The impact of various simulated arthrodesis angles of the proximal interphalangeal joint of the ring and middle finger on grip strength.

INTRODUCTION: Arthrodesis of the proximal interphalangeal (PIP) joint at 40° angle has been proposed by many authors. A smaller angle of arthrodesis results in weaker grip strength of the hand from the quadriga effect. However, arthrodesis at 40° compromises other aspects of hand function including poor aesthetic appearance. This paper aims to quantify the decrease in grip strength at 40°, 20°, and 0° of arthrodesis. MATERIALS AND METHODS: Grip strengths of the hand were measured using a BASELINE dynamometer at settings II, III, and IV. Baseline grip strength of the subjects were first measured without wearing a splint. Thereafter, subjects wore thermoplastic splints to simulate arthrodesis of the middle and ring finger PIP joint at 40°, 20°, and 0°, and grip strengths were measured again. The grip strength of the hand with simulated arthrodesis was then calculated as a ratio of the baseline. RESULTS: There were 50 subjects yielding 100 sets of results. The results show that average grip strength ratio of the hand decreases progressively from 40° and 20° and to 0° of arthrodesis for both the middle and ring finger. However, the difference in grip strength ratio between 40° and 20° of arthrodesis was minimal. Simulated arthrodesis of the middle finger affected the grip strength ratio more than arthrodesis of the ring finger, and compromised gripping of a smaller handle more than a wider one. CONCLUSION: The decrease in grip strength from 40° to 20° simulated fusion of PIP joint was minimal. Therefore, in so far as grip strength loss is concerned, arthrodesis of the PIP joint at an angle less than 40° can be considered for patients with individual functional and aesthetic concerns.

An atypical presentation of a flexor intratendinous ganglion of the hand.

Intratendinous ganglions of the hand are rare. We report an unusual case of a ganglion arising within the flexor tendon in the hand. The intratendinous ganglion arose from the flexor digitorium profundus tendon of the little finger, causing flexion deformity of the finger.

Open Dislocation of the Lunate and Triquetrum: A Case Report.

The Mayfield sequence of progressive perilunar instability is commonly encountered. A reverse-perilunate sequence has also been described, where forces are transmitted from the ulnar wrist, resulting in progressive disruption of the ulnocarpal and lunotriquetral intervals. A concomitant dislocation of both the lunate and triquetrum together is a rare injury and has not been reproduced in cadaver models nor widely encountered in clinical cases. We report a rare case of an open volar dislocation of the lunate and triquetrum, and outline the management principles and outcomes in our patient. This case highlights that not all perilunar injuries occur in the conventional sequence. Differing paths of force transmission may result in atypical patterns of carpal disruption. Nonetheless, the broad management principles are similar. Achieving carpal reduction and stabilization, soft-tissue coverage, and early rehabilitation results in reasonable patient outcomes.

Ulnar Neuropathy after Distal Radius Fractures - A Case Series and Review of Literature.

Background: Ulnar neuropathy after a distal radius fracture is rare and has limited reports in literature. As such, there is no consensus regarding the optimal treatment and management of such injuries. We report our experience with managing these uncommon injuries. Methods: A retrospective review was conducted where patients presenting with ulnar neuropathy after sustaining a distal radius fracture were identified from January 2021 to December 2023 from our hospital database. Results: A total of four patients were identified. All of them underwent surgical fixation for their respective fractures. None of them underwent immediate or delayed exploration and decompression of the ulnar nerve. All patients had clinical improvement at 3 months after their initial injuries. Three patients eventually had resolution of the neuropathy between 5 and 9 months post injury, while one had partial recovery and developed a neuroma but declined surgery due to symptoms minimally affecting work and daily activities. Conclusions: Ulnar neuropathy after distal radius fractures may not be as rare as previously thought. Expectant management of the neuropathy would be a reasonable treatment as long as there is no evidence of nerve discontinuity or translocation and that there is clinical and/or electrodiagnostic improvement at 3-4 months after the initial injury. Level of Evidence: Level IV (Therapeutic).

Long-term results using a treatment algorithm for chronic sesamoiditis of the thumb metacarpophalangeal joint.

PURPOSE: We report a series of 18 patients with chronic sesamoiditis of the metacarpophalangeal joint of the thumb treated in the period from 1997 to 2002. We describe a diagnostic clinical test (sesamoid provocation test [SPT]) and present the long-term results of the senior author's treatment algorithm. METHODS: The study included 20 thumbs in 18 patients (8 men and 10 women) with an average age of 36 years. The mean duration of symptoms at initial presentation was 6 months. The dominant thumb was symptomatic in 80% of patients, and 30% of patients gave history of prior trauma. The diagnosis was made clinically and aided by the SPT. Radiographs were normal in 65% of thumbs. The treatment algorithm consisted of steroid injection(s) into the subsesamoid joint. Sesamoidectomy was reserved for patients who were symptomatic (visual analog pain score ≥ 3) after 2 steroid injections. The patients were contacted by telephone in 2010 for an assessment of long-term results. RESULTS: Eight thumbs improved with a single steroid injection whereas 5 thumbs required a second steroid injection. Of the 6 thumbs that underwent sesamoidectomy, 1 required secondary surgery for recurrent symptoms. At long-term follow-up (average, 9 y), 1 patient, who had declined sesamoidectomy, continued to have persistent pain affecting thumb function. CONCLUSIONS: Previous reports have suggested that nonoperative treatment is not effective in the management of chronic sesamoiditis. We found that steroid injections were an acceptable treatment modality with long-lasting results. Failures can be successfully treated with sesamoidectomy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Multiple intraneural glomus tumors on a digital nerve: case report.

Glomus tumors are soft-tissue tumors that are commonly found in the hand. Intraneural glomus tumors, however, are rare, and the few reported cases are mostly solitary tumors. We present a woman with a symptomatic swelling on her finger whose imaging findings suggested multiple tumors on the digital nerve, most compatible with a neuroma. Surgical excision and histology, however, confirmed the presence of multiple glomus tumors of the digital nerve. The patient's symptoms resolved after surgery. We describe the biology, typical presentation, and clinico-pathologic features of glomus tumors associated with a peripheral nerve and explore issues that the clinician should consider with multiple tumors.

Metallosis Following Titanium Implant Use in the Hand: A Case Report and Review of Current Literature.

Adverse reaction to metal debris (ARMD) consists of a spectrum of changes ranging from pure metallosis to aseptic lymphocytic vasculitis-associated lesion and granulomatous inflammation. Currently described ARMD cases are mainly limited to arthroplasty, typically total hip and knee arthroplasties in the lower limb and total wrist arthroplasty in the upper limb. Hypersensitivity to a metallic implant in fracture fixation is rare, and a severe form of metallosis has not been reported so far. In this paper, we present a case of ARMD occurring 10 years after the use of titanium implants for fracture fixation in the hand. Intra-operative findings, histopathological results, and a literature review on ARMD are also described.

Versatility of the turn-around technique of the lateral arm flap for hand reconstruction.

The lateral arm flap is a popular flap for hand resurfacing. Despite its many advantages, its use is restricted by the available width of the flap. We describe the application of this long and narrow flap in a turn-around manner, greatly increasing its versatility while achieving primary closure of the donor site. The lateral arm flap was designed with extension onto the forearm (extended lateral arm flap) and harvested in the usual manner. During inset, the distal segment of the flap is brought through a 180 degree "U-turn" to lie adjacent to the proximal segment. We analyzed the outcomes of 31 turn-around lateral arm flaps performed between 1988 and 2008. All flaps healed well without any vascular compromise. Reconstruction of defects with a variety of configurations was performed with a maximum flap size of 144 cm. Four patients required split skin grafting to the forearm. Primary closure of the lateral arm donor site was achieved in all patients. In this article, we demonstrate the ease, reliability, and versatility of this simple modification in extending the usefulness of the lateral arm flap in hand reconstruction.

Rice bodies, millet seeds, and melon seeds in tuberculous tenosynovitis of the hand and wrist.

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the hand and wrist at presentation is extremely rare, and the diagnosis is often missed. Operative findings of "rice bodies, millet seeds, or melon seeds" are highly suggestive of tuberculous tenosynovitis. Six patients with TB of the hand and wrist at various stages of disease with characteristic operative findings are reviewed. Four patients had underlying immunosuppression. One patient had previous pulmonary TB, whereas 3 patients had radiographic evidence of previously undiagnosed pulmonary TB. The interval to presentation ranged from 1 week to 2 years. Two patients had median nerve irritation, 3 patients had osteomyelitis, and 1 patient had flexor tendon rupture. Mycobacterial cultures were positive in 4 patients; acid-fast bacilli stain, and polymerase chain reaction were positive in remaining 1 patient; and both stain and culture were negative in the last patient who had history of pulmonary TB. All 6 patients were managed with combination therapy comprising antituberculous chemotherapy and at least 1 debulking tenosynovectomy. Two patients had 2 debridements. Of these 2 patients, 1 underwent wrist arthrodesis during the second procedure. Mean follow-up was 4 years. There were no recurrences after the most recent debridement. The diagnosis of TB of the hand and wrist is often missed. The surgeon has to be aware of the significance of loose bodies when performing routine excision of innocuous looking wrist ganglia. Combination therapy comprising thorough excisional debridement and antituberculous chemotherapy will minimize recurrence of this difficult-to-treat disease.

Articularly placed interfragmentary screw fixation of difficult condylar fractures of the hand.

PURPOSE: To retrospectively review the outcomes of intra-articularly placed interfragmentary screws for fixation of difficult condylar fractures of the metacarpal and proximal phalangeal heads. METHODS: We placed interfragmentary screws intra-articularly in 10 patients with 11 fractures to achieve a rigid fixation construct in which the non-articular portion of the bone fragment is too small to allow a stable fixation, or where the bone fragment is entirely osteochondral. RESULTS: The mean duration of follow-up was 15.9 months (range, 6-45 mo). All fractures united within 16 weeks (average, 8.1 wk). We observed subsidence in 1 case; another patient had screw protrusion that required removal. The range of motion of the involved metacarpophalangeal joints for the metacarpal head fractures was 79° (range, 60° to 90°). The range of motion of the involved proximal interphalangeal joints for the proximal phalangeal head fractures was 86° (range, 80° to 90°). CONCLUSIONS: Intra-articularly placed interfragmentary screw fixation is a good technique for treating difficult condylar fractures of the hand.

Technique of olecranon bone grafting for surgical fixation of scaphoid fractures.

Currently described sources of bone graft, such as iliac crest and distal radius, for supplemental fixation of scaphoid fractures are suboptimal. In our experience, olecranon bone has the advantage of providing a convenient source of corticocancellous block graft that can be harvested within the same sterile operative field used for fixation of the scaphoid fracture, and it also causes less postoperative pain compared to that obtained from iliac crest. Here, we describe our surgical technique for harvest and use of olecranon bone graft for fixation of scaphoid fractures.

Suture osteosynthesis in the bony reconstruction of thumb duplication.

Metacarpal osteotomies are done to correct deviation deformity in thumb duplication. We describe a suture-only technique of metacarpal osteosynthesis, without using K-wires. Thirteen Flatt Type IV thumbs and five Wassel Type VII thumbs were reconstructed with this technique. The median follow-up was 23 months. After osteotomy, the metacarpal bone fragments were sutured together with 5-0 polyglactin or 4-0 polydioxanone sutures. Metacarpal fragment displacement was not observed on postoperative radiographs obtained at 1 and 2 weeks. Bony union was achieved at 6 weeks without loss of alignment. The metacarpophalangeal joint alignment was anatomical (≤5° deviation) in eight cases. The mean pre- and postoperative metacarpophalangeal joint alignments were 27° and 9°, respectively. The 11 patients who were available for grading with the Japanese Society for Surgery of the Hand Score were assessed as good. Complete internalization of the bony fixation eliminates infections associated with exposed K-wires without compromising the overall outcome.Level of evidence: IV.

Contralateral pedicled lateral arm flap for hand reconstruction.

Large defects of the hand usually require reconstruction with flap resurfacing to provide durable coverage and preserve function. Pedicled flaps are preferred when there are no vessels available or they are of questionable quality for anastomosis. Such clinical settings may be due to the primary pathology, or when the vessels are preserved for secondary reconstruction. We introduce the contralateral pedicled lateral arm flap as a viable alternative.From 1988 to 2006, we treated 22 consecutive patients aged between 6 and 70 (18 males and 4 females). The indications for flap reconstruction included hand defects resulting from trauma (n = 16), infection (n = 3), burn (n = 2), and complication of free flap (n = 1). The flap was designed with extension into the forearm and raised based on the posterior radial collateral artery. All patients underwent intensive postoperative mobilization. The flap was divided 3 weeks later after a week of ischemic preconditioning.All the flaps survived. There was no wound infection. The flap size ranged from 18 cm to 127.5 cm. Eighteen reconstructions were fasciocutaneous and 4 were osteofasciocutaneous. Three patients underwent subsequent toe-digit transfer. All patients achieved activities of daily living independently by the third postoperative day. There was no significant shoulder and elbow joints stiffness.The contralateral pedicled lateral arm flap is a reliable option for resurfacing large defect of the hand where pedicled flap is indicated. There is minimal morbidity associated.

Scapholunate Ligament Reconstruction With a Novel Technique for Passing Split Extensor Carpi Radialis Brevis Tendon Graft Through Bone Tunnels.

We report 2 patients with acute scapholunate dissociation with static instability and wide scapholunate gapping. They underwent scapholunate reconstruction using a split extensor carpi radialis brevis (ECRB) tendon graft via a dorsal approach. This technique is adapted from the modified Brunelli tenodesis, utilizing a portion of the ECRB instead of a flexor carpi radialis tendon graft to reconstruct the scapholunate interosseous ligaments and dorsoradiotriquetral ligaments. The novel aspects of this technique include the use of a trifold plastic sheet of biaxially oriented polypropylene to facilitate the smooth passage of the 2 mm size ECRB tendon graft through the 2 mm bone tunnel. This enables us to avoid drilling larger holes in carpal bones with a relatively poor vascular supply and allows this technique to be utilized in patients with more delicately sized scaphoid and lunate bones. A 2 mm drill bit was used to create the scaphoid and lunate tunnels, which is smaller than that in the published literature. This trifold biaxially oriented polypropylene plastic sheath can be adapted to the use of many other techniques that require passing a tendon graft through a bone tunnel.

Resurfacing hemipulp losses of the thumb: the cross finger flap revisited: indications, technical refinements, outcomes, and long-term neurosensory recovery.

Volar-oblique injuries of the thumb pulp are particularly disabling. Many methods have been described to treat these injuries and provide return of sensibility. The conventional cross finger flap is an established technique and is well suited for intermediate-sized partial pulp losses. We review our experience with this flap and describe technical refinements that have contributed to improved early outcome and long-term neurosensory recovery. Thirty patients underwent 31 cross finger flaps to the thumb for volar-oblique pulp defects. Defect sizes ranged from 1.5 to 5 cm in length and 1.5 to 3 cm in width. Dorsal skin of the index finger proximal phalanx was used in 26 patients, index finger middle phalanx in 2 patients, and long finger middle phalanx in 3 patients. Nine patients were available for long-term follow-up and were subjected to functional assessment (DASH questionnaire), sensitivity testing (2-point discrimination, Semmes-Weinstein monofilament testing), and range of motion evaluation. Thirty of 31 flaps survived. In 1 patient, trauma to the attached flap from the long finger middle phalanx resulted in flap ischemia. This was revised with a fresh cross finger flap from the index finger proximal phalanx. Employed patients were able to return to their original jobs. Recalled patients (n = 9) were assessed at a mean of 29 months after surgery (range, 12-70 months). All recalled patients regained normal sensibility on 2-point discrimination testing. Functional outcome was satisfactory in 8 patients (DASH score, 0-20). The last patient (DASH score, 61.67) complained of hypersensitivity and cold intolerance that affected his work. The conventional cross finger flap provides reliable coverage for volar-oblique hemipulp losses of the thumb, with patients regaining at least protective sensibility in the long term. The proximal and middle phalanges of both the index and long fingers may serve as donor sites, allowing the surgeon to best select skin cover based on defect size and options in finger positioning.

Revisiting the Elastic Band Tourniquet in Pediatric Upper Limb Surgery.

Pediatric upper limb surgery requires fine tissue handling in a bloodless surgical field. Standard pneumatic tourniquets are often ineffective in the very young, as they do not fit all limb circumferences. We describe a simple and effective elastic band tourniquet technique and report our experience of safety with 113 cases.

Factors affecting the prognosis of pyogenic flexor tenosynovitis.

BACKGROUND: Pyogenic flexor tenosynovitis is a closed space infection involving the digital flexor tendon sheaths of the upper extremity that can cause considerable morbidity. The purpose of the present report is to describe the various risk factors leading to poor outcomes and to recommend a clinical classification system for this condition. METHODS: We studied seventy-five patients with pyogenic flexor tenosynovitis over a six-year period. The amputation rate and total active motion were used as outcomes measures. The clinical factors influencing outcomes were identified and analyzed. RESULTS: The five risk factors associated with poor outcomes were (1) an age of more than forty-three years, (2) the presence of diabetes mellitus, peripheral vascular disease, or renal failure, (3) the presence of subcutaneous purulence, (4) digital ischemia, and (5) polymicrobial infection. On the basis of the clinical findings and outcomes, three distinct groups of patients could be identified, each with a progressively worse outcome. Patients in Group I had no subcutaneous purulence or digital ischemia; these patients had the best prognosis, with no amputations and a mean 80% return of total active motion. Patients in Group II demonstrated the presence of subcutaneous purulence but no ischemic changes; these patients had an amputation rate of 8% and a mean 72% recovery of total active motion. Patients in Group III had both extensive subcutaneous purulence and ischemic changes; these patients had the worst prognosis, with an amputation rate of 59% and a mean 49% return of total active motion. CONCLUSIONS: We propose a three-tier clinical classification system that can aid in prognosis and guidance in the treatment of pyogenic flexor tenosynovitis of the upper extremity.

Elbow ganglion arising from medial epicondyle pseudarthrosis.

We present a patient with an asymptomatic painless medial elbow swelling of one year's duration, which was diagnosed as a ganglion originating from a non-united avulsion fracture of the medial epicondyle with a pseudarthrosis. Medial elbow ganglia are unusual lesions typically arising from the medial aspect of the ulnohumeral joint capsule, often in combination with symptoms of cubital tunnel syndrome. To our knowledge, a ganglion arising from a pseudarthrosis has not been reported in the literature, and should be considered in the differential diagnoses of lesions encountered over the site of fracture non-union in proximity to a joint.

Necrotizing Fasciitis Caused by Cryptococcus gattii.

Necrotizing fasciitis (NF) is a severe soft-tissue infection that can lead to high morbidity and mortality. The etiology of NF is often polymicrobial. Although rare, fungal organisms have been known to cause NF. Cryptococcus is a fungal infection that may lead to NF. Here we report the case of a 73-year-old man who had diabetes and presented with pain and swelling in the left hand after being bitten by an insect over the dorsum of the hand. Operative débridement revealed NF caused by Cryptococcus gattii. Antifungal medication was started, and the patient underwent multiple débridements of the hand with subsequent skin grafting. Four months later, the hand wound was completely healed. Authors have reported several cases of NF secondary to Cryptococcus neoformans in immunocompromised patients. The emerging C gattii pathogen affects immunocompetent patients. Although the transmission route is mainly respiratory, direct inoculation has been described as well. Ours is the first reported case of NF secondary to C gattii. It is important to consider fungal elements as a source of NF. Appropriate treatment includes aggressive surgical débridement and antifungal therapy.