Congenital Clinodactyly of the Thumb.

Aims: To present five patients with thumb clinodactyly and the results of surgical treatment in two patients who were followed till skeletal maturity. Case Presentation: Four patients (five thumbs) exhibited an ulnar interphalangeal angulation and were all associated with a triphalangeal thumb, while in only one patient a radial deviation associated with a longitudinal epiphyseal bracket of the proximal phalanx was noted. Three patients (four thumbs) received primary surgical treatment for thumb polydactyly. A three-phalangeal thumb was retained in all. Two of these thumbs were also treated surgically for clinodactyly. Removal of the accessory delta phalanx and reconstruction of the soft tissues was performed in a 3-year-old girl. Follow-up at 18 years of age revealed reduced size of the thumb, limitation of flexion and a secondary radial interphalangeal deviation. A closing wedge osteotomy of the shaft of the proximal phalanx, leaving the delta phalanx undisturbed, was performed in a 12-year-old girl. Follow-up at 18 years of age revealed no loss of thumb alignment but not improved function. Discussion: The aim of surgical reconstruction of thumb clinodactyly is to create a painless thumb of adequate mobility, stability, alignment and size. Removal of an angulated middle phalanx in a very young child should be associated with a ligament reconstruction from the soft tissues. In an older child or adult, an osteotomy of the shaft of the proximal phalanx or fusion of the oblique joint and realignment with bone resection may be indicated. The real value of a surgical procedure may be evaluated only when the satisfactory result remains unimpaired beyond skeletal maturity. Conclusion: Surgical reconstruction of thumb clinodactyly may require specific challenges and techniques to obtain a painless, properly aligned, stable thumb with improved function that will retain the satisfactory result beyond skeletal maturity.

Complicated Fracture and Resorption of an Osteochondroma.

Aims: To describe two unusual complications of a typical solitary pedunculated femoral osteochondroma that included a distal fracture of the exostosis and a missed fragment following surgical treatment as well as to evaluate the progress of the untreated free fragment at follow-up. Case Presentation: A 13-year-old boy consulted for a painful bruising of the medial side of the right knee following injury. Radiological survey indicated a pedunculated osteochondroma of the distal femoral metaphysis but there was no evidence of a fracture line. Surgical removal of the lesion was uncomplicated but the post-operative radiographs indicated an osteocartilaginous portion of the osteochondroma missed in the thigh musculature. No further surgical intervention was undertaken. Radiographic followup revealed gradual regression and complete resorption of the free fragment 3 years later. No complications have been recorded at the most recent follow-up, 10 years later. Discussion: Fracture through the base or stalk of a pedunculated osteochondroma is a rare complication but the diagnosis of a distally fractured exostosis has not been previously reported. Regression or resorption of a solitary pedunculated osteochondroma following a fracture is also very rare. Although recurrence of the lesion in the reported patient would be very likely, complete resorption was evident instead within 3 years. Conclusion: An obscure distal fracture of a penduculated osteochondroma may be suspected in cases that a clinical diagnosis of a fractured exostosis is not associated with the radiographic detection of a fracture line through its stalk. Radiographic control during surgery is necessary to ensure complete removal in cases with a clinically, or even radiologically, diagnosed fractured exostosis. Surgical excision of a distally fractured osteochondroma may be avoided, since complete resorption of the distal fragment may be evident in a few years.

Residual Symptoms of Occult Pediatric Ankle Injuries: MRI-Diagnosed Bone Bruising.

Aims: To define the nature of non-radiographically evident injuries of the ankle and hindfoot in children who exhibited persistent pain, swelling and refusal to bear weight after 6 weeks of immobilisation. Methods: Ten children (7 boys, 3 girls; age range 5 to10 years) were included in the study. They presented with normal plain radiographs after an acute traumatic ankle injury. They were all immobilised for 6 weeks. The detection of residual symptoms and signs indicated the need of a limited magnetic resonance imaging (MRI). It revealed bone bruising localized to the hindfoot in all cases. Bone bruises were classified according to anatomical location and whether they were solitary lesions or were combined with other soft tissue injuries. Results: From a total of 10 cases, 6 were unifocal, 3 of them were localized to the talus and 3 to the calcaneus, while in 4 multifocal cases bone bruising involved all the bones of the hindfoot. All cases were associated with a varying degree of soft tissue injuries including signs of ankle and subtalar joint effusion, but there was no evidence of ligamentous injuries in our patients. The total period of immobilisation reached 3 months for unifocal bone bruises and 4 months for multifocal lesions. In all cases, a prolonged recovery period exceeding 2 months followed before return to normal activities including sports. The long-term follow-up ranged from 2 to 5 years. No complications were detected. Conclusion: A limited MRI examination is indicated in children with residual symptoms following acute ankle injuries. Bone bruising localized to the hindfoot was the “occult” bone lesion diagnosed in all our cases. This study indicates that bone bruising or contusion should be classified as a distinct clinical entity best visualized on MRI with fat suppression

A New Approach to the Surgical Treatment of Olecranon Bursitis.

Aims: To describe a new approach to the surgical treatment of the nonseptic olecranon bursitis. Methods: The study included 14 patients (13 men, 1 woman; age range 51-77 years) treated in a 10-year period. Patients with a systemic inflammatory disease were excluded. All patients had already been treated with bursal aspiration associated with multiple punctures of the cyst wall and compressive dressing. Clinical features, ultrasonography and analysis of the aspirated bursal fluid were indicative of a nonseptic olecranon bursitis. The new approach included surgical incision to drain the bursa and the use of a Penrose drain tube for post-operative drainage for an average of 5 days. The wound was treated by secondary closure. No antibiotics were used. Results: Eleven patients showed rapid secondary healing of the wound which reached 7 to 14 days following the Penrose drain removal. Wound healing was delayed in 3 patients and required approximately a month. The long-term follow-up ranged from 2 to 10 years. No recurrences or complications were encountered. Conclusion: This novel approach proves that excision of the bursa is not a mandatory step in the surgical treatment of olecranon bursitis. It is worthwhile to consider this new approach as the first step in the surgical management of the, non-responsive to conservative treatment, nonseptic olecranon bursitis.

Three Distinct Episodes of Thumb Felon in a Fur Industry Worker.

Aims: To present and discuss the etiology of three distinct episodes of thumb felon in a fur industry worker, in association with the required precautions. Case Presentation: A 61-year-old man working in a fur industry was treated for three distinct episodes of a felon of the right thumb within an 8-month period. He was treated successfully with surgical drainage and antibiotics following each episode. He was symptom-free and returned to work about two months following each episode. Felon formation, in all cases, was due to a Streptococcus constellatus infection secondary to mink hair penetration through the distal nail groove of his thumb. Using protective gloves, no further relapses have occurred during a 5-year follow-up. Discussion: A felon is an abscess of the pulp of a finger or thumb usually due to percutaneous trauma. Streptococcus constellatus, which is included in the Streptococcus milleri group, is often associated with various pyogenic infections. In the reported case, the lack of hand protection during fur processing was the cause of mink hair infiltration into the pulp of the patient’s thumb through the distal nail groove and of the three episodes of felon formation due to the secondary infection by Streptococcus constellatus. Conclusion: Lack of hand protection during fur processing could make hands vulnerable to micro-injuries and secondary infections.

Nail Shedding: A Case Report.

Aims: The etiology of nail shedding in an 85-year-old man as well as predisposing and precipitating factors were evaluated, focusing on whether nail loss was secondary to infection or not. Presentation of Case: An 85-year-old man was examined for complete detachment and loss of the nail plates of the index and middle fingers of his right hand. There were no previous nail disorders or a recent traumatic injury. He was non-smoker and was not receiving any drug therapy before nail loss. Clinical symptoms and signs persisted after 10 days empirical use of antibiotics and local treatment. Culture samples by that time indicated an Enterobacter cloacae local infection. He was treated with topical application of the gentamycin injection solution on the nail beds. There was normal regrowth of the nails. No abnormality of the nail unit of both fingers was evident 2 years later. Discussion: The pathogenesis of nail shedding in our patient was assessed. Although a causal relation of nail loss and a primary Enterobacter cloacae infection was highly suggestive, other causes such as missed minor trauma, ischemia or idiopathic could not be excluded. Conclusion: A primary Enterobacter cloacae infection was the most likely cause of an acute nail shedding of the index and middle fingers of the right hand in an 85-year-old man. Treatment with local use of the gentamycin injection solution was proved a welltolerated, safe and efficacious mode of treatment.