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Extensor mechanism laxity at the metacarpophalangeal joint as identified by a new provocative test: predisposition to dislocation
ARTICLE IN PRESS EXTENSOR MECHANISM LAXITY AT THE METACARPOPHALANGEAL JOINT AS IDENTIFIED BY A NEW PROVOCATIVE TEST: PREDISPOSITION TO DISLOCATION T. SHINOHARA, R. NAKAMURA, M. SUZUKI and N. MAEDA From the Department of Orthopaedic Surgery, Tokai Hospital, Nagoya, Japan and the Department of Hand Surgery, Nagoya University School of Medicine, Nagoya, Japan
A tendon subluxation test was performed on the unaffected side in 13 patients with traumatic extensor tendon dislocation of the middle finger and on both middle fingers in 800 healthy controls to identify extensor mechanism laxity at the metacarpophalangeal joint. Ten of the 13 patients with dislocation had laxity of middle finger extensor tendon, compared with 174 of the 800 (22%) controls. The difference in these rates of extensor tendon laxity is significant (Po0.0001), and suggests that extensor mechanism laxity at the metacarpophalangeal joint may predispose to traumatic extensor tendon dislocation. Journal of Hand Surgery (British and European Volume, 2005) 30B: 1: 79–82 Keywords: extensor, tendon subluxation, dislocation, metacarpophalangeal joint, provocative test, sagittal band
ulnar deviation under resistance applied by the examiner (Fig 1). When this test was performed, the extensor tendon either remained in nearly the same position as at rest or displaced to the ulnar side. The position of the extensor tendon on the metacarpal head at the MP joint was classified into two types based on degree of displacement of the tendon (Fig 2). Extensor tendons with only slight displacement to the ulnar side, in which the radial margin of the tendon remained radial to the midline of the metacarpal head, were considered stable and classified as normal. Tendons with greater ulnar displacement, in which the radial margin displaced to the ulnar side of the metacarpal midline, were considered unstable and classified as lax. When the test results of a control differed between his/her right and left hands, he/she was classified as having a lax extensor mechanism. The w2 test or Fisher’s exact test were used for the statistical analysis.
INTRODUCTION Traumatic extensor tendon dislocation at the metacarpophalangeal (MP) joint is comparatively rare, and occurs most frequently in the middle finger. It results from a rupture of the transverse fibres of the extensor hood on its radial side, allowing ulnar dislocation of the extensor tendon at the level of the MP joint. Two types of extensor tendon dislocation can occur. One results from light external force and the other from strong external force. Since extensor tendon dislocation can occur with minor forces, there may be anatomical predisposing factors. Specifically, we believe that extensor mechanism laxity may contribute to extensor tendon dislocation. We have assessed extensor mechanism laxity in patients with traumatic extensor tendon dislocation and healthy individuals.
PATIENTS AND METHODS RESULTS
We performed a tendon subluxation test on the contralateral, unaffected middle finger of 13 patients with traumatic extensor tendon dislocation and bilaterally in 800 healthy individuals with no history of joint disease or of other dysfunction or trauma to the hands. The extensor tendon dislocation group included eight men and five women, with a mean age of 38 (range, 21–70) years. All patients in this group had presented with ulnar dislocation of the extensor tendon involving the middle finger (Table 1). The healthy control group included 400 men and 400 women, with a mean age of 36 (range, 20–55) years. The same examiner tested all subjects in both groups. In our test for extensor mechanism laxity, the MP joint was actively extended from a position of flexion and
In the extensor tendon dislocation group, three patients had normal and 10 lax extensor mechanisms. Among the 800 controls there were 626 (78%) normal and 174 (22%) lax extensor mechanisms. 756 (95%) of 800 the control subjects had the same type of extensor mechanism on both sides. The proportion of subjects with laxity in the extensor tendon dislocation group was significantly higher than in the control group (Po0.0001: Fisher’s exact test). All eight men in the extensor tendon dislocation group had lax extensor mechanisms (100%), compared with two of the five women. In contrast 339 of the 400 male controls had normal extensor mechanisms (85%) and only 61 (15%) had the lax type. Furthermore, 287 of the 400 (72%) female controls were 79
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2005
Table 1——Characteristics of our patients with extensor tendon dislocation of the middle finger of the MP joint Case
Age
Gender
Side
Cause of injury
Results of tendon subluxation test1
1 2 3 4 5 6 7 8 9 10 11 12 13
23 70 21 32 36 28 45 40 37 45 31 56 35
M M M F F M F F M F M M M
R L R R R R L R R R R L R
Motorcycle accident Flicking the finger Direct blow Tossing a package Twisting the finger Twisting the finger Flicking the finger Snapping the finger Direct blow Direct blow Crumpling paper Snapping the finger Snapping the finger
Lax Lax Lax Lax Lax Lax Normal Normal Lax Normal Lax Lax Lax
Lax: finger showing greater extensor tendon subluxation in the provocative test. Testing was performed in the middle finger contralateral to that with tendon dislocation. 1 Normal: finger showing little extensor tendon subluxation in the provocative test.
Fig 1 The tendon subluxation test. The wrist is supported by the examiner’s left hand, while the patient actively extends the middle finger against resistance from the examiner’s right index finger.
normal. This difference in the rates of laxity in men and women controls is significant (Po0.0001: w2 test). In the extensor tendon dislocation group, a direct-force injury had occurred in four patients, three of whom had lax-type findings. An indirect external-force injury had occurred in the other nine patients, seven of whom had laxity.
DISCUSSION Traumatic extensor tendon dislocations at the MP joint are rare but most frequently involve the middle finger. After exclusion of patients with rheumatoid arthritis, we are aware of 119 reported patients (141 fingers) with
Fig 2 Findings in our extensor tendon subluxation test. (a) Normal type: there is minimal displacement of the extensor tendon. (b) Lax type: the extensor tendon shows greater displacement and subluxation.
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81
Table 2——Previously and presently reported patients with extensor tendon dislocation Authors
Araki et al. (1987) Boyes (1964) Carroll et al. (1987)1 Elson (1967) Harvey and Hume (1980)1 Iftikhar et al. (1984)1 Inoue and Tamura (1996)1 Ishizuki (1990) Kang and Smith (2001)1 Kettelkamp et al. (1971) McCoy and Winsky (1969)1 Rayan and Murray (1994) Ritts et al. (1985) Watson et al. (1997)1 Wheeldon (1954) Shinohara et al. (present study) Total 1
Number of patients
5 2 7 1 5 2 27 16 1 5 2 13 2 16 2 13 119
Involved digit Index
Middle
Ring 1
1
4 2 4
4
1
1
7
5 2 21 16 2 5 2 10 2 12 1 13 101
3
Little
3
1 1 2
4
3
2 1 2
1
4 1
4
21
12
Patients with multiple-digit involvement are included.
extensor tendon dislocations, including those in our own cases (Table 2). Of these, 101 (72%) involved the middle finger, and all but one of these had ulnar dislocation. Anatomic studies indicate that the extensor tendon of the middle finger at the MP joint level is more rounded in cross section, lies more precariously on the bony prominence of the metacarpal head and is attached more loosely to the transverse fibres than the extensor tendons of the other three fingers (Kettelkamp et al., 1971; Wheeldon, 1954). These observations readily explain why extensor dislocation is most prevalent in the middle finger. As extensor tendon dislocation can occur with only slight external forces, such as those associated with finger snapping, anatomical factors probably predispose to this condition. Laxity of the capsular structures and sagittal band (Harvey and Hume, 1980) or the MP joint (Iftikhar et al., 1984) have been reported in patients with idiopathic ulnar dislocation of the extensor tendon, but laxity of the extensor mechanism at the MP joint has not been systemically studied. One clinical report has suggested that congenital variation in the integrity of the extensor hood and its intrinsic muscle insertions cause an imbalance and predispose to tendon dislocation (Ritts et al., 1985). Our results demonstrated a significantly higher proportion of lax-type extensor mechanisms in our 13 patients with extensor tendon dislocation than in the control group. All men with tendon dislocation showed laxity in the contralateral hand, compared with two of the five women. Thus, extensor mechanism laxity on the nondislocated side was more common among men than women in the dislocation group though our numbers are small. In the controls, laxity was significantly more frequent among
women than men which is consistent with more general observations that joint laxity is more prevalent among women than men (Fairbank et al., 1984; Larsson et al., 1987). Accordingly, our findings suggest that extensor mechanism laxity may strongly predispose to traumatic extensor tendon dislocation in men. Many authors have pointed out that traumatic extensor tendon dislocation at the MP joint is caused by injury to the sagittal band (Ishizuki, 1990; Koniuch et al., 1987; Rayan et al., 1997; Young and Rayan, 2000). The mechanism of injury can be classified into two types. The first is a direct injury, in which a direct external force such as that which occurs when hitting the hand against a wall, is applied to the metacarpal head. The second is an indirect injury which results from a slight external force such as that associated with finger snapping. Since many of our patients had lax-type findings and both types of injury were sustained, extensor mechanism laxity may predispose to both.
References Araki S, Ohtani T, Tanaka T (1987). Acute dislocation of the extensor digitorum communis tendon at the metacarpophalangeal joint. Journal of Bone and Joint Surgery, 69A: 616–619. Boyes JH. Bunnell’s surgery of the hand, 4th edn. Philadelphia, JB Lippincott Co, 1964: 470–471. Carroll IV C, Moor JR, Weiland AJ (1987). Posttraumatic ulnar subluxation of the extensor tendons: a reconstructive technique. Journal of Hand Surgery, 12A: 227–231. Elson RA (1967). Dislocation of the extensor tendons of the hand. Journal of Bone and Joint Surgery, 49B: 324–326. Fairbank JCT, Pynsent PB, Phillips H (1984). Quantitative measurements of joint mobility in adolescents. Annals of the Rheumatic Diseases, 43: 288–294.
ARTICLE IN PRESS 82
Harvey FJ, Hume KF (1980). Spontaneous recurrent ulnar dislocation of the long extensor tendons of the fingers. Journal of Hand Surgery, 5: 492–494. Iftikhar TB, Hallmann BW, Kaminski RS, Ray AK (1984). Spontaneous rupture of the extensor mechanism causing ulnar dislocation of the long extensor tendon of the long finger. Journal of Bone and Joint Surgery, 66A: 1108–1109. Inoue G, Tamura Y (1996). Dislocation of the extensor tendons over the metacarpophalangeal joints. Journal of Hand Surgery, 21A: 464–469. Ishizuki M (1990). Traumatic and spontaneous dislocation of extensor tendon of the long finger. Journal of Hand Surgery, 15A: 967–972. Kang N, Smith P (2001). Congenital absence of the juncturae tendini contributing to dislocation of the extensor tendons. Journal of Hand Surgery, 26A: 501–505. Kettelkamp DB, Flatt AE, Moulds R (1971). Traumatic dislocation of the long-finger extensor tendon. Journal of Bone and Joint Surgery, 53A (2): 229–240. Koniuch MP, Peimer CA, VanGorder T, Moncada A (1987). Closed crush injury of the metacarpophalangeal joint. Journal of Hand Surgery, 12A: 750–757. Larsson L-G, Baum J, Mudholkar GS (1987). Hypermobility: features and differential incidence between the sexes. Arthritis and Rheumatism, 30 (12): 1426–1430. McCoy FJ, Winsky AJ (1969). Lumbrical loop operation for luxation of the extensor tendons of the hand. Plastic Reconstructive Surgery, 44: 142–146.
THE JOURNAL OF HAND SURGERY VOL. 30B No. 1 FEBRUARY
2005
Rayan GM, Murray D (1994). Classification and treatment of closed sagittal band injuries. Journal of Hand Surgery, 19A: 590–594. Rayan GM, Murray D, Chung KW, Rohrer M (1997). The extensor retinacular system at the metacarpophalangeal joint. Journal of Hand Surgery, 22B (5): 585–590. Ritts GD, Wood MB, Engber WD (1985). Nonoperative treatment of traumatic dislocations of the extensor digitorum tendons in patients without rheumatoid disorders. Journal of Hand Surgery, 10A: 714–716. Watson HK, Weinzweig J, Guidera PM (1997). Sagittal band reconstruction. Journal of Hand Surgery, 22A: 452–456. Wheeldon FT (1954). Recurrent dislocation of extensor tendons in the hand. Journal of Bone and Joint Surgery, 36B: 612–617. Young CM, Rayan GM (2000). The sagittal band: anatomic and biomechanical study. Journal of Hand Surgery, 25A: 1107–1113. Received: 24 February 2004 Accepted after revision: 7 September 2004 Dr Takaaki Shinohara, MD, Department of Orthopaedic Surgery, Tokai Hospital, 1-1-1 Chiyodabasi Chikusaku, Nagoya 464-8512, Japan. Tel.: +81 52 711 6131; fax: +81 52 712 0052. E-mail: [email protected]
r 2004 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2004.09.002 available online at http://www.sciencedirect.com
A tendon subluxation test was performed on the unaffected side in 13 patients with traumatic extensor tendon dislocation of the middle finger and on both middle fingers in 800 healthy controls to identify extensor mechanism laxity at the metacarpophalangeal joint. Ten of the 13 patients with dislocation had laxity of middle finger extensor tendon, compared with 174 of the 800 (22%) controls. The difference in these rates of extensor tendon laxity is significant (Po0.0001), and suggests that extensor mechanism laxity at the metacarpophalangeal joint may predispose to traumatic extensor tendon dislocation. Journal of Hand Surgery (British and European Volume, 2005) 30B: 1: 79–82 Keywords: extensor, tendon subluxation, dislocation, metacarpophalangeal joint, provocative test, sagittal band
ulnar deviation under resistance applied by the examiner (Fig 1). When this test was performed, the extensor tendon either remained in nearly the same position as at rest or displaced to the ulnar side. The position of the extensor tendon on the metacarpal head at the MP joint was classified into two types based on degree of displacement of the tendon (Fig 2). Extensor tendons with only slight displacement to the ulnar side, in which the radial margin of the tendon remained radial to the midline of the metacarpal head, were considered stable and classified as normal. Tendons with greater ulnar displacement, in which the radial margin displaced to the ulnar side of the metacarpal midline, were considered unstable and classified as lax. When the test results of a control differed between his/her right and left hands, he/she was classified as having a lax extensor mechanism. The w2 test or Fisher’s exact test were used for the statistical analysis.
INTRODUCTION Traumatic extensor tendon dislocation at the metacarpophalangeal (MP) joint is comparatively rare, and occurs most frequently in the middle finger. It results from a rupture of the transverse fibres of the extensor hood on its radial side, allowing ulnar dislocation of the extensor tendon at the level of the MP joint. Two types of extensor tendon dislocation can occur. One results from light external force and the other from strong external force. Since extensor tendon dislocation can occur with minor forces, there may be anatomical predisposing factors. Specifically, we believe that extensor mechanism laxity may contribute to extensor tendon dislocation. We have assessed extensor mechanism laxity in patients with traumatic extensor tendon dislocation and healthy individuals.
PATIENTS AND METHODS RESULTS
We performed a tendon subluxation test on the contralateral, unaffected middle finger of 13 patients with traumatic extensor tendon dislocation and bilaterally in 800 healthy individuals with no history of joint disease or of other dysfunction or trauma to the hands. The extensor tendon dislocation group included eight men and five women, with a mean age of 38 (range, 21–70) years. All patients in this group had presented with ulnar dislocation of the extensor tendon involving the middle finger (Table 1). The healthy control group included 400 men and 400 women, with a mean age of 36 (range, 20–55) years. The same examiner tested all subjects in both groups. In our test for extensor mechanism laxity, the MP joint was actively extended from a position of flexion and
In the extensor tendon dislocation group, three patients had normal and 10 lax extensor mechanisms. Among the 800 controls there were 626 (78%) normal and 174 (22%) lax extensor mechanisms. 756 (95%) of 800 the control subjects had the same type of extensor mechanism on both sides. The proportion of subjects with laxity in the extensor tendon dislocation group was significantly higher than in the control group (Po0.0001: Fisher’s exact test). All eight men in the extensor tendon dislocation group had lax extensor mechanisms (100%), compared with two of the five women. In contrast 339 of the 400 male controls had normal extensor mechanisms (85%) and only 61 (15%) had the lax type. Furthermore, 287 of the 400 (72%) female controls were 79
ARTICLE IN PRESS 80
THE JOURNAL OF HAND SURGERY VOL. 30B No. 1 FEBRUARY
2005
Table 1——Characteristics of our patients with extensor tendon dislocation of the middle finger of the MP joint Case
Age
Gender
Side
Cause of injury
Results of tendon subluxation test1
1 2 3 4 5 6 7 8 9 10 11 12 13
23 70 21 32 36 28 45 40 37 45 31 56 35
M M M F F M F F M F M M M
R L R R R R L R R R R L R
Motorcycle accident Flicking the finger Direct blow Tossing a package Twisting the finger Twisting the finger Flicking the finger Snapping the finger Direct blow Direct blow Crumpling paper Snapping the finger Snapping the finger
Lax Lax Lax Lax Lax Lax Normal Normal Lax Normal Lax Lax Lax
Lax: finger showing greater extensor tendon subluxation in the provocative test. Testing was performed in the middle finger contralateral to that with tendon dislocation. 1 Normal: finger showing little extensor tendon subluxation in the provocative test.
Fig 1 The tendon subluxation test. The wrist is supported by the examiner’s left hand, while the patient actively extends the middle finger against resistance from the examiner’s right index finger.
normal. This difference in the rates of laxity in men and women controls is significant (Po0.0001: w2 test). In the extensor tendon dislocation group, a direct-force injury had occurred in four patients, three of whom had lax-type findings. An indirect external-force injury had occurred in the other nine patients, seven of whom had laxity.
DISCUSSION Traumatic extensor tendon dislocations at the MP joint are rare but most frequently involve the middle finger. After exclusion of patients with rheumatoid arthritis, we are aware of 119 reported patients (141 fingers) with
Fig 2 Findings in our extensor tendon subluxation test. (a) Normal type: there is minimal displacement of the extensor tendon. (b) Lax type: the extensor tendon shows greater displacement and subluxation.
ARTICLE IN PRESS EXTENSOR TENDON DISLOCATION
81
Table 2——Previously and presently reported patients with extensor tendon dislocation Authors
Araki et al. (1987) Boyes (1964) Carroll et al. (1987)1 Elson (1967) Harvey and Hume (1980)1 Iftikhar et al. (1984)1 Inoue and Tamura (1996)1 Ishizuki (1990) Kang and Smith (2001)1 Kettelkamp et al. (1971) McCoy and Winsky (1969)1 Rayan and Murray (1994) Ritts et al. (1985) Watson et al. (1997)1 Wheeldon (1954) Shinohara et al. (present study) Total 1
Number of patients
5 2 7 1 5 2 27 16 1 5 2 13 2 16 2 13 119
Involved digit Index
Middle
Ring 1
1
4 2 4
4
1
1
7
5 2 21 16 2 5 2 10 2 12 1 13 101
3
Little
3
1 1 2
4
3
2 1 2
1
4 1
4
21
12
Patients with multiple-digit involvement are included.
extensor tendon dislocations, including those in our own cases (Table 2). Of these, 101 (72%) involved the middle finger, and all but one of these had ulnar dislocation. Anatomic studies indicate that the extensor tendon of the middle finger at the MP joint level is more rounded in cross section, lies more precariously on the bony prominence of the metacarpal head and is attached more loosely to the transverse fibres than the extensor tendons of the other three fingers (Kettelkamp et al., 1971; Wheeldon, 1954). These observations readily explain why extensor dislocation is most prevalent in the middle finger. As extensor tendon dislocation can occur with only slight external forces, such as those associated with finger snapping, anatomical factors probably predispose to this condition. Laxity of the capsular structures and sagittal band (Harvey and Hume, 1980) or the MP joint (Iftikhar et al., 1984) have been reported in patients with idiopathic ulnar dislocation of the extensor tendon, but laxity of the extensor mechanism at the MP joint has not been systemically studied. One clinical report has suggested that congenital variation in the integrity of the extensor hood and its intrinsic muscle insertions cause an imbalance and predispose to tendon dislocation (Ritts et al., 1985). Our results demonstrated a significantly higher proportion of lax-type extensor mechanisms in our 13 patients with extensor tendon dislocation than in the control group. All men with tendon dislocation showed laxity in the contralateral hand, compared with two of the five women. Thus, extensor mechanism laxity on the nondislocated side was more common among men than women in the dislocation group though our numbers are small. In the controls, laxity was significantly more frequent among
women than men which is consistent with more general observations that joint laxity is more prevalent among women than men (Fairbank et al., 1984; Larsson et al., 1987). Accordingly, our findings suggest that extensor mechanism laxity may strongly predispose to traumatic extensor tendon dislocation in men. Many authors have pointed out that traumatic extensor tendon dislocation at the MP joint is caused by injury to the sagittal band (Ishizuki, 1990; Koniuch et al., 1987; Rayan et al., 1997; Young and Rayan, 2000). The mechanism of injury can be classified into two types. The first is a direct injury, in which a direct external force such as that which occurs when hitting the hand against a wall, is applied to the metacarpal head. The second is an indirect injury which results from a slight external force such as that associated with finger snapping. Since many of our patients had lax-type findings and both types of injury were sustained, extensor mechanism laxity may predispose to both.
References Araki S, Ohtani T, Tanaka T (1987). Acute dislocation of the extensor digitorum communis tendon at the metacarpophalangeal joint. Journal of Bone and Joint Surgery, 69A: 616–619. Boyes JH. Bunnell’s surgery of the hand, 4th edn. Philadelphia, JB Lippincott Co, 1964: 470–471. Carroll IV C, Moor JR, Weiland AJ (1987). Posttraumatic ulnar subluxation of the extensor tendons: a reconstructive technique. Journal of Hand Surgery, 12A: 227–231. Elson RA (1967). Dislocation of the extensor tendons of the hand. Journal of Bone and Joint Surgery, 49B: 324–326. Fairbank JCT, Pynsent PB, Phillips H (1984). Quantitative measurements of joint mobility in adolescents. Annals of the Rheumatic Diseases, 43: 288–294.
ARTICLE IN PRESS 82
Harvey FJ, Hume KF (1980). Spontaneous recurrent ulnar dislocation of the long extensor tendons of the fingers. Journal of Hand Surgery, 5: 492–494. Iftikhar TB, Hallmann BW, Kaminski RS, Ray AK (1984). Spontaneous rupture of the extensor mechanism causing ulnar dislocation of the long extensor tendon of the long finger. Journal of Bone and Joint Surgery, 66A: 1108–1109. Inoue G, Tamura Y (1996). Dislocation of the extensor tendons over the metacarpophalangeal joints. Journal of Hand Surgery, 21A: 464–469. Ishizuki M (1990). Traumatic and spontaneous dislocation of extensor tendon of the long finger. Journal of Hand Surgery, 15A: 967–972. Kang N, Smith P (2001). Congenital absence of the juncturae tendini contributing to dislocation of the extensor tendons. Journal of Hand Surgery, 26A: 501–505. Kettelkamp DB, Flatt AE, Moulds R (1971). Traumatic dislocation of the long-finger extensor tendon. Journal of Bone and Joint Surgery, 53A (2): 229–240. Koniuch MP, Peimer CA, VanGorder T, Moncada A (1987). Closed crush injury of the metacarpophalangeal joint. Journal of Hand Surgery, 12A: 750–757. Larsson L-G, Baum J, Mudholkar GS (1987). Hypermobility: features and differential incidence between the sexes. Arthritis and Rheumatism, 30 (12): 1426–1430. McCoy FJ, Winsky AJ (1969). Lumbrical loop operation for luxation of the extensor tendons of the hand. Plastic Reconstructive Surgery, 44: 142–146.
THE JOURNAL OF HAND SURGERY VOL. 30B No. 1 FEBRUARY
2005
Rayan GM, Murray D (1994). Classification and treatment of closed sagittal band injuries. Journal of Hand Surgery, 19A: 590–594. Rayan GM, Murray D, Chung KW, Rohrer M (1997). The extensor retinacular system at the metacarpophalangeal joint. Journal of Hand Surgery, 22B (5): 585–590. Ritts GD, Wood MB, Engber WD (1985). Nonoperative treatment of traumatic dislocations of the extensor digitorum tendons in patients without rheumatoid disorders. Journal of Hand Surgery, 10A: 714–716. Watson HK, Weinzweig J, Guidera PM (1997). Sagittal band reconstruction. Journal of Hand Surgery, 22A: 452–456. Wheeldon FT (1954). Recurrent dislocation of extensor tendons in the hand. Journal of Bone and Joint Surgery, 36B: 612–617. Young CM, Rayan GM (2000). The sagittal band: anatomic and biomechanical study. Journal of Hand Surgery, 25A: 1107–1113. Received: 24 February 2004 Accepted after revision: 7 September 2004 Dr Takaaki Shinohara, MD, Department of Orthopaedic Surgery, Tokai Hospital, 1-1-1 Chiyodabasi Chikusaku, Nagoya 464-8512, Japan. Tel.: +81 52 711 6131; fax: +81 52 712 0052. E-mail: [email protected]
r 2004 The British Society for Surgery of the Hand. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhsb.2004.09.002 available online at http://www.sciencedirect.com