Single Buried Intramedullary K-Wire Fixation in Nonthumb Metacarpal Shaft Fractures with Immediate Postoperative Mobilization without Any Immobilization.

Objective: This study aims to evaluate the outcomes of single intramedullary K-wire fixation in nonthumb, metacarpal shaft fractures with immediate postoperative hand mobilization without any immobilization. Method: This is a retrospective case series conducted from January 2019 to December 2022. We included patients with closed, simple transverse, or short oblique metacarpal shaft fracture treated with single, 1.4 mm, intramedullary K-wire fixation. Gentle postoperative range of motion exercise was encouraged in every patient without any hand, finger, or wrist motion restriction material. Clinical outcomes were evaluated with total active flexion; grip strength; disability of arm, shoulder, and hand (DASH) score; and the American Society for Surgery of the Hand Total Active Flexion (ASSH TAF) score. Results: This study included 34 patients, 25 males and 9 females with a mean age of 33.14 years (ranging 18-59). A total of 43 metacarpal shafts were treated. The mean DASH score at two and 6 weeks postoperative was 41.5 (ranging 19.16-60.34) and 9.58 (ranging 0.83-23.27). The mean final DASH score at last follow-up was 3.48 (ranging 0-8.33). Mean TAF at 2 weeks postoperative, 6 weeks postoperative, and at final follow-up was 203.8 (ranging 185-240), 238.2 (ranging 220-270), and 259.25 (ranging 240-270) degrees, respectively. The mean grip strength of the injured hand was 66.14 and 86.1% of the uninjured hand at 6 weeks and 3 months postoperative. There was no nonunion, malrotation, or infection. In conclusion, single intramedullary K-wire fixation gives excellent outcomes in the treatment of single or multiple, simple, metacarpal shaft fractures without the need of postoperative immobilization.

The Isolated Motor Branch of the Ulnar Nerve Injury During Open Carpal Tunnel Release.

A 76-year-old woman underwent open carpal tunnel release (OCTR). She had sudden sharp shooting pain in her hand, in the mid-palmar area, during the operation. She was then unable to abduct or adduct her thumb and fingers after surgery. She had no sensation impairment of the ulnar digit. The nerve conduction study confirmed a complete transection of the motor branch of the ulnar nerve (MUN). The MUN was repaired, and the patient recovered her intrinsic hand muscle function two years after the operation. The mechanism of injury, related anatomy and potentially dangerous area, clinical findings, management, and prevention are discussed.

Anatomic Study of the Motor Branch of the Ulnar Nerve Regarding Carpal Tunnel Surgery: A Cadaveric Study.

Background: Motor branch of the ulnar nerve (MUN) injury during carpal tunnel surgery is rare and it should never be injured during carpal tunnel release (CTR). However, an iatrogenic injury of the MUN can cause catastrophic physical and mental suffering. The aim of our study is to understand the anatomy of the MUN in relation to carpal tunnel in order to prevent iatrogenic injury during CTR. Methods: We dissected 34 fresh cadaver hands and located the MUN in relation to the anatomical axis used for carpal tunnel surgery. Possible mechanisms of injury and the vulnerable area of the MUN were determined along the dissection. Results: The MUN turned towards the thumb distal to hook of hamate. It then travelled on the floor of the carpal tunnel which was formed by intrinsic hand muscles under flexor tendons. The nerve located at 29.39 ± 7.41, 35.01 ± 3.14 and 38.79 ± 4.03 mm (Mean ± SD) in the central axis of ring finger, the vertical axis of the third web-space and the central axis of middle finger respectively. The nerve's turning point, 10.9 ± 2.63 mm distal to the centre of hook of hamate where it lies just below the level of the transverse carpal ligament. Conclusions: Surgeons should be aware of the nerve's location. Surgical dissection or passing of any surgical instruments around the hook of hamate should be done with care. Level of Evidence: Level IV (Therapeutic).

Dorsal V - Y Advancement Flap for Lateral Finger Defect Based on Dorsal Skin Branch of Proper Digital Artery.

Managing lateral soft tissue defects, distal to the proximal interphalangeal joint, of the finger can be challenging. The use of antegrade homodigital island flap can be limited due to the length of the defect. Using a heterodigital island flap can be precluded by an injury in the adjacent fingers. Using the locoregional flap from the hand can result in a more extensive soft tissue dissection, which can create additional donor site morbidity. We present our execution technique of the homodigital dorsal skin advancement flap. The pedicle of the flap is based on dorsal branches of the digital artery perforator; hence the proper digital artery and nerve are unharmed. The operation is limited only to the injured digit, which can reduce donor site morbidity.

Modified Oblique Triangular Neurovascular Island Flap Technique to Prevent the Development of Hooked Nail Deformity.

Hooked fingernail deformity can develop after any type of fingertip amputation. A more proximal amputation is associated with a higher probability of developing hooked fingernails. Proximal fingertip amputations with very short remaining nail beds are recommended for revision amputation with nail bed ablation. This procedure eliminates the possibility that the patient may have a functional nail. When the nail matrix is still retained, an oblique triangular neurovascular island flap may preserve the nail and digit length. At our institution, the modified oblique triangular neurovascular island flap is routinely used for patients who underwent fingertip amputation with a retained nail bed. These modifications may aid in preventing the development of hooked nail deformity and creating a round pulp contour without the need for fixation, composite grafts, or distant soft tissue transfer.

Double Motor Nerve Transfer for All Finger Flexion in Cervical Spinal Cord Injury: An Anatomical Study and a Clinical Report.

PURPOSE: To explore the feasibility of restoring all finger flexion after a cervical spinal cord injury. METHODS: Double nerve transfer was conducted in 22 cadaver upper extremities. Donor nerves were the brachialis branch of the musculocutaneous nerve and the extensor carpi radialis brevis (ECRB) branches of the radial nerve. Recipient nerves were the anterior interosseous nerve (AIN) and the flexor digitorum profundus (FDP) branch of ulnar nerve (ulnar-FDP). Nerve transfers were evaluated on 3 parameters: surgical feasibility, donor-to-recipient axon count ratio, and distance from the coaptation site to the muscle entry of recipient nerve. A complete C6 spinal cord injury reconstruction was accomplished in a patient using a double nerve transfer of ECRB to ulnar-FDP and brachialis to AIN. RESULTS: In the cadaver study, nerve transfers from ECRB to AIN, brachialis to AIN, and ECRB to ulnar-FDP were all feasible. The transfer from the brachialis to ulnar-FDP was not possible. Mean myelinated axon counts of AIN, brachialis, ulnar-FDP, and ECRB were 2,903 ± 1049, 1,497 ± 606, 753 ± 364, and 567 ± 175, respectively. The donor-to-recipient axon count ratios of ECRB to AIN, brachialis to AIN, and ECRB to ulnar-FDP were 0.24 ± 0.15, 0.55 ± 0.38, and 0.98 ± 0.60, respectively. The distance from coaptation of the ECRB to the ulnar-FDP muscle entry was shorter than for the other nerve transfers (54 ± 14.29 mm). At 18 months, there was restoration of flexion in all fingers and functional improvement from double nerve transfer of the brachialis to the AIN and the ECRB to the ulnar-FDP. CONCLUSIONS: Restoration of all finger flexion may be feasible by the ECRB to ulnar-FDP and brachialis to AIN double nerve transfer. CLINICAL RELEVANCE: Double nerve transfer can be used in C6-C7 spinal cord injury and patients with lower arm-type brachial plexus injury who have no finger flexion but have good brachialis and ECRB.