Use of Mini TightRope® for Delayed Presentation of a Fifth Carpometacarpal Joint Dislocation.

Introduction: Isolated dislocations of the fifth carpometacarpal joint (CMCJ) are uncommon injuries of the hand that is often missed but can be diagnosed correctly with a high index of suspicion and adequate imaging. Treatment for chronic cases is usually open reduction with temporary fixation using Kirschner wires, but for this case, we used Mini TightRope® as well to allow for early finger exercise. The case presented here is unique because of a delayed dislocation of a CMCJ detected 9 weeks from initial injury which was treated with a novel form of fixation with Mini TightRope®. Case Report: A 70-year-old, right-hand dominant, male farmer injured his left hand when he slipped and fell on a concrete surface, landing on the ulnar side of his left hand. He was immediately seen in the clinic, just with a swollen left hand but no obvious deformity and with apparently normal PA and oblique radiographs of the hand. Nine weeks later, he came back due to persistent ulnar-sided hand pain; repeat radiographs and a CT scan of the left hand showed ulno-palmar dislocation of the fifth CMCJ. He then underwent trial closed reduction of the 5th CMCJ dislocation but failed. Open reduction, temporary K-wire fixation, and fixation using Mini TightRope® through the 4th and 5th metacarpals were done. A full range of motion of the hand was allowed immediately post-operative. Reduction was maintained and no complications were noted on subsequent follow-up visits. Conclusion: This paper presents a brief literature review on 5th CMCJ dislocation, discussing the anatomic considerations contributing to joint stability, helpful radiographic parameters for diagnosis, and enumeration of treatment options.

Causes of Iatrogenic Median Nerve Injury after Endoscopic Carpal Tunnel Release.

Background: Endoscopic carpal tunnel release (ECTR) is a less invasive procedure but has a higher risk of complications. We analysed ECTR cases dividing them into three periods according to a single surgeon's experience when the ECTR was performed: the initial, midterm and late period. Cases of iatrogenically induced median nerve injuries that occurred after ECTR were then noted and evaluated. Methods: We reviewed 195 ECTRs done with the 2-portal technique and divided the patients into three groups according to periods of when ECTR was done. The indications for ECTR surgery were limited to severe CTS cases. These groups of patients were similar in terms of age, duration of disease, electrophysiological study results and severity of the disease. The patients were evaluated for median neuropathy pre- and postoperatively using Semmes-Weinstein monofilament test (SWT), Disabilities of the arm, shoulder and hand (DASH) Score, Coin-flip test (CFT), postoperative paraesthesias and complications, such as pillar pain, and so on. Electrophysiological evaluation was performed only preoperatively. Results: Postoperative median nerve recovery was overall good. Normal recovery was noted in 181 cases (93%). SWT, DASH and CFT were all significantly improved upon follow-up in all three groups. In terms of iatrogenic neuropathy, median nerve palsy worsened (including those transiently worsened) after ECTR in 11 cases (5.6%), even in the later period. The sensory disturbance was equally worsening from the radial to the ulnar side. Conclusions: The fact that there were neurologically worsened cases even in the later period, when the operator is higher skilled in the technique, suggests that the surgical technique itself may be the one posing higher risk than the level of surgical skill. The most likely causes of aggravated nerve palsy were a direct injury by cannula insertion at the proximal portal, or additional median nerve compression during cannula insertion into the carpal tunnel. Level of Evidence: Level IV (Therapeutic).

Intraneural Ganglion of the Thumb Digital Nerve - A Case Report and Review of Literature.

Intraneural ganglia are rare, benign cysts that form within the epineurium of the affected nerve. Patients present with features of compressive neuropathy, including numbness. We report a 74-year-old male patient with pain and numbness on his right thumb of 1-year duration. Magnetic resonance imaging revealed a cystic lesion with a possible scaphotrapezium-trapezoid joint connection. The articular branch was not identified during the surgery and decompression with excision of the cyst wall was done. A recurrence of the mass was noted 3 years later, but the patient was asymptomatic and no additional intervention was done. Decompression alone can relieve the symptoms of an intraneural ganglion, but excision of the articular branch may be essential in preventing its recurrence. Level of Evidence: Level V (Therapeutic).

Refractory satellite ganglion cyst in the hallux and finger.

Painful ganglion cysts that develop in the hallux and finger usually enlarge progressively to the peripheral direction. Simple resection of satellite ganglion cyst alone has been reported to cause a high rate of recurrence and treatment is often very difficult. The purpose of this study is to evaluate the appropriate surgical treatment for painful satellite ganglion cysts in the hallux and finger and discuss the origin of the ganglion cysts in cases treated surgically at our hospital. We reviewed five cases (three males and two females, ages 55-87 years), three of which occurred in the hallux and two in the finger. In all cases, the preoperative magnetic resonance image showed a large fluid of the flexor tendon sheath. And also, joint effusion was found in the metatarsophalangeal joint and the proximal interphalangeal joint. The first case of the hallux ganglion underwent simple excision of the cyst and had recurrences three times. In the other four cases, the additional synovectomy of the metatarsophalangeal joint and the proximal interphalangeal joint was performed along with ganglion cyst excision. These cases had no recurrence up to 1 year after operation. Recently, there have been reports that tendon sheath ganglions are connected to the ankle, wrist, hallux, and phalangeal joints. Although there are a few cases in our department, satellite ganglion cyst of the hallux and finger possibly originates from adjacent joints. Additional synovectomy of the affected joint should be performed for the excision of satellite ganglion cyst to prevent recurrence.