Computed Tomographic Arthrography (Arthroscanner) of the Wrist Joint: Why, How, and When.

Background: Acute or chronic wrist pain is a common presentation to a general orthopedic surgeon. The wrist joint is considered one of the most complex articulations in the human body. The complex arrangement of the wrist's intrinsic and extrinsic ligaments and their biomechanics are challenging for the surgeon to diagnose the wrist pathology despite clinical examination. Radiographs, CT scans and MRI are a few modalities that diagnose wrist pathologies efficiently. The accuracy, sensitivity, and specificity in evaluating the chondral, bone, and ligamentous lesion are its limitations. Wrist arthroscopy is considered the reference standard for diagnosing intraarticular pathology of the wrist. Surgical intervention, anesthesia, and the learning curve in wrist arthroscopy are its drawbacks. Conclusion: CT arthrography is a reliable option for viewing bone anatomy and diagnosing ligamentous tears, cartilage lesions, avulsion injuries, and chondral defects. This review article will discuss surgical anatomy, methods of performing CT arthrography, interpretation of the results, and their advances.

Non-Suspensionplasty by Abductor Pollicis Longus Tendon for First Carpometacarpal Osteoarthritis of the Thumb.

Many surgical procedures have been described for treating painful osteoarthritis at the carpometacarpal joint of the thumb. We describe the new nonsuspension abductor pollicis longus (APL) arthroplasty of base of the thumb after excision of trapezium. APL arthroplasty formed neojoint scapho-metacarpo-trapezoid joint. This technique is effective, technically straightforward, and appears to be robust.

Fingertip Injuries Outcome Score.

Fingertip injury reconstruction aims to restore function and appearance. We report our new fingertip injuries outcome score (FIOS) based on finger length, bone consolidation, nail aesthetics, sensation, range of motion, grip strength, and return to work to evaluate the functional outcome of fingertip injuries. Methods: We analyzed the reliability and validity of the FIOS in 199 fingertip injuries of varying size, shape, and contours involving soft tissues and the bone. Semi-occlusive dressings and various reconstructive procedures were done based on the geometry. The FIOS had 10 items and specific scores. Results: The mean follow-up of our study was 26.8 months (range, 18-66 months). We classified the results based on the FIOS. A value of 12 or more is considered excellent; 13-18 is good; 19-24 is fair; and greater than 24 is poor. Excellent or good results were achieved in 186 cases. Nine cases had fair results, and four had poor results. We found the FIOS significantly reliable, consistent (Cronbach's alpha 0.796), reproducible, and valid (ANOVA P < 0.05). Conclusions: FIOS is a simple, reliable, and meaningful method to assess the outcome of fingertip injuries. It is clinically relevant and remains a comparison tool for evaluating the efficiencies of treatment.

Delayed Graft Reposition on Flap (GRF) in Six Week Old Allen Type 4 Amputation: Case Report.

An exceptional case like our patient who was a 24-year-old man presented 6 weeks after type 4 Allen amputation to his right index finger where primary surgical stump closure was done, presented to us with the amputated distal part warm preserved. The reposition of distal amputated part using the authors described GRF (Graft Reposition on Flap) technique was done and followed. Good consolidation and bone graft union, good nail with near normal pulp and normal sensation with good functional outcome was achieved at the one-year final follow up.

An Ulnar-Type Dislocation of Fifth Carpometacarpal Joint: Case Report and Review of the Literature.

Unilateral pure dislocation of the fifth carpometacarpal joint (CMCJ) is a very rare injury. We are reporting the second case of an ulnar type of unilateral dislocation of a fifth CMCJ. Indian salutation (Namaskar) test and radiographs aid in diagnosis. Closed reduction and internal fixation by K-wires restored the normal anatomic relationships of the fifth CMC joint. This type of injury is prone to be missed in an emergency room due to soft tissue swelling, and particular attention should be paid to diagnose it in polytrauma patients. A review of the literature is presented.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Bilateral Brachial Plexus Palsy in Restless Patient.

We present a case of bilateral infraclavicular brachial plexus palsy at terminal branching level in organophosphorus poisoning patient. The complication occurred during treatment. The patient was tied to the side railing of the bed with bandage as patient was restless. It is an acceptable practice so that the restless patient does not inflict injuries when he is restrained on the bed. Failure to recognize the significance of this will lead to patient injury.

Graft Reposition on Flap: Mid-Term Result in Allen Type IV Amputation.

Background: The preferable reconstructive surgical options for Allen type IV finger amputation is replantation. The viable alternate option is bone and nail bed graft repositioning on local flaps. The wider scope of this "graft reposition on flap" (GRF) technique was introspected. Methods: Fifteen patients who sustained type IV amputations of finger tip were operated between 2013 and 2017 by GRF technique. The results, range of motions, functional out come and its feasibility were analyzed and evaluated. A technical modification of GRF was also described within this series of patients. Results: All patients had good nail bed survival and well settled local flaps. Static two-point discrimination (2PD) was of 6.4 mm (average). 14/15 patients had an acceptable shortening of 4mm (average). Overall patients were happy after surgery and returned back to their work. All had excellent range of movements and 0 VAS. The follow up was 1 to 5 years (mean 2.8 years). Wound infection was seen in one patient whom after debridement developed gross shortening and thick nail. None developed nail deformity. Conclusions: The GRF provided an alternative option for Allen type IV amputations of finger tip. It can be well executed in all reconstructive surgical units and in those with a learning curve for replantations surgeries. The results of GRF were proportionate with the available surgical options in terms of appearance, function and outcomes.

Perthes-Like Lesion in Wrist Joint: Stripping of Ulnar Collateral Ligament.

Background Chronic ulnar-sided wrist pain often proves to be a challenging presenting complaint. A new type of injury to the ulnar collateral ligament (UCL) of the wrist is described in a young female. It is characterized by stripping of UCL from ulnar attachment. Case Description A 32-year-old female sustained an injury after lifting heavy weight. Examination revealed tenderness to the ulnar styloid, terminal radial deviation was painful and decreased grip strength. The arthro-computed tomography (Arthroscanner) diagnosed stripping of ulnar collateral ligament (UCL). The UCL was refixed with transosseous sutures. At one year follow-up, the patient was pain-free with good range of motion and improved grip strength. Literature Review After intense literature review, we found this type of injury was not reported, but we found the same type of injury in the shoulder "Perthes lesion." Clinical Relevance The UCL stripping of the wrist is a rare entity and undiagnosed on routine investigation. This lesion was only diagnosed on an arthroscanner and was missed on MR study which is commonly used for diagnosed wrist pain. This case is being reported for its rarity and to expand the differential diagnosis of the ulnar-sided wrist pain.

New technique "graft reposition on flap" in allen type iv amputation: a report of six cases.

Allen type IV fingertip amputations were treated by a modified technique, when the replantation is difficult to be performed or not an option. The pre-existing technique involves nail bed grafting and local flap. In the modified technique, a free bone graft is added, bone and free nail bed repositioned and pulp reconstruction by local flap. This can be best described "graft reposition on flap" (GRF). GRF was found to be simple and cost effective. It allows preservation of finger length and a fully functional and cosmetically acceptable nail.