Functional outcome of tardy ulnar nerve palsy manifests after 25 years due to nonunion of lateral epicondyle left humerus treated by ulnar nerve transposition: A case report.

INTRODUCTION: Tardy ulnar nerve palsy is a chronic clinical condition characterized by delayed-onset ulnar neuropathy. CASE PRESENTATION: Male 36 years old with 5 years clawing left ring and little finger, weakness of intrinsic muscle and grip, and paresthesia on ulnar nerve distribution. There was a history of elbow trauma 30 years ago. The radiological finding is a non-union of the lateral condyle without significant valgus. Intraoperatively, an intact ulnar nerve was discovered with no significant fibrous tissue. The author performed anterior transposition of the ulnar nerve. After 6 months, there is improvement in power and sensibility, with the quick dash score decreasing from 18 to 6. DISCUSSION: Any increase in a valgus deformity at the elbow joint would lead to stretching of the nerve resulting in neuropraxia. On this case we found there is slight valgus deformity, but there is malunion of lateral epicondyle that causes incongruency of elbow joint that will lead to chronic impingement ulnar nerve. The patient work as officer working in front of computer typing for hours and sometimes lifting heavy objects. These activities irritate ulnar nerve on incongruent joint which causes tardy ulnar nerve palsy. The treatment of choice is ulnar nerve transposition. CONCLUSION: The treatment of choice is anterior ulnar transposition. Any condition that impairs the anatomical structure of the elbow joint can cause ulnar nerve palsy. From this case, we also learn that it is not necessary to correct bone deformity or stabilize the non-union condyle if there is no significant deformity.

Congenital scoliosis associated with total situs inversus: A rare case report.

INTRODUCTION AND IMPORTANCE: Situs inversus totalis is a rare congenital abnormality characterized by a mirror-image transposition of both the abdominal and the thoracic organs. Vertebral anomalies causing congenital scoliosis are classified on the basis of failures of formation, segmentation, or both. The hallmark of surgical treatment is early intervention before the development of large curvatures. The surgical treatment of a congenital deformity mandates the use of neurological monitoring to minimize the risk of perioperative neurological deficit. CASE PRESENTATION: We present a 21-year-old patient who was admitted for her scoliosis deformity correction. Complaints of back pain when standing for a long time and carrying heavy loads for too long. Her systemic examination revealed the apex cardiac beat on the right side, liver dullness on the left side, and rib hump deformity. CLINICAL DISCUSSION: Congenital scoliosis is the most frequent congenital deformity of the spine. Congenital curvatures are due to anomalous development of the vertebrae (failure of formation and/or segmentation). Congenital scoliosis is believed to be related to an insult to the fetus during spine embryological development and associated malformations. In our case, the X-ray showed that the cardiac apex, spleen, stomach, and aorta were present on the right side, and the larger liver lobe and inferior vena cava were noted on the left side. Thus, the image manifestations supported the diagnosis of situs inversus totalis. CONCLUSION: Corrective surgery with osteotomy could be a safe and effective for the treatment of scoliosis associated with situs inversus totalis.

Diagnosis and surgical approach in treating glomus tumor distal phalanx left middle finger: A case report.

INTRODUCTION AND IMPORTANCE: Glomus tumors are rare mesenchymal neoplasms. These tumors originate from the glomus bodies and are commonly found in the fingertips, especially in the subungual location. The cause of this tumor is unknown. Clinically, the symptoms are non-specific and often not identified on physical examination and radiologically accompanied by rare cases, making it difficult to diagnose a glomus tumor. CASE PRESENTATION: Current report present a case of pain at the tip of the middle finger of the left hand in a woman for six years and worsening in the last two years. The patient has visited several doctors with analgesic therapy, but the complaints have not improved. A bluish nail was found on physical examination, and a clinical study with the Love's pin test and the Hildreth test had positive results. Radiographic examination showed destruction with cortical thinning of the medial aspect of the distal phalanx of the left middle finger, and MRI showed a lesion with an erosion of the distal middle finger. In this case, complete surgical excision and biopsy were performed using a transungual surgical approach. The sample was sent for microscopic examination, showing a glomus tumor. CLINICAL DISCUSSION: Cases with clinical symptoms of intense paroxysmal pain, exquisite point tenderness, and sensitivity to cold allow a clinical diagnosis in 90 % of cases. On clinical examinations such as Love's pin test, Hildreth's test, cold sensitivity test, and trans-illumination test with positive results and confirmed by MRI or ultrasound, the diagnosis of glomus tumor can be established. CONCLUSION: This case shows a glomus tumor in the distal phalanges of the middle finger of the left hand-diagnosis enforcement through detailed history taking and physical examination, confirmed by MRI and microscopic examination. Complete surgical excision is an effective treatment. In this case, using a transungual surgical approach based on preoperative MRI, the subungual lesion was found to provide the best exposure.

Vertical Rectus Abdominis Myocutaneous Flap for Reconstruction of Forequarter Amputation Defect after Shoulder Soft Tissue Sarcoma Resection: Technical Consideration.

Forequarter amputations in advanced local malignancy or trauma cases often leave a large defect that is challenging to reconstruct. Options for defect closure are varied. A vertical rectus abdominis myocutaneous (VRAM) flap could be an alternative to close a significantly large defect, which is relatively easier than the more technically demanding free flap. This case presents a 64-year-old man with a soft tissue sarcoma in the left shoulder that was treated by forequarter amputation and subsequent defect closure using a VRAM flap. The VRAM flap was initially used to reconstruct the chest and abdominal walls. There have been no reported uses for the shoulder defect. The repair site defect was viable even with a less aesthetic donor site, and all of the defects were closed without any signs of infection. The VRAM flap is a good option for a large defect closure at the shoulder region, particularly after forequarter amputation.

The Unpredictable Palmaris Longus Tendon Variation in Distal Radio-Ulnar Joint Reconstruction: A Technical Consideration for Undersized Graft.

Background: Distal radioulnar joint (DRUJ) instability results from the disruption of the triangular fibrocartilaginous complex consisting of DRUJ's primary and secondary stabilizers. The gold standard of stabilization procedure remains ligament reconstruction that utilizes tendon grafts to reanimate the volar and dorsal radioulnar ligament (RUL) as the primary stabilizers of the joint. The palmaris longus (PL) tendon, the graft of choice in reconstructive surgery, is commonly used in DRUJ reconstruction. However, it can exhibit anatomic variations from agenesis to the variation in morphology, location, and attachment that is rarely encountered other than in cadaveric studies. Case Presentation: We present a case of a 14-year-old boy with ulnar-sided wrist pain and instability following an injury in a boxing match four months before admission. The clinical and radiological results suggested a DRUJ injury with extensor carpi ulnaris (ECU) tendinitis. A ligament reconstruction using the PL tendon graft was planned. Intraoperatively, the PL was found anomalous with dual distal attachments and a short graft length. Results: We performed Adams ligament reconstruction technique with some modifications to the original design. To overcome the under-sized graft, instead of passing it around the ulnar neck, we added one more bone tunnel on the ulna to enhance the construct stability by a tendon to bone healing. Conclusion: In reconstructive surgeries, surgeons should consider the other sources of grafts as graft variations exist. Otherwise, as in our case, modifications to the standard technique can be made.

Distally based hemisoleus flap for soft tissue defect closure following chronic osteomyelitis of the distal tibia: A case report.

INTRODUCTION AND IMPORTANCE: Chronic osteomyelitis often needs extensive debridement that leaves a gap and needs soft tissue reconstruction procedure. The use of pedicled versus free flap to reconstruct soft tissue following surgical debridement has long been debated. Pedicle flap is more favored by many surgeons for the distal third tibia, mainly due to its lower failure rate. CASE PRESENTATION: We report a 33-year-old man with eight years of chronic osteomyelitis treated with surgical debridement at the distal third tibia, leaving a 5 cm × 6 cm soft tissue defect with exposed bone. Against the common preference, we performed a distally based hemisoleus flap (pedicled flap) covered with a split thickness skin graft. No signs of flap/graft rejection were observed during follow-up, and the patient was able to return to work four months following the surgery. No limitation in patient's daily activity upon two years follow up. CLINICAL DISCUSSION: Preservation of critical perforators is essential during the elevation of the flap. The knowledge and application of the vascularity and angiosome principles are crucial in designing this type of flap, as some anatomical variations do exist. Meticulous tissue handling is required to support the basic knowledge of the lower limb vascular system. CONCLUSION: Distally based hemisoleus flap is a reasonable option for soft tissue defect following chronic osteomyelitis of the distal tibia.

Long term follow-up of Maduromycosis treatment: A case review.

Maduromycosis is a rare deep fungal infection characterized by painless progressive destruction of limb caused by either fungal or filamentous bacteria. Its presentation is usually initiated by trivial penetration injury in farmers or laborers, worsen by immunocompromised status. Due to its painless course, this infection will severely destruct and deform hence leading to high morbidity of patient. We report a rare presentation of maduromycosis in 49-year-old housewife with no history of penetrating injury and no comorbid. Multi-disciplinary team was involved to establish the accurate diagnosis. The patient underwent surgical debridement and was given prolonged anti-fungal therapy. Combination of the treatments with patient's adherence lead to recovery without further recurrence and the patient was able to perform daily living activity.

Double central ray amputation of the third and fourth digits for recurrent giant cell tumors of the hand: A case report.

INTRODUCTION AND IMPORTANCE: Recurrent giant cell tumor of the bone (GCTB) of the hand is very rare to be encountered. Our aim is to alert the surgeons to such condition and double central ray amputation of the third and fourth digits could be an option which may reduce the chance of a re-recurrence and provide an acceptable functional outcome. CASE PRESENTATION: We presented a 25-year-old woman with a recurrent GCTB of the proximal phalanx of the middle finger of the right hand. Considering the recurrent case, a high suspicion of malignancy, and apparent soft tissue extension, the lesion was treated with double central ray amputation of the third and fourth digits through metacarpals. CLINICAL DISCUSSION: Extraosseous soft tissue invasion of recurrent GCTB of the hand had an important role in the treatment recommendation. A balance must be considered between the risk of re-recurrence and the impact of radical resection on function. Double central ray amputation surgery was performed in order to decrease the risk of additional recurrences. Acceptable functionality of the hand as she scored 26/30 (86 % rating) evaluated by Musculoskeletal Tumor Society (MSTS) Scoring System and no signs of local re-recurrence were found for 6 months follow up. CONCLUSION: Double central ray amputation of the third and fourth digits is a good option for management of recurrent GCTB of proximal phalanx of the third digits with gross soft tissue extension to adjacent fourth digits region.