An Anatomical Variant of the Palmar Cutaneous Branch of the Median Nerve: A Case Report.

There is a risk of injury to the palmar cutaneous branch of the median nerve (PCBMN) during a volar approach to the carpus or the distal radius. Anatomic variations of the PCBMN increase this risk. We report an anatomic variant of the PCBMN that coursed superficial and radial to the flexor carpi radialis (FCR), reinforcing the need for meticulous subcutaneous dissection to protect the nerve during a volar approach to the distal radius. In this case, identification of the PCBMN variant warranted a modified surgical approach, ulnar to the FCR instead of radial in order to avoid iatrogenic injury. Level of Evidence: Level V (Therapeutic).

Symptomatic Periungual Fibroma of the Hand.

Periungual fibromas are benign nodules commonly found on acral digital areas that are commonly associated with tuberous sclerosis. They vary in size and are challenging to treat, with a high recurrence rate. We present a case of a patient with a periungual fibroma, which by virtue of its size, was of functional concern. The intraoperative findings and their implications on the clinical outcome, together with a literature review on other treatment modalities, are also presented.

A hands-on microsurgery course for nurses.

Microsurgical procedures are time-consuming and sometimes fatigue-inducing. However, a skilled assistant and scrub nurse can help surgery be performed more smoothly and rapidly. Three microsurgical simulation courses were held for perioperative nurses at our institution. Each course consisted of two lectures and two practice microsurgical sessions, and was evaluated with a post-course survey. The respondents all felt that their knowledge of microsurgical instruments, sutures, microscope set-up, and microsurgical skills had improved following the course. Many felt that their ability to predict what the surgeon would request during a microsurgical case improved, and that they were able to handle instruments and sutures better. The nurses also reported improved confidence in assisting with microsurgical procedures and tolerance of the long operative time in some microsurgical cases. Based on our experience, a basic microsurgery course for nurses can play a significant role in training effective and competent microsurgical scrub nurses.

Sustaining a national surgical training programme during the COVID-19 pandemic.

The COVID-19 pandemic has disrupted all segments of daily life, with the healthcare sector being at the forefront of this upheaval. Unprecedented efforts have been taken worldwide to curb this ongoing global catastrophe that has already resulted in many fatalities. One of the areas that has received little attention amid this turmoil is the disruption to trainee education, particularly in specialties that involve acquisition of procedural skills. Hand surgery in Singapore is a standalone combined programme that relies heavily on dedicated cross-hospital rotations, an extensive didactic curriculum and supervised hands-on training of increasing complexity. All aspects of this training programme have been affected because of the cancellation of elective surgical procedures, suspension of cross-hospital rotations, redeployment of residents, and an unsustainable duty roster. There is a real concern that trainees will not be able to meet their training requirements and suffer serious issues like burnout and depression. The long-term impact of suspending training indefinitely is a severe disruption of essential medical services. This article examines the impact of a global pandemic on trainee education in a demanding surgical speciality. We have outlined strategies to maintain trainee competencies based on the following considerations: 1) the safety and wellbeing of trainees is paramount; 2) resource utilization must be thoroughly rationalized; 3) technology and innovative learning methods must supplant traditional teaching methods; and 4) the changes implemented must be sustainable. We hope that these lessons will be valuable to other training programs struggling to deliver quality education to their trainees, even as we work together to battle this global catastrophe.

The Impact of Coronavirus Disease 2019 (COVID-19) on the Practice of Hand Surgery in Singapore.

The coronavirus disease 2019 (COVID-19) pandemic is rapidly evolving. Tan Tock Seng Hospital and the National Centre for Infectious Disease see the majority of confirmed and suspected cases in Singapore. This article describes the impact of COVID-19 on the practice of hand and reconstructive microsurgery (HRM) in our institution. It details our department's response as the situation escalated and the impact on the HRM elective and emergency workload, including the use of personal protective equipment on the surgical practice of HRM, as well as the effects of the condition on social and academic life.

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.

Transverse or longitudinal? A survey of volar wrist incision preferences.

INTRODUCTION: In volar wrist surgery, the traditional longitudinal incision leaves a scar that may be considered cosmetically unpleasant. Recent studies suggest that transverse wrist incisions result in more aesthetically pleasing scars that are well hidden in the wrist crease. The aim of our study was to explore the public's perceptions of longitudinal versus transverse wrist scars. METHODS: A prospective survey was conducted among the general public. Inclusion criteria were patients aged over 18 years with no prior surgery to the wrist. Survey questions assessed included: (a) longitudinal or transverse scar preference; (b) reasons for preference; and (c) demographic information. RESULTS: There were 107 respondents from the general public. More respondents preferred longitudinal scars. Top three reasons for longitudinal scar preference were: (a) perceived damage to wrist structures by a transverse incision; (b) better cosmesis; and (c) scar from the transverse incision appearing like a self-inflicted injury. Top three reasons for transverse scar preference were: (a) easily concealed by accessories; (b) less noticeable; and (c) better cosmesis. Respondents aged 60 years and above were most concerned about possible damage to wrist structures; younger respondents were most concerned that transverse scars appeared like self-inflicted injuries. CONCLUSION: Respondents from the general public preferred a longitudinal scar to a transverse one. Younger respondents were most concerned about how the transverse scar appeared like a self-inflicted injury while older respondents were most concerned with perceived functional implications of the incisions.

Systematic review on outcome of free functioning muscle transfers for elbow flexion in brachial plexus injuries.

Elbow flexion is widely regarded as the most important function to restore in brachial plexus injuries. Free functioning muscle transfer surgery is indicated in patients with delayed presentation or failure of other primary procedures. Results of the transfer surgeries have been reported in the form of case series, but no further studies are available. This systematic review aims to provide a deeper understanding of this complex surgery and consists of 19 articles that include 364 patients. Data on injury characteristics, surgical techniques, complications as well as outcome measures were analysed. Our results show that functional muscle transfer for elbow flexion enables 87% and 65% of patients to achieve a useful power grade of ≥ 3 and ≥ 4, respectively, although other important outcome factors should be considered.

Results of Achilles Tendon Excision for Purpose of Wound Closure: Case Series.

The loss of Achilles tendon results in reduced plantar flexion strength; however, in patients who are not fit for major reconstructive surgery, with soft-tissue defects overlying the tendon, Achilles tendon excision is a useful adjunct procedure for wound closure. We report 3 patients with infections around the Achilles tendons needing debridement procedures who underwent Achilles tendon excision for the purpose of wound closure. Local healing was achieved in all patients; all returned to their premorbid ambulatory status, and 2 could perform heel raise. Our series showed that Achilles tendon excision eases soft-tissue reconstruction around it and that the primary aim of wound closure was met with a reasonable functional outcome. As such, it is a viable option for selected patients with infections around the Achilles tendon who are poor candidates for flaps.

Acute Arthrodesis of Interphalangeal Joints of the Hand in Traumatic Injuries.

BACKGROUND: Trauma resulting in severe comminution, bone loss, and articular involvement of the fingers is a challenging injury. Osteosynthesis of the digits is nonviable when there is an inability to restore a stable articular surface adequately. Acute arthrodesis of the proximal and distal interphalangeal joints may be an option in such scenarios. The aim of this study is to evaluate the role of finger joint arthrodesis in the setting of trauma, in terms of fusion rates and clinical outcomes. MATERIALS AND METHODS: Patients with injuries treated via acute finger arthrodesis between 2010 and 2012 at a single institution were retrospectively reviewed. Complete finger amputations requiring replantation were excluded. Finger arthrodesis was performed acutely via intraosseous cerclage wires, Kirschner wires, or tension band wiring. Fusion rates were determined by plain radiography, and clinical outcomes were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) score. RESULTS: A total of 11 patients were recruited. All patients were males with an average age of 35.3 years (range: 21-63 years). None of the cases involved the thumb, and there was an equal distribution of injury amongst the fingers. Nine of the 11 patients involved the distal interphalangeal joint with the remaining involving the proximal interphalangeal joint. Radiologic union was achieved in 9 out of 11 patients, and the average time to fusion was 75.5 days. The average DASH score for the patients was 16.5 (10.8-22.5). All patients were able to return to their premorbid occupation, with average time to return to work of 104.3 days (59-168 days). There were no cases of infection or reoperation. CONCLUSION: We propose that posttraumatic acute arthrodesis of the finger joints is a viable treatment in situations in which there is difficulty in restoring the articular congruity, with early return to work and good function.

Radial shaft fracture obliquity as a predictor of distal radioulnar joint instability.

We assessed whether radial shaft fracture obliquity measurements on radiographs could predict intra-operative distal radioulnar joint instability. We also clinically validated previously described predictors of distal radioulnar joint instability, which included a fracture line within 7.5 cm of the lunate fossa, radial shortening >5 mm, and ulna styloid fracture. We retrospectively analysed the radiographs of all surgically managed patients in our unit with radial shaft fractures from 2006 through 2016. The degree of obliquity was analysed on the basis of the maximum fracture-line angle in either the coronal or the sagittal plane. A radial shaft fracture obliquity >30° is predictive of distal radioulnar joint instability ( P = 0.001). Radial fracture shaft obliquity >30° was the most sensitive radiological parameter (76%) for predicting distal radioulnar joint instability. Oblique radial shaft fractures appear to be associated with increased incidence of distal radioulnar joint instability. This radiologic parameter may be used together with established parameters in predicting distal radioulnar joint instability for surgical treatment. LEVEL OF EVIDENCE: III.

Incidence of Carpal Coalition in an Asian Population - Preliminary Findings of a Study on Patients from a Distal Radius Fracture Database.

BACKGROUND: Congenital carpal coalition is usually seen as an incidental finding. The incidence of carpal coalition has been reported from 0.1 to 9.5 %; highest incidence has been reported in people of African descent. The purpose of our study is to evaluate the incidence and subtypes of carpal coalition in an Asian population. METHODS: Review of the radiographs of the patients in our distal radius fracture database from 2009 to 2014 was conducted to determine the incidence and type of carpal coalition. RESULTS: 4141 patients' wrist radiographs were reviewed. 2 cases of carpal coalition were identified; this leads to an incidence of 0.048%. One was of luno-triquetral type and the other was of capito-hamate type. CONCLUSIONS: The preliminary results of our study indicate that carpal coalition in the Asian population is less common than that reported in the Western literature. Our results are inconclusive as to the type of carpal coalition that is more common.

Trigonometry-Integrated 'Lift' Technique (TILT) for Restoring Volar Tilt in Distal Radius Fractures: Description of Technique and Preliminary Results.

BACKGROUND: Restoration of extra-articular and intra-articular parameters are important considerations during operative fixation of distal radius fractures. Restoration of volar tilt by using visual estimation and the 'lift' technique has previously been described. The aim of our study was to describe a mathematical technique for accurately restoring the volar tilt of the distal radius to acceptable anatomic values. METHODS: A retrospective review of cases performed using the trigonometry-integrated ' lift' technique (TILT) was performed. This technique uses the pre-operative volar tilt angle as well as the dimensions of the implant to calculate the 'lift' required to restore volar tilt. Intra-operative angles were measured using a marked transparency overlay on fluoroscopic images. Pre-operative and post-operative volar tilt were measured and analysed. RESULTS: Twenty-seven fractures were included in the study, with 20 being classified as Arbeitsgemeinschaft für Osteosynthesefragen (AO) C-type. Pre-'lift' volar tilt ranged from 0° to -20°. Post-'lift' volar tilt ranged from 2° to 16°, with all but three cases ranging from 5° to 15°. The mean volar tilt achieved was 10.2°. CONCLUSIONS: The trigonometry-integrated 'lift' technique resulted in reliable intra-operative restoration of anatomic volar tilt in distal radius fractures.

Clinical and functional outcome of open primary repair of triangular fibrocartilage complex tears associated with distal radius fractures.

PURPOSE: We evaluate the clinical and functional outcome of open primary repair of acute TFCC tears in distal radius fracture, when there is gross intraoperative distal radioulnar joint (DRUJ) instability after fixation of the distal radius, in the absence of an ulnar styloid fracture or when the ulnar fracture fragment is too small to be fixed. METHODS: A retrospective review of our institution's distal radius fracture database over a 4-year period (January 2010 to December 2013). A total of 12 (1.38%) out of 3379 patients had an open TFCC repair in the same setting as fixation of distal radius. Assessment of outcome involved the analysis of objective and subjective clinical and functional outcomes. RESULTS: All patient regained Activities of Daily Living (ADL) independence; eleven out of 12 patients (91.7%) returned to pre-injury function and 8 out of 11 patients (72.7%) returned to their jobs. DRUJ stability was preserved in 10 patients (83.3%) with 10 patients (83.3%) having grip strength of at least 50%, compared to the uninjured hand, and 7 (58.3%) with grip strength of more than or equal to 75%. Complications of surgery identified can be classified into 4 broad categories: infection, neurological complications, persistent DRUJ instability and prolonged pain. CONCLUSION: The authors believe a primary open repair of the TFCC should be considered when patients present with instability during intra-operative DRUJ ballottement test after distal radius fixation, in the absence of an ulnar styloid fracture or when the ulnar fracture fragment is too small to be fixed.

Free Functional Muscle Transfer Tendon Insertion Secondary Advancement Procedure to Improve Elbow Flexion.

One method of restoring elbow flexion in patients with brachial plexus injuries is through the use of free functional muscle transfer. Most of our patients achieve good outcome, resulting in improved usefulness of the affected limb. However, a minority of our patients have successful reinnervation of the transferred muscle but with a suboptimal strength and range of motion (ROM) of elbow flexion. In this subset of patients, we perform a secondary procedure to improve the moment arm of the muscle on the elbow joint. This involves advancing the transferred muscle distally along the radius. The technique of the advancement procedure is described. We also report on our initial series of 5 patients who underwent this advancement procedure. In one patient, there was improvement in strength alone. In another, there was improvement of the ROM alone. The remaining 3 patients had improvement of both strength and ROM.

The Effect of Wrist Position on Grip Endurance and Grip Strength.

PURPOSE: Studies on grip endurance are scant even though it is an important topic with practical implications. This study compares the effect of wrist position, in the flexion-extension plane, on grip endurance and grip strength. METHODS: Grip strength and grip endurance were quantified bilaterally at 6 different wrist positions (unrestrained, 45°, 30°, and 15° extension, 0° and 30° flexion) in 38 healthy right-handed individuals. RESULTS: Our results show that wrist orthosis significantly reduced grip strength across all positions and the maximum grip strength in the position with an orthosis occurred at 15° and 30° extension for the dominant hand and 15°, 30°, and 45° extension for the nondominant hand. Hand dominance and sex did not significantly affect grip endurance. Using a wrist orthosis did not significantly reduce grip endurance at 45° and 30° extension. CONCLUSIONS: At a position of 30° of wrist extension, maximal grip strength is achieved without significantly compromising grip endurance. This has clinical implications for decisions regarding the optimal position for orthosis and radiocarpal joint arthrodesis. CLINICAL RELEVANCE: This study would aid both surgeons and therapists in facilitating discussion with patients regarding the various therapeutic options in managing wrist pathologies.

Correction of Volar Subluxation Deformities of the Metacarpophalangeal Joints Following a Distal Radius Fracture in a Patient With Systemic Lupus Erythematosus.

Extensor tendon subluxation over the metacarpal head, leading to metacarpophalangeal joint ulnar deviation, is a hand deformity seen in patients with systemic lupus erythematosus. Apart from soft tissue procedures, metacarpal shortening osteotomy is a previously described surgical treatment for this deformity. We present a patient whose fixed deformity was spontaneously corrected after a displaced distal radius fracture. At 1 year, the correction was maintained. We discuss the biomechanical basis behind the phenomenon.