Similar effectiveness of the open versus endoscopic technique for carpal tunnel syndrome: a prospective randomized trial.

This prospective randomized study aims at evaluating the electrophysiological results of endoscopic and open carpal ligament release in patients with carpal tunnel syndrome. Included in the study were 41 patients diagnosed with carpal tunnel syndrome (21 hands in the endoscopic group and 20 hands in the open group). The Boston questionnaire was administered preoperatively and postoperatively to the patients, and their functional capacities and symptom severities were recorded. Physical examination was carried out preoperatively and in the postoperative sixth month. Demographic data and preoperative Boston symptomatic and functional scores were similar between both groups. A significant improvement was obtained in the Boston symptomatic and functional scores of both groups, but no significant difference was found between the groups in terms of improvement in the symptomatic and the functional scores. A significant shortening in median nerve motor distal latency and an increase in the velocity of sensory conductions were determined in both groups in the postoperative electromyography, but no difference was found between them in terms of improvement in the electromyography values. It was shown both clinically and electrophysiologically that endoscopic carpal tunnel surgery was as effective as open surgery as a treatment method for carpal tunnel syndrome.

A comparison of the functional and radiological results of Paris plaster cast and ulnar gutter splint in the conservative treatment of fractures of the fifth metacarpal.

AIM: In the treatment protocol of fractures of the fifth metacarpal, closed reduction and immobilization is generally recommended. This study aimed to compare the radiological and functional results of short-arm plaster cast and a forearm U-splint. PATIENTS AND METHODS: Between January 2011 and June 2012, the study comprised a total of 122 cases with 64 (52.4%) in the cast group and 58 (47.6%) in the splint group. The cases were 92 (75.4%) males and 30 (24.6%) females with a mean age of 30.56 ± 12.27 years (range 10-66 years). Two groups were formed according to the surgical treatment plans of the two surgeons who were to follow up the patients. RESULTS: No statistically significant difference was found between the groups in terms of age, duration of the cast or splint and follow-up period (p > 0.05). The grip strength of Group A was determined as 90.38 ± 1.77% of the healthy side and Group B as 90.58 ± 1.65%. No statistically significant difference was seen between the groups in respect of grip strength (p > 0.05). The degree of dorsal angulation pre-application, post-application and after removal of the groups showed no statistically significant difference between the groups (p > 0.05). CONCLUSION: No superiority was seen in the clinical and radiological results of the two different treatment protocols applied to fractures of the fifth metacarpal. However, when the complications created by a plaster cast and pressure wounds are taken into consideration, the application of a short-arm U-splint can be said to be a better option.

Combining Salter-Harris and Dias-Tachdjian could be better at determining the prognosis of distal tibial physeal fractures.

OBJECTIVES: The aim of this study is determining the factors that affect prognosis of distal tibial physeal fractures (DTPF) and analyzing whether Salter-Harris (SH) or Dias-Tachdjian (DT) classification is more predictive for outcomes. METHODS: Patients treated for DTPF were retrospectively analyzed. Fracture patterns were classified according to SH and DT. Treatment methods and fracture characteristics were noted. Distal tibial angles and joint irregularities were analyzed on patient's final ankle radiographs followed by American Orthopedic Foot and Ankle Score questionnaire. RESULTS: 75 patients followed-up between 6 and 96 months meeting the inclusion criteria were evaluated. Joint irregularity was observed in 41.3% and partial premature physeal closure (PPC) in 34.7% of the patients. Lateral distal tibial angle (LDTA) and talocrural angle related deformity were detected in 20% and 14.7% of the patients, respectively. Partial PPC and joint irregularities that have been developed in pronation-eversion-external rotation and supination-inversion injuries (SH type 3, 4) were 62% and 50%, and 42% and 75%, respectively. On follow-ups of supination-external rotation injuries (SH type 2) joint irregularity has never been observed. Following supination-external rotation and supination-plantar flexion injuries, a low rate of partial PPC have been developed; LDTA related deformity was revealed at a high rate of 39.1% after supination-inversion injuries. There weren't any differences observed between the initial displacement, residual displacement or surgical technique and PPC, joint irregularity and angular deformities. Patients treated by ORIF technique had lower AOFAS scores than patients treated by other surgical techniques. CONCLUSIONS: In this study it was revealed that SH classification system is not sufficient alone to determine the prognosis of DTPF, the injury mechanisms causing SH types might be also significant in prediction of the prognosis of DTPF.

Anxiety and trauma perception and quality of life in patients who have undergone replantation.

The difficulty in keeping an amputated limb biologically alive is overcome day by day thanks to the successful replantation procedures applied in the early period. However, the reflections of this biological success on patients in functional and psychological terms may not be pleasing all the time. In our study, we aimed to evaluate the perceptual responses of patients to trauma after replantation and their possible effects on clinical results. We conducted a retrospective study of 43 patients who underwent replantation. The average age was 32.4 years and the average follow-up period was 38.6 months. When the results of the Short Form-36 (SF-36), Beck's Depression Inventory, and the assessment scores of the disabilities of the arm, shoulder, and hand survey were evaluated, there was a negative correlation between the patients diagnosed with depression and all SF-36 subunits. A negative correlation between the severity of trauma and the average physical and mental values included in the SF-36 evaluations was observed (R = 0.48, R = 0.51, respectively),. These results revealed that the psychology of the patient was one of the important factors that could not be ignored in the success of replantation.

Mid-term clinical and radiographic outcomes of perilunate injuries treated with open reduction and internal fixation.

OBJECTIVE: This study aimed to present the mid-term clinical and radiographic outcomes of patients with perilunate injuries treated with open reduction and internal fixation (ORIF). METHODS: Patients who underwent ORIF due to perilunate injuries from 2004 to 2015 were retrospectively reviewed. Surgery was mostly performed using a standard dorsal approach. Each injury was graded as per Mayfield staging. At the final follow-up, pain intensity was evaluated using a 10-cm visual analog scale (VAS). Wrist and elbow range of motion, handgrip and pinch strength, Modified Mayo Wrist Scores, and the disabilities of the arm, shoulder, and hand (DASH) scores were measured. On plain radiographic examination, the scapholunate (SL) angle, SL interval, carpal height, and continuity of Gilula arcs were evaluated. The presence of arthritis was also assessed using the Herzberg classification. RESULTS: In total, 26 male patients (27 wrists) who met the inclusion criteria were included in the study. The mean age was 40 years (range: 20-58); the mean follow-up was 45 months (range: 16-96). Most of the injuries were fracture-dislocations (n=20; 71.4%). According to Mayfield staging, 7 wrists were grade 3, and 20 wrists were grade 4. According to Herzberg staging, 11 (40.7%) patients were stage 2a. The mean VAS was 2.3 (range: 0-5) at rest and 3.3 (range: 0-7) during activity. The mean wrist flexion and extension were 50° (range: 21-80°; 73.5% of the unaffected side) and 45.1° (range: 20-74°; 70.9% of the unaffected side), respectively. The mean radial and ulnar deviation were 14.6° (range: 6-25°; 63.6% of the unaffected side) and 22.3° (range: 5-40°; 64.7% of the unaffected side), respectively. Grip and pinch strength were 57.6 kg (range: 15-106; 65.5% of the unaffected side) and 18.6 kg (range: 8-28; 78.2% of the unaffected side), respectively. The mean Mayo score was 63.3 (range: 20-90), and the DASH score was 24.1±25.2. The mean SL angle was 61.6° (range: 40-83). There was 1 wrist with a pathological SL interval, 11 wrists with dorsal intercalated segmental instability, and 3 wrists with fractures of the Gilula arcs. The mean carpal height was within the normal range. CONCLUSION: In the treatment of perilunate injuries, satisfactory clinical and radiographic outcomes can be expected from ORIF at mid-term follow-up. LEVEL OF EVIDENCE: Level IV, Therapeutic Study.

Incidence of Venous Thromboembolism After Achilles Tendon Surgery in Patients Receiving Thromboprophlaxis.

BACKGROUND: Surgical or nonsurgical treatment of an Achilles tendon rupture includes a period of immobilization that is a well-documented risk factor for deep venous thrombosis (DVT). The DVT is a source of morbidity in orthopedic surgery because it can progress to pulmonary embolism. The aim of this study was to investigate the incidence of DVT and pulmonary embolism after surgical treatment of an Achilles tendon rupture. METHODS: A retrospective analysis was made of patients who underwent surgical treatment of Achilles tendon rupture between January 1, 2006, and November 30, 2014. Patient data were collected from the hospital medical record system. RESULTS: Of 238 patients with a mean age of 39 years (range, 18-66 years), 18 (7.6%) were diagnosed as having symptomatic DVT. The average body mass index of the patients with DVT was 31.8 (range, 24-33). Of the patients with DVT, 11 were older than 40 years and two-thirds had a body mass index of 30 or greater. Pulmonary embolism was diagnosed in four patients (1.7%), none of whom had DVT symptoms. CONCLUSIONS: Venous thrombosis continues to be a major cause of morbidity and mortality in postoperative patients. Limited data are available for the use of thromboprophylaxis in foot and ankle surgery. In light of the literature review and results of this study, we suggest that routine thromboembolism prophylaxis should be considered for patients with Achilles tendon rupture.

A cadaveric study of ulnar nerve innervation of the medial head of triceps brachii.

The presence of a separately innervated muscle unit of the triceps may have possible surgical importance and can be used for motor reconstructions. The ulnar nerve is closely situated to the triceps muscle and rarely examined above the elbow. The aim of this cadaveric study was to explore a possible contribution of the ulnar nerve to motor innervation of the medial head of the triceps. We dissected 18 limbs from axillae to midforearm. The path of the ulnar nerve was followed, and examination was conducted of attachments to the triceps. Gross photographs were taken and samples histologically stained. Seventeen limbs had ulnar nerve branches proximal to the epicondyles that inserted on the medial head. Eleven of these branches were from the ulnar nerve trunk. The other six were nerve branches from the ulnar collateral branch of the radial nerve. The ulnar nerve and the ulnar collateral branch of the radial nerve are previously unrecognized sources of innervation of the medial head of the triceps brachii. These motor branches must be carefully preserved during the medial surgical approach above the elbow. The ulnar innervated part of the medial head of the triceps muscle may be used like an independent motor unit.

Does bone impaction technique reduce tunnel enlargement in ACL reconstruction?

The aim of this study was to investigate effects of bone impaction technique on tunnel enlargement after ACL reconstruction at a minimum 2 years follow-up. Two groups of patients who had been operated upon with the same arthroscopic technique with the exception of tibial tunnel constitution were compared. Twenty-one patients of group A (drilling to 6 mm followed enlargement to 8-9 mm by using dilators) and 23 patients of group B (directly drilling to the size of the graft) were evaluated clinically and radiographically based on multislice computerised tomography (MSCT) retrospectively. At follow-up, there was no statistical difference between tunnel diameters between two groups at the femoral site, but significant difference at the tibial site (p = 0.00192 for coronal; p = 0.0171 for sagittal diameter). Both groups were comparable according pre- and postoperative Lysholm and IKDC scores (p < 0.5 Mann-Whitney U test). Compacted tunnel walls may resist enlargement, suggesting this technique resulted in better tunnel diameter values especially with intratunnel fixation.

Preclinical symptoms of the diabetic foot.

BACKGROUND: The diabetic foot is one of the main complications of diabetes mellitus, with a high risk of minor or major amputation. The preclinical foot lesions of patients without foot complaints were compared with healthy controls and analyzed. METHODS: This study was conducted with 89 diabetic patients from an endocrinology clinic and 35 nondiabetic control patients. The patients were asked about the presence, types, and durations of pedal complaints; acquired and congenital foot deformities; and atrophy. Patient gaits were inspected for any swelling; skin and nail changes were also recorded. Ranges of articular motion, deformities, crepitations, and any painful perceptions were noted. RESULTS: The differences between groups were significant for sensorial defects, joint changes of the foot, nail abnormalities, and neuropathic changes. CONCLUSIONS: Every patient with an established diagnosis of diabetes can be considered a potential sufferer of diabetic foot for whom medical therapy and foot protection programs are indicated.

Arthroscopic excision of an ununited ossicle due to Osgood-Schlatter disease.

Surgical excision of the ossicles has been suggested for unresolved sequelae of Osgood-Schlatter disease in adults resistant to conservative measures. A 24-year-old, male semiprofessional soccer player had anterior knee pain during sports activity and climbing stairs that had been treated conservatively for 2 years. On physical examination, there was a permanent tibial tubercle with pain. On radiographic examination, an ununited ossicle was seen beneath the patellar tendon. Arthroscopy was performed through the standard low anterolateral and anteromedial portals close to the patellar tendon. Soft tissue at the retropatellar surface and the inflamed infrapatellar fat pad beneath the patellar tendon were debrided with a motorized shaver. Localization of the ununited ossicle was performed by use of an image intensifier. The ossicle was separated from the surrounding soft tissue with a motorized shaver and removed by use of a grasper. After excision of the ossicle, the inflamed surface of the retropatellar tendon was also debrided. The contouring of the irregular surface of the tibial tubercle was performed by use of a motorized bur. After 6 weeks, the patient returned to sports activities without any restrictions. This study showed that all of the described procedures might be done arthroscopically and sports activity may be allowed earlier.

Innervation of the elbow joint and surgical perspectives of denervation: a cadaveric anatomic study.

PURPOSE: Peripheral articular denervation has been proposed as an alternative treatment for degenerative arthritis. It shows particular promise in the elbow because the joint is non-weight bearing and easily exposed. Accurate knowledge of peripheral neuroanatomy is required for future denervation surgeries, yet very few studies focus on the articular branches of the ulnar, median, and radial nerves that provide elbow capsule innervation. METHODS: Twenty-three upper limbs from skeletally mature fresh-frozen cadavers were used for dissection of the ulnar, median, and radial nerves. The presence, number, location, and diameter of articular branches to the elbow capsule were recorded. RESULTS: The ulnar nerve typically supplied 1 to 2 large branches to the elbow capsule (range, 0-4). In the 3 specimens with a greater number, a thinner diameter was noted (<1 mm compared with 1.2 mm). The median nerve contributed an average of 1.3 branches (range, 0-4) and showed an inverse ratio with the ulnar nerve contribution. The posterior interosseous nerve contributed a range of 0 to 4 branches, arising at 5 mm to 2 mm after bifurcation of the radial nerve. CONCLUSIONS: Most previous upper-extremity nerve studies have failed to fully characterize the contributions of all 3 major nerves to capsular innervation. We have thoroughly documented the articular branching patterns of all 3 major nerves and show that all 3 may contribute branches to the capsule.

Osteochondritis dissecans of the medial femoral condyle associated with malformation of the menisci.

Osteochondritis dissecans is a form of osteochondrosis limited to the articular epiphysis and the relationship of osteochondritis dissecans and discoid lateral meniscus has been clearly identified. This article presents a 10-year-old boy with osteochondritis dissecans of the medial femoral condyle associated with hypoplastic medial and partial deficient lateral menisci. The patient presented with activity-related pain and intermittent swellings of his left knee for 2 months without any evidence of significant knee trauma. Magnetic resonance imaging revealed anomalous medial meniscus mimicking displaced bucket-handle tear and partially deficient lateral meniscus with osteochondritis dissecans at the lateral aspect of medial femoral condyle without any significant bone loss with a non-dislocated fragment. Arthroscopy of the knee revealed an incomplete separated osteochondral flap with partial discontinuity that was unstable on probing on the lateral aspect of the medial femoral condyle. The medial meniscus was hypoplastic without a body and only the meniscal rim could be seen. The lateral meniscus had an anomalous vertical insertion of the posterior horn, normal body, but an absent anterior horn. The anterior cruciate ligament was intact, but looked like a peacock's tail. Arthroscopic fixation of the chondral lesion was performed. At 30-months follow-up, the boy had no limitation in his daily and sports activity. The present case is the first description of congenital anomaly of the both menisci and osteochondritis dissecans together. Meniscal or ligamentous anomalies of the knee may be associated with osteochondritis dissecans.

Fat-covered vein graft.

Vein graft is widely used in peripheral vascular surgery. Many free flaps and replantation failures are the result of technical problems in performing the anastomoses. A remarkable number of these technical errors are caused by tension or improper placement of the surgical union. Use of a vein graft may prevent tensioning and give us a more accessible repair site. However, the use of a graft not only doubles the repair side, but may also increase the risk of circulatory disturbance. Many technical, mechanical, and histological factors were cited as factors in the formation of thrombus. The use of a vein graft with a fatty tissue cover may prevent many of the potential risk factors.

Groin flap immobilization by axillary brachial plexus block anesthesia.

Pedicled groin flaps are still widely used as soft tissue coverage in hand surgery. Various methods have been described for immobilization of flaps, such as Ace wraps, plaster, and external fixators. The hands of 5 females and 12 males, totaling 17 patients, with severe injury were reconstructed with groin flaps between 2001 and 2005. Patients were operated on under a combination of axillary block and general anesthesia. Motor block effect of axillary anesthesia was used for immobilization of the upper extremities at groin flap coverage. A combination of axillary brachial plexus block plus general anesthesia had advantages in the prevention of pedicle tension or torsion during the initial recovery period. Reduction of general anesthesia time and improvement of postoperative pain were also observed. Axillary brachial plexus block and general anesthesia are a preferred combination for patients undergoing groin flap operations.

[Aseptic drainage associated with polyglactine sutures used for repair of Achilles tendon ruptures]. / Asil tendonu tamirlerinde poliglaktinin yol açtigi aseptik akintilar.

The aim of surgical treatment of Achilles tendon ruptures is to restore stability of the tendon. Various suture techniques and materials can be used for this purpose. Suture materials may be polyfilament or monofilament, absorbable or nonabsorbable. We presented four patients who developed severe chronic discharges associated with thick polyglactine (Vicryl) used during open repair of acute Achilles tendon ruptures. Surgical removal of suture materials and debridement resulted in complete improvement without any complications. The use of thick suture materials and large knots should be avoided in the repair of Achilles tendon ruptures. Polyfilament and absorbable sutures may pose problems due to their tendency to cause bacterial colonization and tissue rejection.

[The contribution of locked screw-plate fixation with varying angle configurations to stability of osteoporotic fractures: an experimental study]. / Osteoporotik kemikte kilitli plak ve açili vida kullaniminin stabilizasyonun dayanikliligina katkisi: Deneysel çalisma.

OBJECTIVES: This experimental study was designed to find new ways of improving stabilization of fractures in osteoporotic elderly patients through alterations made in the configuration and geometry of locked screw-plate fixation used in the conventional plate technique. METHODS: Four screw configurations with varying angulations were used for plate-bone construction. Forty iron plates of high quality (100x35x3 mm) were divided into four groups and two screw holes, 3 mm in diameter, were drilled on each plate at a distance of 15 mm. In group A, the holes were drilled so that the screws would be vertically sent to the bone interface. In the remaining groups, the holes were drilled for convergent (group B, 15 degrees ) and divergent (group C, 15 degrees ; group D, 30 degrees ) screw orientation. Screw-plate fixation was tested in a modified osteoporotic bone (Osteoporotic Generic Bone, Synbone) on an Instron materials testing system with an axial pullout force of 0.1 mm/sec. Failure loads were read from load-displacement curves and the type of failure was noted. RESULTS: Screws placed in divergent orientations showed the highest axial pull-out strength (group C, 83.3 N/mm; group D, 80.8 N/mm), followed by convergent placement (72 N/mm) and vertical placement (66.7 N/mm). The type of failure was breakage of the bone sample in divergent configurations, and screw pull-out in convergent and vertical configurations. CONCLUSION: Divergent constructs may be a promising alternative to conventional screw placement in treating osteoporotic fractures.

Lack of experience is a significant factor in the missed diagnosis of perilunate fracture dislocation or isolated dislocation.

OBJECTIVE: The aim of this study was to analyze the risk factors contributing to the misdiagnosis of perilunate injuries. METHODS: The study included patients who had perilunate dislocation or fracture dislocation correctly or incorrectly diagnosed on initial examination between 2008 and 2014. Data related to the length of time until correct diagnosis of the perilunate injury; cause of injury; presence of associated fractures, polytrauma or concomitant trauma in the ipsilateral upper extremity; time between injury and first presentation; first treatment applied; presence of ligamentous perilunar injuries only or fracture and dislocation; inadequate radiographic assessment; and experience of the physicians were recorded and analyzed. RESULTS: A total of 44 wrists were included in the study. Of those, 10 (22.7%) wrists (mean patient age: 44.4 years [28 ± 58 years]) with perilunate injuries were misdiagnosed in the initial evaluation. All of the risk factors were found to be similar between the group of patients with correct initial diagnosis and missed diagnosis group, except for the experience of the orthopedic surgeon assessing the injury (p = 0.0001). Of the surgeons who missed the diagnosis, 70% reported that it was their first encounter with a perilunate injury. CONCLUSION: The results of this study indicated that lack of experience was the most important factor in the misdiagnosis of perilunate fracture dislocation or isolated dislocation. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Surgical treatment of type III acromioclavicular dislocation: Bosworth technique versus hook plating.

OBJECTIVE: In this study, it was compared the clinical results of the Bosworth technique and hook plating in acromioclavicular (AC) dislocations. METHODS: 44 patients are retrospectively evaluated in this study whom diagnosed as type III AC dislocations and treated by two different surgical methods in two different clinics. The patients were 30 males and 14 females with a mean age of 44 years (range, 18-80 years). The patients were divided into 2 groups according to the applied surgical technique. Group I comprised 25 patients to whom coracoclavicular fixation was applied by using the Bosworth technique. Group II comprised 19 patients to whom acromioclavicular fixation was applied by using hook plate. All patients are evaulated by The University of California at Los Angeles Shoulder Score (UCLA) and The disabilities of the arm, shoulder and hand (DASH) scoring system. RESULTS: The mean follow-up period was 23 months (range, 12-42 months). A statistically significant diffference was determined between the surgical groups in respect of the modified UCLA scale (p=0.012) and Quick DASH score (p=0.008). Hook plating group had better clinical results according to Bosworth group in terms of both UCLA and DASH score. A statistically highly significant negative correlation was determined between the UCLA and DASH scores (r=0.677, p=0.000). CONCLUSION: Although hook plating had better clinic outcomes compared to Bosworth technique, there is not seen difference between two groups in terms of the time of return to work. Treatment of the AC dislocation should perform early reconstruction for better reduction, fewer complications and higher levels of patient satisfaction.

[The effectiveness of dorsiflexion night splint added to conservative treatment for plantar fasciitis]. / Plantar fasiitis için konservatif tedaviye eklenen dorsifleksiyon gece atelinin etkinligi.

OBJECTIVES: We evaluated the effectiveness and results of night splint applications for the treatment of plantar fasciitis. METHODS: The study included 44 patients (53 feet) with plantar fasciitis. The mean symptom duration was 7.2+/-5.9 weeks (range 1 to 24 weeks). Calcaneal spurs were detected in 12 feet. All the patients received classic conservative treatment and all were recommended to use a night splint that kept the ankle in 5-degree of dorsiflexion for eight weeks. Twenty-five patients (14 females, 11 males; 31 feet) did not accept to use a night splint, whereas 19 patients (12 females, 7 males; 22 feet) did. Evaluations were made with the AOFAS ankle-hindfoot rating scale and a visual analog scale (VAS) before and after two months of treatment. The mean follow-up periods were 33.8 months (range 12 to 54 months) and 32.7 months (range 13 to 53 months) for those who completed treatment with and without the use of a night splint, respectively. RESULTS: Although there were no significant differences between the two groups with regard to the initial AOFAS and VAS scores, patients using a night splint exhibited significantly higher improvements in both scores at the end of the second month (p=0.01 and p=0.001, respectively). Heel pain recurred in three feet (13.6%) and in nine feet (29%) with and without night splint applications, respectively. Overall, the presence of a calcaneal spur, bilateral involvement, and body mass index were not correlated with patient satisfaction and recurrences. There was no correlation between the presence of a calcaneal spur and body mass index. However, symptom duration till treatment showed a significant correlation with recurrences (r=0.326, p=0.031). CONCLUSION: Patients without previous treatments for plantar fasciitis obtain significant relief of heel pain in the short term with the use of a night splint incorporated into conservative methods; however, this application does not have a significant effect on prevention of recurrences after a two-year follow-up.

[Dissemination pathways in high-pressure injection injuries of the hand: an experimental animal model]. / Elin yüksek basinçli enjeksiyon yaralanmalarinda dagilim yollari: Deneysel hayvan modeli.

OBJECTIVES: High-pressure injection injuries of the hand may compromise the function of the hand or even result in amputations. Based on our clinical observations, we aimed to demonstrate neurovascular dissemination in an animal model. METHODS: Ten adult New Zealand rabbits with a mean weight of 200 g were used. Under xylazine-ketamine anesthesia and using a triple connection system, the rabbits were injected one milliliter of black Indian ink in the third finger tip of the upper limbs at 4 atmospheric pressure. The rabbits were sacrificed via intracardiac injections for transhumeral amputation of all the upper limbs. All amputations were fixed in 10% formalin, decalcified, and specimens obtained from fingers and distal and proximal regions of the wrist were stained with hematoxylin and eosin for histopathologic examination. RESULTS: Transverse sections of the third finger showed subcutaneous deposition of Indian ink particularly in the pulp in all the specimens. In addition, all specimens from the distal wrist showed penetration into fascia, tendon sheaths, and neurovascular bundles of the third finger. CONCLUSION: Our results suggest that, in addition to the tissues mentioned in the literature, neurovascular bundles are primarily and seriously affected by high-pressure injection injuries of the hand.