Superficial acral fibromyxoma: insights from case management and comprehensive literature review.

Superficial acral fibromyxoma, also known as digital fibromyxoma, is a slow-growing, benign, solitary soft tissue tumor. First described in 2001 by Fetsch et al., it is a condition that often occurs in middle-aged individuals. However, it has also been reported across a wide range of ages, ranging from 4 to 86 years, with males more commonly reported. The condition often presents as solitary soft tissue swelling over the periungual or subungual. We present the management experience of the rare presentation of this rare tumor and a detailed review of the past literature on this condition. Detailed management of the condition has been described, along with the outcome after 2 years of follow-up and treatment experience. Our detailed analysis shows that 2 years is the shortest duration of follow-up to rule out recurrence. Hence, most of the cases reported earlier had given the false sense of the recurrence rate of the tumor, which could lead to undertreatment of the condition. The purpose of this article is to allow the readers to understand better the tumor's characteristics with bone involvement and the tumor's diagnostic strategies and treatment options.

Flexor tendon degeneration affects short-term outcomes of open trigger digit release.

We aimed to investigate the association between flexor tendon degeneration and outcome of open trigger digit release. We recruited 162 trigger digits (136 patients) who had open trigger digit release from February 2017 to March 2019. Intraoperatively, six features of tendon degenerations were identified: irregular tendon surface, tendon fraying, intertendinous tear, synovial thickening, hyperaemia of sheath and tendon dryness. Longer duration of preoperative symptoms was associated with worsening tendon surface irregularity and fraying; increased number of steroid injections was associated with worsening tendon surface irregularity and dryness; higher DASH score was associated with severe tendon fraying, dryness and intertendinous tear; limited proximal interphalangeal joint (PIPJ) motion was associated with severe tendon dryness. At 1-month post-surgery, DASH score remained high in severe intertendinous tear group while PIPJ motion remained limited in severe tendon dryness group. In conclusion, the severity of various flexor tendon degenerations influenced the outcome of open trigger digit release at 1-month but did not affect the outcome at 3- and 6-months post-surgery.

Video-assisted thoracoscopic surgery (VATS) aided full-length phrenic nerve transfer for restoration of elbow flexion.

BACKGROUND: In complete brachial plexus injury, phrenic nerve (PN) is frequently used in neurotization for elbow flexion restoration. The advancement in video-assisted thoracoscopic surgery (VATS) allows full-length PN dissection intrathoracically for direct coaptation to recipient without nerve graft. PURPOSE: We report our experience in improving the surgical technique and its outcome. METHODS: Seven patients underwent PN dissection via VATS and full-length transfer to musculocutaneous nerve (MCN) or motor branch of biceps (MBB) from June 2015 to June 2018. Comparisons were made with similar group of patients who underwent conventional PN transfer. RESULTS: Mean age of patients was 21.9 years. All were males involved in motorcycle accidents who sustained complete brachial plexus injury. We found the elbow flexion recovery were earlier in full-length PN transfer. However, there was no statistically significant difference in elbow flexion strength at 3 years post-surgery. CONCLUSION: We propose full-length PN transfer for restoration of elbow flexion in patients with delayed presentation.

The Outcome of Moderate-to-Severe Complications Related to Peripheral Intravenous Devices at Upper Limb.

Background: Intravenous access is very crucial in administration of fluids, medications and nutrition. Almost all inpatients will require it and the simplest and quickest access is peripheral with the preferred sites being either dorsum hand, radial wrist or forearm. It has its complications, of which most are avoidable. Literature has emphasised the complications and reported on preventive measures but lacks the sequelae of the complications related to peripheral intravenous devices (PIVD). We report on the sequelae of moderate-to-severe complications of these patients. Methods: Thirty-three patients had moderate-to-severe complications related to PIVD in a tertiary centre from January 2017 to December 2017. All data were obtained from electronic medical report (EMR). Results: Majority had extravasation (45.5%) and abscess (39.4%), whereas two patients had thrombophlebitis (6.1%) and three patients developed necrotising fasciitis (9.1%). All patients with abscess and necrotising fasciitis underwent surgical intervention (n = 16); four patients had multiple debridements. All infections were treated with empirical antibiotics and changed after culture results were obtained. Seven patients had sepsis/bacteraemia wherein two of them passed away. A total of 31 patients were discharged. Two patients had secondary suturing of the wound, one had split-thickness skin grafting (SSG) coverage and the others had daily dressing until the wound healed by secondary intention. Conclusions: PIVD-related complications can be debilitating and may occur despite strict preventive measures. Early clinical diagnosis and prompt treatment of these complications can decrease its morbidity. Level of Evidence: Level IV (Prognostic).

Reliability of WhatsApp images of plain radiographs to diagnose fractures of the hand and wrist.

We assessed the reliability of plain radiographs interpreted through WhatsApp messaging system in orthopaedic hand trauma consultation in a large teaching hospital. Plain radiographs of 25 hand fractures and five normal radiographs were captured from a picture archiving and communication system using iPhone XS smartphone, anonymized and sent to 53 orthopaedic residents' and consultants' personal smartphones. The participants independently assessed the images and answered questions on fracture identification and characteristics, diagnostic confidence, further imaging and surgical inclination. The study was repeated after a 1-month washout period using the picture archiving and communication system on the hospital desktop. The results showed good (0.60 < ƙ < 0.80) intraobserver agreement on fracture identification and characteristics. The overall diagnostic accuracy for hand fractures was 95% on WhatsApp and 99% on the desktop. In conclusion, images of plain radiographs transmitted via WhatsApp were reliable for interpretation in orthopaedic hand trauma consultation.Level of evidence: IV.

Relationship of ulna styloid fracture to the distal radio-ulnar joint stability. A clinical, functional, and radiographic outcome study.

BACKGROUND: Ulna styloid fracture occurs approximately about 55% of all distal end of radius fractures. However, the clinical and functional outcome of these fractures remains indefinite. RESULTS: Only 56 patients with distal radius fractures had concomitant ulna styloid fractures. The mean age was 32 years (range: 18-69; SD: ± 12.7). The majority were men. The mean time from injury was 18.7 months (range: 6-84; SD: ± 13.3). The most common was Frykman 2, followed by 6, type 8, and type 4. All were closed fractures; 60.7% were base, and 39.3% were tip fractures. 50% were treated with casting, 48.3% plating, and 1.8% external fixation. The mean period of casting was 7.67 weeks (range: 4-16; SD ± 3.1). The ulna styloid was united in 35.7%. There is no significant difference in the range of movement between those with ulna styloid union and non-union. The Ballottement test and Piano key sign was statistically insignificant between both groups. All the displacements were dorsal except in 1 case. The mean displacement of ulna styloid is 1.88mm (SD±1.08, Range: 0.20-4.60mm). The mean VAS score at rest and work is not statistically significant. The mean grip strength and functional score (DASH) are similar in both groups. CONCLUSION: Ulna styloid fractures do not contribute to the DRUJ instability and the status of the union of the ulna styloid and the site of the ulna styloid fracture (tip or base) did not have a bearing on the range of movement and functional status of the affected wrist. Temporary DRUJ immobilization might allow TFCC recovery.

A traumatic open knee wound in a replaced knee resulting in a prosthetic joint infection.

Knee arthroplasties are successful procedures that allow patients to return to their pre-arthritic functional levels. However, the success rates can be blemished by prosthetic joint infections, which are devastating complications that commonly render patients worse off than before the index surgery. Inoculation of the pathogens is frequently from the index surgery, or through the bloodstream. Herein, we report a case of a prosthetic joint infection by which the pathogens were most likely inoculated from direct contact, through a traumatic open knee wound occurring from a road traffic accident. Management of the infection, involving an incision & drainage with modular parts exchange, as well as the challenges with the soft tissue envelope is highlighted. At one year of follow-up, the infection seemed to be curtailed. Currently, the patient is very satisfied with the condition of his knee, which has a range of motion of 0 to 135 and his pre-morbid function has been regained. This case denotes the importance of early identification, soft tissue management, as well as a multidisciplinary approach in managing such conditions.

Upper limb infections: A comparison between diabetic and non-diabetic patients.

BACKGROUND: Upper limb infections are common among patients with diabetes mellitus and their sequelae can be debilitating. They tend to present with severe infections but minimal symptoms probably due to neuropathy and vasculopathy among diabetics. The study aims to compare the demographic characteristics, clinical presentations and outcomes of upper limb infections between diabetic and non-diabetic patients. METHODS: All patients with upper limb infections who were admitted in a tertiary hospital from June 2017 to December 2020 were included in this study. Demographic data, clinical presentations, investigations and outcomes were obtained retrospectively from electronic medical record. There were 117 patients with diabetes mellitus and 127 with no diabetes mellitus. Comparisons were made between these two groups, and statistical analysis was done with SPSS. RESULTS: There were 244 patients included; 117 were diabetic and 127 were non-diabetic. Diabetic patients were more likely to present with emergent scenarios, especially necrotizing fasciitis and infective tenosynovitis (p < .05) with higher erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) readings (p < .05). Their microbiological cultures were less likely to be negative (p < .05). Diabetic patients also had poorer clinical outcomes with higher risk of amputation, re-operation and longer duration of hospital stay (p < .05). CONCLUSION: Upper limb infections among diabetic patients should be treated aggressively. Early diagnosis and surgical intervention might decrease the morbidity and mortality in this group. Prevention of infections should be emphasized.

Clinical outcome of Maggot Debridement Therapy followed by Negative Pressure Wound Therapy for chronic hand wound with Multi-Drug Resistant Organism infection: Two cases and review of the literature.

The advancement in science and research has led to development of medical maggots which feed exclusively on dead tissue. Medical maggots have three important functions namely debridement, disinfection, and stimulation of wound healing. The modern use of medical maggots now goes by the term "Maggot Debridement Therapy" (MDT) for use in wound management. MDT is still used infrequently due to the effectiveness of surgical debridement and antibiotics for treatment of wound infection. Lately, there was emergence of Multi-Drug Resistant Organism (MDRO) likely due to inappropriate antibiotics usage. Maggot secretions have been shown to be effective in inhibiting some MDRO, for example, Methicillin-resistant Staphylococcus aureus, thus making MDT an attractive option for wounds with MDRO. We report two patients with multiple medical comorbidities, diagnosed with serious MDRO Diabetic Hand Infections treated with three cycles of MDT followed by Negative Pressure Wound Therapy.

A Novel Supraretinacular Endoscopic Carpal Tunnel Release: Surgical Technique, Clinical Efficacy and Safety (A Series of 48 Consecutive Cases).

Purpose: Endoscopic carpal tunnel release has been shown to have a shorter recovery period than open surgery. This study was aimed at assessing the efficacy and possible clinical complications of a novel supraretinacular endoscopic carpal tunnel release technique. Methods: A total of 50 cases involving 46 patients were evaluated in this prospective study, in which all surgeries were performed by a single surgeon between 2016 and 2018. The patients were evaluated preoperatively; at 3, 7, and 14 days after surgery; and at 1, 3, and 6 months after surgery. The effectiveness of the surgery was evaluated using pinch and grip strengths, modified table test, visual analog scale pain score, the Disabilities of the Arm, Shoulder and Hand, the Boston Carpal Tunnel Questionnaire symptom severity scale, and the Boston Carpal Tunnel Questionnaire functional status scale. The Friedman test and Wilcoxon signed-rank test were used for a statistical analysis. Results: At 6 months after the surgery, all measured parameters showed improvements. The pinch strength score improved from 2.29 kg before the surgery to 2.96 kg 6 months after the surgery (P = .003), the grip strength score improved from 12.10 kg to 13.98 kg (P = .028), the modified table test score increased from 6.55 kg to 8.76 kg (P < .001), the visual analog scale score decreased from 6.31 to 0.52 (P < .001), the Disabilities of the Arm, Shoulder and Hand score reduced from 41.66 to 14.10 (P < .001), and the Boston Carpal Tunnel Questionnaire symptom severity scale and the Boston Carpal Tunnel Questionnaire functional status scale scores reduced from 2.68 to 1.51 (P < .001) and from 2.56 to 1.44 (P < .001), respectively. There were no serious injuries or complications reported in this series. Conclusions: This new supraretinacular endoscopic carpal tunnel release technique was shown to be efficacious in this series. Type of study/level of evidence: Therapeutic IV.

A comparison of delta wire technique versus extension block pinning in the treatment of bony Mallet finger.

ZIEL: Diese Studie vergleicht die klinischen Ergebnisse nach Delta-Draht-Technik (Gruppe 1 = 7 Patienten) mit den Ergebnissen nach Extensions-Block-Pinning (Gruppe 2 = 11 Patienten) in der Behandlung des knöchernen Mallet-Fingers. PATIENTEN UND METHODEN: Sechs Monate postoperativ wurde bei allen Patienten das klinische Ergebnis nach den Crawford-Kriterien, die Schmerzen anhand einer visuellen Analogskale (VAS) und der DASH-Score ermittelt. Zusätzlich wurden die aktive Beweglichkeit und das Extensionsdefizit im Endgelenk sowie aufgetretene Komplikationen festgehalten. ERGEBNISSE: Patienten der Gruppe 1 hatten eine signifikant bessere Beugung im Fingerendgelenk, aber auch ein signifikant größeres Extensionsdefizit, obwohl sie signifikant früher ihre Arbeit wiederaufnahmen. Nach den Crawford-Kriterien erzielten 71 % der Patienten der Gruppe 1 und 100 % der Gruppe 2 ein exzellentes und gutes Ergebnis. Keine Unterschiede konnten bzgl. der OP-Dauer, der Schmerzen, dem DASH-Score und der Zeit bis zur knöchernen Heilung festgestellt werden. SCHLUSSFOLGERUNG: In der Kurzzeitbeobachtung werden mit Extension-Block-Pinning bessere Ergebnisse in der Behandlung des knöchernen Strecksehnenausriss am Fingerendglied erzielt als mit der Delta-Draht-Technik.

Nail bed and flap reconstructions for acute fingertip injuries - A case review and report of a chemical burn injury.

Nail bed injuries were commonly found concomitantly with fingertip injuries. Reconstruction of fingertip including the nail bed should be attempted at acute stage. Aim of the surgery was to restore as much finger length and achieve normal nail growth. In chemical burns, the initial presentation might not reflect the exact extent of injury. Appropriate acute management must be initiated while waiting for demarcation. We report a case of young stewardess who presented with fingertip chemical burn injury. Surgical debridement was done on third day post-injury. A cross-finger flap to cover skin defect and split-thickness nail bed grafting from the remnant of injured finger were done. Excellent functional and cosmetic outcome was achieved in 6 months. Surgical treatment in a chemical burn was similar to traumatic injury. Nail bed graft was the best option for nail bed reconstruction. In cases of soft tissue loss, advancement or pedicle flaps are beneficial.

Short-term clinical outcome of orthosis alone vs combination of orthosis, nerve, and tendon gliding exercises and ultrasound therapy for treatment of carpal tunnel syndrome.

STUDY DESIGN: Prospective randomized study. INTRODUCTION: Carpal tunnel syndrome (CTS) has been described as the most common compression neuropathy. Many modalities exist for conservative treatment. Efficacy of each modality has been described in the literature. However, the effectiveness of combination of these modalities is not well established. The purpose of this study is to assess the short-term clinical outcome of conservative treatment for CTS comparing orthosis alone with combination of orthosis, nerve/tendon gliding exercises, and ultrasound therapy. METHODS: Forty-one patients who presented to Upper Limb Reconstructive and Microsurgery Clinic, University Malaya Medical Centre with CTS and positive electrodiagnostic study were recruited. Fifteen patients had bilateral CTS. Fifty-six wrists were equally randomized to orthosis alone and a combined therapy of orthosis, nerve/tendon gliding exercise, and ultrasound therapy. All patients were required to complete the Boston Carpal Tunnel Questionnaire during the first visit and 2 months after treatment. RESULTS: Both the orthosis and combined therapy groups showed a significant improvement in symptoms and function after treatment. The mean difference of symptoms in the orthosis group was 0.53; 95% confidence interval [CI]: 0.23-0.83 (P = .001) and in the combined therapy group was 0.48; 95% CI: 0.24-0.72 (P < .001). Mean difference of function in the orthosis group was 0.59; 95% CI: 0.28-0.91 (P = .001) and combined group was 0.69; 95% CI: 0.49-0.89 (P < .001). However, there was no significant difference in symptom severity and functional status scores between the groups. DISCUSSION: Our findings support other findings where orthosis and exercises improved symptom severity and functional status scores, however, there was no significant difference between orthosis alone and combined treatment. CONCLUSION: Patients who underwent conservative management for CTS showed improvement in symptoms and function. However, the combination of orthosis, nerve/tendon gliding exercises, and ultrasound therapy did not offer additional benefit compared to orthosis alone.

Perceived comfort during minor hand surgeries with wide awake local anaesthesia no tourniquet (WALANT) versus local anaesthesia (LA)/tourniquet.

PURPOSE: Minor hand surgeries can be done under field sterility in procedure rooms. Surgeons are still sceptical about the usage of wide awake local anaesthesia no tourniquet (WALANT) technique. They perceive that patients can tolerate tourniquet for a brief period while they perform minor surgeries under local anaesthesia (LA). We compared the perceived comfort experienced by patients during minor hand surgeries with WALANT and LA/tourniquet. We investigated the difference in preoperative preparation time, operating time and blood loss between the two groups. METHODS: Between July and October 2016, a total of 72 patients were diagnosed with carpal tunnel syndrome, trigger finger or ganglion, at the University Malaya Medical Centre. Forty patients consented to participate in this study and were randomized into WALANT and LA/tourniquet groups. Anaesthesia was administered accordingly and tourniquet was applied. The time taken for preoperative preparation and surgery was recorded. Each surgeon estimated the blood loss. The perceived comfort level of each patient was quantified using a visual analogue score (VAS). Data were analysed using SPSS. RESULTS: The mean VAS for the WALANT group was 2.33 ± 1.94, whereas it was 4.72 ± 3.05 for the LA/tourniquet group, and the difference was statistically significant ( p < 0.05). The mean time for preoperative preparation in WALANT group was 19.17 ± 12.61 min and LA/tourniquet group was 7.05 ± 3.44 min. The difference between these groups was statistically significant ( p < 0.01). There was no significant difference in operating time and blood loss. CONCLUSION: WALANT technique was associated with better patient comfort. Tourniquet was the main reason for discomfort during surgeries. WALANT is an alternative in minor hand surgeries for a bloodless surgical field without the discomfort of tourniquet application.

Granular cell tumour: malignant or benign?

INTRODUCTION: Granular cell tumours (GrCTs) are uncommon soft tissue tumours that are usually benign (approximately 0.5%-2.0% have been reported as malignant). They are very rarely found at the extremities. Differentiating a malignant GrCT from a benign one is important as the former is aggressive and has a poor prognosis, whereas the latter, after surgical resection, has excellent outcomes. A malignant lesion can be suspected on clinical presentation and confirmed via histopathological examination using the Fanburg-Smith criteria. METHODS: This was a retrospective review of all cases of GrCT of the extremities that presented to the Orthopaedic Oncology Unit of University Malaya Medical Centre, Malaysia, from September 2006 to March 2013. RESULTS: There were a total of five cases, all of which involved female patients aged 13-40 (mean age 24) years. Three cases involved the upper limbs and two involved the lower limbs. Using the Fanburg-Smith criteria, three cases were classified as benign, one as atypical and one as malignant. Wide local excision was performed in all five cases and the outcomes were excellent except for the patient with a malignant tumour. That patient presented with lung metastasis about three months after surgery. CONCLUSION: Malignant and benign GrCTs can be differentiated on clinical presentation and by using the Fanburg-Smith criteria. We believe that wide local excision is the best treatment for both benign and malignant tumours. The role of adjuvant chemotherapy and radiotherapy in malignant GrCTs should be studied. All patients with GrCTs should receive follow-up to check for recurrence and metastasis.