Ulnar nerve compression secondary to migration of pyrocarbon implant following right wrist arthroplasty.

A 50-year-old, right-hand dominant woman presented with a seven-month history of stiffness, pain and swelling on the ulnar side of her right wrist. She had undergone right wrist arthroplasty with a Pyrocarbon Amandys implant seven months previously for post-traumatic degenerative arthritis. She had an uneventful initial recovery until developing carpal tunnel syndrome, for which she underwent carpal tunnel release 5 months after her arthroplasty. Examination revealed a painful and limited range of movement in the affected wrist, with weakness of the first dorsal interosseous muscle and altered sensation in the ring finger. A hard swelling was visible and palpable on the palmar-ulnar aspect of the wrist. X-rays showed that the swelling was due to the dislocated Amandys implant (which was thought to be causing compression neuropathy of the ulnar nerve). The patient underwent removal of the pyrocarbon implant (through a palmar approach) and total wrist fusion one month later, following which the wrist successfully united and all symptoms of ulnar nerve compression resolved. Although some studies have reported migration of pyrocarbon implant following total wrist arthroplasty, to our knowledge, this is the first reported case of ulnar compression neuropathy from a migrated pyrocarbon wrist implant.

Current concepts in Dupuytren's disease.

The last few years have seen a number of significant studies in Dupuytren's disease that may result in a paradigm shift in the management of this condition. This review article assesses recent therapeutic studies from January 2010 to August 2012. These were rated for levels of evidence, trial quality using the Jadad and Detsky scales, and graded by strength of recommendation. Significant studies include the success of Phase III trials of injectable collagenase (CORD I and II), that may radically alter the practice of Dupuytren's. Other highlights include randomized controlled trials that address the ongoing debate on needle fasciotomy vs limited fasciectomy, and also the utility of night-time post-operative splinting. Furthermore, the concept of "clinically important differences" in Dupuytren's outcomes research is considered in the context of the CORD I trial. The implications of these studies for current practice and future research are discussed.

Reconstruction of the extensor central slip using a distally based flexor digitorum superficialis slip.

Several methods have been reported for reconstruction of the extensor central slip. We describe the successful use of a distally based slip of the flexor digitorum superficialis tendon for the reconstruction of an incompetent central slip of the extensor mechanism. The flexor digitorum superficialis tendon was transferred from volar to dorsal through the base of the middle phalanx and then woven through the extensor tendon over the proximal phalanx. The technique is straightforward and appears to be robust.

A cohort study of acute plastic surgery trauma and burn referrals using telemedicine.

A store-and-forward telemedicine system was used to supplement normal telephone referrals to the plastic surgery unit at the Queen Victoria Hospital (QVH). During a 12-week prospective study, 11 units (8 hospitals and 3 minor injury units) with the telemedicine system and 10 units (8 hospitals and 2 minor injury units) without it regularly made referrals (at least 10) to the QVH. There were 389 referrals from the telemedicine-equipped units and 607 telephone referrals from the non-telemedicine units. The telemedicine system was used for 246 of the 389 referrals (63%) made from telemedicine-equipped units. There was a significant difference in the management of patients when the telemedicine system was available, with more patients booked directly into day surgery and fewer attending for assessment. The burns unit and the day surgery unit demonstrated a significantly improved accuracy of triage. Telemedicine could have a valuable role to play in the triage and planning of acute plastic surgery referrals.

Avoiding pitfalls of the pins and rubbers traction technique for fractures of the proximal interphalangeal joint.

Treatment of comminuted intra-articular fractures of the digits with the Pins and Rubbers Traction System (PRTS) has been reported in many small series to give good results. Our experience in more than 40 cases with this technique, however, has not always been favorable. We analyzed outcomes and complications of PRTS treatment in 25 patients with proximal interphalangeal joint fractures reviewed at a mean 13 months (range, 6-52 months) after surgery. Mean arc of motion at this joint was 67.2 degrees (range, 35-110 degrees ) and at the distal interphalangeal joint 40.7 degrees (range, 0-90 degrees ). The latter was immobile in 3 (12%) and 7 patients (28%) had superficial pin track infections. Loss of extension at both joints was a major factor in poor outcomes. Based on this experience, we suggest ways of avoiding common pitfalls of PRTS treatment. Concurrent internal fixation impacts significantly on interphalangeal joint stiffness.

Experience with a new ultralow-profile osteosynthesis system for fractures of the metacarpals and phalanges.

Current osteosynthesis systems for the hand generally recommend thicker plates for metacarpal than for phalangeal fractures. We report a prospective review of 20 hand fractures treated with a new plating system in which 0.6-mm-profile-height plates are used for both metacarpals (11 cases) and phalanges (9 cases). After a follow-up period ranging from 6 to 24 months, there were 8 excellent, 7 good, and 2 poor results (American Society for Surgery of the Hand criteria), with no incidence of plate failure. These outcomes were compared with a matched cohort of 20 similar fractures treated with the widely used Stryker-Leibinger system. We found no significant differences in ranges of motion or complications between the 2 groups. The new plating system was technically straightforward to use and equally effective. Use of the thinner microplates for metacarpal fractures was not associated with any untoward outcomes.

Ulnar tendinous interconnection in type IIIA thumb hypoplasia--a pollex adductus.

We present an anatomic variation of type IIIA thumb hypoplasia in which a tendinous interconnection between the flexor pollicis longus and the extensor pollicis longus occurred on the ulnar aspect of the thumb. Interconnection between extrinsic flexor and extensor systems is well known in type IIIA thumb hypoplasia and has been reported on the radial side (pollex abductus). In our patient the ulnar location of the interconnection remained unrecognized until recurrence of the deformity in adolescence.