Current Concepts in Scapholunate Instability Without Arthritic Changes.

Scapholunate instability (SLI) is the most common carpal instability described. SLI leads to a degenerative arthritic pattern known as scapholunate advanced collapse (SLAC). Diagnosis of SLI can be challenging in pre-dynamic and dynamic stages. CT arthrogram, MR arthrogram and dynamic fluoroscopy are helpful in diagnosis while arthroscopy remains the gold standard. SLI is a multi-ligament injury, which involves not only the scapholunate interosseous ligament (SLIL) but also the extrinsic carpal ligaments. Hence, it is better described as an injury compromising the 'dorsal scapholunate(dSLL) complex'. A repair can be attempted for acute SLI presenting within 6 weeks of injury. Reconstruction is the mainstay of treatment for chronic SLI without degenerative changes. Multiple repair techniques have been described which include capsulodesis and tenodesis procedures. The clinical outcomes of the techniques have improved over the years. However, a common problem of all these techniques is the lack of long-term data on the outcomes and deteriorating radiological parameters over time. SLI staging is an important factor to be considered in choosing the reconstruction techniques for a better outcome. Currently, there is a trend towards more biological and less invasive techniques. Regardless of the technique, it is important to preserve the nerve supply of the dorsal capsuloligamentous structures of the wrist. Arthroscopic techniques being minimally invasive have the advantage of less collateral damage to the capsuloligamentous structures. Rehabilitation involves a team approach where a protected dart thrower's motion is allowed after a period of immobilization. Strengthening SL-friendly muscles and inhibiting SL-unfriendly muscles is a key principle in rehabilitation.

Flexor Digitorum Superficialis tendon transfer for a long-standing boutonniere deformity finger - a retrospective study of 11 cases.

INTRODUCTION: A long-standing boutonniere deformity is challenging to treat because of well-established complex pathophysiological changes in the extensor expansion mechanism. The role of ulnar slip flexor digitorum superficialis tendon transfer for central slip reconstruction in such chronic deformities is analyzed and correlated with the functional outcome. HYPOTHESIS: Ulnar slip FDS tendon corrects the long-standing boutonniere deformity and replicates anatomical repair. METHODS: We conducted a retrospective study between 2014 and 2016 and operated on 11 patients by FDS tendon transfer to the extensor expansion's central slip. We compared the preoperative and postoperative range of movements in the proximal interphalangeal joint, distal interphalangeal joint, Visual analogue score, and grip strength. Also, we statistically correlated various parameters and non-parameters affecting the functional outcomes. RESULTS: The mean time interval between the injury and surgery was 39 months. The average follow-up of our study was 15.4 months. Ten of the 11 patients had good functional outcomes with statistically significant improvement in the movements and grip strength (p<0.05). CONCLUSIONS: Ulnar slip FDS tendon transfer is effective for central slip reconstruction in a long-standing boutonniere deformity. Minimal degrees of proximal interphalangeal joint extension deficit is inevitable due to the chronicity and adaptive changes in the ligament-tendon-bone complex. LEVEL OF EVIDENCE: IV; retrospective case study.

Supraclavicular Flap for Severe Post-burn Neck Contracture in Children.

The neck is essential and vital for all head movements and performing daily functional activities. The second-degree deep dermal and full-thickness burns causing anterior neck contracture restricts movement and if untreated develop deformities, in the oral cavity, eyes, posture, and chin growth and development, especially in children. Neck contracture results in kyphoscoliosis, lower lip seal resulting in impaired vision, balance, swallowing, feeding, and speech as well as social stigma, depression, and embarrassment. The treatment for post-burn anterior neck contractures is contracture release and reconstruction with skin grafts (split and full-thickness), axial pattern flaps, perforator propeller flaps, microvascular free flaps, tissue expansion, prefabrications, and skin substitutes. In addition to functional and esthetic recovery, post-surgery social and vocational rehabilitation is essential for children. We report a ten-year-old boy with severe anterior neck post-burn contracture managed with unilateral supraclavicular flap and residual areas with a split-thickness skin graft.

Open Surgical Decompression for Large Multiloculated Spinoglenoid Notch Ganglion Cyst With Suprascapular Nerve Neuropathy.

Suprascapular nerve entrapment at the spinoglenoid notch causes infraspinatus weakness and wasting. Patients present with shoulder pain and weakness. The spinoglenoid notch cyst is the reason for suprascapular nerve compression. Magnetic resonance imaging (MRI) confirms the diagnosis of spinoglenoid cyst and its nerve compression. Also, MRI rules out other differential diagnosis causing shoulder pain and weakness. One of the treatment modalities for small and asymptomatic cyst is conservative, which has produced acceptable results and functional outcome. Open or arthroscopic aspiration or decompression is indicated for patients with single small cysts where conservative treatment failed, and cyst associated with suprascapular nerve compression. We report a 32-year-old dancer with a large multiloculated multiple spinoglenoid cysts compressing the suprascapular nerve causing infraspinatus wasting and shoulder dysfunction. We performed an open surgical decompression of the suprascapular nerve and excised multiple ganglions. The patient improved significantly and regained his shoulder function and muscle wasting at two-year follow-up.

Open dorsal distal interphalangeal joint dislocations: A report of 20 cases.

INTRODUCTION: Several isolated closed dislocations of the dorsal interphalangeal joint are reported, and sometimes they may be associated with other fractures/dislocations. Less is known about the open dorsal dislocation of the distal interphalangeal joint. HYPOTHESIS: Open dorsal dislocations are stable after reduction and prone to develop dorsal interphalangeal joint stiffness. METHODS: Twenty patients with open dorsal dislocation were treated by open reduction and volar plate repair. The diagnosis was made, and the displacement was noted. Associated injuries, fractures, and dislocations were also reported. Postoperative x-rays, range of movements, visual analog score, return to work, and functional outcomes were analyzed. RESULTS: The average follow-up was 23months (range: 19-27months). There were dorso-radial (n=13), dorsal (n=5) and dorso-ulnar (n=2) dislocations. Follow-up with radiographs showed good reduction and congruent distal interphalangeal joint. The mean range of DIP joint movement was 53% (range: 40-65%) and grip strength 70% (range: 50-76%) of the opposite side. The Median VAS score was 0.6 (range: 0-2). Seventeen out of 20 patients who were operated on<8hours of injury had a significant impact on the functional outcome (p<0.05). Three patients who had treatment delay>8hours of injury developed significant postoperative joint stiffness. DISCUSSION: Adequate debridement and an early open reduction of the dorsal interphalangeal joint dislocation produces stable and congruent joint with good functional outcome and early return to normal activities. Open dislocations do not behave like closed dislocations, and joint stiffness is more common and inevitable. LEVEL OF EVIDENCE: IV; retrospective case study.

1,2 Intercompartmental Supraretinacular Artery-Based Vascularized Graft for Scaphoid Nonunion With Avascular Necrosis.

Background The treatment for scaphoid nonunion with avascular necrosis is vascularized and non-vascularized bone grafts. A vascularized bone graft promotes biological healing and revascularizes ischemic bone. The purpose of this retrospective study is to analyze the outcome of 1,2 intercompartmental supraretinacular artery (1,2-ICSRA)-based vascularized graft in scaphoid nonunion with avascular necrosis. Materials and methods We treated 11 patients with scaphoid nonunion with avascular necrosis using a (1,2-ICSRA)-based vascular graft and Herbert screw fixation between 2013 and 2017. Plain radiographs, computed tomography (CT) scan, magnetic resonance imaging (MRI) confirmed the avascular necrosis in all patients. We noted the age, delay in treatment, time for bone union, preoperative range of movements, grip strength, scapholunate, intrascaphoid angle, and radiolunate angles. We confirmed the bone union by CT scan and measured the functional outcome with pain score, modified Mayo wrist score, grip strength, range of movement, and Disabilities of the Arm, Shoulder, and Hand (DASH) score. Results The mean age of the patients was 29 years (range 20-42 years). The mean follow-up was 31 months (range, 26-36 months). All patients achieved good radiological union and revascularization of the proximal pole necrosis at an average of 14 weeks (range, 12-18 weeks). There was a significant postoperative improvement in grip strength, visual analog scale VAS score, intrascaphoid angle, scapholunate angle, and radiolunate angle (p<.05). The mean range of wrist flexion was 88%, extension 70%, radial deviation 80%, and ulnar deviation 85% of the opposite side. Conclusions Scaphoid nonunion with avascular necrosis can be treated with a 1,2-ICSRA-based vascularized bone graft. Vascularized bone grafts promote biological healing and revascularization of the ischemic bone.

Congenital Absence of Posterior Interosseous Artery: A New Anatomic Variant of the Posterior Interosseous Artery Flap.

Soft tissue cover to the hand can be as simple as a skin graft, local, distant flaps to a complex microvascular free flap. Posterior interosseous artery (PIA) flap is a technically demanding robust flap which can be used to cover a wide range of hand and wrist defects. We report a 25-year-old lady who had severe crush injury where the posterior interosseous flap was planned to cover the dorsum of hand defects. On exploration carefully, the PIA was found to be congenitally absent. An alternative groin flap salvaged the procedure and the patient had good aesthetic and functional outcomes at the five years of follow-up.

Aspergillus flavus Infection of Lower Limb in an Immune-Competent Patient.

Isolated aspergillus infection of the lower limb is uncommon and needs more focus in terms of understanding the pathogenicity, ecological and geographical distribution, identification of species, management and follow-up. Aspergillus flavus involving the lower limb in an immunocompetent individual is a rare entity. Surgical management and antifungal therapy are the mainstays of treatment. We report a 44-year-old farmer who presented with right lower limb swelling of short duration, operated, diagnosed with isolated species of Aspergillus flavus, treated successfully with oral voriconazole to produce excellent wound healing and functional outcome at four years follow-up.

A Rare Presentation of an Isolated Radius Shaft Fracture in a Two-Month-Old Child: Dilemmas and Management.

In this report, we discuss the case of a two-month-old boy with an isolated radius shaft fracture in the right forearm. The history and nature of the injury may be inconclusive in such injuries. A radiograph confirmed that the child had a fracture. We treated the boy conservatively, and the fracture united well in four weeks. Surgeons should be aware of this rare presentation in infants of this age. Inquiry into possible child abuse as well as clinical and metabolic workup is essential in these cases.

A New Variant of Type I Congenital Ulna Deficiency With the Normal Thumb, Webspace, Hand, and Elbow.

Unilateral congenital ulna deficiency of wrist and forearm is rare. It is associated with cartilaginous ulnar anlage, absence of ulnar digits, carpus, partially or completely absent ulna, radiohumeral synostosis, syndactyly, and thumb abnormalities. Various classifications have described this presentation. We report a new variant of type I congenital ulnar deficiency in wrist and forearm with a normal thumb, first webspace, hand, wrist, and elbow in an 18-year-old girl.

Acute upper limb compartment syndrome in children: special focus on nerve recovery.

Background: Many studies have discussed acute compartment syndrome in children associated with or without fractures and have given their visible perspectives. Little is known about the nerve involvement and the factors associated with recovery patterns in these patients. We intend to propose that ischemic nerve and muscles tend to regenerate after surgical decompression but in a different pattern and the given circumstances. Methods: Twenty-four children with acute compartment syndrome in the upper limb were analyzed between 2009 and 2015. Data included demographic features of these patients, the time interval between the injury and surgery, and the attempt to correlate with motor and sensory recovery. Results: The average follow-up was 67.3 months (range 59-80). Of the 24, 14 patients (58%) had immediate recovery of motor and sensory functions. The remaining 10 patients had variable recovery patterns with a mean time for the radial nerve, median nerve and ulnar nerve motor recovery of 6.0, 7.5 and 8.5 months, respectively, and sensory recovery at 12, 12 and 13 months, respectively. The overall study had a mean sensory recovery as per the Medical Research Council (MRC) of S3 in 3 (12%) and S4 in 21 (88%). The mean 2-point discrimination (2PD) was 6.9 mm (range 5-10). Twenty-one patients (88%) had a full range of movements at their final follow-up with a mean Visual Analog Scale score of 0.6; a quick Disabilities of the Arm, Shoulder and Hand score of 5.9 (range 2.3-25.0) and a Mayo wrist score of 79. Conclusions: There was a definite motor and sensory recovery in patients who underwent surgical decompression in acute compartment syndrome of the upper limb irrespective of age, gender, delay in presentation and various etiologies. The motor and nerve fibers can regenerate after ischemic sequela of compartment syndrome.

Tibial chondroblastic osteosarcoma--case report.

Osteosarcoma is a bone tumour that can occur in any bone. It most commonly occurs in the long bones of the extremities near the metaphyseal growth plates. The most common sites are femur (42%), tibia (19%), and humerus (10%). Other locations include the skull or jaw (8%) and pelvis (8%). A number of variants of osteosarcoma include conventional types (i.e., osteoblastic, chondroblastic, fibroblastic types) and telangiectatic, multifocal, parosteal, and periosteal types. We present a 10-year-old boy with Tibial Chondroblastic Osteosarcoma. The clinical features, diagnosis and management are discussed.

Transient osteoporosis of the knee. Case report.

Idiopathic transient osteoporosis is a self-limiting, reversible, and uncommon condition. There is usually an overlap between various clinical syndromes, which includes reflex sympathetic dystrophy and avascular necrosis. This article reports a case of idiopathic transient osteoporosis involving the femur and tibia in the knee following trauma in a 45-year-old man. The diagnosis was confirmed by magnetic resonance imaging. The patient was treated conservatively with bed rest, nonsteroidal antiinflammatory drugs, protected weight bearing, and physiotherapy. He had a full clinical and radiographic recovery.