Lipofibromatous Hamartoma of the Median Nerve - A Rare Condition in the Hand.

Lipofibromatous hamartoma (LFH) of the median nerve is a rare condition in the hand and often remains asymptomatic for a significant period. MRI imaging can reveal unique tumour characteristics; however, the definitive diagnosis is confirmed through a tissue biopsy. In this report, a 38-year-old male presented with a gradually growing mass on his right hand. Physical examination revealed a large soft tissue mass extending from the thenar area to the wrist, causing compression of the median nerve. MRI confirmed the presence of a distinct soft tissue mass on the volar side of the hand. The mass was excised along with a fascicle and confirmed by histological examination. One year after surgery, sensation has improved, but weakness remains and opponensplasty was offered to the patient. Although the treatment strategy of LFH of the median nerve remains controversial, delayed treatment can result in severe compressive neuropathy and irreversible nerve damage. Level of Evidence: Level V (Therapeutic).

Mid-term outcomes of digital nerve injuries treated with Renerve® synthetic collagen nerve conduits: A retrospective single-center study.

BACKGROUND: Biodegradable synthetic nerve conduits have become widely used for peripheral nerve injuries. Recently, bioabsorbable collagen conduits filled with collagen fibers (Renerve®) are commercially available in Japan. We investigated the clinical efficacy and safety of Renerve® conduits for digital nerve repair. PATIENTS AND METHODS: We retrospectively reviewed data of patients who underwent digital nerve repair using Renerve® conduits between August 2017 and February 2022 at our hospital and were followed up for at least 12 months. Seventeen patients (20 nerves) with a median age of 46.5 years (interquartile rage: 26-48 years) were included in the analysis. We analyzed sensory nerve function recovery and residual pain or uncomfortable tingling, as well as safety outcomes. The relationship between nerve defect length and sensory function data was assessed using Spearman's rank correlation. RESULTS: Sensory nerve function at 12 months postoperatively was excellent in six, good in 10, and poor in four nerves, and that at the final follow-up (median period, 24 months; range, 12-30 months) was excellent in nine, good in 10, and poor in one nerve. All nerves with a defect length of <12 mm had excellent or good sensory outcomes. At 12 months postoperatively, the correlation coefficients between nerve defect length and Semmes-Weinstein monofilament test results, static two-point discrimination, and dynamic two-point discrimination were 0.35 (p = 0.131), 0.397 (p = 0.0827), and 0.451 (p = 0.0461), respectively. Residual pain or tingling sensation were observed in four nerves at the final follow-up. No postoperative complications were observed in any of the patients. CONCLUSIONS: This study demonstrated the clinical efficacy and safety of Renerve® conduits for digital nerve repair. Our results will be useful in clinical practice because of the scarcity of real-world data on the use of Renerve® conduits for digital nerve repair.

The 3D-Printed Titanium Truss Cage for the Treatment of Concurrent Complex Malunion, Synostosis and Large Bone Defect Following Forearm Injuries: A Case Report.

A 28-year-old man sustained a complex forearm injury from high-energy trauma, causing ulnar nerve injury, a bone defect, forearm malunion and synostosis. A 3D-printed titanium truss cage was used to solve these problems. This patient achieved union of the bone defect, was pain-free and had no recurrent synostosis 2 years after reconstructive surgery. The advantages of the 3D-printed titanium truss cage included anatomical fit, immediate mobilisation and low morbidity of the donor side of the bone graft. This study reported a promising result from using 3D-printed titanium truss cages to manage complex forearm bony problems. Level of Evidence: Level V (Therapeutic).

A comparison of using a smartphone versus a surgical microscope for microsurgical anastomosis in a non-living model.

BACKGROUND: Although they may not replace standard training methods that use surgical microscopes, smartphones equipped with high-resolution screens and high-definition cameras are an attractive alternative for practicing microsurgical skills. They are ubiquitous, simple to operate, and inexpensive. This study compared anastomoses of chicken femoral vessels using a smartphone camera versus a standard operative microscope. METHODS: Forty anastomoses of non-living chicken femoral vessels were divided into four groups. A resident and an experienced microsurgeon performed anastomoses of femoral chicken vessels with 8-0 and 10-0 sutures, using a smartphone camera and a surgical microscope. The time to complete the anastomosis and the number of anastomosis errors were compared using the Mann-Whitney U test. RESULTS: The time taken to perform an anastomosis by the experienced microsurgeon was significantly longer when using the smartphone (median: 32.5 minutes vs. 20 minutes, P<0.001). The resident completed the anastomoses with both types of equipment without a significant difference in the operative times. When using a smartphone, the operation times were not significantly different between the resident and the experienced microsurgeon (P=0.238). The resident showed non-significant differences in operation time and the number of errors when using a smartphone or an operative microscope (P=1.000 and P=0.065, respectively). CONCLUSIONS: Microsurgical practice with non-living chicken femoral vessels can be performed with a smartphone, though it can take longer than with an operative microscope for experienced microsurgeons. The resident may also experience frustration and tend to make more anastomosis errors when using a smartphone versus an operative microscope.

Ulnar Nerve Strain in Functional Elbow and Shoulder Motions.

Background: Shoulder and elbow motions can affect ulnar nerve strain. However, there is no evidence that links this kind of strain to specific activities. The purpose of this study was to examine ulnar nerve strain at the elbow resulting from normal daily activities. Methods: This study was conducted using thirty fresh frozen cadaveric elbows from subjects who had no deformities or history of previous upper extremity surgery. Strain was calculated based on nerve elongation. Ulnar nerve strain at the elbow from motion related to common daily activities was measured in both normal nerves and nerves in which gliding motion was restricted. The results of these measurement were then compared. Results: Activities related to extreme elbow and shoulder motions, such as cellular phone use, yielded an average strain of 6.3%. In addition, we found that nerve strain increased significantly in conditions in which gliding motion was restricted. Nerve strain due to motion associated with cellular phone use, for example, rose by 69.1%. Conclusions: Elbow flexion and shoulder abduction in daily activities are associated with increases in ulnar nerve strain, but this may not cause permanent damage to the nerve. After nerve gliding motion had been restricted, nerves that normally exhibited less strain often had even increased higher levels of strain than those nerves that normally exhibited high strain.

Distal anastomosis patterns of the descending branch of the lateral circumflex femoral artery.

BACKGROUND: The reverse anterolateral thigh (ALT) flap has shown good results in the treatment of patients who have skin and soft tissue defects around the knee and shin. The objective of this study was to show the anastomotic patterns of the descending branch of lateral femoral circumflex artery (db-LCFA) and locate the appropriate pivot point for reverse ALT flap. MATERIALS AND METHODS: Fifty thighs from 25 embalmed cadavers from the Anatomy Department, Khon Kaen University in 2012, were dissected. The patterns of distal anastomoses of db-LCFA were recorded and appropriate pivot points for the reverse ALT flap were measured. RESULTS: Three patterns of distal anastomosis of the db-LCFA were identified, including the anastomoses to the superolateral genicular arteries (46%), anastomoses to the profunda femoral arteries (28%), and unidentified distal anastomoses (26%). The mean distance of the pivot point was 9.4 ± 3.7 cm from the lateral epicondyle. The mean pedicular length was 13.2 ± 5.4 cm (mean ± SD). Most cadavers, 76%, showed a single db-LCFA. In cases where there was more than one db-LCFA, the distal anastomoses were found to be originating from the most medial db-LCFA. CONCLUSION: The reverse ALT flap technique showed good results in the treatment of patients with skin and soft tissue defects around the knee and shin. Variations of the anastomoses and branching patterns of the db-LCFA may influence flap survival. Additional preoperative vascular evaluations would be helpful in defining the most compatible area from which to harvest the flap.

Validity of the Thai version of Disability of the Arm, Shoulder and Hand Questionnaire (KKU-DASH) in patients with brachial plexus injury.

OBJECTIVE: To assess the reliability and validity of the Thai version of the Disability of the Arm, Shoulder and Hand (KKU-DASH) questionnaire in patients with brachial plexus injuries. MATERIAL AND METHOD: The Thai KKU-DASH version was performed based on translation/back translation methodology. Thirty-four Thai-speaking patients with brachial plexus injuries completed the KKU-DASH and the 36-item short-form health survey (SF-36) questionnaires preoperatively and then were reassessed for test-retest reliability two months later Reliability was investigated for reproducibility and internal consistency The validity was evaluated by using component analysis and the correlations coefficients between the KKU-DASH and the SF-36. RESULTS: The internal consistency of the degree of difficulty, severity of pain, and social activity domains of the KKU-DASH was good to excellent (Cronbach's alpha 1.00, 0.75, and 1.00). The intraclass correlation coefficient (ICCs) for the test-retest reliability was 0.52. For the degree ofdifficulty, severity of pain, social activity, and psychological effect on self-image, the ICC were 0.5, 0.45, 0.57, and 0.53 respectively The convergent validity between the KKU-DASH and SF-36 was -0.76. The convergent validity of each domain between both instruments ranged from 0.46 to 0.69 and the strongest correlation was observed in the social activity domain. CONCLUSION: According to the reliability and validity testing, the KKU-DASH questionnaire is suitable for Thai-speaking patients with brachial plexus injuries.

Anatomical study of arcade of Struthers.

The incidence and the anatomical location of the arcade of Struthers as related to the arm length were studied in 62 arms of adult fresh-frozen cadavers. The distance between the greater tuberosity and the lateral epicondyle was designated as the arm length. The arcades of Struthers were identified in 85.4%. The mean arm length was 27.85 ± 1.3 cm. The mean of the distance between proximal border of the arcade of Struthers and the medial humeral epicondyle was 8.24 ± 2.06 cm. The mean ratio between the distance from the proximal border of the arcade to the tip of the medial epicondyle and arm length was 0.29 ± 0.07. We concluded that the anatomical location of the arcade as related to the arm length was 29% proximally, from the tip of the medial epicondyle. This report of the anatomical location of the arcade of Struthers related to the arm length can be useful to identify this structure in the arms which have differences in arm length during the surgical exploration and anterior transposition of the ulnar nerve procedures.

Intra-tendon sheath injection for trigger finger: the randomized controlled trial.

The most common technique used for non-surgical treatment of trigger fingers is the direct injection of steroids into the flexor tendon sheath over the metacarpal head. However, this method causes more pian to the patient and can result in tendon rupture due to insertion of needle into the tendon. Carlson and Curtis described the mid-axial injection technique which is simple and relatively painless. We aim to compare the pain result from the injection between these two methods. The prospective randomised control trial study was designed. There were 103 trigger fingers included in the study which were divided into two groups: the conventional technique of injection (CI technique) and the mid-axial injection technique (MAI technique). The visual analogue scale for pain score had been recorded at the time of injection: one, three and six weeks. The complication after injection and the recurrent symptoms within one year were also recorded. The Student's t-test, Chi-squared and Fisher-exact analysis were used for statistical testing. The results showed that the mean VAS pain scores immediately after needle insertion were 40.19 +/- 23.3 and 48.39 +/- 26.5 in the MAI and CI technique groups, respectively. The MAI technique was less painful than the CI technique (p < 0.05). There were no complications from the injections in both methods. However, the recurrent rate seems to be higher in the conventional technique (p = 0.23). We concluded that the MAI injection technique provided less pain result than the CI technique and there were no complications from this injection technique.

Anatomic safe zone for proximal ulnar fixation: a cadaver study.

OBJECTIVE: To study the location and characterization of the safe zone with respect to bony landmarks on volar surface of proximal ulna for the protrusion of various ulnar fixations. MATERIAL AND METHOD: The present study was done on 39 upper extremities from 20 embalmed human, adult cadavers. The average ages of the cadavers were 67.28 +/- 10.96 years (range from 40 to 82 years), 10 females, and 29 males. The safe zone dimensions, both in coronal and sagittal planes, were measured. RESULTS: The distance between median nerve and volar surface of proximal ulna in sagittal plane at 2 cm and 4 cm distal to tip of coronoid process were 0.99 +/- 0.15 cm (range from 0.76-1.32 cm) and 0.85 +/- 0.17 cm (range from 0.64-1.75 cm), respectively. The distances between the lateral border of the proximal ulna and medial border of the median nerve in coronal plane at 2 cm and 4 cm distal to the tip of the coronoid process were 0.95 +/- 0.19 cm (range from 0.66-1.36 cm) and 0.82 +/- 0.14 cm (range from 0.52-1.14 cm), respectively. CONCLUSION: Based on the present results, if intra-medullary screws or K-wire fixations were used, it should theoretically be long enough to reach their proximal ulna in order to bite into the cortical bone, but should not be so long as to cut out into its lateral part and, in the sagittal plane, the protrusion should not be longer than 0.92 cm. Orthopedic surgeons must remain vigilant with regard to any types of fixation in the upper extremity because the risk of neurovascular injury is high.

Vascular anatomy of the proximal fibula from embalmed cadaveric dissection.

OBJECTIVES: To study the vascular pattern of proximal fibula with use of embalmed cadaveric specimens. MATERIAL AND METHOD: The present study was done on 33 lower extremities from 19 embalmed human, adult cadavers. The average ages of the cadavers were 68.6 years (range from 36 to 98 years), 11 females and 8 males. The size and site of vessels around the proximal fibula were recorded. RESULTS: There were three main blood supplies of proximal fibular the epiphyseal artery, the lateral genicular artery, and the periosteal blood supply. They are anterior tibial recurrent artery and posterior tibial artery or artery of the neck of fibula posteriorly. Inferior lateral genicular artery was seen in all specimens (33/33). Among them, 42.4% (14/33) had a single artery with double accompanied veins. The average diameter of artery and veins were 1.71 mm (0.75-2.25), and 1.69 mm (1.30-2.10), respectively. The others were single artery and single vein. The average diameter ofartery and veins were 1.66 mm (0.65-2.14), and 2. 1 mm (0. 95-2.30) respectively. Anterior tibial recurrent artery was seen in 31 of 33 specimens (94%). The average size of artery and accompanying vein were 1.24 mm (0.8-2.1), and 1.86 mm (0.8-2.6), respectively. Posterior tibial recurrent artery was an inconsistent branch that appeared in only 11 of 33 specimens (33%). Artery of the neck of fibula appeared in 24 of 33 specimens (72.7%). The others were replaced by the predominant posterior tibial recurrent artery (7/33) and neither of them was found in two specimens. CONCLUSION: Based on the present results, the authors recommend preserving the epiphyseal blood supply, the inferior lateral genicular artery, and the periosteal blood supply for free epiphyseal transfer In addition, surgeons should pay attention to the variation of posterior periosteal blood supply because its variations will affect the viability percentage of proximal fibular epiphyseal transfer.

A comparative biomechanical study of the looped square slip knot and the simple surgical knot.

The looped square slip knot was introduced as a technique for skin closure to avoid the use of sharp instruments in suture removal after hand surgery. We compared the biomechanical properties of this knot with the simple surgical square knot. The ultimate strength of the looped square slip knot was significantly (p = 0.015) higher than the simple surgical knot. There was no significant difference between the two knots in mode of failure. Knot slippage or suture breakage did not occur in any samples when testing security by repetitive loading. Therefore, the looped square slip knot is a safe and convenient alternative to the two-throw surgical knot for use in hand surgery.

Prevalence of carpal tunnel syndrome in workers from a fishnet factory in Thailand.

We determined the prevalence of carpal tunnel syndrome (CTS) at a fishnet factory in order to discern the possible associated risk factors at this type of workplace. The 662 workers were interviewed then physically examined. The prevalence of CTS was 14.5%, which is significantly higher than in the general population. Workers directly involved in the production of fishnets had a significantly higher risk of CTS than the factory's office workers or housemaids (odds ratio = 1.84; range, 1.03-3.29; 95% CI, p = 0.049). There was no association between the length of employment in the factory with CTS (odds ratio = 1.13; range, 0.77-1.66; 95% CI, p = 0.591). Our results confirm that factory jobs with repetitive hyperflexing and twisting of the wrists are at risk of CTS.

Congenital metacarpal synostosis treated by double bone blocks technique: a case report from Thailand.

Congenital metacarpal synostosis is a rare congenital anomaly in the hand, especially in our area. There were several reports of surgical techniques for correction deformities. We report this rare condition in our hospital and treatment with the metacarpal osteotomy and double bone blocks technique of grafting.

Median nerve palsy after operative treatment of olecranon fracture.

Olecranon fracture is not an uncommon fracture in clinical practice. Simple olecranon fracture usually heals quite well without any types of iatrogenic complications. Despite close proximity of the fracture to the nerve, median nerve palsy after operative treatment of olecranon fracture is a rare complication. To the authors' knowledge, this complication has not been previously reported in the Thai or English literature. The authors present a patient who had median nerve palsy after tension-band wiring for olecranon fixation. Intraoperative finding revealed that the median nerve was injured by the tip of K-wire. While this complication is uncommon on a per-person basis, it may results in serious complication, such as nerve palsy or limb ischemia. Orthopedic surgeons must remain vigilant with regard to any type of internal fixation in the upper extremity because the risk of neurovascular injury is high.

Treatment of de Quervain disease with triamcinolone injection with or without nimesulide. A randomized, double-blind, placebo-controlled trial.

BACKGROUND: There is uncertainty as to whether supplemental oral nonsteroidal anti-inflammatory medication improves the effectiveness of steroid injections in the treatment of de Quervain disease. We tested the hypothesis that there are no significant differences in the success rates when this condition is treated with triamcinolone injection with or without supplemental oral nimesulide. METHODS: In a randomized, double-blind trial, 160 patients with de Quervain disease received an injection of 10 mg of triamcinolone acetonide and either 200 mg of oral nimesulide for seven days (eighty patients) or placebo tablets for seven days (eighty patients). An independent, blinded evaluator assessed the primary outcomes (tenderness, pain, and the result on the Finkelstein test) at three weeks after injection. Adverse reactions were assessed, and probabilities of recurrence for both groups were compared. Factors possibly predictive of disease recurrence were also assessed. RESULTS: The success rate after one injection was 67% in the nimesulide group and 68% in the placebo group. The overall success rates after single or multiple injections with a mean follow-up of 13.6 months were 95% for both groups. No significant differences were noted with respect to the success rates (p = 0.69) or pain scores after treatment (p = 0.11). The most common adverse reactions to triamcinolone injection and nimesulide were pain after injection and dyspepsia, respectively. The symptoms of de Quervain disease recurred in 33% of the patients in the nimesulide group and in 37% of those in the placebo group. The median time of recurrence was at the fifth month in the nimesulide group and at the fourth month in the placebo group. The recurrence of symptoms was significantly (p = 0.01) related to the presence of crepitation (relative risk, 2.13; 95% confidence interval, 1.19 to 3.80). CONCLUSIONS: Supplemental oral administration of the nonsteroidal anti-inflammatory drug nimesulide does not improve the effectiveness of a single injection of triamcinolone acetonide in the treatment of de Quervain disease. Patients with crepitation in the first dorsal compartment during thumb extension or abduction are at increased risk for recurrence of this disease. LEVEL OF EVIDENCE: Therapeutic study, Level I-1b (randomized controlled trial [no significant difference but narrow confidence intervals]).