1020
LETTERS TO THE EDITOR
Duncan J.M. Macdonald Department of Orthopaedic Surgery Royal Alexandria Hospital, Paisley Scotland, UK
The authors thank Dr. Elaine MacDuff for reviewing the manuscript. Editor note: Please see the case report in this issue describing a similar case.
REFERENCE 1. Ishida M, Kojima K, Yamahira K, et al. Superficial angiomyxoma of the thumb: report of a rare case and review of literature. Eur J Radiol. 2010;73(1):e29ee32.
http://dx.doi.org/10.1016/j.jhsa.2013.11.045
A Simple Diagnostic Sign for Rupture of the Flexor Digitorum Profundus To the Editor: The function of flexor digitorum profundus (FDP) tendon is usually evaluated by asking the patient to flex the distal interphalangeal (DIP) joint while the examiner holds the proximal interphalangeal (PIP) joint in extension.1 The inability to do so raises the suspicion of FDP injury. We describe another sign for FDP rupture in which the patient holds the finger to be tested against its equivalent finger of the opposite hand with both PIP joints flexed to 90 , the metacarpophalangeal joints in neutral, and the other fingers fully flexed. If the FDP is ruptured, the DIP joint of the affected digit will exhibit full extension (Fig. 1). The following explains the anatomical basis of the sign. The PIP and DIP joints move in coordination as the oblique retinacular ligament relaxes with PIP joint flexion to allow full DIP joint flexion.2 The lateral bands move volarly during PIP joint flexion, provided that the central slip is intact.3,4 This movement will slacken the lateral bands and the FDP will solely act on the DIP joint and flex it. Schreuders et al5 described a similar position of fingers to test for central slip rupture. In their test, the patient is asked to actively extend the DIP joints, and if the central slip is ruptured, there is asymmetry in the degree of extension between the 2 fingers. However, the DIP joint is still not as fully extended as in the sign we present. Therefore, only rupture of the FDP using this position of the fingers can distinctly and effortlessly produce full extension of the DIP joint. We believe that this sign may help assess the integrity as well as the tension of the repair or reconstruction by comparing the affected finger with its equivalent finger of the opposite hand (Fig. 1).
FIGURE 1: A Patient 1 week after an FDP rupture in the left index finger. B Patient with rheumatoid arthritis and chronic rupture of the FDP to the left index finger. C The same patient as in B 2 months after a middle finger flexor digitorum superficialis to FDP (index finger) transfer. The patient regained the flexion of the DIP joint of the left index finger.
Daoud Makki, BsC, MD Department of Trauma and Orthopaedics Countess of Chester Hospital NHS Foundation Trust Chester, UK
REFERENCES 1. Hankin FM, Peel SM. Sport related fractures and dislocations in the hand. Hand Clin. 1990;6(3):429e453.
http://dx.doi.org/10.1016/j.jhsa.2014.02.017
J Hand Surg Am.
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Vol. 39, May 2014
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LETTERS TO THE EDITOR
2. Zancolli E. Structural and Dynamic Bases of Hand Surgery. 2nd ed. Philadelphia, PA: Lippincott; 1979:263e283. 3. Elson RA. Rupture of the central slip of the extensor hood of the finger: a test for early diagnosis. J Bone Joint Surg Br. 1986;68(2): 229e231.
4. Harris C Jr, Rutledge GL Jr. The functional anatomy of the extensor mechanism of the finger. J Bone Joint Surg Am. 1972;54(4):713e726. 5. Schreuders TAR, Soeters JNM, Hovius SER, Stam HJ. A modification of Elson’s test for the diagnosis of an acute extensor central slip injury. Br J Hand Ther. 2006;11:112e113.
Wassel Type III Polydactyly With Symphalangism: A Rare Entity To the Editor: Polydactyly is the most common hand anomaly. It is common in white individuals, and it is also documented in high proportions in Native American and Asian populations. It was classified into 7 types by Wassel.1 The anomaly described in the current report does not fit into any type in the Wassel classification system. A 25-year-old, healthy man of Turkish ethnicity presented to our outpatient clinic with an extra finger on the right hand. The patient had no relevant family history. x-ray studies demonstrated a Wassel type IIIelike duplication with symphalangism of the interphalangeal joint of the radial thumb (Fig. 1). We performed a BilhauteCloquet reconstruction with wedge excision of the nail and skin and osteotomy to radial ray to match the size of the contralateral, normal thumb. A part of resected radial ray was used as bone graft to fill the distal phalanx. Also, we constructed a radial collateral ligament. To preserve the thumb size and enclose the exposed bone, the previously elevated proximally based flap with periosteum, overlying skin, and nailbed were sutured in the midline of reconstructed distal phalanx (Fig. 1). Eight well-documented cases of thumb duplication with symphalangism have been reported in adults.2e4 Takagi et al5 reported several pediatric cases of preaxial polydactyly with cartilaginous symphalangism. Most preaxial polydactyly cases were from Asia, specifically from Saudi Arabia and Japan, which may indicate a genetic background; in every one of them, symphalangism was observed in the radial ray. In The Netherlands, an extremely high rate of thumb triplication is seen, which is attributed to genetic pooling of ZRS mutations.
FIGURE 1: Preoperative x-ray of the thumb.
Department of Plastic and Reconstructive Surgery Haydarpasa Numune Training and Research Hospital Istanbul, Turkey http://dx.doi.org/10.1016/j.jhsa.2014.02.028 REFERENCES 1. Wassel HD. The results of surgery for polydactyly of the thumb: a review. Clin Orthop Relat Res. 1969;(64):175e193. 2. Al-Aithan B, Al-Blaihed L, Mahmoud S, et al. Thumb polydactyly with symphalangism. J Hand Surg Eur Vol. 2005;30(4): 346e349. 3. Boutros S, Weinfeld AB, Stafford J, et al. An unusual case of polydactyly of the thumb. Ann Plast Surg. 1998;41(4):434e435. 4. Al-Qattan MM. The distribution of the types of thumb polydactyly in a Middle Eastern population: a study of 228 hands. J Hand Surg Eur Vol. 2010;35(3):182e187. 5. Takagi R, Kawabata H, Matsui Y. Thumb polydactyly with symphalangism in young children. J Hand Surg Eur Vol. 2009;34(6):800e804.
N. Sinem Ciloglu, MD Alpay Duran, MD Hasan Buyukdogan, MD
J Hand Surg Am.
r
Vol. 39, May 2014
LETTERS TO THE EDITOR
Duncan J.M. Macdonald Department of Orthopaedic Surgery Royal Alexandria Hospital, Paisley Scotland, UK
The authors thank Dr. Elaine MacDuff for reviewing the manuscript. Editor note: Please see the case report in this issue describing a similar case.
REFERENCE 1. Ishida M, Kojima K, Yamahira K, et al. Superficial angiomyxoma of the thumb: report of a rare case and review of literature. Eur J Radiol. 2010;73(1):e29ee32.
http://dx.doi.org/10.1016/j.jhsa.2013.11.045
A Simple Diagnostic Sign for Rupture of the Flexor Digitorum Profundus To the Editor: The function of flexor digitorum profundus (FDP) tendon is usually evaluated by asking the patient to flex the distal interphalangeal (DIP) joint while the examiner holds the proximal interphalangeal (PIP) joint in extension.1 The inability to do so raises the suspicion of FDP injury. We describe another sign for FDP rupture in which the patient holds the finger to be tested against its equivalent finger of the opposite hand with both PIP joints flexed to 90 , the metacarpophalangeal joints in neutral, and the other fingers fully flexed. If the FDP is ruptured, the DIP joint of the affected digit will exhibit full extension (Fig. 1). The following explains the anatomical basis of the sign. The PIP and DIP joints move in coordination as the oblique retinacular ligament relaxes with PIP joint flexion to allow full DIP joint flexion.2 The lateral bands move volarly during PIP joint flexion, provided that the central slip is intact.3,4 This movement will slacken the lateral bands and the FDP will solely act on the DIP joint and flex it. Schreuders et al5 described a similar position of fingers to test for central slip rupture. In their test, the patient is asked to actively extend the DIP joints, and if the central slip is ruptured, there is asymmetry in the degree of extension between the 2 fingers. However, the DIP joint is still not as fully extended as in the sign we present. Therefore, only rupture of the FDP using this position of the fingers can distinctly and effortlessly produce full extension of the DIP joint. We believe that this sign may help assess the integrity as well as the tension of the repair or reconstruction by comparing the affected finger with its equivalent finger of the opposite hand (Fig. 1).
FIGURE 1: A Patient 1 week after an FDP rupture in the left index finger. B Patient with rheumatoid arthritis and chronic rupture of the FDP to the left index finger. C The same patient as in B 2 months after a middle finger flexor digitorum superficialis to FDP (index finger) transfer. The patient regained the flexion of the DIP joint of the left index finger.
Daoud Makki, BsC, MD Department of Trauma and Orthopaedics Countess of Chester Hospital NHS Foundation Trust Chester, UK
REFERENCES 1. Hankin FM, Peel SM. Sport related fractures and dislocations in the hand. Hand Clin. 1990;6(3):429e453.
http://dx.doi.org/10.1016/j.jhsa.2014.02.017
J Hand Surg Am.
r
Vol. 39, May 2014
1021
LETTERS TO THE EDITOR
2. Zancolli E. Structural and Dynamic Bases of Hand Surgery. 2nd ed. Philadelphia, PA: Lippincott; 1979:263e283. 3. Elson RA. Rupture of the central slip of the extensor hood of the finger: a test for early diagnosis. J Bone Joint Surg Br. 1986;68(2): 229e231.
4. Harris C Jr, Rutledge GL Jr. The functional anatomy of the extensor mechanism of the finger. J Bone Joint Surg Am. 1972;54(4):713e726. 5. Schreuders TAR, Soeters JNM, Hovius SER, Stam HJ. A modification of Elson’s test for the diagnosis of an acute extensor central slip injury. Br J Hand Ther. 2006;11:112e113.
Wassel Type III Polydactyly With Symphalangism: A Rare Entity To the Editor: Polydactyly is the most common hand anomaly. It is common in white individuals, and it is also documented in high proportions in Native American and Asian populations. It was classified into 7 types by Wassel.1 The anomaly described in the current report does not fit into any type in the Wassel classification system. A 25-year-old, healthy man of Turkish ethnicity presented to our outpatient clinic with an extra finger on the right hand. The patient had no relevant family history. x-ray studies demonstrated a Wassel type IIIelike duplication with symphalangism of the interphalangeal joint of the radial thumb (Fig. 1). We performed a BilhauteCloquet reconstruction with wedge excision of the nail and skin and osteotomy to radial ray to match the size of the contralateral, normal thumb. A part of resected radial ray was used as bone graft to fill the distal phalanx. Also, we constructed a radial collateral ligament. To preserve the thumb size and enclose the exposed bone, the previously elevated proximally based flap with periosteum, overlying skin, and nailbed were sutured in the midline of reconstructed distal phalanx (Fig. 1). Eight well-documented cases of thumb duplication with symphalangism have been reported in adults.2e4 Takagi et al5 reported several pediatric cases of preaxial polydactyly with cartilaginous symphalangism. Most preaxial polydactyly cases were from Asia, specifically from Saudi Arabia and Japan, which may indicate a genetic background; in every one of them, symphalangism was observed in the radial ray. In The Netherlands, an extremely high rate of thumb triplication is seen, which is attributed to genetic pooling of ZRS mutations.
FIGURE 1: Preoperative x-ray of the thumb.
Department of Plastic and Reconstructive Surgery Haydarpasa Numune Training and Research Hospital Istanbul, Turkey http://dx.doi.org/10.1016/j.jhsa.2014.02.028 REFERENCES 1. Wassel HD. The results of surgery for polydactyly of the thumb: a review. Clin Orthop Relat Res. 1969;(64):175e193. 2. Al-Aithan B, Al-Blaihed L, Mahmoud S, et al. Thumb polydactyly with symphalangism. J Hand Surg Eur Vol. 2005;30(4): 346e349. 3. Boutros S, Weinfeld AB, Stafford J, et al. An unusual case of polydactyly of the thumb. Ann Plast Surg. 1998;41(4):434e435. 4. Al-Qattan MM. The distribution of the types of thumb polydactyly in a Middle Eastern population: a study of 228 hands. J Hand Surg Eur Vol. 2010;35(3):182e187. 5. Takagi R, Kawabata H, Matsui Y. Thumb polydactyly with symphalangism in young children. J Hand Surg Eur Vol. 2009;34(6):800e804.
N. Sinem Ciloglu, MD Alpay Duran, MD Hasan Buyukdogan, MD
J Hand Surg Am.
r
Vol. 39, May 2014
