An anatomical feasibility study using the first metatarsal head as a vascularized bone graft for proximal pole of scaphoid reconstruction.

A cadaveric study showed that vascularized transfer of the articular surface of the ipsilateral first metatarsal head with the lateral collateral ligament could be suitable for reconstruction of the proximal pole of scaphoid and scapholunate ligament. Further study of the technique is recommended.

Topical Negative Pressure Wound Dressing and Its Applications in the Hand-A Review of the Literature.

The use of topical negative pressure wound therapy (NPWT) has become increasingly popular in the management of complex wounds. There are many theories as to the mechanism of action of NPWT, but the essential components of the various systems remain consistent. There are many attractive potential properties of negative pressure dressings that lend themselves to the management of upper limb injuries. This article explores the technique of negative pressure wound dressing, the theories pertaining to mechanism of action, and the increasingly broad indications described for the use of NPWT in the hand. The literature pertaining to the efficacy of NPWT in general is also discussed.

Management of conflict injuries to the upper limb. Part 2: reconstruction and managing complications.

This is the second of a two-part review article on the management of conflict injuries, focused on the reconstructive strategies for bone, nerve and soft tissue and to provide guidance on assessing and managing common complications associated with complex upper limb injuries. Following assessment and early surgical management, the conflict casualty will require further wound evaluation and planning prior to definitive reconstruction of limb injuries. Surgical management of the upper limb injury should aim, where possible, to preserve the limb and allow functional reconstruction. The principles of the second look procedure are to assess wound progression, further reduce the risk of infection and plan definitive reconstruction with adequate soft tissue cover. The prerequisites for successful surgical reconstruction are a stable patient, combined orthoplastic surgery expertise supported by physiotherapists and hand therapists.

Management of conflict injuries to the upper limb. Part 1: assessment and early surgical care.

Upper limb injuries are common in conflict zones. The functions of the upper limb are impossible to replicate with prosthetic replacement and wherever possible attempts should be made to preserve the limb with further secondary reconstruction aimed at restoration of function. Casualty assessment, haemorrhage control and resuscitation are simultaneously undertaken at the receiving medical facility. Primary surgical management involves decontamination and debridement, skeletal stabilization, restoration of vascularity, compartment fasciotomy where indicated and wound temporization with dressings. Operative findings and interventions should be documented and if evacuation of the casualty is possible, copies should be provided in the medical records to facilitate communication in the chain of care. Secondary procedures are required for further assessment and debridement prior to planning reconstruction and definitive fracture stabilization, nerve repair, wound cover or closure.

Clinical outcomes following neurolysis and porcine collagen extracellular matrix wrapping of scarred nerves in revision carpal tunnel decompression.

Scar tether after primary nerve decompression can impair physiological nerve glide and vascularity of the nerve. Revision decompression in the setting of neurostenalgia should address the scarred mesoneurium in order to prevent further entrapment and tether. This study reports on the clinical outcomes of 12 patients with neurostenalgia following carpal tunnel decompression (CTD), treated with revision CTD and a porcine submucosa extracellular matrix nerve wrap (PECM) (Axoguard® nerve protector, Axogen Inc., Alachua, FL). Eleven patients had one primary decompression procedure prior to revision surgery; one patient previously had two operations for CTD. There was a significant reduction in visual analogue pain scores (VAS) and improvement in patients' satisfaction rating and symptom resolution. Patient-reported outcome measures were recorded using the Impact of Hand Nerve Disorders (I-HaND) Scale (Version 2), which demonstrated a significant reduction in hand disability. There were no complications attributable to the procedure and no re-revision procedures necessary at the latest follow-up.

Palmaris profundus in the carpal tunnel.

Carpal tunnel release is a routinely performed operation to relieve pressure caused by compression on the median nerve. In the majority of cases, the causation of the compression will be idiopathic. Among the secondary causes of median nerve compression is the palmaris profundus, a rare anatomical variant separate to the palmaris longus tendon. It has been suggested that it may cause carpal tunnel syndrome as it courses underneath the flexor retinaculum with the contents of the carpal tunnel reducing the space available to the median nerve. Several cases have found it intimately associated with the median nerve within the carpal tunnel. Raising awareness of this anatomical variant is therefore important for those undertaking carpal tunnel decompression in order to avoid unintended damage.

Price of a Finger.

Background: Traumatic loss of an index finger is offered twice the amount of compensation as compared to a loss of little finger. However, the little finger plays a pivotal role in power grip thus is underestimated in its importance. Our aim was to test our hypothesis that loss of the little finger will result in greater or equal loss of grip strength compared to loss of the index finger. Methods: Grip strength in the power grip position was measured in 12 healthy volunteers using a JAMAR hand dynamometer. Grip strength of their dominant hand was recorded as a mean kg force of three attempts in three grip configurations 1) using all fingers 2) excluding the index finger and 3) excluding the little finger. Grip strength percentage compared to the full hand was calculated and statistical significance was investigated with a two-tailed T-test. Results: Participants' age varied from 19-64 years, with 4 males and 8 females. Mean full hand grip strength was 28.3 kg force; grip strength with index finger excluded was 65.8% and with little finger excluded was 66.2%. There was no significant difference in grip strength percentage when comparing index or little finger exclusion (p = 0.92). Conclusions: We did not find a difference in power grip using a simulated model of index or little finger loss in a healthy volunteer cohort. This should be taken into account in traumatic loss and work compensation.

Service reconfiguration in the department of hand surgery during the UK COVID-19 lockdown: Birmingham experience.

In early 2020, the COVID-19 pandemic swept through the UK and had a major impact on healthcare services. The Birmingham hand centre, one of the largest hand trauma units in the country, underwent a dramatic service reconfiguration to enable robust and safe provision of care that would withstand the peak of the pandemic. Streamlining our service significantly reduced patient footfall and hospital admission while preventing intra-hospital viral transmission. Many of the changes implemented have been kept as permanent adjustments to our practice as this new model of care yields higher patient satisfaction and efficacy to withstand the pressures of further peaks in the pandemic.

King cobra bite - Can early decompression prevent digital amputation?

King cobra bites are extremely rare in the western world. These bites can be fatal due to the large volume of the venom injected. We report a case of digital ischaemia from a King cobra bite in a young man who was working in a zoo in Netherlands. He was protected from systemic envenomation as he was wearing a protective glove. However, his right index finger developed subsequent gangrene and he underwent a ray amputation. The current literature on the management of snake bites to hands is reviewed and the role of early decompression discussed.

The Versatile Hook Plate in Avulsion Fractures of the Hand.

Avulsion fractures can pose technical difficulties for surgical fixation. The fragments are often small and around finger joints with access being difficult due to attachment of ligaments or tendons. Traditionally, these have been treated using K wires, lag screws, or pullout sutures.Hook plates were originally described for operative management of mallet fractures. We have been using hook plates in our unit for over 10 years. However, over the years, we have extended their use to other avulsion fractures in the hand such as proximal interphalangeal joint fracture dislocations, central slip avulsions, flexor digitorum profundus avulsions and collateral ligament avulsions.The aim of this article is to describe the technique of fabricating a hook plate and using it for avulsion fractures in the hand. A few illustrative cases are discussed along with a review of the current literature. METHODS: In a retrospective review of our use of hook plates in hand fractures from 2008 to 2014, a total of 63 cases were identified from the hospital data base. There were 35 cases of Mallet fractures, 16 cases of proximal interphalangeal joint fracture dislocations, 5 cases of flexor digitorum profundus avulsion fractures, 5 cases of Central slip avulsions, and 2 collateral ligament avulsions. RESULTS: All fractures healed well with this technique with no biomechanical failures and good functional outcome. Plates needed removal in a total of 25 cases, of which 14 were in mallet fractures. Thirteen (21%) cases suffered complications, of which the majority were again related to mallet fractures. CONCLUSIONS: The hook plate is a simple device that can be created quite easily with readily available materials. We have extended the use of these plates to avulsion fracture fixation in the hand and found this to be a versatile technique. The risk of fragmenting the small fracture fragment is reduced because the hooks secure it and the plate is fixed in the bone. If done meticulously, joint congruence can be achieved. It has a biomechanical advantage over current methods of fracture fixation of small but important bone fragments in the hand.

Stability of Unicortical versus Bicortical Metacarpal Fracture Internal Fixation Trial (SUBMIT): study protocol for a randomized controlled trial.

BACKGROUND: Metacarpal fractures are common, accounting for 40 % of all hand injuries. The use of plates for the fixation of these fractures allows early aggressive hand therapy post-operatively, reducing post-operative stiffness. Traditionally, bicortical fixation is the standard practice, where both dorsal and palmar cortices of the metacarpal are drilled through, with screws engaging both cortices. Recent biomechanical studies have shown that unicortical fixation, where only the near cortex is drilled and engaged by the screw, results in no difference in stiffness, load to failure or failure mechanism, when compared with bicortical fixation. This trial aims to compare fracture union, complication rate and functional outcomes between unicortical and bicortical fixation for adults with displaced metacarpal fractures. METHODS/DESIGN: All adults with displaced diaphyseal metacarpal fracture requiring plate fixation are potentially eligible to take part in this study. A total of 315 consenting patients will be randomly allocated to either unicortical or bicortical plate and screw fixation. The surgery will be performed in specialist hand trauma units across the UK. Data regarding fracture healing, hand function, quality of life, and complications will be collected at 2 weeks, 6 weeks and 6 months following surgery. DISCUSSION: This pragmatic, prospective, multi-centre, randomized controlled trial is expected to deliver results in 2018. TRIAL REGISTRATION: ISRCTN 18006607 . Registered on 19 Nov 2015.

Free radial forearm fasciocutaneous flap in the treatment of distal third tibial osteomyelitis.

BACKGROUND: Osteomyelitis of the lower limb, associated with soft-tissue defects, is a reconstructive challenge. Microvascular free-tissue reconstruction is an important surgical option with the superiority of free muscle and myocutaneous flaps being explored by various publications. Muscle flaps provide good quality vascularized tissue which can be contoured into defects, but their bulk can often lead to the reconstruction having a suboptimal aesthetic outcome. This result is usually most evident in the lower third of the tibia. We present our series of free radial forearm fasciocutaneous flaps for reconstruction of distal third tibial soft-tissue defects following debridement of osteomyelitic foci and bony stabilization. METHODS: A retrospective case-note review of 20 patients treated with free radial forearm fasciocutaneous flap reconstruction of distal third tibial soft-tissue defects following excision of osteomyelitis and adjacent scar tissue, and bony stabilization between January 1999 and December 2006 was conducted. RESULTS: There were 20 patients who had established osteomyelitis of the distal third of tibia following previous open fractures. The mean size of the soft-tissue defect at the time of the free fasciocutaneous flap procedure was 72.3 cm(2) and the mean bony defect was 3.4 cm. The mean duration of the procedure was 417 minutes and flap ischemia time did not extend beyond 60 minutes in any of the cases. Overall flap survival was 100% and all patients had radiologic bony union at a mean of 5.73 months. The average period of follow-up was 22.5 (range, 19-36) months, and none of the patients had a recurrence of the disease during the follow-up period. CONCLUSION: Free fasciocutaneous flap reconstruction for soft-tissue defects of the lower limb in our series was seen to be safe, reliable, and provided an aesthetic outcome with high patient satisfaction rates. We advocate the use of free fasciocutaneous flaps for small-to-moderate sized defects of the distal third of the tibia after debridement for chronic osteomyelitis. Although we have used radial forearm flaps in our series, more modern free fasciocutaneous flaps with less donor-site morbidity may be preferred.

Fasciotomy: a call for proper placement.

INTRODUCTION: It is important that acute compartment syndrome is recognised and treated early. Treatment involves surgical decompression and it is imperative that this is performed in a timely and appropriate manner. The knowledge of plastic and orthopaedic surgery trainees of the safe technique for performing lower leg fasciotomy was examined. METHODS: Survey of knowledge of fasciotomy was performed amongst plastic and orthopaedic surgery trainees. They were asked to fill in a questionnaire during a regional teaching session. RESULTS: There were 29 respondents; 19 plastic surgery trainees and 10 from orthopaedic surgery. Most trainees had little experience of watching, assisting or performing fasciotomies. When asked to mark the placement of fasciotomy incisions and plane of dissection, only 47% of plastic and 10% of orthopaedic surgery trainees were correct. DISCUSSION: Clinical experience and knowledge of lower leg fasciotomy is poor amongst trainees surveyed. In this paper, the pathophysiology, diagnosis and treatment of compartment syndrome are described. Examples of poorly placed fasciotomy incisions, as well as the consequences of these, are also presented.

Correction of Stahl ear deformity using a suture technique.

Correction of partial ear deformities can be a challenging task for the plastic surgeon. There are no standard techniques for correcting many of these deformities, and several different techniques are described in literature. Stahl ear is one such anomaly, characterized by an accessory third crus in the ear cartilage, giving rise to an irregular helical rim. The conventional techniques of correcting this deformity include either excision of the cartilage, repositioning of the cartilage, or scoring techniques. We recently encountered a case of Stahl ear deformity and undertook correction using internal sutures with very good results. The technical details of the surgery are described along with a review of literature on correcting similar anomalies.