Isolated Unilateral Absence of Lunate: A Case Report and Review of Literature.

Isolated unilateral absence of lunate is an extremely rare condition with only one such case reported in English literature so far. The rarity of this condition can lead to diagnostic dilemma, especially if patient has an old history of trauma or surgery around the wrist, leading to unnecessary intervention and difficulty in ensuring a good surgical outcome. We present such a case and discuss the clinical pointers to the diagnosis of this condition. Level of Evidence: Level V (Therapeutic).

Osteoid osteoma of the hook of hamate: An unusual cause of ulnar side wrist pain.

Ulnar side wrist pain is a complex clinical situation because of the pathologies involving multiple closely located structures on the ulnar side of the wrist. Incidence of osseous lesions leading to ulnar side wrist pain is very rare. The effectiveness of commonly employed Magnetic resonance imaging, for diagnosing the pathology in the ulnar side of the wrist might be limited in diagnosing such osseous lesions and can lead to missed diagnosis. We herein present such a rare case of Osteoid osteoma of the hook of hamate presenting as ulnar side wrist pain. The condition, presented a "diagnostic challenge", where it required Computed Tomography to diagnose and guide for appropriate management.

Options for Restoring Finger Extension in Mangled Forearm Injuries.

Restoration of finger extension in mutilating hand injuries is crucial for restoring prehension and independent use of the hand. Patients often express desire to restore finger extension once finger flexion is achieved. However, the extensive forearm injury precludes use of any of conventional donors like the wrist or finger flexors for transfer to restore finger extension. Two patients with sequelae of mangled forearm injuries, underwent biceps and long head of triceps transfer to the finger extensors to improve opening up of the fingers. We discuss the treatment considerations while planning these transfers and provide the technical details, rehabilitation and outcome of these patients. Both the patients expressed dramatic improvement of their hand function and were satisfied with the outcome. Biceps and long head of triceps could serve as an effective second-line donor for restoration of finger extension when the conventional donors are not available. Level of Evidence: Level V (Therapeutic).

How to do an outside-in/outside-in microsuture for nerve repair.

Peripheral nerve injuries are common and debilitating. The goals of nerve repair are to accurately approximate the fascicular tissue, whilst ensuring continuous overlying epineurium and eliminating external sprouting of neural tissue. We describe a modification of standard micro-suturing which allows superior epineural eversion and fascicular coaptation.

Management of extensor tendon injuries concerning distal radius fractures.

Introduction: Rupture of the extensor tendons secondary to fractures involving the distal radius is a well-recognized rare complication. In patients with implants particularly, there exists a tendency for attributing the implant as a cause for the tendon rupture. We retrospectively studied the patients with extensor tendon injuries related to distal radius fractures, analyzed the factors leading to the rupture, suggest few preventive measures and describe the management strategy of these ruptures. Materials and methods: 21 patients who were treated for extensor tendon rupture following distal radius fractures in the period of 2014-2022 were retrospectively analyzed. 19 patients had been managed with surgery and two patients conservatively for the distal radius fracture. The time interval between the fracture fixation and tendon rupture, the time interval between tendon rupture and presentation, the extensor tendons injured and the position of the impinging screws or bony spur in relation to the extensor compartments, necessity for implant removal and modality of tendon reconstruction were studied in these patients. Results: Extensor pollicis longus was found to be ruptured in all the patients except one patient with Extensor indicis proprius rupture alone. The time interval between the fracture fixation and tendon rupture averaged at 32.5 months. End to end repair of the ruptured tendons was never possible even in patients who presented earlier. 10 patients underwent intertendinous bridge grafting and 11 patients underwent tendon transfer. All the patients achieved full extension of thumb with no donor deficit. Conclusion: Distal radius fracture related extensor tendon injuries pose a technical challenge to the surgeon and concern to the patient in the form of recurring surgeries. However, with immediate presentation to the surgeon and their use of appropriately designed management algorithm, these patients could be immensely satisfied with the outcome.

Forearm Deformities in Birth Brachial Plexus Palsy - Patient Profile and Management Algorithm.

Forearm deformities are often seen in children with severe birth brachial plexus palsy (BBPP). They may be either a supination or a pronation deformity and both hinder normal use of the hand and parents often request for corrective surgery. However, the correction of these deformities can be challenging due to a paucity of options. Also, there is less information in literature on the management of forearm deformities in BBPP compared to the information with regard to nerve surgery or correction of shoulder deformities. This article presents a synopsis of incidence, pathogenesis, clinical presentation and parental concerns related to these deformities. The decision-making considerations, management strategies and outcome expectations are also discussed. Patient selection is very crucial, and the treatment plan must be individualised depending on the disability, parental expectations and existing motor power in the involved limb. Correction of both the deformities have different considerations; however, effective correction of these deformities is immensely satisfactory to the patient/parents in terms of improved function and appearance of the limb. Level of Evidence: Level V (Therapeutic).

Does the Functional Status of the Upper Limb Influence Limb Length Discrepancy in a Child with Birth Brachial Plexus Palsy?

Background: Limb length discrepancy (LLD) is a frequent observation in children with birth brachial plexus palsy (BBPP) and a common concern among parents. A common assumption is that the LLD decreases if the child is using the involved limb more. However, there is no literature evidence for this assumption. The present study was conducted to assess the correlation between the functional status of the involved limb and the LLD in children with BBPP. Methods: One hundred consecutive patients (age > 5 years) with unilateral BBPP seen at our institute underwent measurements of limb lengths to assess the LLD. The arm, forearm and hand segments were measured separately. The functional status of the involved limb was assessed using modified House's Scoring system (Scores 0-10). The correlation between limb length and functional status was assessed using the one-way Analysis of Variance (ANOVA) test. Post-hoc analyses were performed as required. Results: A length difference was observed in 98% of the limbs with brachial plexus lesions. The average absolute LLD was 4.6 cm with a standard deviation of 2.5 cm. We found a statistically significant difference in LLD among the patients with a House score of <7 ('Poor function') and 7 and above ('Good function'; p < 0.001) with later indicative of independent use of the involved limb. We found no correlation between age and LLD. More extensive plexus involvement resulted in higher LLD. The maximal relative discrepancy was found in the hand segment of the upper extremity. Conclusions: LLD was seen in most of the patients with BBPP. The functional status of the involved upper limb in BBPP was found to be significantly associated with LLD. Though causation cannot be assumed. We found that children using the involved limb independently tend to have the least LLD. Level of Evidence: Level IV (Therapeutic).

Role of External Rotation Osteotomy of the Humerus in Patients with Brachial Plexus Injury.

Background: A deficit of external rotation of the shoulder is a common sequelae of brachial plexus injury (BPI). This internally rotated posture of the limb becomes more apparent and functionally limiting once the patient recovers elbow flexion resulting in the hand striking the abdomen on attempted flexion ('tummy flexion'). This precludes hand-to-mouth reach, resulting in an inability to eat with the involved hand. The aim of this study is to present the outcomes of an external rotation osteotomy of the humerus in adult BPI. Methods: All BPI patients who underwent an external rotation osteotomy of the humerus at our institution over a 5-year period from January 2015 to December 2020 were included in this study. Data with regard to the age, gender, type of BPI, time from injury to nerve surgery and from nerve surgery till external rotation osteotomy, degree of pre- and postoperative external rotation, time to union, patient satisfaction and complications were recorded. Results: The study included 19 patients (18 men and one woman) with an average age of 30 years (range 20-58). The average time interval from the injury to the nerve surgery was 3.8 months, and between the nerve surgery and the external rotation osteotomy was 29.5 months. No patient had any preoperative external rotation and all attained a resting posture of 15°-20° of external rotation, were able to reach the mid-line of the body, and none complained of loss of internal rotation. There was an implant failure in one patient that was managed with splinting till union and removal of implants later. Conclusions: External rotation osteotomy of the humerus is a simple and effective procedure to place the limb in a better aesthetic and functional position. Level of Evidence: Level IV (Therapeutic).

Anatomic Variations of the Musculocutaneous Nerve and Clinical Implications for Restoration of Elbow Flexion.

PURPOSE: The restoration of elbow flexion is of primary importance in the management of patients with brachial plexus injuries. Superior functional outcomes via fascicle transfer from the ulnar and median nerves have resulted in this transfer being considered the mainstay of recovery of elbow flexion in patients with intact C8 and T1 function. An understanding of the anatomy of the musculocutaneous nerve (MCN) and its branching pattern is key while performing these transfers. METHODS: A prospective cohort study was conducted in patients who underwent nerve transfer for the restoration of elbow flexion following a traumatic brachial plexus injury. The anatomic course and branching pattern of the MCN were recorded in eligible cases, both as a line diagram and using intraoperative photographs. RESULTS: One hundred fifty patients underwent nerve transfer for the restoration of elbow flexion following an injury to the brachial plexus. The MCN in 138 patients (92%) was found to pierce the coracobrachialis muscle before emerging lateral to it. One hundred thirty-four patients (89.3%) demonstrated the "classical" anatomy. One hundred fifteen patients (76.6%) had a single primary branch to the biceps, whereas 25 patients (16.6%) demonstrated a discrete motor branch to each head. One hundred thirty-three dissections (88.6%) revealed a single muscular branch to the brachialis arising posteromedially from the MCN, distal to the origin of the branch to the biceps brachii. Notable unreported variations, such as the MCN penetrating the biceps as it descended, multiple brachialis branches, and trifurcation of divisions of the MCN, were documented. CONCLUSIONS: Variations in MCN anatomy are quite common, and even unreported variations can be encountered. CLINICAL RELEVANCE: Exploration of the MCN and its branches for nerve transfers requires knowledge of these anatomic variations and vigilance to prevent inadvertent injuries while dissecting them for nerve transfer surgery.

Reliability of Extensor Pollicis Brevis (EPB) Entrapment Test in Identifying a Separate Compartment for EPB in Patients with de Quervain Disease.

Background: The presence of a separate compartment for the extensor pollicis brevis tendon (EPB) has an implication in the treatment outcome for de Quervain disease. The EPB entrapment test, proposed by Alexander and colleagues, claims to correlate with the presence of a separate compartment for EPB. The purpose of our study is to evaluate the reliability of the EPB entrapment test in predicting a separate compartment for EPB in patients with de Quervain disease. Methods: This was a prospective observational study involving 50 consecutive patients who underwent de Quervain release by a single surgeon. Preoperatively, EPB entrapment test was performed by the operating surgeon. The outcome of the test was recorded and the presence of a separate compartment for the EPB was determined during surgery. Sensitivity, specificity, positive predictive value and negative predictive value of the EPB entrapment test was determined. Results: EPB entrapment test was positive in 28 of 50 patients. In 21 of them, a separate compartment for the EPB was noted. The positive predictive value of the test was found to be 75.8%. The test had a false positive rate of 26.9%, a false negative rate of 12.5%, sensitivity of 87.5% and specificity of 73%. There is a significant association between a positive EPB entrapment test and the presence of a separate compartment for the EPB (p value <0.001). The sensitivity of the test increases to 95.8% if pain on both extension and abduction of the thumb is considered a positive response. Conclusions: The EPB entrapment test is a reliable clinical test to look for the presence of a separate compartment for EPB. Considering the response of pain on both extension and abduction of the thumb further improves the sensitivity of the test. Hence, we suggest including this response also as a positive test. Level of Evidence: Level II (Diagnostic).

Brachioradialis to Extensor Carpi Ulnaris Transfer - An Additional Transfer to Prevent Radial Deviation Deformity of the Wrist following Tendon Transfers for Posterior Interosseous Nerve Palsy.

The usual recommendation in posterior interosseous nerve (PIN) palsy is to use the flexor carpi radialis instead of the flexor carpi ulnaris (FCU) for restoration of digital extension. The use of FCU takes away the only remaining ulnar deviator of the wrist. Although preserving the FCU prevents severe radial deviation deformity, we found that some patients still develop a radial deviation deformity, especially during wrist extension. We have used a brachioradialis (BR) to extensor carpi ulnaris (ECU) transfer to prevent the development of a radial deviation deformity and find that it restores the normal radio-ulnar balance of the wrist by providing a dynamic ulnar stabiliser. It is a simple addition to the standard two tendon transfers for PIN palsy with minimal donor morbidity. We have used this triple transfer for PIN palsy in seven patients with satisfactory results and no complications. Level of Evidence: Level V (Therapeutic).

Restoration of Hand Function in Isolated Lower Brachial Plexus Injury with Brachioradialis to Flexor Pollicis Longus and Biceps to Flexor Digitorum Profundus Transfer.

Background: Isolated lower (C8T1) brachial plexus injury (BPI) is uncommon and the aim of treatment is to achieve a satisfactory grasp enabling the use of the hand for daily activities. The aim of this study is to report the outcomes of the transfer of brachioradialis (BR) to flexor pollicis longus (FPL) and biceps to the flexor digitorum profundus (FDP) for an isolated lower BPI. Methods: This is a retrospective study of all patients with an isolated lower BPI who underwent a BR to FPL and biceps to FDP transfer for restoration of digital flexion over a 1-year period from May 2019 to June 2020. Patient demographic and injury data were collected at the presentation. Outcomes data included the ability to grasp and perform activities of daily living and DASH score. Results: The study included three patients (all men) with an average age of 30.3 years. All sustained an isolated lower BPI following a road traffic accident and tendon transfers were performed at a mean of 9.3 months after the initial injury. At a mean of 1-year follow-up, all three recovered grade M4 motor power of digital flexion, achieved good grasp function with pulp-to-palm distance of <1 cm. All are able to use the hand for independent as well as bimanual activities. The individual DASH scores were 36, 30 and 30. Conclusions: BR to FPL for thumb flexion and biceps to FDP using fascia lata graft to restore finger flexion is simple and effective surgeries in patients with isolated lower BPI. Level of Evidence: Level V (Therapeutic).

Wrist Extensor Deficit Detection Test - A Simple Test to Determine Wrist Extension Caused by Digital Extensors in Patients with Extended Upper Brachial Plexus Palsy.

Motor deficit in patients with extended upper brachial plexus palsy is variable. A patient with only thumb and finger extensors may seem to have active wrist extension because of them secondarily acting at wrist and causing wrist extension. To determine the presence of wrist extensors, it is important to block the wrist extension caused by the finger and thumb extensors. Conventional muscle testing is often ineffective in these patients as they learn a variety of trick movements over the time. We describe a simple clinical test to reveal the strength of the wrist extensors only by negating the effect of digital extensors on the wrist. If wrist extensors are absent, a nerve or tendon transfer can be done to address this deficit and improve the functional outcome. Level of Evidence: Level V (Diagnostic).

Considerations in the Selection of Donor Nerves for Nerve Transfer for Reanimation of Elbow and Shoulder in Traumatic Brachial Plexus Injuries.

The advent of nerve transfers has revolutionised the treatment of brachial plexus and peripheral nerve injuries of the upper extremity. Nerve transfers offer faster reinnervation of a denervated muscle by taking advantage of a donor nerve, branch or fascicle close to the recipient muscle. A number of considerations in respect of donor selection for nerve transfers underlie their success. In this review article, we discuss the principles of donor selection for nerve transfers, the different options available and our considerations in choosing a suitable transfer in reanimating the elbow and the shoulder. We feel this will help nerve surgeons navigate the controversies in the selection of donor nerves and make appropriate treatment decisions for their patients. Level of Evidence: V (Therapeutic).

Non-union of the Clavicle Osteotomy Site in an Infant with Birth Brachial Plexus Palsy.

Non-union of the clavicle in the paediatric population is extremely rare. Some anecdotal case reports show non-union following clavicle fracture. However, we could not find any report of non-union following osteotomy for brachial plexus surgery. We report non-union of clavicle following its osteotomy for brachial plexus exploration surgery in a 6-month child. We present successful management of the clavicle non-union in this patient and propose preventive steps. Level of Evidence: Level V (Therapeutic).

Forequarter Replantation.

Traumatic forequarter amputations are rare injuries in which the arm, clavicle, scapula, and proximal shoulder muscles are avulsed from the body. Historically, forequarter amputation has been treated with hemorrhage control, wound debridement, and soft tissue coverage. To our knowledge, successful forequarter replantation has not been previously reported. We present a rare case of forequarter amputation treated successfully with replantation. At the 4.5-year follow-up after replantation, the patient had antigravity elbow flexion, modest shoulder elevation, modest extrinsic finger function, and crude sensation. We discuss relevant technical considerations that indicate that, despite challenges, forequarter replantation can be achieved with success.

Diabetic Hand Infections: Factors at Presentation Influencing Amputation and Number of Surgical Procedures.

Background Diabetic hand infections are associated with significant morbidity and disability. Amputations cause permanent disability, and multiple surgical procedures lead to morbidity. Diabetic foot infections have been well-studied but literature on hand infections is limited. We undertook a retrospective study of patients with diabetic hand infections operated at our center to study the factors at presentation with significant association with amputation and number of surgical procedures. Patients and Methods Demographic data of 51 patients was collected. The six parameters, namely, duration of diabetes, "onset of symptoms to presentation" interval, presence of comorbidities, HbA1c level, random blood sugar (RBS) levels at admission, and culture characteristics were selected for statistical analysis to find a relationship with the two outcome variables: number of procedures done and need for amputation. Results On bivariate analysis, Gram-negative infection was found to have a significant relationship with the need for multiple of procedures ( p = 0 . 014). The mean difference between the "onset of symptoms to presentation" interval between the amputation/non-amputation groups (2.9 days, p = 0 . 04) and the multiple procedures/non-multiple procedure groups (4.4 days, p = 0 . 02) was found to be statistically significant. Presence of comorbidities, long duration of diabetes, HbA1c, and RBS levels at admission did not show any statistically significant association with the two outcome variables studied. Conclusion In the present study, we found that infection with Gram-negative organisms is significantly related to the need for multiple surgical procedures. A delay in presentation can influence the risk of amputation as well as multiple procedures. Institution of early appropriate care is important to get a good outcome.

A Unique Case of Replantation of Previously Replanted Fingers.

Replantation of digital amputations is now the accepted standard of care. However, rarely will a replantation surgeon be presented with amputated fingers which have been previously replanted. In our literature search, we could find only one publication where a replanted thumb suffered amputation and was successfully replanted again. We report the technical challenges and the outcome of replanting two fingers which suffered amputation 40 months after the initial replantation and were successfully replanted again. Replantation was critical since the amputated fingers were the only two complete fingers in that hand which had initially suffered a four-finger amputation. The second-time replantation of previously replanted fingers is reported to allay the concern of the reconstructive surgeon when faced with this unique situation of "repeat amputation of the replanted finger." Second-time replantation is feasible and is associated with high-patient satisfaction. Replantation must be attempted especially in the event of multiple digit amputations.

Kienbock's Disease: Treatment Options - A Search for the Apt!

Kienbock's disease remains a condition of uncertain etiology and our understanding about the pathogenesis is still evolving. However, a lack of consensus on the treatment is the most striking as there are wide array of treatment options described ranging from 'doing nothing' to a free vascularized bone graft reconstruction of the lunate. Furthermore, most treatment modalities report equivalent success rate but cumulative evidence is lacking. This 'black hole' in the literature presents difficulties to surgeons treating the condition and even patient's confidence with the treatment. All the treatment options described reliably relieve pain, thus improving function and patient satisfaction. However, the disease process is not reliably altered by any of the treatment options described till date. The operative treatment chosen depends on the stage of the disease, ulnar variance, age of the patient and surgeon preference. The treatment options in early stage (before lunate collapse) aim to preserve the lunate while once the lunate is collapsed its removal is performed. The lunate preserving operations basically are either decreasing the load on the lunate to possibly permit its revascularization or are the procedures which are aimed at augmenting the vascularity of the lunate. Radius shortening osteotomy is the most popular treatment in the early stages especially in the patients' with negative ulnar variance and the proximal row carpectomy is most popular in the advanced stages of the disease. Authors present their algorithm of management of Kienbock's disease and discuss the various treatment options described in the literature in an attempt to find the apt in 2020.

Technical considerations and outcome of free functioning gracilis muscle transfer for finger flexion in patients with Volkmann's Ischemic Contracture.

INTRODUCTION: Severe Volkmann's Ischemic Contracture (VIC) is a reconstructive challenge for the surgeon because of the loss of entire flexor muscle mass and lack of powerful wrist extensors for restoration of finger flexion. In such cases, free functioning muscle transfer (FFMT) using gracilis is our choice. We herein summarize the technical considerations to achieve a successful outcome and report functional outcome achieved in our series. PATIENTS AND METHOD: Between 2007-2018, 22 patients of VIC underwent gracilis FFMT for restoration of finger flexion. FFMT was done as a second stage following an initial stage of neurolysis/excision of fibrotic flexor muscles/contracture release/flap cover in these patients. Cases were retrospectively reviewed and their functional outcome at a minimum of one-year follow up was analyzed. Follow-up duration ranged from 2-13 years (average-4 years). At the final follow up, the motor and sensory recovery was evaluated using the Medical Research Council Grading and their function using Disabilities of the Arm, Shoulder, and Hand (DASH) score. RESULTS: The average age at surgery ranged from 3-45 years (average-18.4 years). All the transferred muscles survived. Secondary procedures to further improve the hand function were done in nine patients. The motor recovery for finger flexion was graded as M2 in two, M3 in nine and M4 in 11 cases. These 20/22 patients who recovered M3/M4 finger flexion expressed high satisfaction with the operation while other two also felt that they were better after the surgery. DASH score was available for 13 patients and it averaged 13.21 (Range-1.8-34.5). Grip strength was available for 10/22 patients and it averaged 10.5 kg (range-0-21kg) amounting to 24% of the normal side. The sensory recovery was graded as S4 in two, S3 in 17 and S2 in three cases. CONCLUSION: Gracilis FFMT is a reliable option for restoration of finger flexion in patients with severe VIC. Outcome is better when done after an early preliminary stage of excision of fibrosed muscles and neurolysis which allows recovery of intrinsic function and sensation. FFMT is best carried out 3-6 months after the first stage with supple skin and good passive range of movement in the fingers.