Role of platelet rich plasma in fracture non-union of scaphoid - Case series.

This case series of 4 patients was studied at Queen Mary Hospital, Hong Kong from 2007 to 2011 to evaluate the clinical and radiological outcome of scaphoid fracture non-union treated with Open reduction and internal fixation ORIF supplemented with Bone Graft (BG) from iliac crest and Platelet Rich Plasma PRP. The purpose was to achieve union with pain free adequate range of movement. Patients presenting with scaphoid fracture non-union were included in our study. Total 4 patients with an average age of 35±7.7 years (range 31 to 47 years) and mean follow-up of 21.75±14.97 months, (range 05 months to 3.5 years) were included. All patients achieved union with pain free Range of motion of wrist as well as thumb. We recommend open reduction and internal fixation with bone graft along with platelets rich plasma for non-union of scaphoid.

The status of triangular fibrocartilage complex after the union of distal radius fractures with internal plate fixation.

PURPOSE: Distal radius fractures are associated with a high incidence of triangular fibrocartilage complex (TFCC) tears. This study aims to evaluate the status of TFCC after the healing of distal radius fractures, and its clinical significance. METHODS: Wrist arthroscopies were performed on 43 distal radius fractures, with an average age of 54 years old. RESULTS: Twenty-six complete tears and 15 partial healed tears were noted. Five out of eight patients with intact TFCC tears had neither signs nor symptoms, while eight patients with TFCC tears had no complaint. While no association was found between ulnar wrist pain and TFCC tears, there was association between DRUJ instability and TFCC tears and fovea tears. The function outcome did not differ with respect to the integrity of TFCC. CONCLUSIONS: A large majority of TFCC tears remained unhealed after the union of distal radius fractures. However, not all patients with tear were symptomatic.

Fatal bilateral lower-limb deep vein thrombosis and pulmonary embolism following single digit replantation.

Venous thromboembolism in hand surgery is rare. There is no report in the literature on postoperative mortality from venous thromboembolism following microsurgery in upper limbs. We report the case of a 56-year-old Chinese man who died from pulmonary embolism as a result of bilateral lower-limb deep vein thrombosis following prolonged surgery under general anaesthesia after replantation of a finger. This case raises awareness of the need for precautions against venous thromboembolism following prolonged microsurgery and identification of high-risk patients.

Does aging matter? The efficacy of carpal tunnel release in the elderly.

Open release remains the gold standard in the treatment of carpal tunnel syndrome in cases where conservative treatment fails. However, the efficacy of carpal tunnel release in the elderly has been debated in the literature throughout the years. This review aims to review the current evidence pertaining to the efficacy of carpal tunnel release in the elderly. Based on the current evidence, the outcome of carpal tunnel release is unpredictable in the elderly. Elderly patients are also less satisfied with the operation compared to younger patients. The authors recommend that these messages be conveyed to elderly patients before surgery. Moreover, open carpal tunnel release should be offered in the early stages of treatment whenever operative management is indicated.

Current management of hand enchondroma: a review.

Enchondromas are benign bone tumours originating from cartilages. It is mainly discovered incidentally in radiographs or due to symptoms like pathological fracture or pain. Conservative treatment through regular check-up and surgical excision using curettage are the two major treatment methods for enchondromas. This review concludes that small localized asymptomatic lesions can be treated conservatively while most expanding or symptomatic lesions should be treated with simple curettage. Adjuvant treatments like high-speed burring or alcohol instillation are not recommended.

New technique: tendon interposition arthroplasty in Distal Interphalangeal Joint arthritis in Chinese population - New horizon for treatment.

OBJECTIVE: To evaluate the clinical outcome of managing distal inter-phalangeal joint arthritis by using excisional arthroplasties with soft-tissue interposition to provide pain-free joint with adequate range of motion and preserving the bone stock. METHODS: The case series was conducted at Queen Mary Hospital, Hong Kong from 2013 to 2015 and comprised patients with distal inter-phalangeal joint arthritis. Excisional arthroplasty was performed for all patients. Interposition was performed using extensor retinaculum/ palmaris longus. An axial K wire for 3-4 weeks was applied to maintain the reconstructed part in satisfactory alignment. Mallet splint was applied for another 3 weeks. Free active mobilisation was allowed afterward. Clinical assessment was done at least at 3, 6 and 12 months. RESULTS: There were three patients in the series, and all the 5 fingers, including one thumb, achieved good range of motion with no complication except in 1(33.3%) patient who needed re-exploration of index finger for retained suture with no documentary infection. All patients (100%) had significant pain relieved with mean visual analogue scale score of 3/10±SD at 3 months and 0/10 at 1-year follow-up. All achieved good range of motion. All (100%) were satisfied with postoperative surgical outcome. CONCLUSIONS: Interposition arthroplasty gave the patients adequate range of motion with preservation of bone stock.

A rare combination: locked volar distal radio-ulnar joint dislocation with isolated volar capsule rupture.

Distal Radioulnar Joint (DRUJ) dislocation is a commonly missed injury. A high clinical suspicion is required as the dislocation may not be obvious in the conventional views of radiographs. Volar DRUJ dislocations are far less common than the dorsal ones. Since triangular fibrocartilage complex (TFCC) is the major stabilizer of DRUJ, it is common that the irreducible DRUJ dislocation is associated with TFCC tear. We report a patient who had irreducible volar DRUJ dislocation blocked by the volar lip of sigmoid notch, with only isolated volar capsule rupture.

A new building block: costo-osteochondral graft for intra-articular incongruity after distal radius fracture.

Even with the invention of locking plates, intra-articular fractures of distal radius with extreme comminution remain a challenge for orthopaedic surgeons. Osteochondral graft is a potential choice to reconstruct the articular defect. We report a patient who had a fracture of distal radius with costo-osteochondral graft for articular reconstruction which has not yet been described in the English literature. At nine-year follow-up, he was pain free and had full range of movement of the wrist. The authors suggest that costo-osteochondral graft could be an option with satisfactory result.

Current management of acute scaphoid fractures: a review.

The aim of this review was to present currently available evidence on the management of acute scaphoid fractures. Acute scaphoid fractures are usually diagnosed by a combination of history, physical examination, and radiography. However, in many patients scaphoid fractures are still missed. Thus, the general trend is to over-treat patients with a suspicion of scaphoid fracture. Many aspects of scaphoid fracture management are still controversial and different institutions vary in their approach.

Schwannoma in the upper limbs.

Schwannomas are the commonest tumours of peripheral nerves. Despite the classical description that schwannomas are well encapsulated and can be completely enucleated during excision, a portion of them have fascicular involvement and could not be completely shelled out. A retrospective review for 8 patients was carried out over 10 years. 75% of schwannoma occurred over the distal region of upper limb (at elbow or distal to it). It occurs more in the mixed nerve instead of pure sensory or motor nerve. 50% of patients had mixed nerve involvement. Fascicular involvement was very common in schwannoma (75% of patients). Removal of the tumour with fascicles can cause functional deficit. At present, there is no method (including preoperative MRI) which can predict the occurrence of fascicular involvement; the authors therefore proposed a new system to stratify patients who may benefit from interfascicular nerve grafts. In this group of patients, the authors strongly recommend that the possibility and option of nerve graft should be discussed with patients prior to schwannoma excision, so that nerve grafting could be directly proceeded with patient consent in case there is fascicular involvement of tumour found intraoperatively.

Peak load resistance of the JuggerKnot™ soft anchor technique compared with other common fixation techniques for large mallet finger fractures.

INTRODUCTION: To identify the strongest peak load resistance among four mallet finger fracture fixation methods (Kirschner wire, pull-out wire, tension-band wiring and the JuggerKnot™ (Biomet) soft anchor fixation). METHODS: Fixation techniques were assigned among 24 specimens from six cadaveric human hands in a randomized block fashion. Peak load resistance was tested at 30°, 45° and 60° of flexion of the distal interphalangeal joint. RESULTS: The mean peak load of tension-band wiring was 67.8 N at 60° of flexion which was most superior. The JuggerKnot™ fixation had mean peak loads of 13.35 N (30°), 22.51 N (45°) and 32.96 N (60°). No complications of implant failure or fragmentation of the dorsal fragment was noted. CONCLUSIONS: Tension-band wiring was the strongest fixation method but was most prominent on the skin surface as seen in three specimens. The JuggerKnot™ soft anchor fixation had similar peak load resistance as k-wire fixation and pull-out wiring.

Where is the Lesion? Glomus Tumours of the Hand.

Glomus tumours are vascular hamartomas that are commonly found in the hand, particularly the subungual region. They appear as solitary or multiple tumours, and often present as a bluish discoloration of the nail plate. Different diagnostic tests are outlined, as well as imaging studies such as magnetic resonance imaging and ultrasound. Misdiagnosis and delayed diagnosis of these tumours are common, while a familial tendency is a potential risk factor but not yet proven. Complete surgical excision often results in complete symptomatic relief, while recurrences are largely due to incomplete excision or the growth of a new glomus tumour. This article aims to review the key aspects of glomus tumours and provide a diagnostic algorithm so that the lesion can be recognized and treated earlier.

Ten-year results using a dynamic treatment for proximal phalangeal fractures of the hands.

Fractures of the proximal phalanges of the hands can be treated by many methods. With surgical intervention, a loss in proximal interphalangeal joint movement is common. Using the stabilizing effect of the zancolli complex-metacarpophalangeal retention apparatus and an external device such as a thermoplastic metacarpophalangeal block splint, proximal phalangeal fractures can be stabilized in terms of axis, length, and rotation.This study reports the authors' 10-year results managing these fractures with dynamic treatment. All patients with closed fractures of the proximal phalanges admitted to Queen Mary Hospital, Hong Kong, China, between July 2000 and June 2010 were analyzed. Fractures with rotational deformities or displaced intra-articular configurations were excluded. A dynamic splint that kept the metacarpophalangeal joint maximally flexed while allowing free movement of the proximal and distal interphalangeal joints of the injured finger was applied for at least 4 weeks. Results were evaluated using the Belsky classification and grip strength assessment. The results of 97 patients (103 fractures) were analyzed. At a minimum 1-year follow-up, 75% of patients attained excellent or good results. Neither nonunion nor delayed fracture union was noted. The 25% of patients who attained poor results were older than those who attained excellent or good results (average age, 53.1 vs 35.1 years, respectively) and tended to comply poorly with the rehabilitation program. Using the stabilizing effect of the zancolli complex-metacarpophalangeal retention apparatus and a metacarpophalangeal block splint, bone healing and movement recovery can be achieved simultaneously.

The beauty of stability: distal radioulnar joint stability in arthroscopic triangular fibrocartilage complex repair.

The triangular fibrocartilage complex (TFCC) has an important role in the stability of the distal radioulnar joint (DRUJ) stability. We designed a new method of TFCC tear repair that has satisfactory post-operative DRUJ stability. From May 2004 to August 2010, 14 patients who underwent this operation were reviewed. The average post-operative follow-up period was 8.2 months; 66.7% of the patients with TFCC tear in sigmoid notch had clinical DRUJ instability, while only 50% of tear in fovea and 16.7% of tear in base of ulnar styloid had clinical DRUJ instability. Transosseous suture via inside-outside technique was used for repair. At the final follow-up, all 14 patients have soft end point with < 5 mm translations of the DRUJ shown by the stress test. Based on this small sample with satisfactory outcome assessed by the Mayo modified wrist score and DRUJ stability, we recommend TFCC tear in sigmoid notch, which has a higher chance of DRUJ instability, to be repaired by transosseous suture.

Review on mallet finger treatment.

Mallet finger is a common injury involving either an extensor tendon rupture at its insertion or an avulsion fracture involving the insertion of the terminal extensor tendon. It is usually caused by a forceful blow to the tip of the finger causing sudden flexion or a hyperextension injury. Fracture at the dorsal aspect of the base of the distal phalanx is commonly associated with palmar subluxation of the distal phalanx. Most mallet finger injuries are recommended to be treated with immobilisation of the distal interphalangeal joint in extension by splints. There is no consensus on the type of splint and the duration of use. Most studies have shown comparable results with different splints. Surgical fixation is still indicated in certain conditions such as open injuries, avulsion fracture involving at least one third of the articular surface with or without palmar subluxation of the distal phalanx and also failed splinting treatment.

Mycobacterium marinum infection of the hand and wrist.

PURPOSE: To review records of 166 patients who underwent treatment for Mycobacterium marinum tenosynovitis of the hand and wrist to identify factors associated with functional outcome. METHODS: Records of 97 men and 69 women aged 13 to 85 (mean, 50) years who underwent treatment for suspected M marinum tenosynovitis of the hand and wrist were retrospectively reviewed. All underwent open biopsy; synovectomy was performed when florid synovitis was present. Rifampicin and ethambutol were usually prescribed. Clarithromycin, minocycline and/or levofloxacin were used as adjuvants if there was drug intolerance, allergy, or relapse. The duration of antibiotic treatment depended on the clinical recovery. Patients were followed up for one year after completion of drug treatment. Functional outcome was considered excellent for those with >195º total active motion (TAM) and >75% return of motion, good for those with 130º to 195º TAM and 50 to 75% return of motion, fair for those with 65º to 129º TAM and 25 to 49% return of motion, and poor for those with<65º TAM and <25% return of motion. RESULTS: The mean delay in presentation was 4.9 (0.3-120) months. 93 of the patients presented with disabilities (flexion deformity or reduced range of motion), 64 of whom presented one month after injury. 37 (22%) of the patients had received intralesional steroids prior to admission, 30 of whom presented one month after injury. 32 (19%) patients were treated with antibiotics alone, whereas 134 (81%) patients underwent debridement in addition to antibiotic treatment. The mean duration of antibiotic treatment was 7.2 (range, 0-29) months. Of the 156 patients who completed the follow-up, functional outcome was satisfactory in 128 (82%) and unsatisfactory in 28 (17%). Steroid injections and late presentation led to worse functional outcome. Patients with unsatisfactory outcome were more likely to have received intralesional steroid injections (43% [16/37] vs. 10% [12/118], p<0.001, Pearson Chi squared test), have presented >2 months after injury (27% [21/79] vs. 9% [7/77], p=0.004, Pearson Chi squared test), and have undergone synovectomy (23% [28/124]) vs. 0% [0/32], p=0.001, Fisher's exact test). Worse functional outcome correlated with late presentation (r=0.218) and the greater number of debridement procedures (r=0.453). CONCLUSION: Delayed antibiotic treatment of M marinum infections and steroid injections were associated with unsatisfactory outcome. Clinicians must have a high index of suspicion for this condition and avoid inappropriate management such as intralesional steroid injections. Public awareness to this condition should be raised.

Epidemiology of occupational hand injury in Hong Kong.

OBJECTIVES: To study the epidemiology of occupational hand injuries and associated social and industrial factors. DESIGN. For this retrospective case series of patients with occupational hand injuries, case records were retrieved to gather data. In addition, all the subjects were interviewed by a single interviewer using a predesigned questionnaire. SETTING: Division of Hand Surgery, Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong. PATIENTS: A total of 250 patients with occupational hand injuries were treated during the period from 1999 to 2001. This period was chosen to obtain 10 years of follow-up data to assess return to work and any secondary injuries. MAIN OUTCOME MEASURES: Personal particulars (gender, age, marital status, education level, length of stay in Hong Kong, type of employment, wage system, personal habits, family size, number of breadwinners, income), type of industry and mode of injury, causes of injury according to the worker, work conditions, type of injury, and treatment given. RESULTS: Two groups of workers in our study had more occupational hand injuries, namely those with less than 1 year of experience on a new job and immigrants from China. Factors associated with a large proportion of occupational hand injuries were male gender with personal risk factors (smoking and regular consumption of alcohol, long working hours), and in the case of machine operators, inadequate training and use of safety devices. CONCLUSION: Occupational hand injuries lead to loss of working hours and compensation. For prevention, the workplace should be made into a safer and work-friendly environment. Workers should also have sufficient training.

The last defence? Surgical aspects of gouty arthritis of hand and wrist.

OBJECTIVE: To review the epidemiology, pathophysiology, clinical manifestations, diagnosis, and treatment of gouty arthritis of the hand and wrist, with a focus on the surgical aspects. DATA SOURCES AND EXTRACTION: Electronic databases including MEDLINE, PubMed, and the Cochrane library were searched with the key words of "gouty arthritis", "hand", "wrist", and "surgical". STUDY SELECTION: A total of 55 articles were selected for inclusion in this review. DATA SYNTHESIS: There is no existing study for the overall prevalence of gout in Asia, though one study showed that it was 3.1% in Taiwan. Its pathophysiology entails hyperuricaemia, trauma, lower temperatures, and previous diseases. Gouty arthritis of hand and wrist presents as acute wrist pain, subcutaneous or peritendinous tophi, tenosynovitis, entrapment neuropathy, tendon rupture, or even bone destruction. Demonstration of negatively birefringent crystals in the absence of organisms and a normal white cell count in synovial fluid confirm the diagnosis. Medical treatment including non-steroidal anti-inflammatory drugs, colchicines, allopurinol, uricosuric agents, and lifestyle modifications remain the mainstay of treatment. Surgical treatment options for tophaceous gout involve decompression by aspiration, incision and drainage, tenosynovectomy, shaving procedures, and complex surgical approach. CONCLUSION. While medical treatment remains the mainstay of treatment for gouty arthritis of the hand and wrist, 5% of patients may not respond. In this group, surgery is often performed in advanced stages, but yields less-than-satisfactory outcomes. Gouty arthritis is difficult to treat when it starts to cause stiffness and deformities. Although more studies are needed to evaluate the outcomes, the authors suggest that one possible solution is pre-emptive surgery.

Hand infection in diabetic patients.

The diabetic hand infection is less reported in the literature. Therefore, it is easily ignored and underestimated resulting in increased morbidity among the diabetic population. Diabetic hand is a rapid in progression, extensive and severe tissue destruction. We analyze the clinical course and outcome of hand infection in diabetic patients. We reviewed all the admissions with hand infection from January 2006-April 2010. Thirty-seven patients were found with associated diabetes mellitus. The demographic data, culture report, number of operations and management, hospital stay and outcome-like amputation were recorded. The average age was 62 years. Pain and swelling were the chief complaints. The cause of infection was varied. The infection was superficial in 13 and deep in 24 patients. Forty-one percent of culture report revealed polymicrobial organism. The increased length of hospital stay, reoperations and amputation were associated with deep infection and polymicrobial organism. Prompt medical and surgical attentions are the most important factors. A proper glycemic control, elevation of the affected extremity, thorough and adequate surgical debridement and appropriate antibiotics are the important considerations when dealing with diabetic hand infection.