Ulnar tunnel syndrome: pathoanatomy, clinical features and management.

Ulnar tunnel syndrome is compression of the ulnar nerve at the level of the wrist within Guyon's canal. It is most commonly caused by a ganglion cyst but may also be secondary to fractures, inflammatory conditions, neoplasm, vascular anomalies, aberrant musculature or a combination of these. Assessment should include a detailed history focusing on duration, site and progression of symptoms. The level of compression can be estimated clinically on examination by assessing motor and sensory changes in the hand. Investigations are used to confirm diagnosis or to clarify the underlying cause. X-rays and computed tomography can be used to exclude fractures. Ultrasound is used to diagnose ganglion cysts and vascular anomalies, and can localise the level of compression. Nerve conduction studies can be used to support the diagnosis and look for proximal compression. Mild symptoms can be managed non-operatively. Surgical exploration and decompression is the gold standard treatment for neuro-compressive causes with largely good outcomes.

Long-term donor site morbidity after free nonvascularized toe phalangeal transfer.

PURPOSE: Free nonvascularized toe phalangeal transfer is an established surgical option for the reconstruction of hypoplastic digits. This study assessed long-term morbidity in the feet using this technique. METHODS: We reviewed 40 children treated between 1991 and 2007 by free nonvascularized toe phalangeal transfer. The diagnosis was digital hypoplasia resulting from symbrachydactyly in 33 cases, constriction ring syndrome in 3 cases, thumb hypoplasia in 3 cases, and perinatal subclavian venous thrombosis in 1 case. The patients were followed up after surgery for a mean of 10 years (range, 3-19 y). The Oxford Ankle Foot Questionnaire was administered to patients and families to assess patient symptoms and patient and parental satisfaction. We assessed toe length ratio, the presence of visible deformity, and distal hypoplasia of the donor toes clinically and radiographically. RESULTS: Emotional problems related to foot appearance were common. We also found functional problems with footwear in some patients. All patients had floppy unstable toes with visible deformity. Increasing foot deformity was seen with growth, which led to deterioration in foot aesthetics, particularly where multiple donor toes had been harvested. We identified distal and middle phalangeal and metatarsal hypoplasia in the donor toes. CONCLUSIONS: Donor site morbidity for free toe phalangeal transfer is greater than previously documented. This should be considered during surgical decision making for reconstruction of hypoplastic digits. Preoperative counseling should include discussion regarding possible consequences of phalangeal harvest on donor toes and options for donor site reconstruction. Long-term follow-up of the donor site is essential to accurately assess results. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic III.

Onychomatricoma: an unusual case of ungual pathology. Case report and review of the literature.

Onychomatricoma represents a rare fibro-epithelial nail bed tumour. Numerous clinical variants of the condition have been described, and explicit diagnostic criteria have been recently developed. In this article, we outline the clinical and histopathological features of a case of onychomatricoma and review the literature with regards to the clinical presentation, differential diagnosis and management.

Prevention of high-pressure injection injuries to the hand.

OBJECTIVES: To identify populations at high risk for, and the usual mechanisms of injury in, high-pressure injection injuries to the hand. METHODS: A case note review of a historical cohort of 76 patients, presenting with high-pressure injections injuries to the hand over a 12-year period, collected information including sex, age, hand dominance, and occupation of the patient and mechanism of injury, when documented. RESULTS: Eighty-two percent of these injuries were work-related, affecting mainly manual workers (84%), including 13 painters, 10 mechanics, 8 farmers, and 3 water blasters. The mechanism of injury, recorded in 63%, was most commonly a ruptured hose or inadvertent gun discharge during cleaning or use. CONCLUSIONS: Preventative measures could include a targeted safety program for equipment users, engineering improvements in gun and hose design, economic incentives, and workplace legislation.

Slipper cast management of emergency foot problems.

Foot conditions are frequently seen in the emergency department. In many cases, although weight bearing is painful, it is not precluded, per se. When a soft dressing does not provide sufficient support, a below knee walking cast may be applied. We present an alternative dressing that may be of benefit in selected foot injuries. The dressing is fashioned with cast padding, foam sheeting and plaster. It is designed and molded to fit like a slipper. The plaster slipper has distinct advantages in that it is comfortable, lighter for the patient, and avoids the problem of ankle stiffness. We believe that this option is underused in the emergency setting.

Fiberglass cast application.

Plaster of Paris has been largely superceded for casting in orthopedic departments by synthetic cast materials. Despite its weight, its relative brittleness, its unpopularity with patients, and its messiness in application, plaster of Paris remains the mainstay of casting in the emergency department. This is due to a combination of economic reasons, the belief that synthetic casts leave less room for swelling and its relative ease of application compared to synthetic materials. We present a technique for synthetic cast application that avoids the problems of the rapidly setting cast and therefore allows the time for less experienced hands to produce a well-fitting cast or splint. We believe that this option, which allows the patient to have a lighter synthetic cast, rather than the traditional plaster of Paris cast, will be welcomed by both the patient and physician.

Convergence insufficiency: a treatable cause of problems in microsurgery.

Microsurgical training concentrates on the practical mechanisms of performing vessel anastomoses, with little attention given to medical problems that may adversely affect the trainee's performance. Undiagnosed vision problems are rarely considered in microsurgical training, and may not be manifested until other limiting factors, such as basic instrument and suture handling, are mastered. While vision problems tend to be diagnosed and treated immediately among ophthalmology trainees, visual and ocular pathology is poorly understood outside of that specialty. We present a case of a surgeon who had been performing microsurgery for 10 years with an undiagnosed binocular vision problem that consistently affected microsurgical proficiency. Once diagnosed, the problem responded to therapeutic exercises within weeks. We suggest ophthalmologic referral of any surgeon who has unexplained problems with microsurgical technique (especially problems involving stereoscopic vision) to exclude a treatable visual cause.