Anomalous Flexor Carpi Radialis Tendons Giving Rise to a Novel Surgical Technique in the Treatment of Thumb Carpometacarpal Joint Arthritis: A Case Report.

Introduction: Incidental discovery of anomalous muscles and anatomical variants within the forearm and wrist through surgical exposure and advanced imaging techniques is relatively common. Case Report: The patient presented with pain and swelling in her hand that was refractory to rest and anti-inflammatory medications. Here, we describe the intraoperative discovery of an anatomical variant of the flexor carpi radialis (FCR), as well as an anomalous flexor carpi radialis brevis (FCRB) in a 58-year-old patient being treated for thumb carpometacarpal joint (CMCJ) arthritis. Conclusion: To the best of our knowledge, this is the first description of both anomalies within a single patient and the first use of the surgical technique, described here, in treating the patient's thumb CMCJ arthritis. This report reinforces the importance of meticulous dissection and identification of individual anatomy to optimize patient outcomes.

Comparing Accuracy of Wrist Intra-articular Needle Placement Via Ulnocarpal Approach by Training Level: A Cadaveric Study.

Background: Intra-articular injections are a standard therapy and diagnostic tool for a variety of wrist conditions. Accurate needle placement is crucial for proper therapeutic benefit and prevention of complications. While some studies claim accurate needle placement requires imaging, others conclude that anatomical guidance is sufficient. This study aimed to evaluate the accuracy of intra-articular wrist needle placement with the ulnocarpal approach across differing levels of training using clinical anatomy alone. Methods: Fourteen fresh-frozen, above-elbow cadaveric specimens were used. Intra-articular needle placement into the wrist via an ulnocarpal approach was attempted by nine study participants: two interns, two junior-level residents, two senior-level residents, two hand fellows, and one attending hand surgeon. Each injection was performed based on clinical examination and landmarks alone. The number of attempts and total time taken for each injection was recorded. Results: Overall success rate was 71%, (89 of 126 attempts) and did not vary significantly across levels of training. Average time for needle placement among all participants was 10.9 ± 6.5 seconds. Timing of successful intra-articular needle placement (10.4 ± 5.2 seconds) significantly differed between levels. However, timing did not trend in any direction with more or less training. No significant difference was noted in total attempts or attempts with successful outcomes when comparing level of training. Conclusion: The ulnocarpal approach is a viable option for injection or aspiration of the wrist without image guidance. We were unable to show any relevant trends with timing or number of attempts in comparison to level of training. Level of Evidence: V.

Biomechanical comparison of plantar-to-dorsal and dorsal-to-plantar screw fixation strength for subtalar arthrodesis.

OBJECTIVE: To compare screw fixation strength for subtalar arthrodesis. METHODS: Eight matched pairs of cadaver feet underwent subtalar joint arthrodesis with two 7.3mm cannulated screws. Randomization was used to assign screw orientation, such that one foot in each pair was assigned dorsal to plantar screw orientation (DP Group), and the other foot, plantar to dorsal orientation (PD Group). Standard surgical technique with fluoroscopy was used for each approach. Following fixation, each specimen was loaded to failure with a Bionix ® 858 MTS device, applying a downward axial force at a distance to create torque. Torque to failure was compared between DP and PD Groups using Student's t test, with p=0.05 used to determine statistical significance. RESULTS: Statistical analysis demonstrated that the mean torque to failure slightly favored the DP Group (37.3Nm) to the PD Group (32.2Nm). However, the difference between the two groups was not statistically significant (p=0.55). CONCLUSION: In subtalar arthrodesis, there is no significant difference in construct strength between dorsal-to-plantar and plantar-to-dorsal screw orientation. The approach chosen by the surgeon should be based on factors other than the biomechanical strength of the screw orientation.

Biomechanical comparison of plantar-to-dorsal and dorsal-to-plantar screw fixation strength for subtalar arthrodesis / Comparação biomecânica da força de fixação de parafuso com orientação de plantar para dorsal e vice-versa para artrodese subtalar

ABSTRACT Objective To compare screw fixation strength for subtalar arthrodesis. Methods Eight matched pairs of cadaver feet underwent subtalar joint arthrodesis with two 7.3mm cannulated screws. Randomization was used to assign screw orientation, such that one foot in each pair was assigned dorsal to plantar screw orientation (DP Group), and the other foot, plantar to dorsal orientation (PD Group). Standard surgical technique with fluoroscopy was used for each approach. Following fixation, each specimen was loaded to failure with a Bionix ® 858 MTS device, applying a downward axial force at a distance to create torque. Torque to failure was compared between DP and PD Groups using Student's t test, with p=0.05 used to determine statistical significance. Results Statistical analysis demonstrated that the mean torque to failure slightly favored the DP Group (37.3Nm) to the PD Group (32.2Nm). However, the difference between the two groups was not statistically significant (p=0.55). Conclusion In subtalar arthrodesis, there is no significant difference in construct strength between dorsal-to-plantar and plantar-to-dorsal screw orientation. The approach chosen by the surgeon should be based on factors other than the biomechanical strength of the screw orientation.

RESUMO Objetivo Comparar a força de fixação dos parafusos para artrodese subtalar. Métodos Oito pares de pés de cadáveres frescos foram submetidos à artrodese da articulação subtalar com dois parafusos canulados de 7,3mm. A randomização foi usada para atribuir a orientação do parafuso, de modo que um pé em cada par foi designado com orientação de dorsal para plantar (Grupo DP), e o outro pé com orientação de plantar para dorsal (Grupo PD). Técnica cirúrgica padrão com radioscopia foi usada para os procedimentos. Após a fixação, cada amostra foi testada até a falha com um dispositivo Bionix®858 MTS, aplicando força axial descendente a uma distância para criar torque. O torque de falha foi comparado entre os Grupos DP e PD, usando o teste t de Student, com p=0,05 usado para determinar significância estatística. Resultados A análise estatística demonstrou que a média do torque até a falha favoreceu ligeiramente o Grupo DP (37,3Nm) em relação ao PD (32,2Nm). No entanto, a diferença entre os dois grupos não foi estatisticamente significativa (p=0,55). Conclusão Na artrodese subtalar, não há diferença significativa na força de compressão entre as orientações dos parafusos dorsal-plantar e plantar-dorsal. A abordagem escolhida pelo cirurgião deve ser baseada em outros fatores, sem preocupação com a força biomecânica da orientação dos parafusos.

Capillary Hemangioma of the Finger in an Adult after a Burn: A Unique Case Mimicking Pyogenic Granuloma.

INTRODUCTION: Capillary hemangiomas and pyogenic granulomas are benign vascular neoplasms that are usually identified clinically by their characteristic features. Capillary hemangiomasmost commonly develop in infancy on the head and neck and nearly all spontaneously ingress by the teenage years. Pyogenic granulomas, however, typically present in adults and can be induced by trauma. It is exceedingly rare for capillary hemangiomas to present in adulthood or after trauma. We present an extremely unusual case of capillary hemangioma on the tip of the finger of an adult male presenting immediately after a burn. The mass was clinically diagnosed as pyogenic granuloma but histopathologically diagnosed as a capillary hemangioma. To our knowledge, this is the only presentation of its kind. CASE REPORT: A 29-year-old African American, right-hand-dominant male laborer presented to the outpatient orthopedic hand clinic with a 2--week-old growing mass on the tip of the right small finger. A clinical diagnosis of pyogenic granuloma was made. Silver nitrate therapy was ineffective, though surgical excision resulted in complete resolution of the mass. Surprisingly, the histopathological diagnosis was instead consistent with capillary hemangioma. CONCLUSION: Clinicians should maintain a high clinical suspicion for both pyogenic granulomas and capillary hemangiomas in children and adults with a vascular soft tissue mass, even after trauma. With this in mind, health-care providers should maintain a low clinical threshold to send soft tissue masses for histopathology to obtain an accurate diagnosis and to provide the best care possible.

Outcomes of Staged Treatment for Complex Distal Radius Fractures.

Introduction Distal radius fractures are common, but the results and complications of treatment with early external fixation and staged open reduction internal fixation have not been previously reported. Materials and methods Patients who received staged distal radius fracture treatment from 1/1/2008 to 12/31/2015 at the University of Alabama at Birmingham were identified. Patient, injury, and treatment characteristics, as well as complications, were collected from the medical record. Results There were 50 fractures in 47 patients, with mean follow-up of 9.3 months. Thirty-eight were open and 45 were intra-articular. For definitive treatment, 41 received a volar approach and nine a dorsal approach. Twenty wrists experienced one or more complications, including two non-unions. Five patients developed infections - one Kirschner wire site infection, one external fixator (ex-fix) pin site infection, and three deep infections. All deep infections occurred in tobacco users. The rate of deep infection with volar approach was 2.4%, compared to 22.2% with dorsal approach. Ex-fix pin sites overlapped radiographically with the plate in 20 fractures, with three deep infections in this group (15%) and no deep infections in the group without overlap. None of these differences reached statistical significance. Conclusions This protocol results in reliable healing of complex fractures, with a 96% union rate. However, 40% sustained complications. We conclude that this protocol is useful for temporizing complex fractures but caution that the complication rate is high. Since recent literature indicates that low-grade open distal radius fractures do not require emergent debridement and that immediate internal fixation is safe, complications might be avoided by restricting this protocol to complex or physiologically unstable patients.

Extradigital Glomus Tumor with Atypical Neuritis Presentation.

Glomus tumors are rare tumors of the arteriovenous junction that play a role in temperature regulation. They are most commonly found in the subungual finger. We present the case of a 77-year-old female with a chief complaint of a painful mass in her ulnar wrist. The differential diagnosis at the time was broad. Following a detailed history and physical exam, the etiology was believed to be that of a peripheral nerve sheath tumor. The patient was taken to the operating room for resection and biopsy of the mass. Histological evaluation confirmed that the mass was a glomus tumor. Our patient's symptoms had completely resolved and functional status had improved to baseline by the time of her two-week postoperative clinic visit. This case report demonstrates the many complexities in the diagnosis of a glomus tumor and the important role of surgical treatment in obtaining relief from extradigital glomus tumors.