Middle finger tenolysis using WALANT surgical technique in a pediatric patient: A case report.

INTRODUCTION AND IMPORTANCE: Wide Awake Local Anesthesia No Tourniquet (WALANT) is a surgical technique used in hand surgery that allows for active patient participation during surgery while avoiding the pain and discomfort associated with general anesthesia and tourniquets. Using this technique for tenolysis enables a surgeon to assess the repair intraoperatively. However, this technique is more commonly used in adults than in pediatric patients. We aimed to present a case that may contribute to the use of the WALANT technique on the pediatric population. CASE PRESENTATION: This case presents the successful use of the WALANT technique multiple times in a 7-year-old Hispanic male patient to repair recurrent tendon adhesions and joint contracture due to a prior gunshot wound that caused a comminuted, displaced fracture with intra-articular extension of the third finger. CLINICAL DISCUSSION: To the best of our knowledge, few reports and case series of WALANT hand surgery in children are available within the literature. The presented case is rare in terms of the mechanism of injury, the age of the patient, and the fact that multiple WALANT interventions were successfully performed on the same patient. CONCLUSION: Our findings showcase the potential of the WALANT technique on pediatric patients as an alternative to traditional techniques. Due to the scarcity of pediatric WALANT cases in the literature, and the benefits provided by the technique, this case report may be of clinical relevance.

Effect of Proximal Row Carpectomy and Wrist Arthrodesis on the Resting Length of Extrinsic Digit Flexor Tendons: A Cadaveric Study.

Background Spastic joint contractures remain a complex and challenging condition. For patients with upper extremity spastic dysfunction, improving the muscle balance is essential to maximize their hand function. Multiple procedures, including proximal row carpectomy (PRC) and wrist arthrodesis (WA), are considered among the different surgical alternatives. However, the biomechanical consequences of these two procedures have not been well described in current literature. Hence, the objective of our study is to assess the change in the extrinsic digit flexor tendon resting length after proximal row carpectomy and wrist arthrodesis. Methods Six fresh-frozen cadaver upper extremities (four females and two males) with no obvious deformity underwent dissection, PRC, and WA. All the flexor digitorum profundus (FDP), flexor digitorum superficialis (FDS), and flexor pollicis longus (FPL) tendons were marked proximally 1-cm distal to their respective myotendinous junction and cut distally at the marked point. The overlapping segment of each distal flexor tendon from its proximal mark was considered the amount of flexor tendon resting length change after PRC and WA. A descriptive evaluation was performed to assess the increment in tendon resting length. Additionally, a regression analysis was performed to evaluate the relation between the tendon resting length and the proximal carpal row height. Results Following PRC and WA, the mean digit flexor tendon resting length increment achieved across all tendons was 1.88 cm (standard deviation [SD] = 0.45; range: 1.00-3.00 cm). A weak direct relationship ( R = 0.0334) between the increment in tendon resting length and proximal carpal row height was initially suggested, although no statistical significance was demonstrated ( p = 0.811). Conclusion This study provides an anatomic description of the increased extrinsic digit flexor tendon resting length after PRC and WA in cadaveric specimens. Findings provide a useful framework to estimate the amount of extrinsic digit flexor resting length increment achieved after wrist fusion and the proximal carpal row removal.

Recurrent Diffuse Pigmented Villonodular Synovitis in the Hand of a Pediatric Patient: A Case Report.

Diffuse pigmented villonodular synovitis is characterized by synovial inflammation and hemosiderin deposition. It mainly occurs in adults, with the hip and knees being the most common sites of involvement. It is associated with high recurrence rates, with open synovectomy being the most common treatment method to avoid recurrences. Few cases of diffuse pigmented villonodular synovitis have been reported in pediatric patients, especially in uncommon locations such as the hand. This case presents pathology-confirmed diffuse pigmented villonodular synovitis in the hand of a pediatric patient with multiple recurrences despite adequate surgical margins. The patient underwent mass excision with adjuvant radiation treatment after his last recurrence, with excellent functional outcomes and no recurrence at the five-year follow-up.

Non-union in a hook of hamate fracture of a skeletally immature baseball player.

An isolated hook of hamate fracture is an extremely rare condition in skeletally immature patients. Early diagnosis and treatment are vital for the functional outcome of athletes such as baseball players. The hook of hamate fracture may be missed at initial presentation due to nonspecific symptoms and false-negative radiographs, which may eventually lead to a nonunion. Currently, there is no clear indication of surgical intervention for nonunion of the hook of hamate in a skeletally immature patient. This report presents the case of a twelve-year-old skeletally immature male with a hook of hamate fracture who underwent surgical bone fragment excision three months after initial injury due to a nonunion of the hamate bone. At the two-year postoperative visit, excellent results were obtained, and patient was able to continue his sports activity without any functional impairment.

Post-traumatic tenosynovial chondromatosis following a triquetrum fracture: a case report.

Tenosynovial chondromatosis (TC) is a rare progressive benign tumor from the synovial lining of tendon sheath. The TC mostly affects males between the ages 30 to 50 years old at the ventral side of wrist. There are two different forms of TC that have been proposed in previous studies: an idiopathic cause (primary TC) and a joint related diseases cause (secondary TC). Even though trauma has been written to be a common reason for TC, a case of a secondary TC affecting the dorsal wrist following a triquetrum fracture has never been written before. The aim of this report is to present a rare case of a solitary post-traumatic TC at the dorsal wrist following a triquetrum fracture. We describe the clinical presentation, imaging modalities, histopathological and treatment challenges to manage this difficult lesion.

Functional and Disability Assessment Among Hispanics With Zone 2 Flexor Tendon Injuries: Comparative Study Between Flexor Digitorum Superficialis Repair and Flexor Digitorum Superficialis Excision.

INTRODUCTION: Flexor tendon lacerations in zone II have been reported to be the most complicated of all tendon injuries. Currently, there is no consensus on treatment in surgical management for patients with flexor tendon laceration of flexor digitorum profundus and flexor digitorum superficialis (FDS). The aim of this study was to evaluate whether the repair of FDS tendons provided superior functional outcomes compared with FDS excision in Hispanic patients. METHODS: Total active motion, original Strickland criteria, and the disability of arm shoulder and hand questionnaire were provided postoperatively at 3 and 6 months to all consecutive Hispanic patients who underwent zone II flexor tendon repair. The cohort was divided into two groups, those who underwent FDS repair and those underwent FDS excision. RESULTS: Functional and disability outcome analysis showed a notable improvement with FDS repair using total active motion, Strickland criteria, and disability of arm shoulder and hand score at the 3 months postoperative interval. No statistical differences were identified regarding functional and disability outcomes at the 6-month evaluation between both groups. CONCLUSIONS: Among Hispanics, the FDS-repaired group had similar functional and disability outcomes at their 6 months postoperative evaluation compared with the FDS-excised group. Increased awareness for tendon rerupture during the initial 3 months of index surgery is recommended for FDS-excised patients.

Management of Open Tibial Shaft Fractures: Does the Timing of Surgery Affect Outcomes?

BACKGROUND: Open tibial shaft fractures require emergent care. Treatment with intravenous antibiotics and fracture débridement within 6 to 24 hours is recommended. Few studies have examined outcomes when surgical treatment is performed >24 hours after occurrence of the fracture. METHODS: This retrospective study included 227 patients aged ≥18 years with isolated open tibial shaft fractures in whom the time to initial débridement was >24 hours. The statistical analysis was based on time from injury to surgical débridement, Gustilo-Anderson classification, method of fixation, union status, and infection status. RESULTS: Fractures débrided within 24 to 48 hours and 48 to 96 hours after injury did not show a statistically significant difference in terms of infection rates (P = 0.984). External fixation showed significantly greater infection rates (P = 0.044) and nonunion rates (P = 0.001) compared with intramedullary nailing. CONCLUSION: Open tibial shaft fractures should be débrided within 24 hours after injury. Our data indicate that after the 24-hour period and up to 4 days, the risk of infection remains relatively constant independent of the time to débridement. Patients treated with external fixation had more complications than did patients treated with other methods of fixation. Primary reamed intramedullary nailing appears to be a reasonable option for the management of Gustilo-Anderson types 1 and 2 open tibial shaft fractures. LEVEL OF EVIDENCE: Level III retrospective study.