c titio n e r, general surgeon, o rth o p a e d ic su rg e o n a n d p lastic su rg e o n can sh o w a c om m on interest; a n d th e physician, n e u ro lo g ist a n d d e rm a to lo g ist are n o t excluded. I n th is p a p e r I shall discuss w h y a h a n d goes w ro n g u n d e r trea tm e n t, a n d h ow we c a n e n d e a v o u r to p ut it right. ^ T H E FIXED C LA W H A N D In th is type o f case (Fig. 1) th ere is p ra ctic a lly no m ovem ent at the in te rp h ala n g ea l (IP) jo in ts , the w rist is flexed and possibly fixed, the th u m b a d d u c te d , the m eta ca rp o -p h alan g e a l (M P) jo in ts e x tended. T h e re is w asting, d e fo rm ity and severe loss o f fu n c tio n . T h e only h elp 18 years ago w as from K a n av e l, w h o show ed in 1929 th a t a h a n d allow ed to be in a b a d p o sitio n develops a fixed claw h a n d , w hereas a hand in th e p o sitio n o f fu n c tio n recovers. H e said th a t in infections th e in vasion sp re ad s u p th e lum b ric al canals, round th e c apsule, a n d th a t th is causes a fixed claw h a n d . A p a rt fro m infection, how ever, th is c o n d itio n is seen in P a p e r p re s e n te d a t th e c o m b in e d S u rg ic a l F o r u m o f th e D e p a r tm e n t o f S urgery, U n iv e rs ity o f th e W itw a te r s ra n d , a n d th e A ss o c ia tio n o f b u rg eo n s o f S o u th A fric a ( J o h a n n e s b u r g S u b -g ro u p ) o n 8 J u ly , 1958, and a t a s y m p o s iu m o n H a n d S u rg e ry , R e h a b ilita tio n A ss o c ia tio n , o re n th u rs t C lin ic , J o h a n n e s b u r g , o n 15 O c to b e r, 1958. o f the “S .A . M e d ic a l Journal.” b u rn s w here o nly skin is involved, a n d in im m obilised h a n d s. F o r instance, it h a s been seen a fte r a w rist d islo ca tio n , in severe c rip p lin g p ain a fte r herpes z o ster, a n d in radial palsy, single e x te n so r te n d o n injuries a n d o th e r lesions not related in a n y w ay to infection. Intrinsic M uscles on M o v em e n t Vary in P osition a n d Function. S tu d y in g the M P jo in ts , let us n o te th a t th e d istal a rtic u la r surface is an extended stru c tu re c o n sisting n o t only o f the d istal b o n y a rtic u la r surface b u t a lso o f a thic k e n in g o f the v o lar cap su les— th e p a lm a r ligam ent. T h is receives o n its sides a special p o rtio n o f th e c o lla te ral ligam ent a n d a p o rtio n o f the in sertion o f the d o rsa l interossei. D issec tio n s d u rin g a n a to m ic a l co u rses d o n o t involve stu d y o f th is view o f the a n a to m y , and m uch is lo st thereby. (See F ig. 2, A a n d B). T h is extended d istal a rtic u la r surface glides o ver the m e ta c a rp a l head fro m e x tension to flexion a n d , by reason o f th e d ire c t a n d in direct a tta c h m e n t to it o f th e d o rsa l a nd v o lar interossei, th e line o f axis o f the m uscles a n d the fu n c tio n a l activities v ary a cc o rd in g to the p a rtic u la r p o sition a t th e tim e. Fig. 2. (A ) R ig h t index finger, d is ta l a r tic u la r s tru c tu re s . (B) M id d le finger d is ta l a r tic u la r s tru c tu re s . J, E x te n s o r te n d o n . 2, T ra n s v e r s e fibres o f a p o n e u ro s is . 3, P ro x im a l a r tic u la r s u rfa c e o f p h a la n x , 4 , D o r s a l in te ro s se o u s m uscle. 5, V o la r in te ro s se o u s m uscle. 6, F ib r o u s c o n n e c tio n to p a lm a r fascia a n d fib ro u s flexor s h e a th . 7, C o lla te r a l lig am e n ts. 8, P o r tio n o f c o lla te r a l lig am e n t fo rm in g p a lm a r lig a m e n t. 9, L u m b ric a l m uscle. 10, D e e p tra n sv e rs e p a lm a r lig a m e n t. In extension the d o rsa l interossei can a b d u c t, b u t otherw ise they ten d to pull th e a rtic u la r surfaces to g eth e r a nd ja m the p a lm a r lig a m a n t a g ain st th e m e ta c a rp a l head. T h e v o la r interossei m a y a ctu ally h y p erextend a n d a d d u c t the fingers, and th is is the p o sitio n u su a lly seen in th e late fixed claw h a n d w here the d o rsa l interossei seem to h ave w asted th ro u g h inactivity, a n d the v o la r interossei sh o w a R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 4 P H Y S I O T H E R A P Y December, 1959 Fig. 3. C h a n g in g p o s itio n o f d o rs a l a n d v o la r intero sse i in e x te n s io n a n d flexion. F in 4 (A ) I n th e lo w e r figure th e ca llip e rs m e a s u re s th e d is ta n c e fro m th e c e n tre o f o rig in og th e c o lla te ra l lig a m e n t to a lin e p ro je c te d fro m th e a rtic u la r s u rfa c e o f th e h e a d a s s een fo rm th e sid e. A n im a g in a ry a rc is th e n d e sc rib e d (as sh o w n in th e u p p e r p ic tu re ) w h ich sh o w s th a t th e co n v e x ity ol tne a r tic u la r s u rfa c e o f th e h e a d c o in c id e s w ith th e lo w e r p a r t o f th e a rc u p to th e lin e c o rre s p o n d in g to th e c e n tre o f th e lo n g ax is o f th e b o n e . T h e r e a l t e r th e lin e o f th e a r tic u la r s u rfa c e falls a w ay w ith in th e a rc, th u s e x p la in in g w hy th e c o lla te ra l lig am e n ts a re ta u t on flexion a n d relaxed in ex ten sio n . (B) C o lla te ra l lig a m e n ts o f M P jo i n t in 3 p o s itio n s. Fig. 5. (A ) F ix ed claw h a n d . (B) R e la x a tio n o f d o r s a l fibres o f c o lla te ra l lig a m e n t in e x te n s io n o f M P jo in t. (C ) D o r s a l in te ro s s e o u s m u scle p u llin g jo in t s u rfa c e s to g e th e r in ex te n s io n . (D ) V o la r in te ro s se o u s m u scle h y p e re x te n d in g (a n d a d d u c tin g ) th e M P jo in t. F ig. 6. (A ) H a n d in p o s itio n o f fu n c tio n . (B) C o lla te r a l lig a m e n t ta u t in flexion o f M P jo in t. , _ (C ) D o rs a l .in te ro s s e o u s m u scle in p o s itio n o f m e c h a n ic a l a d v a n ta g e (in flexion o f M P jo in t). (D ) V o la r in te ro s se o u s m u scle (a n d lu m b ric a l). N o te c h a n g e d fu n c tio n o f v o la r in te ro s se o u s m uscle in flexion. R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) December, 1959 P H Y S I O T H E R A P Y Page 5 dom in a n c e ov er the d o rsa l interossei a nd p ro d u c e the chara cte ristic deform ity. In flexion the d o rs a l interossei assist flexion a n d late ra l m ovem ents. T h e v o la r interossei will a lso p a rta k e in flexion o f the M P jo in ts . In extension, m ax im u m c o n tra c tio n will p ro d u c e m in im u m m ovem ent, w hereas in flexion m inim um c o n tra c tio n will p e rm it a m axim um m ovem ent a nd assist recovery. T h is c o n ce p t o f a lte rin g a n a to m y and fu n c tio n in different po sitio n s gives a d ynam ic c o ncept to the stu d y o f the h a n d , w ith c o n s ta n t v a ria tio n s a n d changes in m echanics a n d fu n c tio n s (Fig. 3). Collateral Ligam ants. W hen th ere is extension a n d h y p e rextension o f the M P jo in ts, the d orsal fibres o f the c o lla te ral lig a m a n ts a re relaxed, b u t in flexion the fibres a re ta u t. In th e I P jo in ts , the c o llateral lig a m en t is b ro a d a nd the h ead is m o re circular, so th a t the a rc o f th e fibres is such th a t w ith a n y position o f the I P jo in t som e fibres a re relaxed. T hese jo in ts , therefore m ay becom e stiff in a n y p o sitio n if k e p t in th a t position long e n o u g h , w hereas it is safe to keep a M P jo in t flexed as lo n g as one likes. (See Fig. 4, A a n d B.) I n p ro longed im m o b iliz atio n o f fingers in extension, especially o f-th e ring o r little fingers, a sn a p will tak e place from extension to flexion on su sta in ed pressure, a n d vice versa. T h is is the ‘sn a p p h e n o m e n o n ’, due to stre tc h in g o f th e colla te ral lig a m a n t o ver the m o st p ro m in e n t p o in t o f the m e ta c a rp a l head. M icroscopically, it is seen in such a case th a t a b u n c h in g up o f the fibres o f th e collateral ligam ent has h a p p en e d , and th is is seen to o in th e nuclei. T h e fibres a re w avy instead o f stra ig h t, th e nuclei also w avy a nd closer to g eth e r— b u nched up, as it were— and c o rre sp o n d in g to the clinical sta te o f fixation. W hen a M P jo in t gets stiff fro m im m o b ilisa tio n in e xten­ sion, the p a lm a r ligam ent is ja m m ed a g ain st th e m eta ca rp al head th ro u g h th e pull o f the d o rsa l in te ro sseo u s insertions, and a tte m p ts to flex the jo in t a re ineffective a n d o nly a ‘pseudo-flexion’ will ta k e place. T h e d o rsa l p a rt o f the jo in t m ay be stre tc h ed open, b u t th ere is n o gliding o f the distal a rticu la r surface over th e head o f th e m e ta c a rp a l in to flexion. Fully D eveloped F ix e d Claw H and. Fixed claw h a n d is a fully developed d e fo rm ity d e p endent on a n a c c u m u la te d d isability asso c iated w ith th e effects of w rist d ro p , p ro lo n g ed e x tension o f th e M P jo in ts, a nd in a d e q u a te m ov em e n t o f the finger jo in ts , as follow s: 1. M P joint extension alone will result in fixation in th a t p o sition (c o llate ral lig a m en t sh o rte n in g ), w ith (a) p se u d o ­ flexion (d o rsa l in te ro sseo u s p a lm a r ligam ent insertions), (b) sn a p p h e n o m e n o n (co llate ral ligam ent sh o rte n in g ), Ac) m uscle w asting (disuse a tro p h y ), a n d de fo rm ity (m uscle do m in a n c e o f v o lar interossei). T h e lesion m ay a p p ly to one finger only, b u t usually m ore th a n one a re affected as the n eig h b o u rin g jo in ts in re lation to the p a th o lo g ica l o n e (se p tic a rth ritis ,m e ta c a rp o -p h a la n g e a l frac tu re, single e x te n so r te n d o n in ju ry a d h esio n s) also becom e affected. W h en the w rist c a n be ex te n d ed , a n d th e fingers a re th ere fo re s tro n g a n d the th u m b o p p o se d , the disability a p plies only to the M P jo in ts , b u t th e w rist position is the key to the fu rth e r a n d m o re severe sta te , w hen stiff fingers and a d d u c tio n o f th e th u m b a re su p e rad d e d . 2. W rist drop p ro d u c es th e follow ing d e v elopm ents: (a) I t allow s ex te n sio n o f th e M P jo in t th ro u g h th e pull on the e x te n so r ten d o n s a n d slack o f th e flexor ten d o n s a nd lum bricals, a n d , even if th ere is no local pa th o lo g y , fixation m ay o c c u r th ro u g h w rist d ro p a lo n e , m ain tain ed th ro u g h neglect o r co n tin u e d p a in . T h is is seen a lso in m an y o th er lesions th a t a re a sso ciated w ith w rist d ro p m ain tain ed for a long tim e. T h e p o sition o f ease is n o t th e p o sition o f fu n c tio n . A n y h a n d allow ed to assum e th e p o sitio n o f ease, w ith a su p p o rte d elbow , will fall in to th a t d re ad fu l p o sition o f w rist d ro p a n d ex ten d ed M P jo in ts. A n d h ow m uch w orse it is if pain o r c u m b e rso m e dressings re stric t m ove­ m ents as well ! (b) P o w er is lost in th e fingers because the flexor ten d o n s a re slack. W eak m o v em e n ts a t th e I P jo in ts w ith o u t full range will lead to stiffness and ev en tu ally fixation o f the finger jo in ts . (c) T h e th u m b e x tends a n d a d d u c ts from e x te n so r te n d o n pull a n d slackness o f th e sh o rt th u m b m uscles o f the th e n a r em inence. W hen the long flexor o f th e th u m b c o n tra c ts a nd th e IP jo in t o f th e th u m b no w flexes, th e th u m b is a d d u cted fu rth e r, with tig h te n in g o f the lo n g e xtensor o f the th u m b a nd ‘bo w -strin g in g ’ o f th e th u m b fu r th e r in to a d d u c tio n . T he p ictu re o f the fu lly developed fixed claw h a n d is th u s o n e o f fixed M P jo in ts in e x tension, a tro p h y a nd de fo rm ity , w rist d ro p , w eak, partially-fixed IP jo in ts, a nd a fixed a d d u cted th u m b . T h e a n a to m ic a l e x p la n atio n o f th e p ro g ressio n to fixed claw h a n d is th e o p p o site o f th a t involved in th e process o f recovery o f a h a n d in th e p o sition o f fu n c tio n . (See F ig. 5, A , B, C a n d D , a n d Fig. 6, A , B, C a n d D .) Treatm ent. M P jo in ts in flexion never get stiff, and early recover m ovem ent. E x te n sio n o f th e w rist assists M P jo in ts to flex, gives p ow er to fingers, a n d allow s th e th u m b to becom e o p posed and to recover in th a t p o sitio n . In a b a d h a n d , one m u st get th e w rist up, a n d th e IP jo in ts m oving. In th e early stages o f an im p e n d in g claw h a n d , get the M P jo in ts fo rw a rd in to flexion. I t has been said th a t th ere is no tre a tm e n t fo r a fixed claw h a n d . T h is is n o t tru e. D o rs a l fibres o f th e M P c o llateral ligam ents can be c u t, o r the c o lla te ral ligam ants m a n ip u la te d by flexing th e M P jo in ts , a n d th e h a n d can be p u t up in a p o si­ tio n o f fu n c tio n . T h is m u st be m ain tain ed fo r m o n th s ; a n d the pa tie n t will re co v e r useful h a n d fu n c tio n . I n th e w orst h a n d s, sta rt with th e M P jo in ts m ain tain ed in flexion by the use o f p la ste r o f P a ris ; th e I P jo in t c a n th en use the p la ste r cross-slab as leverage, w ith o r w ith o u t elastic tra c tio n . T h e w rist is well extended to give full pow er to th e IP jo in t m ov em e n ts th ro u g h the flexor tendons. T he th u m b is o p p o se d . T h is p o sitio n m ay be m ain tain ed fo r w eeks. In one case®, the p la ste r o f P aris w as left on fo r 2-3 m o n th s ; full recovery to o k place. P h y sio th e ra p ists fro w n a n d p lead fo r rem oval o f the p la ste r o f Paris. T h is is d o n e w hen recovery is o n its way. W rist d ro p a n d m o b ility c ertain ly a id recovery o f extension a n d the re tu rn o f M P m ovem ents, w ith the a lte rin g p o sition o f the w rist, b u t it is m y experience th a t th is will alw ays com e if th e M P jo in ts have been k e p t in flexion. T hey c a n n o t get stiff in th is p o sitio n , unless sk in sc a rs o r te n d o n scar to skin is present in the palm . , I t is im p o rta n t to recognise th e h a n d in early stages o f fixation. If resistance to flexion is e n co u n tere d a t the M P jo in ts , a c t a t once, a n d m a n ip u la te the M P jo in ts in to flexion a n d m ain tain th em so fo r a b o u t a w eek; the recovery will be d ra m a tic . FINGER DEFORMITIES F inger D eform ities fr o m H y p erex ten sio n o f the P ro x im a l Interphalangeal jo in ts with F lexion o f the D ista l joints. T h is c o n d itio n m ay o c cu r fro m m an y causes. K a p la n has sta te d th a t if the c ap su le o f th e jo in t ru p tu re s hyperextension occurs, b u t an analysis o f cases show s the follow ing: (a) Physiological. S om e p e ople c a n flex th e d istal IP jo in ts while still m a in ta in in g the pro x im a l IP jo in t extension. T h is is th e reverse o f n o rm a l, in w hich flexion occu rs first in th e pro x im a l jo in t a n d the late ra l b a n d s ‘b u tto n -h o le ’ ov er th e sides o f th e jo in t to give length to th e e x te n so r te n d o n fo r su b seq u e n t flexion o f th e d istal jo in t. W hen the d istal jo in t is flexed first, the late ra l b a n d s a re tau te n e d in to e xtension, a n d ‘b o w -strin g ’ the p roxim al IP jo in t in to hyperextension. (b) Burns. In b u rn s, sc a r u n d e r th e d istal jo in t will p ro d u c e this d e fo rm ity ; so will sc a r over th e pro x im a l ph a la n x , w hich prevents th e lateral b a n d s ‘b u tto n -h o lin g ’, so th a t th e d istal jo in t s ta rts to flex. * Illu s tr a te d a t th e m e etin g s by a d ia g ra m . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) Page 6 P H Y S I O T H E R A P Y December, 1959 (c) D iip n u ie n '.t C om r a n w e . T h i s d e f o r m i t y h a s al s o been seen in D u p u y t r e n ' s c o n t r a c t u r e . W h a t h a p p e n s is t h a t th e p r o x i m a l I P j o i n t o v e r c o m e s t h e sc ar o n th e v o l a r s ur fa ce. In t h e p a t i e n t 's ef for ts at e x t e n s i o n o f the lingers wit h th e M P j o i n t s still flexed by t h e d e f o r m i t y , t h e in trinsic m u sc le s o v e r a c t , a n d th e l ate ra l b a n d s pa s s do r sa l l y . In the c o n t i n u e d m a i n t a i n e d e x t e n s i o n o f t h e p r o x i m a l I P j o i n t , flexion o f t h e di sta l I P jo in ts f u r t h e r b o w - s t r i n g s ' t h e lat er al b a n d s d o r s a l l y — h en ce t he d e f o r m i t y . (See Fig . 7.) /’/if. 7. D u p u \ ir e n 's con lracturc F t,p. 8. P o st-p a ra I> iic t \p c o f h > p c re \te n sio n deform iiN o f p roxim a l I P joint. Id) Post-paralytic. A s i m i l a r d e f o r m i t y h a s be en seen in a p o s t - p a r a l y t i c case, a n d h e r e a w e a k n e s s o f e x t e n s o rs a n d c o m p e n s a t o r y o v e r - f u n c t i o n o f t h e in t ri n s i cs s e e m s to be t he ba si s fo r t h e p r o d u c t i o n o f a n 'in t r i n si c p lu s' ha nd . It is r e p o r t e d t h a t a si m i l a r d e f o r m i t y s o m e t i m e s oc cur s w h e n t h e p r o f u n d u s t e n d o n flexes t h e d i st al IP j o i n t in the a b s e n e c o f a su b l i m i s t o flex th e p r o x i m a l IP j o i n t — bu t no t in m y e x p er ie n ce . (See Fig. 8.) . Ilie n u n e Im m o b iliza tio n —a new concept. Binuin-holc d e fo rm ity is d u e t o loss o f f u n c t i o n o f the ce n t r a l slip o f th e e x t e n s o r t e n d o n . T h e p r o x i m a l | p j o i n t flexes a n d the di sta l j o i n t ex te nd s . T h e r e p a i r o f this d e f o r m i t y is s u r gi ca l, a n d th e results o f t e n p o o r . S im pl e s u t u r e is ineffective o r else re sul ts in loss o f f u n c t i o n a n d stiffness in ex t e n s i o n . T h e r e a r e t w o f u n c t i o n a l e l e m e n t s in th e a p o n e u r o s i s , viz. ( I ) t h e c e n t r a l e x t e n s o r m e c h a n i s m at th e p r o x i m a l l p j o i n t , a n d (2) t h e m e c h a n i s m f o r t he lat er al b a n d , which glide s s e p a r a t e l y on m o v e m e n t o f t h e d ist al I P j o i n t . W h e n a n e x t e n s o r t e n d o n a n d a p o n e u r o s i s a r e s u t u r e d , at first th e p r o x i m a l IP joint s h o u l d be i m m o b i li s e d , whil e uni on o c c u r s in th e s u t u r e d c e n t r a l e x t e n s o r t e n d o n . T h i s t a k e s i a p p r o x i m a t e l y 5 weeks, a n d o n e m u s t a l l o w f r e e d o m o f m o v e m e n t in th e d ist al IP j o i n t , t o k ee p the gli d in g a c t i o n o f th e lat eral b a n d s . S u b s e q u e n t l y , the distal j o i n t s h o ul d be im m o b i li z e d a n d the p r o x i m a l j o i n t a l lo w ed free, so that th e l at er al b a n d s c a n m o v e o v e r t h c sides in th e t r u e fashi on, a n d flexion anti ex t en s i o n d e v e l o p a t t h e p r o x i m a l I P jo in t. T h e c e n t r a l e x t e n s o r t e n d o n d e v e l o p s its f u n c t i o n o f e x t e n d i n g th e p r o x i m a l IP j o i n t in a c o - o r d i n a t e d f as hi on in re l at i o n t o the di stal j o i n t . A l t e r n a t e finger j o i n t i m m o b i l i s a t i o n ha s a p l ac e in the t r e a t m e n t o f a n y in j u ry o f th e e x t e n s o r a p o n e u r o s i s . rin g e r S iiff ness. A ca s e il l u s t r a t i n g th e c a u s e o f finger siiflness, a n d th e t r e a t m e n t , is w o r t h m e n t i o n i n g . A y o u n g l a d y d e v e l o p e d a g l o m u s t u m o u r o n th e p u l p o f h er right ind ex finger, a n d it w a s s o p a i n f u l t h a t a f t e r t r e a t m e n t she w as seen e v e n t u a l l y wi th a c o m p l e t e l y stiff finger in e x te ns io n . T h e r e w as n o o t h e r c a u s e t h a n i m m o b i li z a t io n . A flap w as t u r n e d at t h e p r o x i m a l IP j o i n t , a n d t h e lat er al a n d c e n t r a l slips o f th e a p o n e u r o s i s s e p a r a t e d at th i s poi nt , e x p o s i n g the d o r s a l fi bres o f th e c o l l a t e r a l l i g a m e n t s , wh ich w er e t h e n s e p a r a t e d a n d excised f r o m th e u n d e r l y i n g head o f the p h a l a n x . F l ex io n b e c a m e pos si bl e at th i s stage, a n d re c o v e r y e n s u e d w it h r e t u r n o f full f u n c t i o n . F o r re c o v e r y in l in ger stiffness, th e co ll a t e r a l lig am en ts m u s t allow m o v e m e n t , e i t h e r h a v i n g been s t r e t c h e d o r c u t o r assi ste d by el a s t ic t r a c t i o n . A d e t e r m i n e d p a t i e n t is n ee d e d , a b l e t o c o - o p e r a t e in t he face o f p a i n : a n d t h e n * m u s t be a n e x t e n d e d wr ist t o give full p o w e r t o flexion b>^ flexor t e n d o n s free o f s c a r a n t f in c o n t i n u i t y , a n d e x t e n s o r t e n d o n s , t o o . free o f a d h e s i o n s , t o a l l o w flexion t o occur. M IS C F L L A N IT O U S In t w o cas es o f t o t a l l y d is a b le d h a n d s f r o m c r u s h injuries w h i c h h a d re su lt ed in m e t a c a r p a l f r a c t u r e w i t h flexor an d e x t e n s o r t e n d o n fi xat ion t o d e e p a n d sk i n sc a r, a n d with w r i s t d r o p , M P e x t e n s i o n a n d fixa tio n, a n d t h u m b a d d u c t i o n , a c o n s i d e r a b l e d eg r ee o f r ec o ve r y w as po ss ib le by t h e fo llo w­ ing m e a s u r e s : (i) F re e i n g t e n d o n s , (ii) re se c tin g p o r t i o n s of m e t a c a r p a l s w h e r e s c a r a n d d e f o r m i t y m a d e r ec ur re n ce o f a d h e s i o n s t o t e n d o n s i ne v it ab le , (iii) flexing M P j o in ts , (iv) fi xat ion by p l a s te r o f P a r i s w-itli wrist e x t e n s i o n , M P j o i n t flexion a n d c r o s s b a r lev er age fo r fingers, (v) elastic t r a c t i o n , a n d (vi) clee tr ic s t i m u l a t i o n o f flexors a n d ex te ns o rs tit a n ea r l y stage. Tendon Transplants a nd G rafts In late p o l i o m y e l i t is cas es, t(jc r es ul ts o f t e n d o n t r a n s ­ p l a n t s h a v e been ver y s a t is f a c t o ry , c o m b i n e d s o m e t i m e s with a r t h r o d e s i s o f t h e wrist. In sp a st i c cas es, o p e r a t i o n s m a y relieve d e f o r m i t y , bu t r ar e ly give m u c h i m p r o v e m e n t in f u n c t i o n . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) D e c e m b e r, 1959 P H Y S I O T H E R A P Y Page 7 Skill Coverage. p e r h a p s t h e m o s t i m p o r t a n t a d v a n c c in h a n d su r g e r y in r ecent y ea r s is the use o f sk i n c o v e r a g e w h e n ne ed ed . T i m e a n d a g ai n ea r l y s k i n p l a c e m e n t o v e r t e n d o n s , b o n e a n d ex p os ed j o i n t s h a s sa v ed li m b a n d f u n c t i o n . O n e c a n w a i t a w eek t o assess the d eg r ee o f ne cr o si s in skin a n d t e n d o n , etc., f o r il is n o t a l w a y s po ss ib le i m m e d i a t e l y t o assess t he d eg r ee o f d a m a g e , w h i c h is a l m o s t a l w a y s m o r e t h a n t h e first i m p re s s io n su gg e st s. E v en a lo n g er lapse o f tim e d o c s no t p r e v e n t co v e r a g e . W h e n o n e is in d o u b t in the ea rl y st ag es, a d r e s s i n g o f tulle g r a s tied o v e r wi th s o m e p re ss u re will a l m o s t a l w a y s e n s u r e a h e a l t h y su r f a c e on i nsp ec tio n a t t h e e n d o f t he week. In a case seen 18 d a y s a f t e r g r o s s i nj ury , in w h i ch the d o r s a l s t r u c t u r e s o f th e righ t f o r e a r m , wrist a n d d o r s u m o f the h a n d wer e lost, b o n e d e n u d e d o f p e r i o s t e u m w as visible i n cl u di ng len g t h s o f ra d i u s, ul na a n d m e t a c a r p a l s . Fre e pus e sc ap ed f r o m th e wrist a r e a , a n d th e rin g a n d sm all fingers an d t h e m e t a c a r p a l s we re lo ose a n d n ec ro ti c. C a r p a l b o n e s wer e exci se d, a n d th e flexor t e n d o n s c o u l d be seen f r o m th e d o r s u m b a t h e d in pus . F r e e d r a i n a g e was e s t ab lis h ed in t he p a l m , a n d a dr e ss i n g o f tulle g ra s was sewn in to th e pl ace wit h pr ess ure . A week later, a l ar ge a b d o m i n a l flap w as used as c o ve r ag e. T h e e x p o s e d b o n e s we re n i bb le d until b l ee d i n g o c c u r r e d . H e a l i n g t o o k pl ace w i t h o u t si n u s es a n d . w it h i n a sh o r t time, e x t e n s o r t e n d o n g r af ts t o t h e a b d u c t o r s a n d e x t e n s o r s o f t he t h u m b a n d r e m a i n i n g fingers co u l d be d o n e t h r o u g h t he flaps. O n e le a r n s f r o m thi s ea s e t h a t , a f t e r 18 d a y s o f e x p o s u r e o f b o n e a n d t e n d o n s , c o v e r a g e is still po ss ib le, a n d thi s h a s b ee n o u r e x p e r i e n c e w i t h o t h e r cases o f e x p o s e d b o n es a n d j o i n t s in negle cte d c o m p o u n d f r a c t u r e s a n d d i s l o c a ti o n s o f th e a n k l e a n d tibia. Diffe re nt m e t h o d s o f r e c o n s t r u c t i n g t h u m b s c a n be a c c o m p l i s h e d , s u c h as by skin pe d ic le f r o m t he a b d o m e n , a n d l a t e r bo n e g ra ft i n g . T r a n s p l a n t a t i o n o f a s t u m p o f a n u m p u t a t c d m i d d l e finger a n d m e t a c a r p a l t o th e t h u m b h a s b ee n used succe ss ful ly , a n d s o ha s r o t a t i o n o f a m e t a ­ c a r p a l . E ach c a s e s h o u l d be c o n s i d e r e d in its o w n m e r i t s : we a r e a l w a y s as sis te d by a g o o d p at ie n t, a n d the n a t u r a l a d a p t a b i l i t y o f r e m a i n i n g digits fo r p ra ct ic al use. S U M M A R Y In this t al k, a n effort h a s been m a d e t o ex p l a i n th e a n a t o m i ­ cal r e a s o n s for re c o v e r y o f a c o r r e c t l y p o s i t i o n e d h a n d as a g a i n s t t h e d e t e r i o r a t i o n t o a fixed c l a w h a n d in a p o o r l y p o s i t i o n e d h a n d . T h e d e f o r m i t y o f h y p e r e x t e n s i o n o f p r o x i m a l inter- p h a l a n g e a l j o i n t s wi th flexion o f d i st al i n t e r p h a l a n g e a l j o i n t s lias been s h o w n t o be d u e t o se veral in t er es t i n g m e c h a n i c a l caus es. T h e c o n c e p t o f a l t e r n a t e i m m o b i l i z a t i o n to ret ain a n d r es t o r e finger m o v e m e n t s is p r o p o u n d e d . E arl y skin c o v e r a g e by (laps o f e x p o s e d t e n d o n s , b o n e a n d j o i n t s is s t r o n g l y a d v o c a t e d at t h e m o m e n t th e n ecr osi s o f c o v e r i n g sk in is di sc e rn a b l e . T H E B I R T C H E R M E G A S O N V! U L T R A S O N I C U N I T To the more than 20,000 p h ysician s now using u ltra ­ sonic th erap y in the treatm en t of a host of acute and chronic conditions, th is precision instrum ent adds new dim ensions of accuracy and treatm en t ease. D e s c r ip tiv e s and m edical jou rn a l r e p r i n t s on requ est. A N E W C O N C E P T I N ULTRASONIC T R E A T M E N T TfMicUVUTHhmz.(PTY.) LTD. “ C ape Y o rk ” , 252 Je p p e S t., Johannesburg P .O . B ox 3378 an d al P resident H ouse, 20 B a rrac k S tre e t, C ape Town Telephone 41-1172 Telephone 23-8106 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )