Restoration of shoulder abduction in brachial plexus avulsion injuries with double neurotization from the spinal accessory nerve: a report of 13 cases.

In upper (C5-C7) and total (C5-T1) root avulsion brachial plexus injury, a method of double neurotization from a single donor spinal accessory nerve to two target nerves (suprascapular nerve and axillary nerve) may be done, leaving donor nerves available for reconstruction procedures to restore other aspects of upper limb function. A mean range of shoulder abduction of 91° (SD 25°) was achieved through this procedure in our study of 13 cases, of which seven cases were C5-C7 root avulsion and six cases were C5-T1 root avulsion brachial plexus injuries. Six of the former group and three of the latter group achieved >90° shoulder abduction. The technique of double neurotization from a single donor nerve provides favourable results in restoring shoulder abduction in avulsion brachial plexus injuries. LEVEL OF EVIDENCE: IV.

Dorsal fracture dislocations of the proximal interphalangeal joint treated by open reduction and interfragmentary screw fixation: indications, approaches and results.

Many operative and non-operative treatments of dorsal fracture dislocations of the proximal interphalageal (PIP) joint have been described. Return of good joint function requires anatomical reduction of the articular fragments and restoration of joint congruity and a stable functional arc of motion, with the fixation construct stable enough for early mobilization. To prevent recurrent dorsal subluxation, the attachments of the ligamentous palmar restraints and the bony buttress provided by the palmar lip of the middle phalanx base must be restored. Open reduction and internal interfragmentary screw fixation using 1.5 or 1.3mm screws was employed in 12 fingers in 10 patients with unstable dorsal fracture dislocations of the PIP joints of Schenck grades III and IV. At an average follow-up of 8.7 months, all patients in this series achieved good to excellent results and an average total active interphalangeal motion of 132 degrees (range 105 degrees -165 degrees). Additional benefits over non-operative techniques included improved patient comfort and simplified nursing care and therapy supervision.

Cerclage-wiring-assisted fixation of difficult hand fractures.

Difficult hand fractures with multiple butterfly fragments, multiple cortical splits or intraarticular extension continue to pose a challenge for optimal stable fixation that allows early postoperative mobilisation. In this study, we describe the use of cerclage-wire-assisted fixation of 17 difficult hand fractures in 16 patients. The cerclage wires helped to maintain the reduction, so providing sufficient initial stability for placement of a plate and screws. Stable fixation of the fracture was then accomplished without losing the reduction. One to three cerclages of stainless-steel wires were used for the preliminary fixation. Stable fixation was then accomplished by a bridging or neutralising plate technique. Postoperatively, the fixation was sufficiently stable to allow immediate mobilisation. With an average follow up of 44.5 months, all 17 fractures united without loss of reduction. At final follow-up, the average total active range of motion was 247 degrees (range 220-260 degrees ).

Anatomic reconstruction of the distal radioulnar ligaments: long-term results.

Chronic post-traumatic dynamic distal radioulnar joint instability following rupture of the distal radioulnar ligaments may cause disabling and progressive ulnar-sided wrist symptoms. We use a free tendon graft to anatomically reconstruct both dorsal and palmar distal radioulnar ligaments simultaneously. Nine patients who underwent this procedure between 1990 and 1997 were assessed using a modified Mayo Wrist Score. Following surgery, average wrist scores improved from 66 (95% CI, +/-3.0) to 92 (95% CI, 92+/-6.9) and were maintained in the long term (average score, 87 at 9 years). Joint stability was restored and maintained in seven of the nine patients, but two developed recurrent instability. Pain, grip strength and function were better following surgery in the short and long term. Range of supination and pronation decreased slightly from an average of 169 degrees pre-operatively to 155 degrees (90% of normal) in the long term. Long-term radiographs show no distal radioulnar or ulnocarpal joint osteoarthritis.

The prevention of neuroma formation by diathermy: an experimental study in the rat common peroneal nerve.

INTRODUCTION: There have been anecdotal reports of the efficacy of diathermy (electrocoagulation) in the prevention of neuroma formation. However, this has not been investigated in the laboratory. In this experiment involving 40 rats, diathermy was applied to the terminal proximal ends of transected rat common peroneal nerves to evaluate its effect on neuroma formation. MATERIALS AND METHODS: Monopolar and bipolar diathermy set at 45 W, applied for different durations (4 seconds and 10 seconds), were evaluated. Under histological control, the presence of neuroma formation and the diameter of the nerve ends were evaluated at 3 months. The contralateral common peroneal nerve in the same rat served as the control. The dorsal root ganglia of 2 rats in each group were also harvested for histological study. RESULTS: The incidence of neuroma formation was 30% in the group which received high-duration monopolar diathermy (10-second application), versus 90% in the control group (P <0.05). The mean diameter of the nerve ends was smaller at 0.51 mm [standard deviation (SD), 0.29] versus 0.85 mm (SD, 0.24) in the control (P <0.05). The incidence of neuroma formation was 30% in the group which received low-duration monopolar diathermy (4-second application), and 83% in the control group (P <0.05). The diameter was 0.43 mm (SD, 0.14) versus 0.85 mm (SD, 0.28) (P <0.05). High-duration bipolar diathermy applied for 10 seconds, showed a neuroma formation of 25% versus 100% in the control group (P <0.05). The diameter of the nerve ends was 0.48 mm (SD, 0.07) versus 0.79 mm (SD, 0.36) in the control group (P <0.05). The incidence of neuroma formation was 60% in the low-duration bipolar group, which received bipolar diathermy application for 4 seconds, and 90% in the control group (P = 0.25). The diameter of the nerve ends in the low-duration bipolar group was 0.52 mm (SD, 0.24) versus 0.76 mm (SD, 0.40). The incidence of neuroma formation and the difference in diameter in the low duration-bipolar group were both not statistically significant. CONCLUSION: This study demonstrates the effectiveness of monopolar diathermy in reducing the rate of neuroma formation. For bipolar diathermy, an application of 10 seconds was effective in reducing neuroma formation but an application of 4 seconds was not associated with a significant reduction in neuroma formation.

Severe upper limb complications from parenteral abuse of Subutex.

INTRODUCTION: Subutex is a sublingual formulation of buprenorphine that is used to treat opioid dependency. It may be abused parenterally with disastrous consequences. CLINICAL PRESENTATION: We present 4 cases of parenteral abuse of Subutex resulting in severe upper limb complications. TREATMENT: Two vascular complications were treated with combinations of anticoagulants, vasodilators, brachial plexus bock and iloprostol. One severe hand abscess required surgical debridement, and 1 median nerve injury required neurolysis. OUTCOME: All patients had a poor outcome. Both patients with vascular complications required multiple amputations, the patient with a thenar abscess had severely impaired thumb function, and the patient with median nerve injury has ongoing neuralgic pain, numbness and thenar weakness. CONCLUSION: The incidence of complications of parenteral abuse of Subutex is increasing in Singapore. These complications have a poor outcome despite adequate management, and are best prevented by education or legal means.

Audit of hypertension in general practice.

An audit of hypertension management was done in October 2004 in nine general practice (GP) clinics. Two structure, ten process and two outcome indicators were assessed. Results showed that targets were achieved in only four indicators, i.e., weight recording (89%), BP monitoring (85.8%), follow-up interval not exceeding 6 months (87.9%) and mean diastolic BP (73.9%). The other indicators (hypertension registry, reminder mechanisms for defaulters, recording of smoking, height, fundoscopy, monitoring of lipid profile, blood sugar, ECG, renal function and achievement of target mean systolic pressure) showed adequacy percentages varying from 22.1 to 68.7. Out of the 1260 patients assessed, 743 (59%) achieved a mean BP < or = 140/90 (or < or = 130/80 mmHg with diabetes mellitus / renal insufficiency) in the last 3 recorded readings. There was a vast difference between individual clinics. Reasons for not achieving targets were discussed and remedial measures for implementation were recommended.

Combined volar and dorsal plating for complex comminuted distal radial fractures.

PURPOSE: To review outcomes of combined volar and dorsal locked plating for AO type-C3 complex comminuted distal radial fractures. METHODS: Records of 24 patients aged 17 to 77 (mean, 53.3) years who underwent combined volar and dorsal locked plating for AO type-C3 distal radial fractures with volar and dorsal metaphyseal and intra-articular comminution were reviewed. 21 were closed fractures, and 3 were Gustilo-Anderson type-1 open fractures. Bone union, volar tilt, radial inclination, radial height, range of motion, grip strength, and any complications were assessed by a single hand surgeon. RESULTS: After a mean follow-up of 17 (range, 14-25) months, the mean palmar flexion was 49º (range, 30º-80º), dorsiflexion was 52º (range, 30º-80º), supination was 86º (range, 60º-90º), pronation was 77º (range, 30º-90º), radial deviation was 16º (range, 5º-30º), and ulnar deviation was 27º (range, 10º-50º). The mean grip strength of the injured hand was 69.2% of the uninjured side. The mean time to radiological union was 3.9 (range, 2.5-6.0) months; no patient had non-union. At the time of union, the mean volar tilt was 5º (-22º-14º), radial inclination was 18.6º (8º-28º), and radial height was 8.5 mm (5.0 mm-13.6 mm). One patient had collapse of the dorsal fragment resulting in a dorsal tilt of 22º and limited (30º) forearm pronation. The severity of dorsal metaphyseal comminution had not been recognised and bone grafting was not performed. The patient also had minor complications of little finger flexor tendon irritation and carpal tunnel syndrome. She underwent implant removal and carpal tunnel release at 8 months. One patient had implant-related extensor digitorum communis irritation. Another patient had non-specific chronic wrist pain, which was resolved at one year. No patient had infection, tendon rupture, or complex regional pain syndrome. Four patients underwent implant removal, including 2 who had no implant-related problems. CONCLUSION: Combined volar and dorsal plating enables early mobilisation and good outcome for certain complex comminuted distal radial fractures.

Heterodigital arterialized flaps for large finger wounds: results and indications.

Deep defects of the hand and fingers with an unhealthy bed exposing denuded tendon, bone, joint, or neurovascular structures require flap coverage. However, the location and size of the defects often preclude the use of local flap coverage. Free-flap coverage is often not desirable either, because the recipient vessels may be unhealthy from surrounding infection or trauma. In such situations, a regional pedicled flap is preferable. A solution to this is the heterodigital arterialized flap. This flap is supplied by the digital artery and a dorsal vein of the finger for venous drainage. Unlike the neurovascular island flap, the digital nerve is left in situ in the donor finger, thus avoiding many of the neurologic complications associated with the Littler flap. The digital artery island flap is centered on the midlateral line of the donor finger. It extends from the middorsal line to the midpalmar line. The maximal length of the flap is from the base of the finger to the distal interphalangeal joint. By preserving the pulp and the digital nerve, a sensate pulp on the donor finger remains that reduces donor-finger morbidity and also preserves fingertip cosmesis. Twenty-nine flaps were performed in 29 patients and the outcomes in the donor finger and the reconstructed finger were reviewed. The flap survival was 100 percent. There were no cases of flap ischemia or flap congestion. Good venous drainage of the flap through the additional dorsal vein was helpful in preventing the occurrence of early postoperative venous congestion, which is common in island flaps of the fingers, which depend on only the venae comitantes for drainage. Donor-finger morbidity, measured in terms of range of motion and two-point discrimination in the pulp, was minimal. Ninety-seven percent of the donor fingers achieved excellent or good total active motion according to the criteria of Strickland and Glogovac. Pulp sensation in the donor fingers was normal in 28 of the 29 donor fingers. No cold intolerance of the donor finger or the adjacent finger is reported in this series.

Nail bed reconstruction with split-thickness nail bed grafts.

The results of reconstruction of chronic post-traumatic nail deformities are thought to be unpredictable. We have reviewed eight patients treated by split-thickness nail bed grafts for deformities arising from defects in the sterile matrix. Appearance, adherence and function were improved in all cases, with no significant morbidity of the donor area.

Interphalangeal joint arthrodesis with oblique placement of an AO lag screw.

A damaged interphalangeal (IP) joint may be treated by fusion. Arthrodesis should leave the joint at the most functional angle and give sound bony union in the shortest possible time, maintaining maximum proximal and distal joint motion. The lateral oblique placement of a single AO lag screw, proximal to distal, achieves these aims. This method gives sufficient proximal bone for screw purchase and better control of the desired angle of fusion. This technique has led to fusion in 22 of 23 joints (96%), taking an average of 8.2 weeks.

Condylar advancement osteotomy for correcting condylar malunion of the finger.

Unicondylar fractures of proximal and middle phalanges of the finger can unite with intra-articular malunion, which may result in joint pain, stiffness and deformity. There is currently no satisfactory technique of corrective osteotomy for these fractures. Extra-articular osteotomies often do not give good results and existing techniques of intra-articular osteotomy through the healed fracture site are technically difficult due to the small bone fragment, difficulty achieving stable fixation and the risk of avascular necrosis. We propose a different method of intra-articular correction with a longitudinal osteotomy and advancement of the malunited condyle. The "condylar advancement osteotomy" can overcome problems encountered with the other techniques. Excellent results were obtained in six patients.

Congenital isolated upper limb hypertrophy with hand abnormality--a report of 2 cases.

Two cases of congenital isolated hypertrophy of the left upper limb with different hand deformities are described. A 4-year-old girl had splayed fingers and an abducted thumb due to anomalous muscles. Excision of these muscles corrected the deformity. The other, an 8-year-old boy, had severe ulnar drift of the fingers (windblown-like hand). He had corrective osteotomies of the second and third metarcarpals and reconstruction of the collateral ligaments. The deformity was corrected and at the latest follow up there was with no recurrence of the deviation. Both cases regained good hand function.

Anterior subfascial transposition of the ulnar nerve.

After anterior subfascial transposition, the ulnar nerve lies superficial to the flexor-pronator muscle group but deep to its fascia. Eight patients with cubital tunnel syndrome were treated with this method and reviewed retrospectively. The average age at the time of operation was 52 years. All patients had severe cubital tunnel syndrome based on Dellon's classification. The average follow-up period was 2 years and 9 months. Post-operative outcome assessment was based on the modified Bishop rating system. Six patients had excellent and two had good outcomes. All were back at work by the 5th post-operative week. There were no complications or recurrence of symptoms. Anterior subfascial transposition of the ulnar nerve is an effective method of surgical treatment for patients with severe cubital tunnel syndrome.

A case of Bizarre Parosteal Osteochondromatous Proliferation of the hand.

We report a case of Bizarre Parosteal Osteochondromatous Proliferation (BPOP) of the hand that was initially misdiagnosed as an osteochondroma. BPOP, although a benign lesion, behaves aggressively with rapid growth and high risk of local recurrence after local resection. The distinguishing features of BPOP as opposed to an osteochondroma are discussed.

Upper limb digital replantation and revascularisation in children.

Amputations in children are not common and experience in microvascular digital replantation in children is not extensive. We report our experience of ten digital replantations in eight children over a two-year period. Paediatric replantation with its minute anatomy is technically very demanding. Joints should be reconstructed, epiphyses preserved and bone shortening kept as minimal as possible. Complications are not more than those in adults. All the replanted digits in our series survived. Seven of the ten replanted digits were normal in size. Six of the eight patients regained good to excellent functional use of the replanted digits. All but three of the joints at and distal to the level of injury regained active motion ranging from 10 degrees to 70 degrees with an average of 42 degrees. One had primary fusion of the distal interphalangeal joint of his amputated index finger. All the preserved epiphyses had remained open at the last follow-up. Replantation in children may be technically difficult but is very rewarding. We had a high success rate with good functional return and continuing growth.

Renal cell carcinoma presenting as a solitary thyroid nodule.

An unusual case of renal cell carcinoma of the right kidney with a solitary thyroid metastasis as the only presenting symptom is reported. Right thyroid lobectomy was done followed by right radical nephrectomy. A solitary metastasis of the renal cell carcinoma has a much better prognosis than the usual stage IV tumours and an aggressive management with radical nephrectomy and excision of the solitary metastasis is advocated.

Stonefish envenomations of the hand--a local marine hazard: a series of 8 cases and review of the literature.

INTRODUCTION: The Singapore shoreline has changed significantly in recent years, but the stonefish (Synanceia sp.) continues to inhabit our native waters and human envenomation still occurs regularly. In this paper, we document their clinical course, review our management experience and propose a treatment algorithm. CLINICAL PICTURE: Envenomation is associated with appreciable local morbidity, excruciating pain and gross oedema of the affected limb. Severe systemic morbidity and deaths have been reported in the literature but are very rare. TREATMENT: Prompt first aid with immersion in hot water (45 degrees C) inactivates the venom. Supplementary analgesia, tetanus prophylaxis and broad-spectrum antibiotics are recommended. Specific antivenom is available and indicated for severe envenomations with systemic symptoms. Complicated puncture wounds and retained spines require surgical debridement. OUTCOME: Eight cases of stonefish envenomations to the hand were treated over the last 1.25 years (October 2001 to January 2003). Length of hospital stay averaged 3.9 days. There were no deaths or significant systemic morbidity, but 1 case required surgical debridement for local necrosis. Complete resolution of swelling, with return to full function, occurred on average by 8.2 days. CONCLUSIONS: Prompt recognition of envenomation, early first aid and hot water soaks result in rapid relief of pain and symptoms. Our local experience suggests that the majority of stonefish envenomations do not result in significant or protracted morbidity and require only supportive management. Systemic morbidity and mortalities are rare.

Ossifying lipoma of the hand: a case report.

INTRODUCTION: Ossifying lipoma is an uncommon tumour and its occurrence in the hand is rare. It is often not diagnosed preoperatively. CLINICAL PICTURE: Our case presented with a lump in the hand which was painful with activity. The lipomatous component of the tumour was radiologically not distinguishable. TREATMENT: The hand was explored through a wide palmar incision, revealing a lipomatous tumour. The tumour was completely excised and diagnosis made after histological examination. OUTCOME: After 1 year, the patient has had normal function of the hand with no tumour recurrence. DISCUSSION: The diagnosis of ossifying lipoma could be made with certainty only after radiological examination, excision and histological examination. The bony component is of mesenchymal origin and may come about as a result of metaplastic transformation.

Osteocutaneous lateral arm flap in hand reconstruction.

Complex injuries of the hand often have severe soft tissue damage and associated intercalary segmental or distal loss of bone. Bone grafting to restore the skeletal scaffold is essential for soft tissue reconstruction. With a poor vascular bed, non-vascularised free bone grafts are not desirable. We describe 14 cases of vascularised humeral bone grafting for these difficult reconstructions. The bone was harvested as an osteocutaneous lateral arm flap. Constant osseous branches from the main pedicle of the posterior radial collateral artery which travel along the lateral intermuscular septum to the bone were preserved. Humeral bone grafts as a composite with the lateral arm flap are able to provide 1.5 x 10 cm of well vascularised bone for hand reconstruction. All 14 flaps survived and X-rays of the graft at 3 to 6 months showed consolidated bony union with little or no bony resorption.