Nonvascularized Double Metatarsal Transfer After Excision of Epithelioid Hemangioma of Hand: A Case Report.

CASE: Epithelioid hemangioma (EH) is an uncommon, benign, locally aggressive neoplasm, and it may present as multifocal lytic lesions with soft tissue involvement in the hand. We report the midterm follow-up of a patient with recurrent EH of the hand that was reconstructed successfully, with a nonvascularized double metatarsal transfer, after tumor excision. To the best of the authors' knowledge, this is the first case report where a nonvascularized double metatarsal transfer has been used successfully after tumor resection. CONCLUSION: Osteoarticular replacement with matched metatarsal transfer after en bloc resection may be used successfully for reconstruction, after the resection of EH involving the metacarpal.

Does endovascular repair of post-traumatic thoracic vascular injury of the subclavian/axillary arteries followed by brachial plexus injury improve outcome?

Traumatic injuries to the axillary artery or subclavian artery along with a brachial plexus injury are infrequent. Although the traditional management has been conservative because of robust collaterals, the functional improvement of the limb depends on the degree of brachial plexus injury and on the revascularization status. We report three cases of endovascular repair post-traumatic axillo-subclavian artery injuries followed by brachial plexus injury with good functional outcomes. Endovascular repair of post-traumatic subclavian and axillary artery injuries followed by brachial plexus injury is safe and feasible, and improves limb outcomes.

Endoscopic Anterior Transposition of Ulnar Nerve (EATUN) for Treatment of Tardy Ulnar Nerve Palsy.

BACKGROUND: Tardy ulnar nerve palsy is the development of late onset ulnar nerve dysfunction and is usually treated by open anterior transposition of ulnar nerve. Open technique is done using a longitudinal incision about 6-8 inch. in length with chances of development of medial antebrachial cutaneous nerve neuromas. PURPOSE: In this study, we describe the technique of Endoscopic Anterior Transposition of Ulnar Nerve (EATUN procedure) to treat tardy ulnar nerve palsy and analyze the results. METHODS: Seven patients diagnosed to have tardy ulnar nerve palsy was treated by EATUN. The humerus-elbow-wrist angle (HEW), pre- and post-operative intrinsic muscle power and sensory assessment, Dellon scores, and the Q-DASH was analyzed. RESULTS: The minimum follow-up was 12 months (Mean 27.4 months, Range 12-36 months). Improvement in Dellon and Q-DASH scores following EATUN procedure was statistically significant. There was objective improvement of intrinsic muscle power and sensation on follow-up, though not statistically significant. No instance of neuroma of the medial cutaneous nerve of forearm was noted. CONCLUSIONS: The endoscopic anterior transposition of the ulnar nerve is a good option in surgical management of tardy ulnar nerve palsy. LEVEL OF EVIDENCE: Therapeutic Level IV. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s43465-021-00366-w.

Restoration of elbow flexion in adult traumatic brachial plexus injury - a quantitative analysis of results of single versus double nerve transfer.

BACKGROUND: Restoration of elbow flexion is one of the key components of adult brachial plexus surgery. Nerve transfers are routinely used to attain elbow flexion. PURPOSE: This study aims to quantify the recovery of elbow flexion power and to compare the outcome following single nerve transfer and double nerve transfer to branches of the musculocutaneous nerve in adult traumatic brachial plexus injury. METHOD: We conducted a retrospective cohort study of patients with traumatic upper brachial plexus injury who underwent nerve transfer of the musculocutaneous nerve with either Ulnar nerve fascicles (SN) or both Ulnar and Median nerve fascicles (DN) for restoring elbow flexion. Patients with a minimum follow up of 18 months after surgery were included in this study. Elbow flexion strength was quantified using a force transducer and software module and the results were compared between the two groups. RESULT: The median strength of elbow flexion was 14.3 Newton meter. In the SN group, the mean strength of elbow flexion was 5.4 ± 5 Nm, and for DN group it was 20.4 ± 9.9 Nm. Elbow flexion strength following DN procedure was significantly better when compared with SN. CONCLUSION: The additional nerve transfer of median nerve fascicles with musculocutaneous nerve branch to the brachialis muscle does not add clinically obvious morbidity to the patient but has definite benefit as observed in this study. We advocate double fascicular nerve transfer for elbow flexion in upper brachial plexus injuries if the median and ulnar nerve functions are normal.

Necrotizing soft tissue infection of the upper extremities in patients with diabetes mellitus in a tertiary care center-a retrospective study.

BACKGROUND: Necrotizing soft tissue infection (NSTI) of the upper extremities is a rare, but potentially life-threatening infection in patients with type 2 diabetes mellitus (T2DM). We analyzed the clinical characteristics and the outcome of NSTI of upper extremities in these patients. METHODS: This was a retrospective study analyzing the clinical characteristics and the outcomes of 33 T2DM patients with NSTI of upper extremities, who were treated in the department of hand surgery between January 2011 and December 2017. RESULTS: Predisposing factors for NSTI were recognized in 16 (48.5%) patients. Eleven (33.3)% patients had septic shock while ten (30.3%) had acute renal insufficiency at the time of presentation, of which six required dialysis. The mean glycosylated hemoglobin was 9.6(±2.6)% and the random plasma glucose at admission was 271(±96) mg/dl. Monomicrobial infection was seen in 16(49%) patients and polymicrobial infection in 9(27%) patients. Gram-positive causation was found in 25(66%) patients. Twelve (36.4%) patients required amputation, six (18.2%) of which were major. Death occurred in more than one-fifth (21.2%) of the patients during treatment. CONCLUSION: Necrotizing soft tissue infection of the upper extremities in T2DM is associated with increased risk of severe infection, amputation and mortality.

The Efficiency of WhatsApp in Teleconsultation of Finger Vascularity in Hand Surgery.

Background Teleconsultation over the smartphone is now widely used in modern medicine in the management of burns, flap cover, upper extremity trauma, and in the assessment of the feasibility of reimplantation in amputated fingers. The development of the WhatsApp application has enhanced the smartphone's efficiency remarkably to transmit images in clinical and academic settings with its failsafe and encrypted technology. In hand surgery, a teleconsultation technology must communicate details of finger vascularity effectively. However, there is a paucity of evidence on the functionality of these modern teleconsultation technologies in Hand Surgery. Here, the authors have estimated the efficiency of the WhatsApp teleconsultation in the assessment of finger vascularity. Materials and Methods In two phases, the authors transmitted clinical photographs of vascular and avascular fingers to experienced hand surgeons over the WhatsApp and asked them to assess the finger vascularity. The efficiency of the WhatsApp teleconsultation in assessing the details of finger vascularity was estimated from their responses. Results Despite 81.06% of the hand surgeons rating the vascular fingers on the transmitted photographs correctly, only 44.95% detected the avascular digits accurately; that is, 55.05% of the surgeons failed to diagnose the avascularity of fingers. This suggests serious implications in a clinical setting. The intra- and the inter-rater reliability values were 0.232 and 0.6086 (with 95% confidence interval), respectively, which indicated poor reliability of the WhatsApp teleconsultation regarding the assessment of finger vascularity. Conclusion The authors, therefore, conclude that WhatsApp is inadequate in teleconsultation given the value of vascularity details of the fingers in making a diagnosis in hand surgery.

Multiple Stab Incisions and Evacuation Technique for Contrast Extravasation of the Hand and Forearm.

Extravasation of intravenous contrast agents in the hand and forearm during computed tomography scanning is rising with the use of automated pressure injectors. The main concern in such a situation is progression to acute compartment syndrome and necrosis of the overlying skin. Management has been mainly nonsurgical comprising upper limb elevation and orthosis, with surgical techniques such as liposuction and saline evacuation mainly used for large volume (>50 mL) extravasations. We have developed a technique of multiple stab incisions and drainage for the treatment of contrast extravasations.

Synovial sarcoma of the brachial plexus - a rare tumor in a rare area: a case report.

BACKGROUND: Synovial cell sarcomas are usually seen in a juxta-articular location. However, they occur rarely in the head and neck region. CASE PRESENTATION: We report a rare case of brachial plexus synovial sarcoma in a 24-year old South Asian man treated successfully with surgical excision followed by radiotherapy. CONCLUSIONS: Synovial sarcoma arising from the brachial plexus is rare. The treatment is multimodal with complete excision (often challenging owing to the proximity of the neurovascular structures) and adjuvant therapy.

The zonal pattern of arterial supply to the brachial plexus and its clinical significance.

PURPOSE: To provide the anatomical basis of blood supply of brachial plexus for the clinical microsurgical treatment of brachial plexus injury. METHODS: Thirteen adult anticorrosive cadaveric specimens (8 males, 5 females) were dissected in this study. 3 fresh cases (2 males, 1 female) were used to observe the zonal pattern of arteries supplying brachial plexus, and 10 cases (6 males, 4 females) were used to observe the source and distribution of the brachial plexus arteries under microscope. RESULTS: The brachial plexus is supplied by branches of the subclavian-axillary axis (SAA), and these branches anastomose each other. According to distribution feature, blood supply of the brachial plexus could be divided into three zones. The first zone was from the nerve roots of intervertebral foramina to its proximal trunks, which was supplied by the vertebral artery and the deep cervical artery. The second zone was from the distal nerve trunks of the brachial plexus, encompassing the divisions to its proximal cords, which was supplied by direct branches of the subclavian artery or by branches originating from the dorsal scapular artery. The third zone was from the distal portion of the cords to terminal branches of the brachial plexus, which was supplied by direct branches of the axillary artery. CONCLUSIONS: The zonal pattern of arterial supply to the brachial plexus is a systematic and comprehensive modality to improve anatomical basis for the clinical microsurgical treatment for brachial plexus injury.

Management of Hemophilic Cysts and Pseudotumors of the Hand in Bleeding Disorders: A Case Series.

PURPOSE: Hemophilic cysts and pseudotumors (HCPTs) of the hand are rare and are secondary to bleeding disorders such as hemophilia A and B. This is a report of our experience in the management of this rare condition. PATIENTS AND METHODS: Seven male patients with hemophilia A presenting with progressive swelling of the hand were treated between 2004 and 2013 at a tertiary referral hospital. All patients had clotting factor replacement based on our previously reported protocol. The age of the patients ranged from 3 to 49 years (median age, 19 years). RESULTS: Four patients had soft tissue hemophilic cysts and 3 had bony hemophilic pseudotumors. Two patients had traumatic pseudoaneurysm of the ulnar artery in addition to the cysts. The soft tissue cysts required surgical excision in 3 patients under factor cover as per the protocol. The bony lesions were initially managed nonsurgically by factor replacement, but 2 patients failed to respond and required amputation of the fingers. The ulnar artery aneurysm was excised and artery ligated in 1 patient and the artery was vein grafted owing to poor hand perfusion in 1. CONCLUSIONS: Based on our observations in the management of HCPTs of the hand and the existing literature, we conclude that the soft tissue cysts require surgical excision along with factor replacement and distal bony lesions smaller than 3 cm respond to factor replacement. Larger bony lesions require surgical treatment. Treatment of hemophilic cysts and pseudotumors should be undertaken only in centers with a major hematology backup. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

The clinical and microbiological profile of the diabetic hand: A retrospective study from South India.

BACKGROUND: Pyogenic Infections of the hand in diabetes are largely a tropical entity and published material in the area are rather meagre. PATIENTS AND METHODS: This is a retrospective study on the pattern of hand infections and involves the microbiological profile of 39 cases of diabetes hand-related infections admitted to the hospital between the years 2004 and 2010. RESULTS: This study included 39 patients, among whom 23 (59%) had necrotizing fasciitis (NF), and 16 (9-abscess and 7-tenosynovitis) had nonnecrotizing infection. Among 25 culture positive patients, polymicrobial infections were isolated in 13 (52%) patients, a single organism was isolated in 9 (36%) and 3 (12%) had sterile cultures. Out of the 41 different bacterial isolates, 51.12% were Gram-negative and 48.78% were Gram-positive. Patients with NF had a higher mean glycated hemoglobin (10.83 ± 2.59 vs. 8.64 ± 1.8%, P = 0.020), when compared to the nonnecrotizing group. Patients with NF also had more polymicrobial infections (P = 0.017), and a longer duration of hospitalization when compared to patients without NF (21.8 ± 9.96 vs. 12.7 ± 14.5 days, P = 0.021). Seven (17.94%) patients required amputation of the affected digits of which six (15.38%) had NF. CONCLUSION: Patients with poor glycemic control, polymicrobial infection, delay in presentation, and a prior surgical intervention at another medical center was associated with more severe necrotizing infections. The duration of hospitalization and amputation rates was greater among patients with NF.

En bloc Excision and Matched Metatarsal Transfer for Expansive Benign Osteolytic Lesions of the Metacarpal.

PURPOSE: Benign aggressive expansile osteolytic lesions such as giant cell tumors and aneurysmal bone cysts involving the metacarpal head pose problems in management. Unacceptably high rates of recurrence are reported after curettage and bone grafting. An en bloc excision of such tumors ideally requires osteoarticular replacement of the excised metacarpal heads to retain mobility and function. We used nonvascularized metatarsal head and shaft harvested from the foot to replace the metacarpal defect after en bloc resection to retain movement and function of metacarpophalangeal (MCP) joint. The purpose of this study was to evaluate results of patients who underwent this procedure. METHOD: Nine patients treated with metatarsal transfer for osteoarticular reconstruction after en bloc excision of benign aggressive osteolytic metacarpal head tumors were reviewed retrospectively. The postoperative evaluation included examination of radiographs, joint mobility, and patient rated return of function using the Michigan Hand Questionnaire. RESULTS: Of 9 patients, 4 had aneurysmal bone cyst, 4 had giant cell tumor, and 1 an atypical cartilaginous lesion. Patients were aged between 14 and 45 years at the time of surgery. After an average of 44 months of follow-up (minimum follow-up of 24 months; range, 24-104 months), all patients had good postoperative function, satisfactory results, and no recurrence of tumor. The mean active range of motion at the reconstructed MCP joint was 75° (range, 0° to 90°). The Michigan Hand Questionnaire score averaged 80 (range, 69-92). No patient complained of donor site morbidity. One patient underwent MCP joint fusion after a pin tract infection. CONCLUSIONS: Use of a matched metatarsal graft for osteoarticular reconstruction after en bloc excision of benign aggressive tumors involving the metacarpal head is a potential treatment option. In this limited series, consistent results with respect to functional range of motion at MCP joint, and without recurrence of tumor or notable donor site morbidity were obtained. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Open proximal phalangeal shaft fractures of the hand treated by theta fixation.

BACKGROUND: Many implants and techniques are used for the treatment of open phalangeal fractures with varying grades of stability. The ubiquitous and simple Kirschner (K) wiring does not provide adequate stability to allow early mobilization of fingers. Lister described a combination of coronal interosseous wire and oblique K-wire technique for phalangeal fracture fixation with a stable construct that allowed early mobilization. Due to the fancied resemblance of this construct to the Greek alphabet θ (theta), we have referred to this as the theta fixation. MATERIALS AND METHODS: Ten patients with open proximal phalangeal shaft (transverse) fractures were treated with theta fixation between January and June 2010. Outcome was analysed in terms of stability, early mobilization, fracture healing and function of hand. They were graded according to the Belsky score. RESULTS: 90% patients were graded excellent and 10% good, with none having fair or poor results. All fractures allowed the mobilization at a mean of 2.9 days and all healed at an average of 6.1 weeks. No loss of stability was seen on followup X-rays. All patients returned to their old profession. CONCLUSION: The theta fixation technique is a safe, simple and effective method for open transverse phalangeal fractures with results comparable to other techniques. This method gives superior fracture stability to allow early mobilization of joints and thus early return of function. It is also a cost effective way of management for the developing world.

Tuberculous botryomycosis of the hand: case report.

We report a case of a 17-year-old boy who presented with botryoid lesions of both hands. These lesions resembled those of cutaneous botryomycosis. We treated him with surgical debridement and were unable to isolate infective agents initially. However, 3 months later Mycobacterium tuberculosis grew in the culture. One year of antituberculous drug therapy resulted in healing of the lesions.