Schwannoma in the Thenar Eminence: a Case Report.

This report describes a rare presentation of schwannoma in the thenar aspect of a surgeon and reviews the literature. A 35-year-old surgeon had a slow-growing swelling in his left thenar eminence. Clinical and radiological findings suggested it was a well-encapsulated mass within the abductor pollicis brevis muscle. A complete surgical excision was done, and the histopathological findings confirmed schwannoma, a benign peripheral nerve tumor. The surgeon remained symptom-free and had no recurrence at 1 year of follow-up. Though a benign peripheral nerve tumor is rare in the hand, it remains one of the differential diagnoses for a thenar eminence swelling. Surgical enucleation preserving the nerve fascicles achieves an excellent functional outcome.

Flexor Pronator Slide Under Local Anesthesia without a Tourniquet for Non-Ischemic Contractures of the Forearm.

Background: The flexor pronator slide is an effective treatment option for ischemic contracture and contracture related to spastic cerebral palsy, but little is known about the use of the flexor pronator slide in other non-ischemic contractures. I propose a flexor pronator slide to simultaneously correct wrist and finger flexor contractures and preserve the muscle resting length. To avoid overcorrection of the deformity, I propose the use of a wide-awake local anesthesia with no tourniquet (WALANT) procedure, in which the patient is able to continually assist the surgeon in assessing the contracture release and improvement in finger movement. Additionally, the WALANT flexor pronator slide releases the specific muscles responsible for wrist and finger contractures (i.e., the flexor digitorum profundus, flexor carpi ulnaris, flexor carpi radialis, flexor digitorum superficialis, and pronator teres), sparing the intact finger functions. Description: The patient in the video received a WALANT injection of 1% lidocaine with 1:100,000 epinephrine and 8.4% sodium bicarbonate in the operating room, and surgery was started 30 minutes after the injection to obtain the maximum hemostatic effect1. The injections were performed from proximal to distal along the volar-ulnar skin markings from the distal upper arm to the distal third of the forearm. The total volume utilized in this patient was <7 mg/kg (approximately 100 mL). A 25 or 27-gauge needle was infiltrated under the skin at the medial aspect of the elbow and in the distal and proximal forearm fascia. A total of 25 to 40 mL anesthetic was injected at each site, which serves to numb the ulnar nerve. over the volar-radial and volar side of the mid-forearm and distal forearm to numb the median nerve. For the WALANT procedure, an additional 8 mg of dexamethasone was added as an adjuvant to prolong the analgesia and the duration of the nerve block. The skin incision was made over the ulnar border of the forearm, extending proximally just posterior to the medial epicondyle up to the distal third of the upper arm. The origin of the flexor carpi ulnaris was elevated first, then the flexor digitorum profundus and flexor digitorum superficialis were mobilized from the ulna and the interosseous membrane. The release continued in an ulnar-to-radial direction. The patient was awake throughout the procedure, so that the improvement in the contracture could be better assessed. Further dissection around the ulnar nerve was done to release the arcade of Struthers, the Osborne ligament, and the triceps fascia in order to prevent ulnar nerve kinking during anterior transposition. The medial epicondyle was identified, and the flexor pronator wad was released meticulously without joint capsule perforation and medial collateral ligament injury. The muscles were finally examined for contracture in full wrist and finger extension, and further release was performed if remaining contracture was observed. All released muscles were tension-free, suspended on the trunks and branches of the median nerve, ulnar nerve, and radial and ulnar arteries. The ulnar nerve was transposed anteriorly to the medial epicondyle. The subcutaneous tissues were sutured with an absorbable suture, and the skin was closed with the same suture in a subcuticular fashion with a drain. Alternatives: Fractional or Z-lengthening of the flexor tendons is the alternative for finger and wrist flexion contractures. Rationale: This patient had previously undergone multiple flexor tendon surgeries in the hand and forearm. The patient developed tight ring, middle, and little finger contractures that could not be passively extended with the wrist in neutral or dorsiflexion. This patient could not extend the proximal or distal interphalangeal joints of the middle, ring, and little finger in wrist extension. Conversely, wrist flexion extended all fingers. When the surgeon tried to extend the fingers with the wrist in extension, excessive force was required and a jog in the movement was appreciated in all small joints. This denoted contractures of the long flexors and flexor tendons of the forearm. Fractional or Z-lengthening may release the flexion contracture in such cases, but leads to loss of active flexion, disrupts the muscle resting length, and causes loss of flexion strength. Because our patient had very tight finger contractures, they were deemed not amenable to fractional or Z-lengthening. Therefore, we preferred the use of a flexor pronator slide to simultaneously correct wrist and finger flexor contractures while preserving the muscle resting length. To avoid overcorrection of the deformity, we preferred to perform a WALANT procedure, during which the patient could continually assist the surgeon in assessing the contracture release and improvement in finger movement. This patient returned to her computer job after the surgery. Expected Outcomes: The flexor pronator slide is an effective treatment option for ischemic contracture and contracture related to spastic cerebral palsy. In 1923, Page described the flexor pronator slide as a surgical option for the late management of compartment syndrome2,3. He noted that the procedure allowed extensive correction of the flexion contracture with less impact on the muscle resting length compared with alternative procedures. Sharma and Swamy noted good hand function in 14 (74%) of 19 patients and an average grip strength of 75% of the contralateral hand following a flexor pronator slide for the treatment of moderate Volkmann contracture3. A flexor pronator slide will simultaneously correct wrist and finger flexor contractures and preserve muscle resting length. To avoid overcorrection of the deformity, the flexor pronator slide can be performed as a WALANT procedure, during which the patient is able to continually assist the surgeon in assessing the contracture release and improvement in finger movement. Additionally, a WALANT flexor pronator slide releases the specific muscles responsible for wrist and finger contractures, sparing intact muscles. Good functional outcomes are expected, with a full return to work by 3 months postoperatively. Major complications, such as overcorrection of the deformity, anterior interosseous neurovascular bundle injury, ulnar nerve injury, and wound dehiscence, are unexpected for this procedure. Important Tips: The treatment for a non-ischemic contracture of the wrist and fingers requires flexor pronator slide surgery to simultaneously correct the deformity without losing the resting muscle length and strength.Both fractional or Z-lengthening and flexor pronator slide surgery for such contractures yield straightforward contracture release. However, maximal preservation of the flexion power and muscle resting strength when releasing these contractures is possible only by shifting the flexor pronator muscles distally without affecting its resting length, which can be achieved by flexor pronator slide.A WALANT flexor pronator slide avoids overcorrection of the deformity because the patient is able to continually assist the surgeon in assessing the contracture release and improvement in finger movement. Acronyms and Abbreviations: FCU = flexor carpi ulnarisFCR = flexor carpi radialisWALANT = wide-awake local anesthesia with no tourniquetFPL = flexor pollicis longusDASH = Disabilities of the Arm, Shoulder and HandFDP = flexor digitorum profundusFDS = flexor digitorum superficialis.

Non-vascularized toe phalangeal transfer for reconstruction of a giant cell tumour of the proximal phalanx.

This article describes a 50-year-old woman with a giant cell tumour involving the base of the proximal phalanx, which was resected and reconstructed with a non-vascularised toe phalanx graft. The toe phalanx graft united well, and there was no tumour recurrence at the 24-month follow-up.

Dorsal capsule release and lateral band translocation for a stiff swan neck deformity without articular involvement.

BACKGROUND: The treatment for proximal interphalangeal joint (PIP) stiffness in extension requires extensor tenolysis, concomitant procedures to restore flexion, and intensive therapy. A stiff swan neck deformity without articular involvement is rare and the treatment is always challenging. METHODS: Six patients with stiff swan neck deformities were operated between 2016 and 2023, and the outcome was analyzed retrospectively. A dorsal capsule release and radial lateral band translocation volar to the PIP joint axis were done. This translocation was maintained by a sling formed by the flexor digitorum superficialis and the free margins of the accessory collateral ligament. The range of movements in the PIP joint, visual analog scale (VAS), and functional outcomes were analyzed by the Michigan Hand Outcome Questionnaire (MHOQ) score. RESULTS: The mean follow-up was 49.5 months (range 48-52 months). The mean preoperative PIP joint extension was 8 (range 5-10) degrees of extension), and the mean preoperative PIP joint flexion was 0. All patients improved after the surgery and the mean flexion of the PIP joint at follow-up was 95 degrees; extension was 1 degree (range 0-5 degrees). The mean Michigan Hand Outcomes Questionnaire (MHOQ) score was 92 (range 90-95) and the VAS was 0. CONCLUSIONS: Dorsal capsule contracture release and lateral band translocation to the volar axis of the PIP joint seem to be the possibilities for correcting stiff swan neck deformity. LEVEL OF EVIDENCE: IV, retrospective case study.

Chronic proximal ulnar collateral ligament injuries thumb-a case report.

A 55-year-old woman presented with multiple episodes of falls that injured her right thumb and restricted her daily activities because of pain and instability. Ultrasound found the rare proximal metacarpal UCL avulsion. The repair was done using suture anchors under wide-awake anaesthesia with no tourniquet (WALANT). The patient regained her thumb movements, got a stable MCP joint, and remained symptom-free at one year of follow-up. Proximal avulsion of the UCL is rare. Ultrasound confirms the avulsion, and surgical reconstruction under wide-awake anaesthesia allows the surgeon and the patient to assess and appreciate the MCP joint stability, thereby efficiently rehabilitating the patient. The functional outcome of proximal UCL repair is good. This report describes a rare presentation of the proximal metacarpal attachment avulsion injury of the ulnar collateral ligament (UCL) in a thumb and reviews the management.

International Residents' Perspectives on Education and Challenges in Microsurgery Training.

Objective Microsurgery remains an integral component of the surgical skillset and is essential for a diversity of reconstructive procedures. The apprenticeship also requires overcoming a steep learning curve, among many challenges. The method of microsurgical training differs depending on the countries' regions and resources of their health care system. Methods The Journal of Hand and Microsurgery leadership held an international webinar on June 19, 2021, consisting of a panel of residents from 10 countries and moderated by eminent panelists. This inaugural event aimed to share different experiences of microsurgery training on a global scale, identifying challenges to accessing and delivering training. Results Residents shared various structures and modes of microsurgical education worldwide. Areas of discussion also included microsurgical laboratory training, simulation training, knowledge sharing, burnout among trainees, and challenges for female residents in microsurgical training. Conclusion Microsurgical proficiency is attained through deliberate and continued practice, and there is a strong emphasis globally on training and guidance. However, much remains to be done to improve microsurgical training and start acting on the various challenges raised by residents. Level of Evidence Level V.

Distal Nerve Transfers in Hand and Forearm for Traumatic Brachial Plexus and Peripheral Nerve Injuries: A Narrative Review.

Background: Various studies published good outcomes in brachial plexus injuries using nerve transfers for shoulder and elbow functions. However, little is known about the outcome of the distal nerve transfers in the forearm and hand. Targeting the nerve distally produces an early return of function in brachial plexus and peripheral nerve injuries (BPPNI). Therefore, researchers have focused on nerve transfers from the motor branches of the ulnar, median, and radial nerve. Similarly, sensory reinnervation is also obtained by potential donor transfers in the forearm and hand. There have been various attempts by surgeons to target the muscle and promote early reinnervation by different nerve transfers. Conclusions: The distal nerve transfers in the forearm and hand are promising when performed early. It effectively restores hand and forearm functions and may be considered a better option than tendon transfer, which has a one-tendon-one function. This narrative review article discusses the different distal nerve transfers for various presentations of BPNNI.

Retrospective Analysis of Finger Entrapments.

Background: Accidental entrapment of fingers poses treatment challenges in the emergency room. The constriction objects cause edema distally and sometimes digital ischemia. Swift and rationally removing or cutting the entrapment objects save the finger from complications. Methods: Thirty patients with finger entrapments were retrospectively analyzed between 2016 and 2020. The entrapments were mostly rings and other metals removed using electrical cutting tools. The time delay from injury to removal was recorded and analyzed with digital ischemia. In addition, the immediate and long-term functional outcome, pain scale (visual analogue score), and return to work were examined. Results: The mean follow-up of our study was 16.5 months (range 12-19 months). All patients had multiple unsuccessful attempts of removal. The rings (60%), workplace metals, door handles, and pipe taps were the commonest entrapments in the series. Distal ischemia (37%), circumferential wounds, and neuropraxia (30%) were common presentations in the series. None of the patients had amputations. There is no significant difference in the functional outcome of patients with a delayed presentation (>6 h) to the emergency room (p = 1.0). There is complete recovery of sensation and improved pain scale (p < 0.05) in the follow-up in all patients. Conclusions: Entrapments in fingers are one of the emergencies in hand surgery, where meticulous planning and removal efficiently restore the hand function. Despite delays in presentations to the emergency room and multiple unsuccessful attempts, the electric saw removed the entrapment objects. It achieved immediate pain relief, sensation, vascularity, and an excellent long-term functional outcome. Level of evidence: IV, Retrospective case study.

Wide-awake local anesthesia no tourniquet and dexamethasone (WALANT-D) for modified Camitz opponens plasty in severe carpal tunnel syndrome-a retrospective study of 30 cases.

Background: To analyze the outcome of modified Camitz opponens plasty using the wide-awake local anesthesia no tourniquet with dexamethasone (WALANT-D) technique in severe carpal tunnel syndrome (CTS). Methods: A retrospective review was performed in 30 hands of 27 patients who underwent Camitz opponens plasty for severe CTS between 2019 and 2021. All patients had 8 mg of dexamethasone mixed with WALANT. Preoperative active palmar abduction, grip strength, side, and pulp pinch strength, Kapandji score, and electrophysiological assessment of compound muscle action potential (CMAP) for abductor pollicis brevis (APB) were compared with the postoperative values. The palmaris longus had dual insertion into the abductor pollicis brevis and extensor expansion. The time interval of post-operative pain-free was noted. The Disabilities of the Arm, Shoulder, and Hand (DASH) and Carpal Tunnel Syndrome instrument (CTSI) also assessed the functional outcome. Results: The mean age of patients was 35 years (range 32-58 years). There were five male and 22 female patients. Of the female patients, three females had severe bilateral CTS. Twenty right and ten left hands were affected. The mean follow-up of our study was 12.5 months (range 10-14 months). The patients were pain-free for an average of 19.5 h postoperatively. There was a significant improvement in the thumb palmar abduction, grip strength, side, and pulp pinch strength, DASH score, CTSI, and APB-CMAP (p < 0.05) at the final follow-up. Conclusions: Modified Camitz opponens plasty with a dual insertion into APB and extensor expansion effectively improves thumb opposition and daily activities. The tendon tensioning, checking the pulley impingement, appreciation of active movements, and a comfortable patient operative experience are advantages of the WALANT. Adding dexamethasone as an adjuvant to WALANT prolongs the analgesia and duration of the nerve block. Level of evidence: IV, Retrospective case study.

Computed Tomographic Arthrography (Arthroscanner) of the Wrist Joint: Why, How, and When.

Background: Acute or chronic wrist pain is a common presentation to a general orthopedic surgeon. The wrist joint is considered one of the most complex articulations in the human body. The complex arrangement of the wrist's intrinsic and extrinsic ligaments and their biomechanics are challenging for the surgeon to diagnose the wrist pathology despite clinical examination. Radiographs, CT scans and MRI are a few modalities that diagnose wrist pathologies efficiently. The accuracy, sensitivity, and specificity in evaluating the chondral, bone, and ligamentous lesion are its limitations. Wrist arthroscopy is considered the reference standard for diagnosing intraarticular pathology of the wrist. Surgical intervention, anesthesia, and the learning curve in wrist arthroscopy are its drawbacks. Conclusion: CT arthrography is a reliable option for viewing bone anatomy and diagnosing ligamentous tears, cartilage lesions, avulsion injuries, and chondral defects. This review article will discuss surgical anatomy, methods of performing CT arthrography, interpretation of the results, and their advances.

Hemi-capitate Arthroplasty for Dorsal Fracture-Dislocations of the Proximal Interphalangeal Joint: Surgical Technique and Illustrative Case.

Osteochondral graft from the carpal bone allows anatomical joint reconstruction in unstable dorsal fracture-dislocations with > 50% of the articular surfaces. The most used graft is the dorsal hamate. Hemi-hamate arthroplasty is technically challenging and has anatomical incongruity, and many authors have evolved various modifications in the palmar buttress reconstruction of the middle phalanx base. Therefore, there are no universally accepted treatment modalities for these complex articular injuries. This article describes the dorsal capitate as the osteochondral graft for middle phalanx volar articular surface reconstruction. Hemi-capitate arthroplasty was done on a 40-year-old man with an unstable dorsal fracture dislocation of the PIP joint. The osteochondral capitate graft united well, and the joint congruency was good at the final follow-up. The surgical technique, illustrative images, and rehabilitation are discussed. With the evolving technical modifications and complications in Hemi-hamate arthroplasty, distal capitate may be considered a reliable and alternate osteochondral graft for unstable PIP joint fracture-dislocations. Supplementary Information: The online version contains supplementary material available at 10.1007/s43465-023-00853-2.

Adductor Branch of Terminal Divisions of the Ulnar Nerve Transfer to the Thenar Motor Branch in a High Median Nerve Palsy: A Case Report.

CASE: The author reports a 4-month-old high median nerve palsy in a 19-year-old man with right forearm fractures, stabilized with dynamic compression plates and screws. Surgical exploration revealed a large median nerve neuroma in the midarm that was excised, and the gap was bridged with sural nerve cable grafts. The extensor carpi radialis nerve was transferred to the anterior interosseous nerve in the forearm. The adductor branch of terminal divisions of the ulnar nerve was transferred to the thenar branch of the median nerve in the hand. CONCLUSIONS: The adductor branch of ulnar nerve transfer to the thenar motor branch in high median nerve palsy efficiently restored thumb opposition in 10 months of follow-up. In addition, the patient's grasp and pinch improved, preserving thumb adduction.

Predictors of Failure for Vascularized and Nonvascularized Bone Grafting of Scaphoid Nonunions: A Systematic Review.

Objective This article compares predictors of failure for vascularized (VBG) and nonvascularized bone grafting (NVBG) of scaphoid nonunions. Methods We conducted a systematic literature review of outcomes after VBG and NVBG of scaphoid nonunion. Fifty-one VBG studies ( N = 1,419 patients) and 81 NVBG studies ( N = 3,019 patients) met the inclusion criteria. Data were collected on surgical technique, type of fixation, time from injury to surgery, fracture location, abnormal carpal posture (humpback deformity and/or dorsal intercalated segmental instability [DISI]), radiographic parameters of carpal alignment, prior failed surgery, smoking status, and avascular necrosis (AVN) as defined by punctate bleeding, magnetic resonance imaging (MRI) with contrast, MRI without contrast, X-ray, and histology. Meta-analysis of proportions was conducted with Freeman-Tukey double arcsine transformation. Multilevel mixed-effects analyses were performed with univariable and multivariable Poisson regression to identify confounders and evaluate predictors of failure. Results The pooled failure incidence effect size was comparable between VBG and NVBG (0.09 [95% confidence interval [CI] 0.05-0.13] and 0.08 [95% CI 0.06-0.11], respectively). Humpback deformity and/or DISI (incidence-rate radios [IRRs] 1.57, CI: 1.04-2.36) and lateral intrascaphoid angle (IRR 1.21, CI: 1.08-1.37) were significantly associated with an increased VBG failure incidence. Time from injury to surgery (IRR 1.09, CI: 1.06-1.12) and height-to-length (H/L) ratio (IRR 53.98, CI: 1.16-2,504.24) were significantly associated with an increased NVBG failure incidence, though H/L ratio demonstrated a wide CI. Decreased proximal fragment contrast uptake on MRI was a statistically significant predictor of increased failure incidence for both VBG (IRR 2.03 CI: 1.13-3.66) and NVBG (IRR 1.39, CI: 1.16-1.66). Punctate bleeding or radiographic AVN, scapholunate angle, radiolunate angle, and prior failed surgery were not associated with failure incidence for either bone graft type ( p > 0.05). Conclusion Humpback deformity and/or DISI and increasing lateral intrascaphoid angle may be predictors of VBG failure. Time from injury to surgery may be a predictor of NVBG failure. AVN as defined by decreased contrast uptake on MRI may be a marker of increased failure risk for both bone graft types.

Complex Dislocation of the Metacarpophalangeal Joint in the Index Finger of a Child: A Case Report.

CASE: The author reports a complex metacarpophalangeal joint dislocation in a 14-year-old adolescent boy with multiple failed closed reduction manipulations and unsuccessful open procedures. The patient underwent another surgical procedure through the same volar approach, and the joint was reduced along with the volar plate repair. The functional outcome at 1-year follow-up was excellent. CONCLUSIONS: Metacarpophalangeal dislocations of the index finger are rare in the pediatric population. The interposition of the volar plate is the significant barrier to reduction and the prime reason for unsuccessful closed reduction attempts. In such cases, surgeons may prefer a dorsal or volar approach to open and reduce the joint. Unsuccessful open reduction is rare.