Forequarter Replantation.

Traumatic forequarter amputations are rare injuries in which the arm, clavicle, scapula, and proximal shoulder muscles are avulsed from the body. Historically, forequarter amputation has been treated with hemorrhage control, wound debridement, and soft tissue coverage. To our knowledge, successful forequarter replantation has not been previously reported. We present a rare case of forequarter amputation treated successfully with replantation. At the 4.5-year follow-up after replantation, the patient had antigravity elbow flexion, modest shoulder elevation, modest extrinsic finger function, and crude sensation. We discuss relevant technical considerations that indicate that, despite challenges, forequarter replantation can be achieved with success.

Anatomic Variations of the Musculocutaneous Nerve and Clinical Implications for Restoration of Elbow Flexion.

PURPOSE: The restoration of elbow flexion is of primary importance in the management of patients with brachial plexus injuries. Superior functional outcomes via fascicle transfer from the ulnar and median nerves have resulted in this transfer being considered the mainstay of recovery of elbow flexion in patients with intact C8 and T1 function. An understanding of the anatomy of the musculocutaneous nerve (MCN) and its branching pattern is key while performing these transfers. METHODS: A prospective cohort study was conducted in patients who underwent nerve transfer for the restoration of elbow flexion following a traumatic brachial plexus injury. The anatomic course and branching pattern of the MCN were recorded in eligible cases, both as a line diagram and using intraoperative photographs. RESULTS: One hundred fifty patients underwent nerve transfer for the restoration of elbow flexion following an injury to the brachial plexus. The MCN in 138 patients (92%) was found to pierce the coracobrachialis muscle before emerging lateral to it. One hundred thirty-four patients (89.3%) demonstrated the "classical" anatomy. One hundred fifteen patients (76.6%) had a single primary branch to the biceps, whereas 25 patients (16.6%) demonstrated a discrete motor branch to each head. One hundred thirty-three dissections (88.6%) revealed a single muscular branch to the brachialis arising posteromedially from the MCN, distal to the origin of the branch to the biceps brachii. Notable unreported variations, such as the MCN penetrating the biceps as it descended, multiple brachialis branches, and trifurcation of divisions of the MCN, were documented. CONCLUSIONS: Variations in MCN anatomy are quite common, and even unreported variations can be encountered. CLINICAL RELEVANCE: Exploration of the MCN and its branches for nerve transfers requires knowledge of these anatomic variations and vigilance to prevent inadvertent injuries while dissecting them for nerve transfer surgery.

A Unique Case of Replantation of Previously Replanted Fingers.

Replantation of digital amputations is now the accepted standard of care. However, rarely will a replantation surgeon be presented with amputated fingers which have been previously replanted. In our literature search, we could find only one publication where a replanted thumb suffered amputation and was successfully replanted again. We report the technical challenges and the outcome of replanting two fingers which suffered amputation 40 months after the initial replantation and were successfully replanted again. Replantation was critical since the amputated fingers were the only two complete fingers in that hand which had initially suffered a four-finger amputation. The second-time replantation of previously replanted fingers is reported to allay the concern of the reconstructive surgeon when faced with this unique situation of "repeat amputation of the replanted finger." Second-time replantation is feasible and is associated with high-patient satisfaction. Replantation must be attempted especially in the event of multiple digit amputations.

Diabetic Hand Infections: Factors at Presentation Influencing Amputation and Number of Surgical Procedures.

Background Diabetic hand infections are associated with significant morbidity and disability. Amputations cause permanent disability, and multiple surgical procedures lead to morbidity. Diabetic foot infections have been well-studied but literature on hand infections is limited. We undertook a retrospective study of patients with diabetic hand infections operated at our center to study the factors at presentation with significant association with amputation and number of surgical procedures. Patients and Methods Demographic data of 51 patients was collected. The six parameters, namely, duration of diabetes, "onset of symptoms to presentation" interval, presence of comorbidities, HbA1c level, random blood sugar (RBS) levels at admission, and culture characteristics were selected for statistical analysis to find a relationship with the two outcome variables: number of procedures done and need for amputation. Results On bivariate analysis, Gram-negative infection was found to have a significant relationship with the need for multiple of procedures ( p = 0 . 014). The mean difference between the "onset of symptoms to presentation" interval between the amputation/non-amputation groups (2.9 days, p = 0 . 04) and the multiple procedures/non-multiple procedure groups (4.4 days, p = 0 . 02) was found to be statistically significant. Presence of comorbidities, long duration of diabetes, HbA1c, and RBS levels at admission did not show any statistically significant association with the two outcome variables studied. Conclusion In the present study, we found that infection with Gram-negative organisms is significantly related to the need for multiple surgical procedures. A delay in presentation can influence the risk of amputation as well as multiple procedures. Institution of early appropriate care is important to get a good outcome.

Concomitant Rupture of Extensor Pollicis Longus and Index Extensor Tendons following Distal Radius Plating-Report of Two Cases and Their Clinical Implication for Tendon Transfer Surgery.

Extensor indicis proprius (EIP) tendon transfer is a standard operation for restoration of the thumb extension following rupture of extensor pollicis longus (EPL). In its standard form often the EIP is transferred to the EPL without inspection of the extensor tendons in the fourth compartment and it is retained in its anatomical fourth compartment. However, in a setting of EPL rupture in relation to the distal radius fracture (with or without fixation), concomitant injury to the extensor tendons to the index finger may result in failure of the transfer and even a loss of index finger extension (index finger drop) further complicating the reconstruction and resulting in immense patient dissatisfaction. We herein present two such rare cases to highlight this clinical scenario and how an awareness of this possibility and inspection of the extensor tendons to the index finger before EIP transfer allowed us to prevent this complication. In essence, if we know it, we can prevent it.

Evaluation of Extensor Pollicis Brevis as a Recipient of Tendon Transfer for Thumb Extension.

Introduction Rerouting of the extensor pollicis longus (EPL) is the standard part of tendon transfer surgery for thumb extension. It is done to overcome the ulnar vector of the EPL action. Extensor pollicis brevis (EPB), however, produces better thumb abduction and extension by virtue of its radial vector. The described anatomical variation of EPB extending the thumb interphalangeal joint (IPJ), therefore, gives the "best combination" of movements by a single-thumb extensor tendon. Materials and Methods We performed this transfer in six patients in whom the EPB was found to be extending the IPJ while checked intraoperatively. Three of these six patients were cases of radial nerve palsy and the other three presented with brachial plexus palsy. The outcome was assessed by measuring palmar and radial abduction of the thumb, Kapandji's score, and Bincaz's scale. Results We found satisfactory results in all the six patients. In our series, patients had an average radial extension of the thumb of 29.2 degrees and an average palmar abduction of the thumb of 65.7 degrees. On evaluation with the Bincaz score; one patient had excellent result, three patients had good results, and two patients had fair results. Conclusion In situations where EPL rerouting is not possible (as in cases where the donor tendon needs to reach the thumb from the ulnar side, for example, flexor carpi ulnaris), transfer to the EPB, provided it is extending the thumb IPJ, would produce better extension and abduction of the thumb than the transfer to the EPL.

Birth palsy in congenital varicella syndrome: A lesson in anatomy.

While brachial plexus palsy sustained due to birth trauma is well known, congenital palsies are decidedly rare. We report such a case caused by congenital varicella syndrome, with associated congenital Horner's syndrome and heterochromia iridis. The surprising juxtaposition of a classic upper plexus palsy and a Horner's syndrome raises points of interest. Similar reports in literature are reviewed, and the genesis of a very characteristic group of findings is discussed.

Functional outcomes of post-traumatic metacarpal hand reconstruction with free toe-to-hand transfer.

INTRODUCTION: We present the functional outcomes of microvascular toe transfer to reconstruct the post-traumatic metacarpal hand deformity. Twelve toe transfers were successfully carried out in 11 patients. MATERIALS AND METHODS: In each patient, the level of injury was classified according to the Wei classification system. Functional outcome was measured in seven patients using the Tamai score. Additional objective tests of function were carried out in three patients, including the Jebsen test, grip strength, pinch strength, web opening, static and moving two-point discrimination and Semmes-Weinstein monofilament testing. OBSERVATION AND RESULTS: The average Tamai score was 69 (range 60-83.5). Six patients achieved 'good' outcomes and one patient, with a double toe transfer, an 'excellent' outcome. The average follow-up time was 43 months (range 10-148 months). CONCLUSION: This study shows how even a single toe transfer can restore useful function to a hand that has otherwise lost all prehensile ability.

Management of extensor tendon injuries concerning distal radius fractures.

Introduction: Rupture of the extensor tendons secondary to fractures involving the distal radius is a well-recognized rare complication. In patients with implants particularly, there exists a tendency for attributing the implant as a cause for the tendon rupture. We retrospectively studied the patients with extensor tendon injuries related to distal radius fractures, analyzed the factors leading to the rupture, suggest few preventive measures and describe the management strategy of these ruptures. Materials and methods: 21 patients who were treated for extensor tendon rupture following distal radius fractures in the period of 2014-2022 were retrospectively analyzed. 19 patients had been managed with surgery and two patients conservatively for the distal radius fracture. The time interval between the fracture fixation and tendon rupture, the time interval between tendon rupture and presentation, the extensor tendons injured and the position of the impinging screws or bony spur in relation to the extensor compartments, necessity for implant removal and modality of tendon reconstruction were studied in these patients. Results: Extensor pollicis longus was found to be ruptured in all the patients except one patient with Extensor indicis proprius rupture alone. The time interval between the fracture fixation and tendon rupture averaged at 32.5 months. End to end repair of the ruptured tendons was never possible even in patients who presented earlier. 10 patients underwent intertendinous bridge grafting and 11 patients underwent tendon transfer. All the patients achieved full extension of thumb with no donor deficit. Conclusion: Distal radius fracture related extensor tendon injuries pose a technical challenge to the surgeon and concern to the patient in the form of recurring surgeries. However, with immediate presentation to the surgeon and their use of appropriately designed management algorithm, these patients could be immensely satisfied with the outcome.

Options for Restoring Finger Extension in Mangled Forearm Injuries.

Restoration of finger extension in mutilating hand injuries is crucial for restoring prehension and independent use of the hand. Patients often express desire to restore finger extension once finger flexion is achieved. However, the extensive forearm injury precludes use of any of conventional donors like the wrist or finger flexors for transfer to restore finger extension. Two patients with sequelae of mangled forearm injuries, underwent biceps and long head of triceps transfer to the finger extensors to improve opening up of the fingers. We discuss the treatment considerations while planning these transfers and provide the technical details, rehabilitation and outcome of these patients. Both the patients expressed dramatic improvement of their hand function and were satisfied with the outcome. Biceps and long head of triceps could serve as an effective second-line donor for restoration of finger extension when the conventional donors are not available. Level of Evidence: Level V (Therapeutic).

Osteoid osteoma of the hook of hamate: An unusual cause of ulnar side wrist pain.

Ulnar side wrist pain is a complex clinical situation because of the pathologies involving multiple closely located structures on the ulnar side of the wrist. Incidence of osseous lesions leading to ulnar side wrist pain is very rare. The effectiveness of commonly employed Magnetic resonance imaging, for diagnosing the pathology in the ulnar side of the wrist might be limited in diagnosing such osseous lesions and can lead to missed diagnosis. We herein present such a rare case of Osteoid osteoma of the hook of hamate presenting as ulnar side wrist pain. The condition, presented a "diagnostic challenge", where it required Computed Tomography to diagnose and guide for appropriate management.

Isolated Unilateral Absence of Lunate: A Case Report and Review of Literature.

Isolated unilateral absence of lunate is an extremely rare condition with only one such case reported in English literature so far. The rarity of this condition can lead to diagnostic dilemma, especially if patient has an old history of trauma or surgery around the wrist, leading to unnecessary intervention and difficulty in ensuring a good surgical outcome. We present such a case and discuss the clinical pointers to the diagnosis of this condition. Level of Evidence: Level V (Therapeutic).

How to do an outside-in/outside-in microsuture for nerve repair.

Peripheral nerve injuries are common and debilitating. The goals of nerve repair are to accurately approximate the fascicular tissue, whilst ensuring continuous overlying epineurium and eliminating external sprouting of neural tissue. We describe a modification of standard micro-suturing which allows superior epineural eversion and fascicular coaptation.

Treatment of upper limb extensor hypertonia: case report.

We describe a case of wrist and finger extensor hypertonia treated successfully by division of the hypertonic musculotendinous units and functional replacement using conventional tendon transfer techniques for radial nerve palsy. This report emphasizes the important role of regional nerve blocks in assessment and in operative decision making in a case of extensor hypertonia of the upper limb.

Correlation between clinical findings and CT scan parameters for shoulder deformities in birth brachial plexus palsy.

PURPOSE: The shoulder is the most common site of secondary deformities after birth brachial plexus palsy. The severity and the pattern of deformity vary in patients and have implications for clinical decision making. This study aimed to find the correlation between clinical findings and computed tomography (CT) scan parameters for these deformities. METHODS: This prospective study included 75 patients aged 3 to 23 years. The clinical parameters included age, extent of involvement (nerve roots affected), degree of shoulder abduction, active and passive external rotation, and Mallet score. These were correlated with 3 CT scan parameters: elevation of the scapula above the clavicle, relative glenoid version, and percentage of the humeral head anterior to the scapular line. RESULTS: There was a significant correlation between lack of active and passive external rotation and relative glenoid version and humeral head subluxation. There was a significant correlation between active abduction and elevation of the scapula above the clavicle. There was no significant correlation between age or Mallet score with any of the CT scan parameters. CONCLUSIONS: These results suggest that presence of active and passive external rotation beyond 10° is associated with significantly lesser shoulder deformity irrespective of the degree of shoulder abduction. Hence, a patient with more than 10° external rotation does not need a screening CT scan evaluation regardless of the degree of shoulder abduction present. Conversely, a lack of external rotation beyond 10° strongly suggests relative glenoid retroversion and posterior subluxation of the humeral head and should be considered a clinical indicator of shoulder deformation. TYPE STUDY/LEVEL OF EVIDENCE: Diagnostic II.

Reconstruction of segmental defects of Achilles tendon: Is it a must in infected complex defects?

Loss of Achilles tendon combined with overlying soft tissue loss is a challenging problem. Multiple techniques like tendon graft with coverage by soft tissue flap or composite flaps have been used. All these options are technically demanding. Reports do exist whereby muscle flaps bridging the defect used as cover in course of time could transmit the tendon force across the defect. We are presenting a case where a free gracilis muscle flap used to cover the soft tissue defect at the Achilles tendon at 2 years follow up provided stable cover and produced active function of the Achilles tendon allowing the patient to stand tip toe. Mechanism of its action has been analysed by MRI and M-mode ultrasound. While in primary Achilles tendon injury reconstruction is still the recommended option, in complex situations mere filling of the gap with the flap without formal reconstruction of the tendon could give good functional outcome. This technique can be used in demanding situations.

Forearm Deformities in Birth Brachial Plexus Palsy - Patient Profile and Management Algorithm.

Forearm deformities are often seen in children with severe birth brachial plexus palsy (BBPP). They may be either a supination or a pronation deformity and both hinder normal use of the hand and parents often request for corrective surgery. However, the correction of these deformities can be challenging due to a paucity of options. Also, there is less information in literature on the management of forearm deformities in BBPP compared to the information with regard to nerve surgery or correction of shoulder deformities. This article presents a synopsis of incidence, pathogenesis, clinical presentation and parental concerns related to these deformities. The decision-making considerations, management strategies and outcome expectations are also discussed. Patient selection is very crucial, and the treatment plan must be individualised depending on the disability, parental expectations and existing motor power in the involved limb. Correction of both the deformities have different considerations; however, effective correction of these deformities is immensely satisfactory to the patient/parents in terms of improved function and appearance of the limb. Level of Evidence: Level V (Therapeutic).

Does the Functional Status of the Upper Limb Influence Limb Length Discrepancy in a Child with Birth Brachial Plexus Palsy?

Background: Limb length discrepancy (LLD) is a frequent observation in children with birth brachial plexus palsy (BBPP) and a common concern among parents. A common assumption is that the LLD decreases if the child is using the involved limb more. However, there is no literature evidence for this assumption. The present study was conducted to assess the correlation between the functional status of the involved limb and the LLD in children with BBPP. Methods: One hundred consecutive patients (age > 5 years) with unilateral BBPP seen at our institute underwent measurements of limb lengths to assess the LLD. The arm, forearm and hand segments were measured separately. The functional status of the involved limb was assessed using modified House's Scoring system (Scores 0-10). The correlation between limb length and functional status was assessed using the one-way Analysis of Variance (ANOVA) test. Post-hoc analyses were performed as required. Results: A length difference was observed in 98% of the limbs with brachial plexus lesions. The average absolute LLD was 4.6 cm with a standard deviation of 2.5 cm. We found a statistically significant difference in LLD among the patients with a House score of <7 ('Poor function') and 7 and above ('Good function'; p < 0.001) with later indicative of independent use of the involved limb. We found no correlation between age and LLD. More extensive plexus involvement resulted in higher LLD. The maximal relative discrepancy was found in the hand segment of the upper extremity. Conclusions: LLD was seen in most of the patients with BBPP. The functional status of the involved upper limb in BBPP was found to be significantly associated with LLD. Though causation cannot be assumed. We found that children using the involved limb independently tend to have the least LLD. Level of Evidence: Level IV (Therapeutic).