Thirteen painful end-neuromas of nerves of the palm and the dorsum of the hand were treated by resection of the neuroma and relocation of the nerve ends into the pronator quadratus muscle proximal to the wrist in ten patients. The effectiveness of this treatment was assessed by measurement of changes in level of spontaneous pain, pain on pressure, pain on movement and hyperaesthesia at the original site and at the site to which the nerve was relocated. Subjective comments on changes of hand function and ability to return to work were also recorded. All ten patients reported total relief or marked improvement in each of the four modalities of pain assessed. In the five patients in whom the neuromas were the only significant cause of hand dysfunction, there was sufficient improvement in hand function to allow the patients to return to work. In this series, the pronator quardratus muscle has proved a suitable site for relocation of sensory nerve ends after resection of painful neuromas in the proximal part of the hand and wrist.

Fibrotic diseases remain a major cause of morbidity and mortality, yet there are few effective therapies. The underlying pathology of all fibrotic conditions is the activity of myofibroblasts. Using cells from freshly excised disease tissue from patients with Dupuytren’s disease (DD), a localized fibrotic disorder of the palm, we sought to identify new therapeutic targets for fibrotic disease. We hypothesized that the persistent activity of myofibroblasts in fibrotic diseases might involve epigenetic modifications. Using a validated genetics-led target prioritization algorithm (Pi) of genome wide association studies (GWAS) data and a broad screen of epigenetic inhibitors, we found that the acetyltransferase CREBBP/EP300 is a major regulator of contractility and extracellular matrix production via control of H3K27 acetylation at the profibrotic genes, ACTA2 and COL1A1. Genomic analysis revealed that EP300 is highly enriched at enhancers associated with genes involved in multiple profibrotic pathways, and broad transcriptomic and proteomic profiling of CREBBP/EP300 inhibition by the chemical probe SGC-CBP30 identified collagen VI (Col VI) as a prominent downstream regulator of myofibroblast activity. Targeted Col VI knockdown results in significant decrease in profibrotic functions, including myofibroblast contractile force, extracellular matrix (ECM) production, chemotaxis, and wound healing. Further evidence for Col VI as a major determinant of fibrosis is its abundant expression within Dupuytren’s nodules and also in the fibrotic foci of idiopathic pulmonary fibrosis (IPF). Thus, Col VI may represent a tractable therapeutic target across a range of fibrotic disorders.

Sixteen patients with paralysis of the anterior interosseous nerve (AIN) in 19 limbs who were treated in a single unit were reviewed at a mean of 6.4 years (range 2-14 years) following onset of the paralysis. There was a high incidence of incomplete lesions (seven limbs) and of associated neurological lesions (six limbs) in the same or opposite upper extremity. Patients treated conservatively and with surgical exploration showed no difference in the time of onset of recovery, the time taken to achieve complete recovery or the extent of recovery. Those with incomplete lesions recovered well irrespective of the type of treatment. A distinct cause of compression of the AIN or visible changes in the AIN were seen in just three of the eight limbs that were explored. Surgery is indicated in complete lesions with no evidence of recovery for at least 6 months; incomplete lesions and other neurological signs are indications for conservative management in the first instance.

A new technique of attachment of the flexor digitorum profundus tendon and flexor tendon grafts to the distal phalanx, without using a button on the nail, is described and its use reported in 14 cases.