A Rare Cause of Chronic Flexor Tenosynovitis of the Finger.

Cat scratch disease (CSD) is an uncommon condition. When a patient is infected, the disease is often self-limiting. Cat scratch disease involving the musculoskeletal system had been described, but the manifestation of the disease in hand remained unexplored. We report a case of chronic flexor tenosynovitis of the left index finger caused by cat scratch disease. In this case, the antibiotic treatment did not improve the clinical outcome. However, surgical debridement of the diseased finger resulted in a tremendous improvement in terms of pain and range of motion.

Psychometric Evaluation of the Disabilities of the Arm, Shoulder and Hand Outcome Questionnaire for Brachial Plexus Injury Using Rasch Analysis.

Background: Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire is the most widely used patient-reported outcome measure (PROM) for assessment of upper extremity disability assessment. However, DASH is a multidimensional measurement with different difficulty levels and ratio apportionment of the items categorised by ordinal scale. This has caused a misinterpretation of the total disability scores. We created a modified DASH adapted to the Rasch model. The aim of this study is to compare the functional recovery and quality of life (QOL) improvement and to assess the validity of the original DASH and modified DASH between C56/C567, C5-8 and total types of brachial plexus injury (BPI) following surgical reconstruction. Methods: A total of 183 BPI patients who underwent reconstructive surgery were evaluated for functional recovery using the range of motion and power of the affected limb, and improvement in QOL with DASH. The collected data were analysed using Rasch measurement theory to detect the misfit items. The original and modified DASH were compared under the three different types of BPI after item reduction by removing the misfit items. Results: There were significant differences in functional recovery between three types of palsy. However, PROM using DASH score with or without misfit items (12 items) did not show any significant differences. Conclusions: DASH is not suitable for comparison of upper extremity disabilities even after being corrected mathematically due to the inclusion of items from many different domains unequally. Therefore, each item of the function (with or without compensation of the uninjured hand), pain and impact to the patients should be evaluated separately. Level of Evidence: Level IV (Prognostic).

Pearls and Pitfalls of Phrenic Nerve Transfer for Shoulder Reconstruction in Brachial Plexus Injury.

Objectives The purpose of this study was to report the functional outcomes of phrenic nerve transfer (PNT) to suprascapular nerve (SSN) for shoulder reconstruction in brachial plexus injury (BPI) patients with total and C5-8 palsies, and its pulmonary complications. Methods Forty-four out of 127 BPI patients with total and C5-8 palsies who underwent PNT to SSN for shoulder reconstruction were evaluated for functional outcomes in comparison with other types of nerve transfers. Their pulmonary function was analyzed using vital capacity in the percentage of predicted value and Hugh-Jones (HJ) breathless classification. The predisposing factors to develop pulmonary complications in those patients were examined as well. Results PNT to SSN provided a better shoulder range of motion significantly as compared with nerve transfer from C5 root and contralateral C7. The results between PNT and spinal accessory nerve transfer to SSN were comparable in all directions of shoulder motions. There were no significant respiratory symptoms in majority of the patients including six patients who were classified into grade 2 HJ breathlessness grading. Two predisposing factors for poorer pulmonary performance were identified, which were age and body mass index, with cut-off values of younger than 32 years old and less than 23, respectively. Conclusions PNT to SSN can be a reliable reconstructive procedure in restoration of shoulder function in BPI patients with total or C5-8 palsy. The postoperative pulmonary complications can be prevented with vigilant patient selection.

A Bilobed Pedicled Groin Flap for Reconstruction of Forearm Skin Defects following Replantation.

The versatility of a pedicled groin flap can be further increased by raising it in a bilobed fashion. This allows the flap to cover both the volar and dorsal surfaces of a hand or forearm defect. A 48-year-old man sustained an avulsion amputation of his right forearm by a rolling machine in a workplace accident. Replantation of the right forearm was performed, and the postoperative course was uneventful. Unfortunately, the wound healing was complicated by circumferential marginal skin necrosis, which was confined to the distal forearm. A bilobed pedicled groin flap was performed for the wound coverage because reconstruction with a free flap would be very risky as the vessels were avulsed from the proximal part of the forearm. A good functional recovery of the hand and fingers was noted at 12 months' follow-up. The advantages of a bilobed pedicle groin flap are that it allows coverage of both the volar and dorsal surfaces at one setting and primary closure of the donor site is possible. Furthermore, a long tube-shaped pedicle in this flap can reduce the patient discomfort and prevent finger stiffness by allowing a range of motion exercise. In conclusion, the bilobed pedicled groin flap is a useful option to cover soft tissue defects involving both the volar and dorsal surfaces over the mid- to distal forearm, especially when the free flap is contraindicated.

Hemi-hamate Arthroplasty in Chronic Fracture-dislocation of Proximal Interphalangeal Joint of Fingers: A Report of Two Cases.

Dorsal dislocations of proximal interphalangeal joint with palmar lip fractures base of middle phalanx of fingers are rare, complex, and often a challenging injury to the treating hand surgeons especially in those chronic cases. Hemi-hamate arthroplasty is the preferred surgical option in treating chronic dorsal fracture-dislocations of the proximal interphalangeal joint. We report two cases with a chronic injury that have been treated with hemi-hamate arthroplasty. Range of motion, pinch and grip strengths, QuickDASH scores, complications, and radiological findings were recorded at follow-up. Good functional outcomes were observed in both patients without major complications. Hemi-hamate arthroplasty can be a reliable surgical treatment for chronic proximal interphalangeal joint fracture-dislocations.

Irreducible Dorsal Distal Interphalangeal Joint Dislocation of Finger: A Case Report and Perspectives on Management.

Irreducible closed dorsal dislocation of distal interphalangeal (DIP) joint of the finger is a rare injury. The causes of irreducibility of the DIP joint are volar plate interposition, entrapment of flexor digitorum profundus tendon behind the head of middle phalanx, and buttonholing of the middle phalanx head through the volar plate or flexor tendon. Open reduction with a volar approach is recommended with the advantages of better wound healing, ease of releasing entrapped structures, and possibilities of a volar plate, collateral ligaments, and/or flexor tendon repair. We report a case of irreducible dorsal dislocation of left ring finger DIP joint secondary to volar plate interposition treated successfully with open reduction.

Contralateral Obturator Nerve to Femoral Nerve Transfer for Restoration of Knee Extension After Acute Flaccid Myelitis: A Case Report.

CASE: A 7-year-old boy presented with left femoral and obturator nerves (ONs) palsy after an asthmatic attack with a viral prodrome, and his right lower limb was unaffected. He was diagnosed with acute flaccid myelitis (AFM) after positive spinal magnetic resonance imaging findings. After contralateral ON to femoral nerve transfer (CONFNT), his left quadriceps was reinnervated at 5.5 months, full knee extension was recovered at 14 months, and good functional outcomes were achieved at 31 months. CONCLUSIONS: This first clinical report on CONFNT demonstrated a feasible good alternative in treating young patients with AFM with unilateral L2-L4 palsy and short duration of deficit.

Surgical Reconstruction for Upper-Extremity Paralysis Following Acute Flaccid Myelitis.

Acute flaccid myelitis (AFM) is a debilitating illness that is defined by the sudden onset of flaccid paralysis in the extremities with spinal magnetic resonance imaging (MRI) demonstrating a longitudinal lesion confined to the gray matter. The purpose of this study was to report the types of upper-extremity palsy and outcomes of surgical reconstruction in patients with AFM. METHODS: Eight patients with a median age at onset of 3.8 years (range, 2.3 to 9.9 years) were identified. There was loss of shoulder abduction and external rotation in all patients, loss of elbow flexion in 5 patients, complete or partial loss of hand function in 3 patients, and spinal accessory nerve palsy in 2 patients. All patients underwent surgical reconstruction, which was categorized into 3 main groups: nerve transfer, secondary muscle transfer, and free muscle transfer. RESULTS: The median follow-up period was 39 months (range, 30 to 94 months). Four patients obtained ≥90° of shoulder abduction whereas the other 4 patients had shoulder abduction of ≤70°. The 5 patients who received free muscle transfer or nerve transfer to restore elbow function obtained ≥140° of elbow flexion. Two patients treated with free muscle transfer to restore finger function obtained satisfactory total active motion of the fingers (180°). CONCLUSIONS: The patterns of paralysis and the strategy and outcomes of surgical reconstruction for patients with AFM differed from those for traumatic and obstetric brachial plexus palsy. All patients had loss of shoulder abduction, and 2 had spinal accessory nerve palsy. Restoration of shoulder function was unpredictable and depended on the quality of the donor nerves and recovery of synergistic muscles. Restoration of elbow and hand function was more consistent and satisfactory. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete list of levels of evidence.