Ultrasound-guided selective nerve blocks for trigger finger surgeries to maintain flexion/extension of fingers - Case series / Bloqueios seletivos guiados por ultrassom para cirurgias de dedo em gatilho para manutenção da flexão/extensão dos dedos - Série de casos

Abstract Background: A patient's ability to move his/her fingers during hand surgery may be helpful to surgeons because it allows the effectiveness of the intervention evaluation and prediction of hand function in the postoperative period. The purpose of this case series is to demonstrate the efficacy of an ultrasound-guided peripheral nerve block technique to maintain the hand flexor and extensor muscles motor function and discuss the benefits of the technique for trigger finger surgery. Case report: Ten patients scheduled to undergo trigger finger surgery were selected. The goal was to maintain flexion and extension of the fingers during the procedure. Thus, ultrasound-guided ulnar, radial, and medial nerve block was performed in the distal third of the forearm, at 5-7 cm proximal to the wrist. The block was performed with 5 mL of 0.375% bupivacaine on each nerve. All procedures were uneventfully performed maintaining the flexion and extension of the fingers. In two cases, it was observed that the motricity maintenance and the patients' ability to move their fingers when requested allowed the success of the surgical procedure after the third intraoperative evaluation. Conclusion: This case series shows that it is possible to maintain the motor function of the hand flexor and extensor muscles to perform finger trigger surgeries using specific ultrasound-guided distal blocks.

Resumo Justificativa: A capacidade de um paciente mover os dedos durante a cirurgia da mão pode ser útil para o cirurgião porque permite a avaliação da eficácia da intervenção e a predição da função da mão no pós-operatório. O objetivo desta série de casos é demonstrar a eficácia de uma técnica de bloqueio de nervo periférico guiado por ultrassom na manutenção da função motora dos músculos flexores e extensores da mão e discutir os benefícios da técnica para cirurgias de liberação de dedo em gatilho. Relato de caso: Foram selecionados 10 pacientes em programação para cirurgia de liberação de dedo em gatilho. O objetivo era manter a flexão e a extensão dos dedos durante o procedimento. Dessa forma, o bloqueio dos nervos ulnar, radial e mediano, guiados por ultrassom, foi feito no terço distal do antebraço, 5 a 7 cm proximais ao punho. O bloqueio foi feito com 5 mL de bupivacaína a 0,375% em cada nervo. Todos os procedimentos foram feitos sem complicações e com manutenção da flexão e extensão dos dedos. Em dois casos, observou-se que a manutenção da motricidade e a capacidade dos pacientes de mover os dedos quando solicitado permitiu o sucesso do procedimento cirúrgico após a terceira avaliação intraoperatória. Conclusão: Esta série de casos mostra que é possível manter a função motora dos músculos flexores e extensores da mão em cirurgias de liberação de dedo em gatilho por meio de bloqueios distais específicos guiados por ultrassom.

The Natural History of Pediatric Trigger Thumb: A Study with a Minimum of Five Years Follow-up

BACKGROUND: Pediatric trigger thumb is due to deformed flexion of the interphalangeal joint. We previously reported that pediatric trigger thumb can spontaneously resolve in > 60% of patients at the median follow-up of 48 months. The purpose of this study was to determine whether there were any more cases of resolution with a follow-up of more than 5 years and whether any residual deformities remain, and so to confirm the natural history of pediatric trigger thumb. METHODS: We prospectively followed 87 thumbs in 67 patients with pediatric trigger thumb and these patients didn't receive any treatment such as passive stretching, splinting or surgery. The date of the first visit ranged from April 1994 to March 2005. The patients were evaluated every six-months prior to resolution and annually after resolution. The median duration of follow-up was 87.3 months (range, 60 to 156 months). RESULTS: Of the 87 trigger thumbs, 66 (75.9%) resolved spontaneously. The median time from the initial visit to resolution was 49.0 months (95% confidence interval, 41.1 to 56.9). There were no residual deformities that resolved beyond 48 months. Although complete resolution did not occur in the remaining 21 thumbs, the flexion deformities did improve in all 21 thumbs. There were no other differences between the two groups besides the average duration of follow-up. There was no difference in resolution based on gender. CONCLUSIONS: Pediatric trigger thumb can spontaneously resolve in > 75% of the cases after a follow-up period of at least 5 years. An operation may be delayed or avoided in the majority of cases. This may help both the families and the surgeons make decisions regarding the proper treatment of pediatric trigger thumb.

The results of percutaneous release of trigger digits by using full handle knife 15 degrees: an anatomical hand surface landmark and clinical study.

OBJECTIVE: Know the results of percutaneous release of trigger digits by using full handle knife 15 degrees. MATERIAL AND METHOD: The author identified 510 cadaveric digits to find the anatomical landmark of Al pulley that relates to the knuckle and measurements of A1 pulley lengths. The proximal margin of the Al pulleys on the perpendicular line from the knuckle to the palm was in the same line in 327 (64.1%) digits, while 464 (91.0%) digits were < or =1 mm and 509 (99.8%) were < or =2 mm. The average lengths of A1 pulleys in each digit were as follows: thumb; 5.30, index finger; 6.32, middle finger; 6.58, ring finger; 6.32, and little finger 5.30 mm. The average lengths of all fingers were 6.13 mm. A further 338 digits of trigger digit in 248 patients were treated by percutaneous release by using full handle knife 15 degrees with these landmarks. RESULTS: Three hundred and thirty-eight trigger digits were treated. There was a complete resolution of symptoms in 314 digits (92.90%) when followed up 6 weeks after operation. One digit, an index finger had residual grade 1 after 3 weeks and complete resolution in 8 weeks. Three digits (0.89%), which were one thumb and two index fingers, underwent local steroid injection because of painful scar. Nineteen digits (5.62%) were stiff at proximal interphalangeal joint because of grade 4 triggering and osteoarthritis of the proximal interphalangeal joint but they increased the range of motion after 6 months. A case (0.30%) had numbness of the radial tip of the thumb, which may have been caused by injury to the radial digital nerve ofthe thumb. No one had open release of A1 pulley. CONCLUSION: This technique was a safe and effective out patient procedure on 248 patients and had a complete resolution of symptoms 92.90%.

Lesões crônicas de tendões flexores na mão: reconstrução em dois estágios / Chronic flexor tendon lesions: reconstruction in two stages

Os autores apresentam resultados de tratamento de lesões crônicas dos tendões flexores na mão, usando técnica em dois estágios. O primeiro pelo implante de prótese de silicone e o segundo com enxerto de tendão. Dão detalhes de técnica, e analisam seus resultados comparando-os com os da literatura. Chegam a conclusão que a técnica dá resultados satisfatórios na maioria dos casos.