Pedicled Osteo-Onchyocutaneous Island Flap for Finger Macrodactyly: A Review of Literature.

We present a case of middle finger macrodactyly reconstructed in a single stage using multiple techniques. We elevated a pedicled osteo-onychocutaneous island flap, excised the remnant distal phalanx with a segment of 1 digital nerve and skin over the dorsum of the middle phalanx, performed epiphysiodesis and reduction of the middle phalanx as well as soft-tissue debulking, and inset the flap over the dorsum of the middle phalanx. Follow-up at 12 months revealed a satisfactory aesthetic and functional outcome.

Direct Radiological Visualization of Loading on Four Flexor Tendon Repair Suture Configurations.

PURPOSE: To study the deformation of 4 suture configurations used in flexor tendon repair using fluoroscopy. METHODS: All flexor tendon repair techniques have a longitudinal component, a link component, and/or a transverse component. We had previously described 4 types of link components, namely an arc (grasping loop), a simple loop (locking loop), a complex loop, and a knot. The effect of loading on suture configurations using each of these link components was tested in flexor tendon from the first ray of porcine feet. Forty flexor tendons were divided into 4 groups of 10 each, and one-half of a tendon repair was simulated on each group using 0.5 mm stainless steel wire. The tendons were mounted on a materials testing machine, and tensile force was applied until failure. The deformation of the suture within the tendon substance was observed using an image intensifier, and the maximal load to failure was measured. RESULTS: The loading of the suture led to unraveling of the suture in an arc, constriction and unraveling in a simple loop, and initial constriction with no further change of the construct in the complex loop with no change in the knot design. The mean pullout strength of the complex loop was statistically greater than all the other 3 designs. CONCLUSIONS: Each of the link component designs demonstrated unique deformation characteristics. The complex loop design had the strongest grasping ability. CLINICAL RELEVANCE: This study identified the differences in the deformation characteristics of the 4 types of link components used in flexor tendon repair. This knowledge may allow for the development of better flexor tendon repair techniques and the adoption of a more precise classification of flexor tendon repair techniques.

Revisiting the reconstructive ladder for soft tissue reconstruction in the lower extremity.

Soft tissue reconstruction of the lower limb has seen a paradigm shift over the past two decades. Typically, these defects arise from trauma, infection or tumor. It is no longer enough to simply achieve coverage. Factors like patient-reported outcomes and aesthetic considerations are essential in the decision-making process. This is especially in light of increasing technological advancement, availability of dermal substitutes, microsurgical expertise and development of the field of microsurgical reconstruction as a whole with more novel flaps and techniques. Advancements in reconstructive modalities have also been equally matched by better emergency medical mobilization, transportation and access, early initiation of subspecialty care, accessibility and types of imaging, as well as oncological advances in radiotherapy and chemotherapy regimens. Yet, this has also meant that our patient profile has expanded to include older patients with more co-morbidities and other considerations such as frailty or the irradiated field which could influence what reconstructive modality is suitable and the goals of reconstruction specific to the patient. Previously deemed unsalvageable limbs are now being successfully reconstructed with good function and aesthesis. In the lower limb, this implicates the ability for early mobilization, range of motion and weight bearing which allow the patient to successfully partake in early rehabilitation. Expedient and reliable healing is also important in the oncological population where a proportion of these patients would need to go on to receive post-operative chemotherapy or radiotherapy. The reconstructive ladder has been what many reconstructive surgeons have been taught upon with regard to the basic principles of pre-operative planning and choosing the appropriate reconstructive modality. In this article, we examine the relevance of the reconstructive ladder in modern practice and the additional considerations in the approach to a soft tissue defect in the lower extremity.

Health Policy Implications of Digital Replantation.

There have been dwindling numbers of replantations in the United States. Despite the advocacy for centralization in hand trauma, the fundamental landscape and attitudes of surgeons toward replantation have remained lackluster. There is growing and substantial evidence to demonstrate the superior outcomes of replantation in comparison to revision amputation in most scenarios. This article aims to delve into the factors contributing to the decreasing numbers of replantations and proposes strategies to overcome this issue.

Current trends in digital replantation-a narrative review.

Background and Objective: Digital replantation for traumatic amputation has become the standard of care with advances in microsurgical techniques and technology. While digital replantation has progressed significantly, there are still gaps in knowledge in many aspects. Some of the controversial topics in digital replantation include the indications and contraindications, anesthesia, number of vessel anastomoses, mechanism of injury, role of vein graft, distal fingertip replantation, and postoperative management. This article is a narrative review that discusses these controversies and current issues pertaining to digital replantation. Methods: PubMed, Web of Science, and Google scholar were searched using keywords relating to "digit replantation", "amputation", and "digital replant" with the following terms: "indications", "contraindications", "anaesthesia", "survival", "vessels", "mechanism of injury", "vein graft", "outcome", and "thrombophylaxis". Relevant articles pertaining to digital replantation and deemed by the authors as current or controversial were included. Key Content and Findings: The reported survival rates of digital replantation are high. With the advancement of microsurgical techniques and technology, the boundaries of digital replantation continue to be pushed. Various methods have been described recently to improve the success rates of difficult replants, such as strategies for venous outflow and vein grafting. However, there are still aspects of digital replantation that remain unanswered, such as the number of veins to anastomose and the thromboprophylaxis regime. Conclusions: The review delves into controversial aspects of digital replantation, including contraindications, anesthesia, and postoperative management. Indications and contraindications will continue to evolve alongside advancements in microsurgical techniques and anesthesia. It highlights key factors influencing survival rates, such as the number of repaired vessels and the mechanism of injury. Finally, the review consolidates strategies for managing challenging digital replantations.

Tactile sensibility on the fingernail.

PURPOSE: To measure tactile discrimination (static and moving 2-point discrimination) and threshold levels (Weinstein enhanced sensory test) over the nail plate in normal subjects and compare these values with those at the corresponding finger pulps. METHODS: Tactile discrimination and threshold values over the nail plates and finger pulps were measured on 300 digits in 30 healthy subjects with a mean age of 23 years. Subjects with cosmetic nail modifications, injuries, neurological deficits, dermatological conditions, or history of upper limb surgery were excluded. Equivalence testing was conducted to look for clinical equivalence between values obtained at both sites. RESULTS: The mean static 2-point discrimination, moving 2-point discrimination, and threshold value over the human nail were 6.7 mm, 2.4 mm, and 0.06 g, respectively. The corresponding values for the finger pulp were 2.4 mm, 2.2 mm, and 0.01 g, respectively. The static 2-point discrimination and threshold values were superior for the finger pulp, whereas moving 2-point discrimination values at both sites were clinically equivalent. CONCLUSIONS: Our study suggests that tactile discrimination and threshold levels can be measured over the nail plate and that moving 2-point discrimination values are clinically equivalent to those obtained on the corresponding pulp. This highlights the importance of the nail plate in the sensory function of the fingertip. The normative data from this study may be useful in establishing the impact of nail injury and the contribution of the nail to the overall function of the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Histology of the volar plate of the thumb metacarpophalangeal joint.

BACKGROUND: The aim of the study was to describe the histology of the thumb MCPJ volar plate. METHODS: Five fresh-frozen thumbs were dissected. The volar plates were harvested from the thumb MCPJ. Histological analyses were performed using 0.04% Toluidine blue and counterstained with 0.005% Fast green. RESULTS: The thumb MCPJ volar plate comprised two sesamoids, dense fibrous tissue and loose connective tissue. The two sesamoids were connected by dense fibrous tissue, with collagen fibers oriented transversely (perpendicular to the long axis of the thumb). In contrast, the collagen fibers within the dense fibrous tissue on the lateral sides of the sesamoid were oriented longitudinally in line with long axis of the thumb. These fibers blended with the fibers of the radial and ulnar collateral ligaments. The collagen fibers in the dense fibrous tissue distal to the sesamoids ran transversely, perpendicular to the long axis of the thumb. The proximal aspect of the volar plate showed only loose connective tissue. The volar plate of the thumb MCPJ was largely uniform with no division of layers from the dorsum to the palmar surface. There was no fibrocartilaginous component in the thumb MCPJ volar plate. CONCLUSIONS: The histology of the volar plate of the thumb MCPJ differs significantly from the conventional understanding of the volar plate, based on the volar plate of finger proximal interphalangeal joints. The difference is likely due to the presence of the sesamoids, which confer additional stability, reducing the need for a specialized trilaminar fibrocartilaginous structure with the lateral check-rein ligaments found in the volar plate of finger proximal interphalangeal joints to confer additional stability.

Comparison of proximal and distal involvement of upper extremity metastatic lesions: an analysis of 55 cases.

We analysed the differences in clinical presentation between proximal (above elbow) and distal (below elbow) upper limb metastases in a retrospective review of patients presenting to our centre from 2011 to 2019. There were 55 cases, 64% involving the humerus and 62% occurring in men. The median age at the time of diagnosis was 64 years. Thirty-one per cent of the cases were proximal lesions. Distal upper limb metastases were more likely to be soft tissue lesions (71%) compared with proximal lesions (8%). The median age of patients with distal lesions was significantly lower at 58 years compared with 65 years for proximal lesions. Overall, non-small cell lung carcinoma was the most common primary malignancy (25%), however haematological cancers were most common in the distal group (29%). Distal upper limb metastases have distinct features that distinguish them from proximal lesions.Level of evidence: IV.

Sandblasting Injury: A Case Report and a Review of Literature.

Sandblasting injuries are uncommon with only four reports in literature. We report a patient with a sandblasting injury of the dorsum of the hand and wrist and summarise published literature on the management of such injuries. We recommend early (<24 hours) C-arm-guided debridement of embedded foreign bodies and repeated saline washouts with a soft surgical scrub brush. Level of Evidence: Level V (Therapeutic).

Management of a mutilated hand: the current trends.

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

A Pragmatic and Evidence-Based Approach to Mallet Finger.

A mallet finger is a common injury that results from a sudden flexion force on an extended distal phalanx or rarely, from hyperextension of the distal interphalangeal joint. Mallet finger can be purely tendinous or bony when associated with an avulsion fracture. The management of this injury is largely conservative with the use of a splint, although surgery may be indicated for select patients. There is little consensus on the indications for surgery or the suitable surgical technique. The aim of this review article is to provide a pragmatic and evidence-based approach to mallet finger that will guide the treating surgeon in providing best care for their patient.

Trigger Finger Associated with Fencing in an Adolescent: A Case Report.

Trigger digits in children are rare and the vast majority of cases are primary and involve the thumb. Although there are isolated reports of trigger digits in children after trauma, we were unable to find any report of a trigger digit in a child caused by repetitive forceful gripping. We report a 14-year-old fencer who developed a trigger of his middle finger to highlight this unusual association. This was initially managed with a splint and analgesics and eventually required two intrathecal steroid injections for resolution of symptoms.

Palmar Dislocations of the 5th Carpometacarpal Joint: Case Report of a Rare Injury and Review of Published Cases.

Isolated palmar dislocation of the 5th carpometacarpal joint (CMCJ) is a rare injury that can be easily missed and requires a high index of suspicion to detect. We report a case of an initially missed isolated ulnopalmar dislocation of the 5th CMCJ and a summary of other published case reports comparing methods of fixation and outcomes. We conclude that a delay in diagnosis will significantly reduce the chances of successfully managing this injury via closed reduction.

Time to Resolution of Triggering after Steroid Injection for First Presentation Trigger Digits.

Background: Steroid injection is a proven treatment for trigger digits. The time taken for resolution of triggering following an injection is a question often asked by patients and one that has not been adequately addressed in existing literature. The aim of this study was to determine the time taken for triggering to resolve after a single steroid injection in patients presenting for the first time with a trigger digit. Methods: A prospective study was conducted in patients with first presentation of a grade II or grade III trigger digit(s) that received a steroid injection. Data with regards to age, gender, digit(s) involved, duration of symptoms, trigger grade, and presence of diabetes were collected. They were given a stamped addressed postcard with instructions to fill in the date that the triggering resolved and mail the postcard back to us. If the postcard was not received at three weeks, we contacted the patient by telephone to ask for the date of resolution of trigger. Results: 56 patients with 66 trigger digits were included in the study. 52 out of 66 digits (79%) had resolution of the trigger at one month. The mean duration for resolution of trigger was 8.8 days (range 1-30 days). Conclusions: Patients can be counselled that a steroid injection is effective in resolving the trigger in 79% of trigger digits presenting for the first time and that the mean time taken for resolution of triggering is 8.8 days. It is recommended to wait for at least one month before considering another injection or alternative treatments.

Heterodigital vascular island flap for simultaneous resurfacing and revascularization of digits.

Devascularized digits with segmental skin and vessel loss require revascularization and resurfacing. This can be addressed by using a heterodigital vascular island flap. This flap brings with it an appropriately sized pristine artery of optimal length for revascularization and provides simultaneous skin cover. We describe 3 cases. Primary wound healing was achieved in all patients with good functional recovery and acceptable donor site morbidity. We compare the options available for reconstructing such defects and discuss other possible surgical indications for this flap.