Plate fixation in challenging traumatic carpal scaphoid lesions.

BACKGROUND: Complex fractures of the carpal scaphoid with poles fragmentation, edges comminution, bone loss and non-union of fractures previously treated by screw fixation remain challenging for hand surgeons. The authors present the indications, advantages and results of scaphoid plating, underlining the importance of correct plate positioning well shaped onto the bone. MATERIALS AND METHODS: The study includes 11 patients presenting acute fracture with distal pole fragmentation, acute fracture with comminution and non-union after prior failure of screw fixation. All patients were treated with volar locked plate fixation, adding a cortical bone graft in cases of non-union. RESULTS: Bone consolidation was achieved in all cases; excellent outcomes in fracture healing and relevant improvement in symptoms and functions were obtained in non-union group that are consistent with the literature. Only one patient underwent early further surgery (first row carpectomy) with poor results. CONCLUSION: The treatment of the selected scaphoid lesions with volar locked plate is a surely efficient technique. The plate can be easily adjusted to the shape of the scaphoid and can achieve an adequate correction of bone deformity and high degree of stability both in non-union and fractures.

Retrospective study in clinical governance and financing system impacts of the COVID-19 pandemic in the hand surgery and microsurgery HUB center.

INTRODUCTION: The authors presented a retrospective study in the surgical activity of the HUB center for Hand Surgery and Microsurgery in Emilia-Romagna comparing the data between March and April 2020, in the peak of Covid pandemic, with the same period in 2019. MATERIALS AND METHODS: During the two months period of March-April 2020 versus 2019 the authors analyzed the surgical procedures performed in elective and emergency surgery with hospitalization and Day or Outpatient surgery regime. Surgical treatments with no hospitalization were planned in the Day-Surgery Service. The financing system impacts were analyzed according to the Diagnosis Related Groups (DRG), the costs accounting method mostly used in European countries. RESULTS: An overall reduction of 68.5% was recorded in surgical procedures, with a more relevant reduction of 92.3% in elective surgery and a significantly less relevant reduction of 37.2% in urgent one. Replantation did not present a reduction in number of cases, while cutting lesions of tendons at the hand and fingers increased such as the bone and ligament injuries during domestic accidents. The negative impact in the financial system recorded a reduction of 32.5%. DISCUSSION: The epidemiology of hand trauma looks not only at the artisanal and industrial injuries, but also mostly at the accidents in daily life activities. The data of the study evidenced the significantly increase in the injuries occurring in the domestic environment. Elective surgery was canceled. The 86% of surgical procedures performed were urgent ones and the 72.8% of these were possible in Day and Outpatient surgery with significantly reduction in hospitalization. All procedures followed a rigid process for patient and healthcare workers with regard for personal protection and safety. Telemedicine was arranged in emergencies, and economic damage was analyzed also in the following rebound effect during summer period. CONCLUSIONS: The significantly less reduction recorded in urgent surgery vs the more relevant reduction in elective one showed how the hand injuries remained a major issue also during the lockdown. The data highlighted the relevant role of the organizational aspects of the surgical procedures and planning in hand trauma. Despite the financial impact of the elective surgery, the presence of a functional and skill Emergency Service and Day-Surgery Service resulted fundamental in the efficacy and efficiency of the patient management and in containment of economic damage. The telemedicine was significantly limited by liability and risk management issues.

A new sign allowing diagnosis in the pathologies of the extensor tendons of the hand.

INTRODUCTION: The thorough knowledge of the anatomy of the extensor tendon system of the hand is crucial for clinical examination and detection of tendon injuries. The Juncturae between the EDCII and other extensor tendons presents different incidences, shapes ("r" or "y") and morphologies (Type I, II, III). The EIP does not receive connection. These characteristics may result in variable effects on extensor tendons during active finger movements. The purpose of this study is to investigate and describe a new sign helping diagnosis for injuries or pathologies of EIP and EDC index finger (EDC II), based on a cadaveric dissection and clinical observation. MATERIALS AND METHODS: The authors performed a clinical observational study in 520 patients in order to distinctly evaluate by means of inspection and palpation the EIP and EDC II tendons and an anatomical analysis of extensor tendon apparatus of long fingers was then performed in 89 cadaver hands focusing the investigation on the juncturae system. RESULTS: The observational studies showed that during the flexion of the III, IV and V fingers, associated to the active extension of the I and II fingers, the EDC of the III, IV and V fingers moved the EDC II in ulnar direction by means of juncturae action. The EIP remained in its position becoming visible and isolated from the migrated EDC II. CONCLUSIONS: This feature allows the distinct clinical evaluation by observation and palpation of both EDC II and EIP tendons and may be helpful in clinical conditions such as diagnosis of tendon lesions, pre-operative planning of EIP transfer and extensor tendon tenolysis associated to soft tissue scar at the second MPj.

A mini-invasive tenolysis of the flexor tendons following hand fractures: case series.

INTRODUCTION: The treatment of the flexor tendon adhesions following phalanx and metacarpal fractures, in closed or open injuries, is a great challenge for the hand surgeon. The outcomes are often poor, because of the severity of the lesion and the aggressiveness of the surgical procedure of the secondary tenolysis. MATERIALS AND METHODS: The authors describe the technical findings and the results of a new mini-invasive tenolysis in order to treat the adhesions in zone 1 and 2 of the fingers, following phalangeal and metacarpal fractures. With an atraumatic Allis or Duval surgical forceps, the flexor tendons are separately and gently tracted making a twisting movement on themselves until the adhesions were torn and the tendons appeared released. RESULTS: The relevant outcomes achieved show this technique is very useful to treat tendon adhesions, without adding trauma and scare to the tendinous canal and surrounding soft tissues.

The carpal tunnel syndrome in children.

INTRODUCTION: Carpal tunnel syndrome (CTS) in children represents a complex challenge for the hand surgeon because of its rarity, poor patient cooperation, frequently associated malformation syndromes and mental retard, atypical symptoms and nuanced and poor sensitivity of instrumental tests. The most frequently associated causes with the CTS in children are rare congenital malformations and diseases, requiring an overall assessment of the young patient and a high degree of suspicion for the potentially associated canalicular syndrome. On the other hand, the associated syndromes may be the main ally for a diagnosis that starts from the knowledge of the literature and the surgeon's suspicion by observing the child wailing. Early diagnosis and decompression treatment is mandatory. MATERIALS AND METHODS: The authors report a case series of 26 children and analyze the etiology and diagnostic algorithms. Patient assessment was based on complete clinical examination and medical history collection of these young patients with the involvement of the family and educators. RESULTS: In all 26 patients treated, along an average period of 23 months (minimum 12, maximum 30), no signs of recurrence or persistence of median nerve disturbances were recorded. CONCLUSIONS: In conclusion, we believe that anamnesis, a careful physical examination and analysis of instrumental examinations, should be accompanied by a thorough knowledge of rare diseases in the context of congenital malformations. The carpal tunnel syndrome, while well known and treated by each orthopedic surgeon, reveals a mysterious aspect in the context of the "fabulous" world of childhood illnesses, even more difficult than rare congenital diseases.

Hyaluronic acid scaffold for skin defects in congenital syndactyly release surgery: a novel technique based on the regenerative model.

Syndactyly release may require skin grafting to fill the skin defects, which might lead to complications or poor cosmetic outcomes. A simple graftless technique for syndactyly release with a hyaluronic acid (HA) scaffold used to cover the bare areas is described. Between 2008 and 2011, release of 26 webs in 23 patients was performed. All skin defects were covered with Hyalomatrix(®) PA. One patient was excluded due to early post-operative infection that required HA scaffold removal before its integration. Web creep, secondary deformities, scar quality, and patient and parental satisfaction were assessed. Mean follow-up of the group of 22 patients was 24 months. There were no secondary deformities and minimal degree of web creep. All patients had close to normal pigmentation and good pliability at the sites of scaffold application. The results confirm the use of a HA scaffold as a promising alternative to skin grafting in syndactyly release surgery.

Ligamentous reconstruction of scapholunate dislocation through a double dorsal and palmar approach.

Six patients were treated for scapholunate dissociation by reconstruction of both the palmar and dorsal parts of the scapholunate interosseous ligament through a combined palmar and dorsal approach. The mean active range of motion of the wrist at final follow-up was 44 degrees of flexion and 58 degrees of extension and the mean hand grip strengths was 88% of that of the contralateral hand. The average time to return to work was 105 days and the mean DASH score at a mean follow-up of 32 months was 18. At follow-up, radiographs showed maintenance of the anatomical reduction of the scapholunate articulation in all cases and the scapholunate angle was normal in five patients.

The upper limb in cerebral palsy: surgical management of shoulder and elbow deformities.

The authors report a simple chart that offers a comprehensive picture of spasticity of the upper limb and provides a more objective method of recording data. Distinction is made between fixed postures and the residual active range of motion at the shoulder and elbow. The presence and function of the muscles can be identified easily on dynamic EMG studies, which are essential for understanding the degree of spasticity and dyssynergy related to a single muscle. When spasticity of the upper arm is managed with a global approach and objectives are defined clearly in advance with the patient and caregivers, treatment of shoulder and elbow deformities can achieve important results for personal hygiene or functional targets.