Two Cases of Intraosseous Pseudomyogenic (Epithelioid Sarcoma-Like) Hemangioendothelioma With Unusual Features, Expanding the Clinicopathological Spectrum.

Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma (PMHE) is a distinct vascular neoplasm mostly observed in the lower extremities of young adults with characteristic histopathological features. In this article, we present 2 unusual cases of PMHE. Case 1: A 28-year-old male presented with pain and stiffness in his left shoulder. Radiologic examination revealed an expansile, lytic, heterogeneously enhancing, destructive lesion in his left scapula, along with multiple avid marrow lesions in his other bones. Biopsy revealed a cellular tumor composed of plump spindly and epithelioid cells arranged in fascicles and focally, in clusters, admixed with neutrophils and histiocytes, with interspersed many osteoclast-like giant cells and reactive bone. Case 2: A 63-year-old male presented pain and swelling in his right middle finger, with no other lesion elsewhere in his body. Radiologic imaging disclosed a 1.5-cm-sized lobulated, expansile, lytic, destructive lesion in the distal end of the third metacarpal bone of his right hand. Biopsy examination revealed a cellular spindle cell tumor, composed of plump spindly cells, arranged in fascicles, including "tadpole-like" or "strap-like" cells and interspersed inflammatory cells. Immunohistochemically, tumor cells in both cases were positive for AE1/AE3, CD31, and Fli1, while negative for desmin and CD34. INI11 was retained. The presented cases of PMHE, occurring at unusual locations, in an older individual in the second case, along with variable histopathological features, noted in the first case, seem to expand the clinicopathological spectrum of these uncommon neoplasms. Differential diagnoses and review of similar cases are presented.

Radial artery-first dorsal metacarpal vein arteriovenous fistula in the first interdigital space of the dorsal hand for hemodialysis.

A radiocephalic arteriovenous fistula in the anatomical snuffbox (tabatière region) was first described in 1969 as the most peripheral site for arteriovenous fistula in the upper limb. In cases in which the internal diameter of the first dorsal metacarpal vein under avascularization is ⩾2.0 mm, we have adopted a new operative technique for creating a radial artery-first dorsal metacarpal vein arteriovenous fistula in the first interdigital space of the dorsal hand, which lies between the thumb and the index finger. This technique is the creation of the arteriovenous fistula using the first dorsal metacarpal vein and the most peripheral site in the upper limb. To our knowledge, no previous report has described the creation of a radial artery-first dorsal metacarpal vein arteriovenous fistula. We herein describe the steps of the technique and report its successful performance in a patient with chronic renal failure.

Evaluation of versatility of use of island first dorsal metacarpal artery flap in reconstruction of dorsal hand defects.

BACKGROUND: Posttraumatic dorsal hand defects with exposed tendons and/or bones represent a challenge to reconstructive surgeons. Many options are suggested ranging from local, regional, distant up to free flaps. First dorsal metacarpal artery island flap was commonly prescribed for reconstructing the thumb or first web space defects. METHODS: During a 30 month's period, 23 patients, 15 males aged between 17 and 48 years and 8 females aged between 18 and 36 years presented by posttraumatic dorsal hand defects. Of them 18 had both exposed tendons and bones while 5 had exposed tendons only. The defects dimensions ranged between 3 × 4 cm and 4.5 × 6 cm. All defects were reconstructed by using a single stage first dorsal metacarpal artery island flaps. RESULTS: All flaps survived completely without complication during the mean follow up period of 2 years. All patients were very satisfied both functionally and aesthetically by the procedure. CONCLUSION: Island first dorsal metacarpal artery flap is a good option for reconstructing mild to moderate dorsal hand defects with acceptable functional and cosmetic results.

Versatility of Dorsal Metacarpal Artery Flaps for Hand Burns.

Burns to the hands can be devastating injuries and early debridement and coverage can prevent these chronic problems. Reconstructive options for these defects include skin grafts; local, regional, and distant flaps; and free flaps. In this series, they set out to demonstrate the versatility, durability, and effectiveness of dorsal metacarpal artery (DMCA) flaps for primary soft tissue coverage. This study involves a review of all consecutive patients who underwent acute soft tissue coverage using DMCA flaps at their institution from December 2014 to December 2017. Four patients were identified, two underwent reverse DMCA flaps, and two others underwent first DMCA flaps. Three patients were males and one female whose age ranged from 33 to 74 (mean 48 years old). Follow-up ranged from 6 to 43 days. One of the four flaps had de-epithelialization of the distal flap with loss of the most distal tip left to heal by secondary intention. The remainder of the flaps survived without incident, and a full thickness skin graft had 100% take onto the index finger donor site. At the final follow-up, all flaps had healed completely and patients had return of almost complete active range of motion. Flaps based on the DMCA have been proven to be versatile and reliable methods for primary hand burn reconstruction.

Dorsal metacarpal veins: anatomic variation and potential clinical implications.

The dorsal metacarpal veins are frequently cannulated. Cannulation success is determined by several variable anatomic features. The objective of this study is to classify, for the first time, the anatomic variants of the dorsal metacarpal veins. In this cross-sectional study, 520 university students and staff were conveniently recruited. The dorsal metacarpal veins in 1040 hands were studied. Venous visibility was enhanced by either tourniquet application or near-infrared illumination. Variant patterns of the dorsal metacarpal veins were classified. The final analysis included 726 hands, for an exclusion rate of 30 %. Eight pattern types were identified. Three anatomic features informed the variation. Bilateral symmetry of the dorsal metacarpal veins was present in 352 participants (83 % of the total). The overall frequency distribution of variants in both hands was similar (P = 0.8). The frequency distribution of variants was subject to sexual dimorphism (P = 0.001), ethnic variation (P < 0.001), and technical variation (P < 0.001). The anatomic variants of the dorsal metacarpal veins were sorted into decreasingly frequent primary, secondary, and tertiary groups. The groups may signify a progressive increase in difficulty of peripheral cannulation, in the mentioned order. As such, primary patterns are the most common and likely the easiest to cannulate, while tertiary patterns are the least common and likely the most difficult to cannulate. The preceding premise, in tandem with the bilateral asymmetry of the veins, is clinically significant. With cannulation difficulty likely signifying an underlying tertiary pattern, the contralateral dorsal metacarpal veins are probabilistically characterized by a primary pattern and are, as such, the easier option for peripheral venous cannulation.

Pollicization of the Second Metacarpal Based on Dorsal Metacarpal Arteries.

Blood supply to the index finger is maintained through volar (palmar arch) and dorsal (intermetacarpal arteries) vascular networks. In traditional index finger pollicization, blood supply is maintained on the volar palmar arch. In case of index finger loss at the metacarpophalangeal joint, remaining length of the second metacarpal is often not used for pollicization because the arc of rotation is limited on digital arteries. In this report, we present a surgical technique for the transfer of the index metacarpal to the thumb on the dorsal vascular network. This method adds no further morbidity and can be used as an alternative method of thumb reconstruction in cases in which the thumb and index fingers are amputated.

Reverse second dorsal metacarpal artery vascularized bone flap for index distal bone loss: A case report.

Fingertip trauma with resultant bony loss is optimally reconstructed with an autologous bone substitute, offering a unique opportunity for use of a local vascularized bone graft. The second dorsal metacarpal artery is well-described for use in soft tissue and bony reconstruction, with recent cadaveric studies suggesting a reverse-flow second dorsal metacarpal artery bone flap could reach defects in the distal phalanx. The aim of the current report is to illustrate the use of this technique in reconstructing the distal digit in a traumatized index finger with bony loss of the middle third of the distal phalanx. A 49-year-old man presented with a traumatic circular saw injury to his left index finger, with the unique finding of distal phalanx bony loss to the middle third of this bone, with no associated disruption of palmar or dorsal structures. Reconstructive goals were solely that of bony reconstruction, with no soft tissue coverage required. A reverse SDMA vascularized bone flap was successfully used for reconstruction, with the vascularized bone flap mobilized on its reverse SDMA pedicle and pivoted at the level of the distal anastomoses between the palmar and dorsal metacarpal arteries. There was uncomplicated donor and recipient site closures, and good functional outcomes with the ability to retain full distal interphalangeal joint motion and force on distal pinch grip. This case shows that the reverse second dorsal metacarpal artery vascularized bone flap may be undertaken to reconstruct bony loss in the distal phalanx.

The second dorsal metacarpal artery chain-link flap: an anatomical study and a case report.

PURPOSE: The purpose of this study was to discuss the distribution characteristics and the anatomical angioarchitecture of cutaneous branches arising from the second dorsal metacarpal artery for the repair of small tissue defects in the hand or fingers using the second dorsal metacarpal artery chain-link flap. METHODS: Fifteen fresh human cadaveric hands were studied using three methods: latex perfusion for microanatomical analysis, denaturation of material and vinyl chloride mixed packing for cast specimens, and latex perfusion creating pellucid specimens. Cutaneous perforators with a diameter of 0.2 mm or greater were evaluated using statistical analysis. Cluster analysis was conducted to determine the overall distribution of the perforators. RESULTS: Two main clusters of perforators distributed at a relative distance of 40.8 and 68.6% from the second web space edge to the midpoint of the second metacarpal bone as a unit. The Chi-square analysis revealed no significant differences in either the radial or ulnar side distribution of the cutaneous perforators from the second dorsal metacarpal artery (p = 0.779). Chain-links formed among adjacent perforators were parallel to the axis of the second metacarpal bone on the dorsum of the hand. Based on the anatomic characteristic, we designed the second dorsal metacarpal artery chain-link flap to recover the defect in the index finger. As a result, the patient was satisfied with the appearance and function. CONCLUSION: This study indicates that there are two main clusters of arterioles in the distal second dorsal metacarpal artery that can be helpful for the second dorsal metacarpal artery pedicle cutaneous chain-link perforator flaps in the repair of defects in the fingers.

Vascularization of the dorsal base of the second metacarpal bone: an anatomical study using C-arm cone beam computed tomography.

BACKGROUND: Vascularized bone grafts of the hand are a promising option for treatment of hand abnormalities. Therefore, the purpose of this study was to analyze the arterial anatomy of the dorsal aspect of the second metacarpal base to further investigate this possible donor site for bone grafts. METHODS: The authors examined 16 fresh frozen cadaveric hands by using a C-arm cone beam computed tomography scanner and depicted the three-dimensional course of the second dorsal metacarpal artery and measured the diameter, length, and arc of rotation of this nutritive vessel. In addition, the authors dissected six of the hands under a dissecting microscope and, after selective injection of gelatin dye solution, the authors analyzed the vessel entrances into the bones histologically. RESULTS: In all examined hands, the second dorsal metacarpal artery was a nutritive vessel to the dorsal base of the second metacarpal. The average diameter was 1.3±0.4 mm and the average length of the vascular pedicle was approximately 3.3±0.3 cm. In 14 of 16 cases, the arc of rotation was sufficient to reach the lunate without difficulty. Histologic analysis showed an intrinsic blood supply in the donor region with a vessel diameter of approximately 58 µm. A clinical case with application in Kienböck disease is presented. CONCLUSION: Pedicled vascularized bone grafts from this area are suitable for clinical application to treat Kienböck disease if standard donor sites are unavailable.

[The anatomical basis of the formation of the pedicled bone grafts on the upper extremity].

The study of the vascular bed of the upper extremities was performed by the method of anatomical preparation of 24 formalin-fixed cadaver specimens from 5 men and 7 women and by the injection of black latex into the arterial bed of 4 male and 4 female cadavers (16 specimens). The arteries, directly feeding the bones, and the arteries that provide blood supply to the muscles, attached to the bones, were studied. M. pectoralis major, m. pronator teres, m. pronator quadratus, mm. lumbricalis and interosseus were examined. These studies were followed by the experimental surgeries during which bone grafts on vascular pedicle were formed and moved. It was found that the feeding arteries of the bone grafts on musculo-vascular pedicle were: on the clavicula--the branches of a. thoracoacromialis, on the brachium--muscular branches of a. brachialis, on the proximal parts of forearm bones--muscular branches of a. radialis and ulnaris, on the distal parts of forearm bones--the branches of a. interosseous anterior, on the metacarpal bones--the branches of aa. metacarpalis palmaris and dorsalis. The size of the bone transplants is determined by the size of the defect of recipient field and varies from 3 to 8 cm. The displacement of vascularised bone graft can be made over the distance from 4 to 8 cm.

Vascular perfusion of the dorsal and palmar condyles of the equine third metacarpal bone.

REASONS FOR PERFORMING STUDY: Palmar osteochondral disease (POD) is an overload arthrosis that commonly affects fetlock joints of racing Thoroughbreds (TB) but the aetiopathogenesis of the disease has not been well defined. OBJECTIVES: The aim of this study was to compare India ink perfusion in the dorsal and palmar condyles of the third metacarpal bone (McIII) in both passively flexed and maximally extended fetlock joints from paired equine cadaver limbs. STUDY DESIGN: Descriptive cadaver study comparing perfusion of condyles of McIII in paired cadaver limbs in flexion (control group) and maximal extension (intervention group). METHODS: Pairs of forelimbs were acquired from 5 TB horses subjected to euthanasia for reasons unrelated to lameness. Limb pairs were perfused intra-arterially with India ink and then randomly assigned to passive flexion or maximal extension of the fetlock joint. Limbs were sectioned sagittally in 3 mm sections through the fetlock and 12 sections per limb processed using a modified tissue-clearing technique. Sections were subsequently digitally imaged and bone perfusion evaluated with image analysis software. RESULTS: Greater perfusion of the dorsal condyle than of palmar condyle was observed in 78% of sections from limbs in passive flexion and 92% of maximally extended sections. Perfusion to the palmar aspect of the condyle was significantly decreased (P < 0.0001) when the limbs were placed in maximal extension compared to passive flexion. CONCLUSIONS: The palmar condyle of McIII had less perfusion than the dorsal condyle when the fetlock joint was in passive flexion and this difference was exacerbated by maximal extension. Based on the anatomical location of POD lesions, perfusion differences between the dorsal and palmar condyles of McIII may be associated with development of these lesions.

Conservative management of Dieterich disease: case report.

Dieterich disease is characterized by avascular necrosis of the metacarpal head. The recent literature has described surgical management of this condition relatively soon after its presentation. We present a case treated conservatively with a satisfactory outcome at 28 months.

Use of the second dorsal metacarpal artery-based bilobed island flap for thumb reconstruction.

We report the use of the second dorsal metacarpal artery-based bilobed island flap harvested from the index and middle fingers for thumb reconstruction. From October 2006 to March 2008, the flap was performed in 13 hands in 13 patients (10 males and 3 females). The mean age at the time of operation was 45 years (range, 38 to 57 years). The flaps of the index fingers ranged in size from 2.1 × 2.5 cm to 4.2 × 3.2 cm. The flaps of the middle fingers were from 2.5 × 2.5 cm to 4.7 × 3.0 cm. The mean pedicle length was 6.5 cm (range, 5.1 to 8.0 cm). Flap survival was achieved in all cases. At final follow-up (mean 43 months; range, 36 to 52 months), the mean static two-point discrimination of the thumb pulps was 7 mm (range, 5 to 10 mm). Our technique is useful and reliable for the thumb reconstruction in select cases, with minimal donor-site morbidity.

The dorsal metacarpal arteries: anatomical study. Feasibility of pedicled metacarpal bone flaps.

The vascular anatomy of the dorsal aspect of the hand is variable. Nevertheless the presence of the first and the second dorsal metacarpal artery (DMA) is constant. DMA3 and 4 are more variable. The anatomical study presented demonstrates the segmental vascularization of the metacarpal bones and the possibility of harvesting metacarpal bone flaps. The reliability of such a flap decreases from the second to the fifth metacarpal bone regarding the frequency of presence of the DMAs. The authors describe six new vascularized bone flaps from the third and the fourth metacarpal bones pedicled on the second or the third dorsal metacarpal artery in an anterograde or retrograde flow mode. This study suggests that the radial and the ulnar side of the third metacarpal bone could be harvested respectively on the DMA2 and DMA3. The radial side of the fourth metacarpal bone could also be a reliable vascularized bone donor site. Flaps can be used proximally or distally based to repair bone defects either on metacarpal and carpal bones or on proximal phalanges.

Use of a bilobed second dorsal metacarpal artery-based island flap for thumb replantation.

PURPOSE: An extensive traumatic defect at the level of the proximal phalanx of the thumb presents difficulty in replantation. We report bilobed second dorsal metacarpal artery-based island flap harvested from both the index and middle fingers for reconstruction of the defect and preservation of the normal thumb length. METHODS: From March 2004 to October 2008, 15 patients (11 men and 4 women; mean age, 35 y; range, 18 to 55 y) with completely or incompletely amputated thumbs associated with extensive defects in the proximal phalanx had replantation and reconstruction. In all cases, a bilobed second dorsal metacarpal artery-based island flap was used due to the large size of the defect. After flap transfer, anastomoses between the veins of the distal part of the thumb and the flap were performed. At the final follow-up, we assessed the mean active range of motion of the metacarpophalangeal and interphalangeal joints of the thumb and the span of the first web in the thumbs that survived. Active motion of the donor fingers was also assessed. RESULTS: In this series, 13 thumbs survived and 2 failed. All flaps survived completely. At the mean follow-up of 27 months (range, 24 to 29 mo), the mean active motion arcs of metacarpophalangeal and interphalangeal joints were 32° (range, 15° to 45°) and 31° (range, 0° to 47°), respectively. Full active range of motion was observed in all patients in both the metacarpophalangeal and the proximal interphalangeal joints of the donor index and middle fingers. CONCLUSIONS: Bilobed second dorsal metacarpal artery-based island flap transfer is a useful and reliable technique for thumb replantation when there is an extensive defect in the proximal phalanx and when a single-digit dorsal metacarpal artery island flap is too small. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Treatment of scaphoid non-unions by a palmar approach with vascularised bone graft harvested from the thumb.

Ten patients with scaphoid non-unions which had been present for longer than 2 years were treated using a vascularised bone graft harvested from the thumb and pedicled on the first dorsal metacarpal artery. Bone harvesting and grafting were performed by a single palmar approach. Concomitant cancellous bone graft was not used. Bone healing was confirmed by CT scans in nine of the ten patients. Persistence of the non-union was observed in one patient who was the oldest in this series, had the longest standing non-union and was a heavy smoker. Twelve months after surgery, nine of the ten patients had significant pain relief with an improved range of motion and grip strength.