Candida albicans Flexor Tenosynovitis after Trigger Finger Release: A Case Report.

Tenosynovitis caused by fungi, especially Candida species, is rare. We report a case of an immunocompetent patient with finger flexor tenosynovitis caused by Candida albicans after trigger finger release (TFR). Intratendon sheath triamcinolone injection and subsequent TFR surgery might contribute to the occurrence of Candida tenosynovitis. We performed a tenosynovectomy twice because the pathology was unclear after the first tenosynovectomy. The culture of synovial tissue from the first tenosynovectomy was negative. However, the culture from the second tenosynovectomy tested positive for Candida albicans. We must consider the possibility of infection with low virulent pathogens such as fungi even if cultures are negative. When hand tenosynovitis is observed in immunocompromised or immunocompetent patients with invasive procedures, such as local injection or surgery, Candida infection should be considered a potential root cause even in the absence of positive results for the presence of fungi in the specimens being tested.

Perspectives and Consensus among International Orthopaedic Surgeons during Initial and Mid-lockdown Phases of Coronavirus Disease.

With a lot of uncertainty, unclear, and frequently changing management protocols, COVID-19 has significantly impacted the orthopaedic surgical practice during this pandemic crisis. Surgeons around the world needed closed introspection, contemplation, and prospective consensual recommendations for safe surgical practice and prevention of viral contamination. One hundred orthopaedic surgeons from 50 countries were sent a Google online form with a questionnaire explicating protocols for admission, surgeries, discharge, follow-up, relevant information affecting their surgical practices, difficulties faced, and many more important issues that happened during and after the lockdown. Ten surgeons critically construed and interpreted the data to form rationale guidelines and recommendations. Of the total, hand and microsurgery surgeons (52%), trauma surgeons (32%), joint replacement surgeons (20%), and arthroscopy surgeons (14%) actively participated in the survey. Surgeons from national public health care/government college hospitals (44%) and private/semiprivate practitioners (54%) were involved in the study. Countries had lockdown started as early as January 3, 2020 with the implementation of partial or complete lifting of lockdown in few countries while writing this article. Surgeons (58%) did not stop their surgical practice or clinics but preferred only emergency cases during the lockdown. Most of the surgeons (49%) had three-fourths reduction in their total patients turn-up and the remaining cases were managed by conservative (54%) methods. There was a 50 to 75% reduction in the number of surgeries. Surgeons did perform emergency procedures without COVID-19 tests but preferred reverse transcription polymerase chain reaction (RT-PCR; 77%) and computed tomography (CT) scan chest (12%) tests for all elective surgical cases. Open fracture and emergency procedures (60%) and distal radius (55%) fractures were the most commonly performed surgeries. Surgeons preferred full personal protection equipment kits (69%) with a respirator (N95/FFP3), but in the case of unavailability, they used surgical masks and normal gowns. Regional/local anesthesia (70%) remained their choice for surgery to prevent the aerosolized risk of contaminations. Essential surgical follow-up with limited persons and visits was encouraged by 70% of the surgeons, whereas teleconsultation and telerehabilitation by 30% of the surgeons. Despite the protective equipment, one-third of the surgeons were afraid of getting infected and 56% feared of infecting their near and dear ones. Orthopaedic surgeons in private practice did face 50 to 75% financial loss and have to furlough 25% staff and 50% paramedical persons. Orthopaedics meetings were cancelled, and virtual meetings have become the preferred mode of sharing the knowledge and experiences avoiding human contacts. Staying at home, reading, and writing manuscripts became more interesting and an interesting lifestyle change is seen among the surgeons. Unanimously and without any doubt all accepted the fact that COVID-19 pandemic has reached an unprecedented level where personal hygiene, hand washing, social distancing, and safe surgical practices are the viable antidotes, and they have all slowly integrated these practices into their lives. Strict adherence to local authority recommendations and guidelines, uniform and standardized norms for admission, inpatient, and discharge, mandatory RT-PCR tests before surgery and in selective cases with CT scan chest, optimizing and regularizing the surgeries, avoiding and delaying nonemergency surgeries and follow-up protocols, use of teleconsultations cautiously, and working in close association with the World Health Organization and national health care systems will provide a conducive and safe working environment for orthopaedic surgeons and their fraternity and also will prevent the resurgence of COVID-19.

Cyclists' fractures in the elderly.

Cyclists' fractures were as common in the elderly as in the young. In cyclists' fractures in the elderly, the ratio of women and the frequency of upper extremity fractures were significantly lower, compared with the young group. PURPOSE: Bicycles are useful for both men and women of any age as a means of transportation. In the present aging society, it is common for elderly people to ride bicycles in their daily lives. There have been no reports describing the characteristics of elderly cyclists' fractures. We conducted this study to elucidate these characteristics. METHODS: Data of cyclists' fractures, excluding head or facial injuries, treated in an urban hospital were retrospectively collected. We documented the mechanism of injury, gender, age, and location of each fracture. We compared the gender, age, and location between cyclists' fractures and non-cyclists' fractures treated in the same period in the same hospital. RESULTS: Fifty percent of cyclists' fractures occurred in cyclists over 60 years old (23% in their 60s, 19% in their 70s, and 7% in their 80s). The proportion of women was significantly higher among cyclists' fractures than among non-cyclists' fractures in patients under 60 years old (p = 0.0001), but was significantly lower in patients over 60 years old (p = 0.002). We found a significant relationship between the fracture location of three categories (upper extremities, lower extremities, and trunk) and CF/NCF (p = 0.04). The proportion of upper extremity fractures in cyclists compared with non-cyclists was similar under 60 years, but significantly lower in patients over 60 years (p = 0.049). CONCLUSIONS: Our study showed that cyclists' fractures were not uncommon in the elderly. In the elderly group, the ratio of women and the frequency of upper extremity fractures were significantly lower, compared with the young group.

Ulnar Neuropathy due to Volar/Ulnar Displacement of the Flexor Tendons after Open Carpal Tunnel Release: Case Report.

Ulnar nerve neuropathy is a rare complication following the carpal tunnel release. Above all, compression neuropathy is much rare. We report an acute ulnar nerve neuropathy following open carpal tunnel release due to the volar and ulnar displacement of the flexor tendons from the carpal tunnel and review the literature.

Fracture of an unossified humeral medial epicondyle: use of magnetic resonance imaging for diagnosis.

Fracture of the humeral medial epicondyle is a relatively common injury in children. Surgery is a good option for treatment, but correct diagnosis is important. Most fractures occur after the ossification of the medial epicondylar apophysis. If a fracture occurs before the ossification of the medial epicondyle, it is undetectable by radiographs. Here we report a case of an unossified medial epicondyle fracture of the humerus. A 9-year-old boy had persistent pain in the medial side of the right elbow after a fall. Despite his pain, he could move his injured elbow with a range from 60 to 90°. Radiographs and computed tomography showed neither fracture nor dislocation in the injured elbow, and soft tissue swelling was the only finding. Neither the trochlea nor the medial epicondyle was ossified. Magnetic resonance imaging showed that the medial epicondyle was separated from the medial metaphysis and displaced. This clear finding led us to surgical fixation. Under general anesthesia, valgus stress showed gross instability of the injured elbow. Two years after the operation, he had no complaints and could play sports with the same range of motion as the left elbow. It is important to keep in mind that medial epicondylar fractures may be hidden in a normal radiograph before the ossification of the medial epicondylar apophysis.

Intra-articular fractures of the distal radius evaluated by computed tomography.

PURPOSE: To describe the fracture lines of intra-articular distal radius fractures as evaluated by computed tomography scans. METHODS: With computed tomography, we examined 95 intra-articular fractures of the distal radius from 91 patients. Multiplanar computed tomography images or 3-dimensional images, or both, were assessed. We divided the periphery of the distal articular surface of the distal radius into 6 segments (sigmoid notch, dorsoulnar, dorsoradial, volar radial, volar ulnar, radial styloid) and examined which segment had fracture lines. For fractures involving the sigmoid notch, we divided them by the location and the direction of the fracture lines entering the sigmoid notch. Next, we categorized the fractures into 3 fracture groups (extension group, neutral group, and flexion group) by the dorsal or volar angulation of the cortex of the distal radius. In all the fractures and in each of the 3 fracture groups, we described the frequency of the fracture lines in each segment and the number of the segments with fracture lines. The location and the direction of the fracture lines in the sigmoid notch were analyzed in each of the 3 fracture groups. RESULTS: The most frequent fracture type, seen in 21% of all fractures, had fracture lines in the sigmoid notch and the dorsoulnar segment. The frequency of the fracture lines was 77% in the sigmoid notch, 71% in the dorsoulnar segment, and 57% in the dorsoradial segment. The volar ulnar segment was lowest in frequency, at 13%. The fractures in the extension group were more common in the dorsoulnar segment and less common in the dorsoradial segment and the radial styloid segment. The scaphoid facet always had a fracture in the flexion or neutral group. In the extension group, the direction of the fracture lines from the sigmoid notch was dorsoradial or parallel to the volar articular edge. In contrast, the direction was parallel or volar radial compared to the volar articular edge in the flexion group. CONCLUSIONS: We documented the location and the direction of intra-articular fracture lines of the distal radius. The location and the direction of fractures showed different tendencies related to the volar/dorsal angulation of the distal radius. CLINICAL RELEVANCE: The findings might help in the evaluation, classification, and treatment of intra-articular fractures of the distal radius.

Spontaneous ulnar dislocation of the index, long, ring and small finger extensor tendons at the metacarpophalangeal joints: a case report.

Finger extensor tendon dislocation at the metacarpophalangeal joint is caused by various etiologies, such as trauma, congenital anomaly, or rheumatoid arthritis. When the dislocation occurs with no etiology, this is called spontaneous dislocation. Although spontaneous extensor tendon dislocation in one, two or three fingers has been described, to our knowledge, simultaneous dislocation in four fingers has not been reported. In this paper, we report a spontaneous ulnar dislocation of all the extensor tendons in the index, long, ring, and small fingers. Repair of the radial sagittal bands of the extensor digitorum communis of the middle and ring fingers reduced dislocation of all the extensor tendons in four fingers.

Melanocortin receptor 4 is induced in nerve-injured motor and sensory neurons of mouse.

We previously identified melanocortin receptor 4 (MC4R) in a search for genes associated with hypoglossal nerve regeneration. As melanocortins promote nerve regeneration after axonal injury, we investigated whether MC4R functions as a key receptor for peripheral nerve regeneration. In situ hybridization revealed that MC4R mRNA is induced in mouse hypoglossal motor neurons after axonal injury, whereas mRNAs for MC1R, MC2R, MC3R, and MC5R are not expressed either before or after nerve injury. This result was confirmed by RT-PCR. The level of MC4R mRNA expression increased significantly from day 3 after axotomy, reached a peak on day 5, and decreased to the control level on day 14. Similar induction of MC4R was observed in axotomized mouse dorsal root ganglia (DRGs). MC4R mRNA expression was induced exclusively among the MCR family in the L4-6 DRG after sciatic nerve injury. We further examined whether alpha-melanocortin stimulating hormone (alpha-MSH) promotes neurite elongation via MC4R. In mouse DRG neuron culture, alpha-MSH significantly promoted neurite outgrowth at a concentration of 10(-8) mol/L. This neurite-elongation effect was entirely inhibited by the addition of a selective MC4R blocker, JKC-363. Therefore, it is concluded that alpha-MSH could stimulate neurite elongation via MC4R in DRG neurons. The present results suggest that induction of MC4R is crucial for motor and sensory neurons to regenerate after axonal injury.

Fibroblast growth factor-inducible-14 is induced in axotomized neurons and promotes neurite outgrowth.

For successful nerve regeneration, a coordinated shift in gene expression pattern must occur in axotomized neurons. To identify genes participating in axonal regeneration, we characterized mRNA expression profiles in dorsal root ganglia (DRG) before and after sciatic nerve transection. Dozens of genes are differentially expressed after sciatic nerve injury by microarray analysis. Induction of SOX11, FLRT3, myosin-X, and fibroblast growth factor-inducible-14 (Fn14) mRNA in axotomized DRG neurons was verified by Northern analysis and in situ hybridization. The Fn14 gene encodes a tumor necrosis-like weak inducer of apoptosis (TWEAK) receptor and is dramatically induced in DRG neurons after nerve damage, despite low expression in developing DRG neurons. Fn14 expression in PC12 cells is also upregulated by nerve growth factor treatment. Overexpression of Fn14 promotes growth cone lamelipodial formation and increases neurite outgrowth in PC12 cells. These Fn14 effects are independent of the ligand, TWEAK. Fn14 colocalizes with the Rho family GTPases, Cdc42 and Rac1. Furthermore, Fn14 physically associates with Rac1 GTPase in immunoprecipitation studies. The neurite outgrowth-promoting effect of Fn14 is enhanced by Rac1 activation and suppressed by Rac1 inactivation. These findings suggest that Fn14 contributes to nerve regeneration via a Rac1 GTPase-dependent mechanism.

Small proline-rich repeat protein 1A is expressed by axotomized neurons and promotes axonal outgrowth.

The ability of neurons to regenerate an axon after injury is determined by both the surrounding environment and factors intrinsic to the damaged neuron. We have used cDNA microarrays to survey those genes induced during successful sciatic nerve regeneration. The small proline-rich repeat protein 1A (SPRR1A) is not detectable in uninjured neurons but is induced by >60-fold after peripheral axonal damage. The protein is localized to injured neurons and axons. sprr1a is one of a group of epithelial differentiation genes, including s100c and p21/waf, that are coinduced in neurons by axotomy. Overexpressed SPRR1A colocalizes with F-actin in membrane ruffles and augments axonal outgrowth on a range of substrates. In axotomized sensory neurons, reduction of SPRR1A function restricts axonal outgrowth. Neuronal SPRR1A may be a significant contributor to successful nerve regeneration.