Morphometry of sigmoid notch: A novel method of shape assessment for clinical practice.

Purpose: Using a novel technique, we assess and describe the distal radioulnar joint (DRUJ) anatomy with reference to sigmoid notch shapes. The purpose of this study was to develop a non-invasive, fast, reliable and reproducible technique for analysing the shapes of sigmoid notch on CT scans. Methods: 40 cadaveric wrist specimens exposing the sigmoid notch and 100 normal adult wrist CT scans with end on axial sections showing the sigmoid notch outline were obtained. The shape of the sigmoid notch was assessed on both using the geometric construction method. Results: Of the 40 cadaveric specimens, 42 % were C-shaped, 33 % were flat,17 % were Ski sloped, and 8 % were S-shaped.Of the 100 wrist CT scans, 48 % were C-shaped sigmoid notch, 17 % were flat, 15 % were ski-sloped, and 20 % were S-shaped shapes. Conclusions: Our sample population had a higher prevalence of C-shaped sigmoids in both cadaveric and CT-based studies. It is considered the most stable shape because of its increased depth. The DRUJ morphology in our sample population can be inferred to have a stable configuration. Clinical relevance: The relationships and measurements demonstrated in this study can be a guide when considering ligament reconstruction for DRUJ instability, managing complex fractures involving the DRUJ and in decision-making for notchplasty, osteotomy and arthroplasty of DRUJ.

Epithelioid malignant peripheral nerve sheath tumour of the ulnar nerve around the elbow: a diagnostic and therapeutic challenge.

Epithelioid malignant peripheral nerve sheath tumour (EMPNST) is a rare histological subtype of malignant peripheral nerve sheath tumour (MPNST), accounting for 5% to 17% of MPNSTs. The clinical and MRI findings of EMPNST mimic those of nerve abscesses, similar to the presentation in Hansen's disease. We present one such case with this kind of diagnostic dilemma. Intraoperative findings suggest a tumour changed the course of management subsequently. The development of neurological deficits postoperatively after tumour resection was a reconstructive challenge. To provide motor power and sensation through a procedure that provides a complete functional outcome for a young patient, distal nerve transfers were chosen. This provided an improvement in the quality of life and hastened the neurological recovery of the involved limb. Level of evidence: V.

Bilateral Post-traumatic Brachial Plexus Injury in an Adult: A Note on the Probable Mechanism of Injury.

Bilateral brachial plexus injury is rare following a motor vehicle accident in an adult. We report a 35-year-old man with a bilateral brachial plexus injury. Explaining the mechanism of such an injury is essential to prognosticate the outcome. Fall from the bike, and the position determines the mechanism. The head-shoulder hitting the surface has an avulsion injury (ipsilateral), and the recoiling effect causes traction injury to the contralateral side. Our case had a C5,6 avulsion injury on the right side (ipsilateral) and a C5,6 traction injury (contralateral) to his left side. Surgical exploration and distal nerve transfers were done on the right side. The patient improved his shoulder and elbow function of grade 3, neurolysis of the brachial plexus was done on the left side, and the recovery was complete at 12 months of follow-up.

Outcomes of radialization with ulnar cuff osteotomy for radial longitudinal deficiency: a medium-term follow-up study.

Addressing the deforming stresses arising from soft tissue and continued skeletal development is crucial to obtain long-term correction of forearm carpal alignment in Radial longitudinal deficiency. The aim of the present study was to report the medium-term follow-up results of radialization with ulnar cuff osteotomy in children. A total of 17 patients (21 involved limbs) with a mean follow-up of 66 months (range 50 to 96) were reviewed. Mean correction of the hand forearm angle at the final follow-up was 51°. Mean hand forearm position preoperatively and at the final follow-up were -1.1 cm (SD 0.9) and +1.3 cm (SD 0.8), respectively. This metaphyseal osteotomy relaxed the radial structures throughout the original phase of deformity correction. The mean ulnar growth was 62% of the contralateral side at the final follow-up. Our technique may provide a feasible solution to the correction and prevent recurrence of deformity while maintaining ulnar growth in the medium to longer term.Level of evidence: III.

Wrist Arthrodesis Using a Trapezoidal Wedge Graft from the Distal Radius and a Low-Profile Reconstruction Plate.

Background: Various intramedullary or dorsally based fusions have been utilised to perform wrist arthrodesis. Although the dorsal plate is rigid and well constructed, the standard of care was replenishing the arthrodesis site with an iliac crest bone graft. Due to the high morbidity of the donor site, alternatives such as distal radius bone grafts have gained popularity. In this study, wrist arthrodesis was performed with a locally accessible trapezoidal wedge graft from the distal radius and a low-profile reconstruction plate to evaluate the radiological and functional outcome. Methods: We retrospectively reviewed 22 wrists, 14 brachial plexus injuries, 4 post-traumatic injuries, and 4 rheumatoid arthritis patients, with a mean follow-up of 31 months. Union was evaluated on radiography. The functional outcomes were evaluated using a visual analog scale incorporated into a questionnaire. Results: All 22 fusions united successfully, with a mean duration of 12 weeks and a wrist position of an average 17.5 degrees of extension and 6 degrees of ulnar deviation. The aesthetics of the wrist showed the most significant change, and overall satisfaction levels increased. Conclusions: A locally accessible cortico-cancellous graft from the dorsum of the radius is a reliable alternative to an iliac crest or carpal bone graft with high potential for the union. It also serves as a stable strut in our construct, allowing us to use a low-profile reconstruction plate. The Reconstruction (3.5 System) plate can be used safely with excellent results and a low implant prominence or breakage risk.

A Novel Method of Spinal Accessory Nerve Banking Using Silicone Catheter for Functioning Free Muscle Transfer.

In secondary brachial plexus reconstruction, exploring an area that has already been operated on is challenging and time-consuming for a surgeon, especially in centers with a single-team approach. Due to their inertness and lack of adverse effects, silicone Foley catheters were used successfully during the reconstruction of flexor tendons. Based on the concept, we have achieved an acceptable functional outcome by banking the spinal accessory nerve in a silicon catheter for gracilis reanimation, which permits smooth dissection, maintains the length, and shortens the operating time for subsequent reconstruction. Level of Evidence: Level V.

Cancellous compression bone grafting using headless screw as a strut in scaphoid nonunion by a single volar approach.

PURPOSE: An array of fixation and grafting techniques for scaphoid nonunion have been described over time, achieving varied results pertaining to union and scaphoid alignment. The aim of this study was to check for union rates and correction of scaphoid parameters achieved by our technique of using screw as a strut and cancellous compression grafting harvested from the distal radius by a single volar approach. METHODS: Retrospective analysis of all patients operated by the said technique was done from 2013 to 2019. Thirty-eight patients including 36 males and two females in the age range of 20-56 years were analyzed. Union rates, change in scaphoid alignment parameters and graft site characteristics were documented. RESULTS: Of the patients analyzed, 5/38 were nonunions of proximal pole, 19/38 of waist and 14/38 were of distal pole which included nonunions of cystic type or with humpback deformity. Patients were followed up for an average of 22.2 months and union was achieved in all cases with a mean period of 15.7 ± 3.7 weeks. There was significant improvement in the scaphoid alignment postoperatively. One case of implant migration and one case of scaphoid nonunion advanced collapse were noted. The mean duration of donor site healing was noted to be 16.9 ± 2.5 weeks except two outliers which took longer time. There were no cases of donor site fracture or other complications. CONCLUSION: Union rates, correction of scaphoid parameters and minimal complications justifies this technique as a novel one in the management of scaphoid nonunion at all levels, with minimal donor site morbidity and attained by the single volar approach.

Epidemiology of Congenital Hand Differences at a Tertiary Hospital in Southern India - Establishment of a New Registry and Assessment Using Both the Swanson/IFSSH and the Oberg, Manske and Tonkin Classifications.

Background: In resource challenged nations, the true magnitude of the congenital hand differences (CHD) remain unknown due to a lack of nation-wide surveillance system. We created a hospital-based registry system with the aim to determine the prevalence and distribution of CHD and compare the Swanson/IFSSH (SI) and Oberg, Manske and Tonkin (OMT) classifications. Methods: Data of children aged 0 to 18 years with CHD was entered into the online registry and classified based on the SI and OMT classifications from January 2018 to December 2021. The prevalence and distribution of CHD and risk factors like family history were summarised using descriptive analysis. Syndromic and heredity associations were further analysed using Fischer exact test and odds ratio. Clustered columns were used to compare the two classification systems. Results: A total of 307 patients with CHD presented during the study with a prevalence of 2.4/1,000 patients. Among them, 164 were unilateral, 21 were born of consanguineous marriages (7.6%) and 10 (3.6%) had a family history of CHD. Although not statistically significant, bilateral involvement was twice as likely to be hereditary compared to unilateral involvement. A total of 10 different syndromes were identified among 27 patients of which Holt-Oram syndrome was most common. The most common CHD was Radial longitudinal defificiency (111). A total of 82 (27%) children had other associated anomalies that could not be grouped as a syndrome. Two patients could not be classified using either SI or OMT classifications. Conclusions: The online registry established an efficient way to store and analyse data related to CHD. It provides new information on its prevalence in South India, which is similar to the existing literature. Most of the CHD can be grouped in both the SI and OMT classifications. However, there still remains some conditions that are unclassifiable. There is a need for a national registry of CDH for effective management, funding and research. Level of Evidence: Level IV (Epidemiological).

A Six-Year Clinical Profile of Distal Radius Fractures in a South Asian Population.

Background: The description, types and management of distal radius fractures have not been evaluated for a South Asian population. The aim of this study was to describe the clinical profile of distal radius fractures in adults over a 6-year period. Methods: The medical records of distal radius fracture patients, aged 18 years and above admitted between August 2014 and 2020 were assessed. Epidemiological profile, fracture classification, treatment and reasons for implant removal were assessed. Results: A total of 1066 distal radius fractures in 1005 inpatients were identified. The mean age was 42.1 ± 15.3 years (50.2 years [male] & 39.7 years [female]). A total of 65.5% patients sustained high-energy injury. 38.6% (n = 411) of fractures were classified as extra-articular AO-23-A, 24.3% (n = 259) as partially intra-articular AO-23-B and 39% (n = 416) as intra-articular AO-23-C. The treatment was non-surgical for 20.9% and surgical for 79.1% of cases. Plate fixation was the most frequently used surgical method followed by percutaneous pinning and external fixation. The proportion of patients treated by each modality remained constant based on a year-wise analysis of data. A total of 56 patients underwent implant removal, most commonly at the request of the patient. Conclusions: Our study is the longest study in a South Asian setting where the population is younger, with a male pre-ponderance, sustaining high-energy injury as compared to the literature. This can be attributed to our study population being inpatients only. As population-based fracture registry is not available in our country, hospital-based studies such as ours provide the best option to study fracture patterns, distribution and trends in treatment. Level of Evidence: Level IV.

Delayed Presentation of Sciatic Nerve Injury with Gap: A Case Report with a Unique Solution from the Past.

CASE: A 35-year-old farmer presented with a foot ulcer on his left flail foot because of a sciatic nerve injury of 1-year duration. A gap of 11 cm was observed in the sciatic nerve for which he underwent 2-staged pedicled peroneal nerve grafting and posterior bone block procedure for the ankle. He had S3 grade sensation at 5-year follow-up without any recurrence of ulcer and a stable foot without external support for walking. CONCLUSION: Staged pedicled peroneal nerve grafting with a posterior bone block procedure is a viable solution for very large sciatic nerve defect with predictable results.

Functional Assessment of 3D Printed Prosthesis in Children with Congenital Hand Differences-A Prospective Observational Study.

Background: Children with congenital differences who require prosthesis, have special needs due to their growth and psychosocial factors. Cosmetic or body-powered prosthesis provides basic functional needs but poses a financial burden on the family. Prostheses with advanced functions need to be deferred until adulthood. 3D printed prosthesis is a novel alternative being cost-effective for children. Since limited literature is available on the functionality of 3D printed prosthesis and none in the South Asian population, this study was done to assess its utility in congenital hand amputations. Methods: Fourteen children with congenital hand amputations were selected for a prospective observational study. Unilateral below Elbow test (UBET), Box and Block test and ABILHAND questionnaire were used for assessment with and without prosthesis after six months. Results: Eleven patients completed the follow-up. Box and Block test improved from a mean score of 24 to 35 with the prosthesis implying an improvement in manual gross dexterity (p -0.049). UBET (p -0.002) and ABILHAND questionnaire (p < 0.001) showed a decrease in score with the use of a prosthesis which suggested a lack of lateral and tripod pinch in the current design of a prosthesis. Patients with below elbow prosthesis performed better. Conclusions: 3D printed prostheses are an excellent option for use as a transitional prosthesis as they are inexpensive, serves to improve needs with respect to grasping activities at both wrist and elbow level amputation and customizable according to patients' need and limb deficiency and replaceable as the child grows with age. Current designs are useful with respect to grasping activities.

The influence of ethnic differences based on upper limb anthropometry on grip and pinch strength.

BACKGROUND: Ethnic differences in upper limb anthropometry have significant variations which can influence surgical outcomes and rehabilitation. We hypothesize that there would be a significant difference in the anthropometry based on ethnicity and gender which will reflect on objective measurements. METHODS: We performed 13 anthropometric measurements of the upper limb, grip and three types of pinch strength in 210 volunteers across seven ethnicities in young adults at our university campus. We compared them statistically based on ethnic and gender differences. RESULTS: There was a significant correlation noted between grip, palmar and tip to tip pinch strength in 12 of the 13 anthropometric measurements. Key pinch correlated with eight parameters. Mean grip and pinch strength are noted to be more in males and from developed nations across all ethnicities. CONCLUSIONS: This study shows that there is significant variation between the anthropometric measurements based on gender and ethnicity which correlates with differences in grip and pinch strength.

Correlation of Flexor Pollicis Longus Tendon Status by Ultrasonography with Plate Position on Radiographs Following Volar Plate Fixation of Distal Radius Fractures with Pronator Quadratus Repair.

BACKGROUND: Purpose was to correlate flexor pollicis longus tendon (FPL) attrition using Ultrasonography with plate position on radiographs following volar locked compression plate fixation (LCP) in patients who have undergone pronator quadratus (PQ) repair for distal radius fractures. METHODS: Status of flexor pollicis longus tendon was analyzed by ultrasonography in patients who underwent volar locked compression plating with pronator quadratus repair at a minimum of one year follow up. Soong's criteria was used to assess the plate position and then correlated the ultrasonography findings of flexor pollicis longus. RESULTS: There were 33 patients included in our study, of which 15 belonged to Soong's grade zero, 10 were grade one and eight were grade two. Flexor pollicis longus attrition was noted in all cases with grade two plating. CONCLUSION: Pronator quadratus repair may not prevent attritional changes in higher grades of Soong's, hence follow up may be required in these patients to identify attritional changes and early implant removal to prevent complications.

Operation theatre protocol for COVID-19 cases requiring orthopaedic surgery: A workflow without altering the existing infrastructure.

INTRODUCTION: The surge in the number of trauma cases following relaxation of lockdowns in the backdrop of COVID-19 pandemic, has strained the existing infrastructure to cater to these patients and also prevent the spread of infection. Moreover, with the rise of newer strains, the period ahead has to be tread carefully to prevent resurgence of infections. There have been recommendations regarding the ideal setup to operate orthopaedic cases in this pandemic scenario. However, many of the hospitals in India with financial and logistic constraints are unable to implement these structural changes into their existing setup. We propose a model which can be used in an existing operation theatre which has a single entry and exit corridor, which is the layout in many hospitals. METHODOLOGY: A protocol with the consultation of a panel of health care professionals was designed on the basis of WHO guidelines in a way so as to remain dynamic. Prior to its implementation, online classes were conducted and a dry run of the protocol was done with the whole team involved. The theatre layout is one with a single entry and exit and had predesignated rooms. The personnel were divided into 3 teams, each with a fixed set of people and preset workflow, to be followed during entry and exit. Five COVID positive cases have been operated since then using the protocol and has been used as a pilot study to further amend the protocol. CONCLUSION: This model can be used as a guideline by hospitals having a limited infrastructure, to develop their own protocol to operate on COVID positive cases, in the present situation of increasing trauma cases post the relaxation of lockdown and also in any subsequent waves of infection with newer strains. Simulation and periodic stringent audits with the entire team would prove successful in rectifying errors and avoiding any possible contamination.

The Middle Trunk Fascicle: A Simple, Effective Nerve Transfer for Suprascapular Nerve in Upper Brachial Plexus Injuries.

A new nerve transfer option of using viable fascicle of the ipsilateral middle trunk for suprascapular nerve reconstruction is presented. The procedure was used in two patients with upper brachial plexus injury involving loss of shoulder abduction and external rotation. Clinical evaluation and nerve conduction studies in both patients confirmed axonopathy of C5, C6 roots and C5 root, respectively. The proximal root stumps were unavailable for nerve grafting due to a very proximal root level scarring. The middle trunk fascicle was dissected on its superior surface and transferred to the non-functional suprascapular nerve. After 24 months follow up full abduction and external rotation could be achieved in both the patients. It is a simple and easy option for transfer to a suprascapular nerve in upper brachial plexus injuries. It lies next only to the upper trunk and does not require any additional dissection time. Donor deficit was not observed in our two patients.

Role of Early Referral and Surgical Intervention in Brachial Plexus Birth Palsy: Awareness Among Obstetricians and Pediatricians in a Teaching Hospital.

A cross-sectional study was conducted using a validated and standardized questionnaire answered by willing pediatricians and obstetricians at our university teaching hospitals. Nearly two thirds of the pediatricians (62.8%) and three fourths of the obstetricians (73.6%) continued to accept the terminology of obstetric brachial plexus birth palsy which is a misnomer; 32.6% of pediatricians felt that they were unaware of the current trends in its management. Parental reluctance (23.5%) and inadequate knowledge in current approaches among surgeons and pediatricians (41.2%) were suggested as chief causes for the delay in their adequate referral and management using surgical exploration, nerve grafting, and nerve transfer. The delayed presentations of birth brachial plexus injuries with missed opportunity for optimum treatment can be partly attributed to inadequate information available on definitive guidelines in its management among the stakeholders including parents, primary care physicians, and surgeons.

Volar Translunate Perilunate Dislocation: Case Report and Analysis of Review of Literature.

Volar translunate perilunate dislocations are the rarest form of perilunate dislocations with only a handful of cases reported till now. The injury mechanism is not uniform, and the pattern of injury does not follow traditional classifications. We report a case of volar translunate perilunate dislocation with a review of literature of very few previous reported cases of these rare injuries.

Outcomes of radialization for radial longitudinal deficiency: 20 limbs with minimum 5-year follow-up.

We report functional and cosmetic outcomes in 14 patients (six bilateral and eight unilateral) with type IV radial longitudinal deficiency who underwent radialization. Follow-up ranged from 5 to 19 years. Outcome measures were grip and pinch strengths, Percival and Sykes score, Vilkki score, Cattaneo grading, and a questionnaire to patients. Radiological assessment included the hand-forearm angle, the hand-forearm position, and ulna length and width. At final follow-up, the length of the affected ulna was 56% of the length of the normal ulna. The distal ulna hypertrophied to 97% of the opposite distal radius and a median loss of correction of hand-forearm angle was 9°. All hands improved on Vilkki severity grade and on the Cattaneo functional and aesthetic grading. We conclude that radialization is an effective procedure in these cases, but secondary procedures may be required for the long-term maintenance of wrist alignment and hand function. Level of evidence: IV.

Bilateral Bifid Median Nerve with Bilateral Carpal Tunnel Syndrome: An Atypical Presentation, a Rare Cause and a Familiar Disease.

We report a case of bilateral carpal tunnel syndrome (CTS) with bilateral bifid median nerve (BMN) without a persistent median artery diagnosed by clinical examination, NCV and Ultrasonography. Bilateral BMN to produce bilateral CTS is extremely rare and is contrary to the popular classifications which state that BMN without persistent median artery or its anomalies will not produce CTS. Ultrasonogram is of additional help to identify such aberrations in the median nerve to prevent iatrogenic injuries during carpal tunnel decompression.

A Prospective Study of Acute Undisplaced and Minimally Displaced Scaphoid Fractures Managed by Aggressive Conservative Approach.

BACKGROUND: To identify acute un-displaced and minimally displaced scaphoid fractures which are unlikely to unite with non-operative treatment at six weeks with CT scan and stabilize them with percutaneous screw fixation with the aim of preventing non-union. METHODS: A scaphoid series radiographs of wrist were obtained for patients with undisplaced or minimally displaced fractures and were immobilized in a thumb spica cast for six weeks. At six weeks, CT scan was done for patients showing doubtful signs of clinical and radiographic union. Patients with a gap less than 2 mm were continued on cast for an additional two to four weeks. Those with gap more than 2 mm underwent percutaneous screw fixation. In both cases the immobilisation was discontinued when the fracture was considered to be united and mobilization was initiated. RESULTS: 21 out of 39 patients managed initially with cast for six weeks showed clinical and radiological evidence of union. 18 patients showed persistent tenderness of which eight showed a clear gap in radiographs and 10 patients had doubtful union. Eight of these 10 patients on CT scan showed fracture gap of more than 2 mm while two patients showed fracture gap of less than 2 mm. Hence, 16 patients underwent percutaneous fixation. Repeat radiographs showed progression to union at an average of 3.8 weeks from surgery. Remaining two eventually united on continuing the cast. All patients showed confirmed union at one year on follow up. CONCLUSIONS: An objective measurement of fracture gap by CT scan at six weeks is useful in predicting cases with tendency for delayed union. Early percutaneous fixation of fractures would not further jeopardize the blood supply of fracture site. This aggressive conservative management also avoids unnecessary surgery in all acute scaphoid fractures.