Single-Stage Flexor Tendon Grafting: Refining the Steps.

Single-stage tendon grafting for reconstruction of zone I and II flexor tendon injuries is a challenging procedure in hand surgery. Careful patient selection, strict indications, and adherence to sound surgical principles are mandatory for return of digital motion.

Current options for treatment of hypothenar hammer syndrome.

Hypothenar hammer syndrome is a rare vascular condition resulting from injury to the ulnar artery at the level of Guyon canal. The ulnar artery at the wrist is the most common site of arterial aneurysms of the upper extremity and is particularly prone to injury. Signs and symptoms include a palpable mass, distal digital embolization to long, ring, or small fingers, pain, cyanosis, pallor, coolness, and recurrent episodes of vasospasm. Modalities for diagnosis, evaluation, and surgical planning include duplex study, contrast arteriography, and computerized tomographic angiography (CTA). Management includes medical, nonoperative, or operative treatments. Appropriate treatment options are reviewed.

Proximal interphalangeal joint injection through a volar approach: anatomic feasibility and cadaveric assessment of success.

PURPOSE: The proximal interphalangeal (PIP) joint is a challenging joint to access reliably for corticosteroid injection. Literature has confirmed both a relatively high failure rate for injections performed with the traditional dorsal approach and an improved clinical response rate for confirmed intra-articular injections. We describe a technique for injecting the PIP joint through a volar approach, assess its reliability through cadaveric dissection, and determine its reproducibility by comparing success rates with the dorsal approach in a cadaver model. METHODS: We dissected the PIP joint of 10 cadaveric digits to document necessary anatomic landmarks for this technique. We then used 20 matched pairs of cadaver hands for the remainder of our study. Four PIP joints on each hand (thumb excluded) were injected with a solution of saline and radio-opaque dye using the dorsal approach. We injected each joint on the contralateral matched hand through the volar approach. We obtained standardized fluoroscopic images of each joint immediately after injection, which were reviewed by an independent observer who was blinded to the technique and who rated outcomes as success, failure, or mixed. Success rates were evaluated based on approach used, digit injected, and degree of pre-existing arthritis. RESULTS: We found reproducible anatomic landmarks that justified our injection technique. The rates of absolute failure were similar in the 2 cohorts. The volar approach demonstrated a higher percentage of successful injections with a smaller percentage of mixed results, although results did not reach statistical significance. There was no statistically significant difference in success rates based on digit injected or grade of arthritis in either cohort. CONCLUSIONS: The volar approach to injecting the PIP joint demonstrated success similar to that of the traditional dorsal approach. Reproducible surface landmarks exist to guide practitioners using this technique. Further study is needed to determine the potential complications and clinical outcomes of the volar approach. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Arterial conduits for distal upper extremity bypass.

Vascular bypass is an accepted surgical procedure for treatment of hand and digital ischemia that is the result of identifiable arterial disease. Although vein grafts have traditionally been used as vascular conduits for reconstruction, arterial grafts present a better alternative, physiologically, for reconstruction and may result in superior outcomes. Arteries suitable for grafts are not abundant and, therefore, upper extremity surgeons must be informed about possible donor sites and techniques for harvest.

Reconstruction for ulnar artery aneurysm at the wrist.

Arterial aneurysms of the upper limb most commonly involve the ulnar artery at the wrist. Hypothenar hammer syndrome is the usual cause of arterial trauma that forms the aneurysm. After excision of the aneurysm, vein or arterial conduits bridge the arterial gap. Digital ischemia is relieved by arterial reconstruction; however, many patients continue to experience cold-related symptoms.

Vascular insufficiency of the upper extremity.

Vascular insufficiency of the upper extremity can be due to acute vascular injury, chronic vasospastic disease, and occlusive disease. Its treatment requires a thorough understanding of the vascular anatomy of the upper extremity, diagnostic modalities, and medical and surgical management options. Promising advances continue to be made in surgical treatment and medical therapy.