Multiple digit camptodactyly caused by anomalous ulnar sided flexor digitorum superficialis insertions.

We report an anomalous insertion of the flexor digitorum superficialis (FDS) tendon causing multiple digit camptodactyly. The abnormal tendon was present in the ring and middle fingers, passing from the FDS tendon (proximal to the proximal interphalangeal-PIP-joint) to the extensor expansion (distal to the PIP joint). It was present on the ulnar aspect only, with no corresponding structure on the radial side. Division of the anomalous insertion corrected the fixed flexion deformity at the PIP joint. This anomaly has not been reported in clinical or cadaveric studies and could have been overlooked if a volar approach had been used.

Cross-over limb replantation: a case report.

Following traumatic bilateral arm amputation in a 46-year-old woman, orthotopic replantation was not possible. The patient underwent replantation of the left forearm to the right proximal forearm. At two years she has a sensate hand, with good recovery of her long flexors of the hand and wrist extensors. DASH score is 93.9 and Chen's score is III (medium). We demonstrate a high level of function compared to the contralateral prosthetic limb. There have only been four similar cases described. Although a rare circumstance, a cross-limb replant can provide a level of function and independence superior to a simple prosthesis. Cross-limb transfer should be considered in situations where bilateral arm amputation is present and neither can be orthotopically replanted.

The anatomy of the subscapular nerves: a new nomenclature.

We propose a new nomenclature for the consistent, additional nerves that branch from the posterior cord of the brachial plexus. We hope this will aid the plexus surgeon and the evolution of plexus reconstruction for both obstetric and adult cases of injury.

Fanconi's anaemia and unilateral thumb polydactyly--don't miss it.

Fanconi's anaemia (FA) is a rare, life threatening inherited syndrome. Patients usually present late in the first decade of life with aplastic anaemia or acute myeloid leukaemia. FA children are also at high risk of solid organ tumours, anogenital squamous cancers, and endocrinopathies. These patients can present with unilateral radial abnormalities including thumb duplication. Hand surgeons can help achieve early diagnosis and improved survival in this group by early referral for screening. In a retrospective study of 202 children with radial ray anomalies seen over a 20 year period seven children had FA. Of these seven with FA, four had bilateral thumb hypoplasia and three had unilateral thumb anomalies--two unilateral thumb hypoplasias and one thumb duplication. The three children with unilateral anomalies were diagnosed late, presenting with bone marrow failure. All three have subsequently died following late bone marrow transplants. This study highlights the link between unilateral radial anomalies, including thumb duplication and FA and the importance of early genetic referral for diagnosis and surveillance.

Free tissue transfers in the first 2 years of life--a successful cost effective and humane option.

Experience shows that young children are favourable candidates for microsurgical reconstruction, having few of the established risk factors for flap failure. In children's reconstructive surgery free tissue transfer (FTT) permits reconstruction whilst retaining growth potential, and reduces the overall number and duration of care episodes, and their related distress to the child and family. We present one centre's experience of free tissue transfer in children less than 2 years of age, over a 15-year period, demonstrating that free tissue transfer can be successfully employed in children under 2 years old. Salient aspects of patient selection, pre-operative counselling, and per-operative management are presented. Data from all free flaps in children under 2 years of age at the time of surgery were collected prospectively. Forty-seven flaps were performed as 37 separate procedures, in 32 children under 2 years of age. In ten patients, double transfers were performed in single procedures. Free tissue transfers were performed for reconstruction of congenital defects, following trauma and meningococcal septicaemia. All but one flap survived. In our series operative and ischaemia times, re-exploration, complication and flap failure rates were not higher than in comparable adult or older paediatric series from this unit, suggesting that there is no microvascular, or other, factor inherent to the infant that should preclude the use of free tissue transfer. Individual microsurgeons with appropriate facilities should not be inhibited from performing free tissue transfers which are humane and cost effective when compared with alternatives for very young children.

Lower limb salvage to allow planned trans-tibial amputation.

Early, primary amputations are still necessary for certain patients sustaining high impact lower limb trauma. For cases with extensive proximal tibial bone loss a turn-up bone flap technique has been described to achieve a below-knee stump suitable for a prosthesis. However, in certain circumstances, for example if posterior soft tissues are injured, this type of reconstruction is not possible. This case report demonstrates that converting a severe open proximal tibial fracture to a successful below-knee amputation is also possible with acute limb shortening, flap cover and planned subsequent trans-tibial amputation.

Congenital brachial palsy: incidence, causes, and outcome in the United Kingdom and Republic of Ireland.

OBJECTIVES: To determine the incidence and study the causes and outcome of congenital brachial palsy (CBP). DESIGN: Active surveillance of newborn infants using the British Paediatric Surveillance Unit notification system and follow up study of outcome at 6 months of age. SETTING: The United Kingdom and Republic of Ireland. PARTICIPANTS: Newborn infants presenting with a flaccid paresis of the arm (usually one, rarely both) born between April 1998 and March 1999. MAIN OUTCOME MEASURES: Extent of the lesion at birth and degree of recovery at 6 months of age. FINDINGS: There were 323 confirmed cases giving an incidence of 0.42 per 1000 live births (1 in 2300). Significant associated risk factors in comparison with the normal population were shoulder dystocia (60% v 0.3%), high birth weight with 53% infants weighing more than the 90th centile, and assisted delivery (relative risk (RR) 3.4, 95% confidence interval (CI) 2.9 to 3.9, p = 0.0001). There was a considerably lower risk of CBP in infants delivered by caesarean section (RR 7, 95% CI 2 to 56, p = 0.002). At about 6 months of age, about half of the infants had recovered fully, but the remainder showed incomplete recovery including 2% with no recovery. The relative risk of partial or no recovery in infants with extensive lesions soon after birth compared with those with less extensive lesions was 11.28 (95% CI 2.38 to 63.66, p = 0.000005). CONCLUSIONS: The incidence of CBP in the United Kingdom and Republic of Ireland is strikingly similar to that previously reported nearly 40 years ago. Most cases are due to trauma at delivery, which is not necessarily excessive or inappropriate. Given the uncertainty about the appropriate management of these infants, serious consideration should be given to a formal clinical trial of microsurgical nerve repair.

Free hand-to-toe transfer: a method to minimise donor-site morbidity in free joint transfers.

Reconstruction of a congenital hand anomaly in a child using single free vascularised transfer of the proximal interphalangeal joint of a second toe with the simultaneous microvascular reconstruction of the donor toe using the stiff joint and its dorsal skin paddle from the hand is described. This is not the first reported case of a toe-finger switch, but it is the first in a free joint transfer, for which it is especially indicated.

Free phalangeal transfer: donor-site outcome.

The role of non-vascularised free proximal phalangeal transfer in digital reconstruction in children remains controversial. Significant cosmetic and functional deficits can result in the donor foot. We compare the donor-site outcome following a new technique of reconstruction using a cylindrical iliac-crest bone graft (n = 11) with the outcome following the technique previously described by Buck-Gramcko (n = 18). We have found better preservation of toe stability and length following the bone-graft technique.

The prespinal route in contralateral C7 nerve root transfer for brachial plexus avulsion injuries.

Contralateral C7 nerve root transfer for brachial plexus injury is described, passing the nerve through a subcutaneous tunnel on the anterior surface of the neck and chest. We recommend passing the nerve graft through the retropharyngeal space. This route has the benefits of a simpler dissection, a shorter distance and protected placement of the graft. It has been used in one clinical case.