Index finger acrometastasis: A unique lung cancer case report.

INTRODUCTION AND IMPORTANCE: Hand metastases are notably rare, comprising around 0.1% of all metastatic diseases, mainly originating from lung cancer, which is responsible for 30-40% of such cases. This report highlights a rare occurrence of distal phalangeal metastasis in a patient with Lynch syndrome, underscoring the diagnostic challenges associated with hand metastases. CASE PRESENTATION: A 70-year-old male diagnosed with Lynch syndrome 35 years ago, following colon adenocarcinoma, presented with severe inflammatory lesions on his right index finger. Patient had previous liver segmentectomies to remove metastatic lesions and had multiple cutaneous squamous cell carcinomas in various regions. Recent diagnostics, including a chest CT, identified a thoracic mass suggestive of squamous cell lung carcinoma. Histopathological analysis confirmed the metastasis of lung cancer to the index finger, necessitating a transphalangeal amputation. CLINICAL DISCUSSION: Hand metastases are extremely infrequent, often mimicking other conditions and requiring a high index of suspicion for accurate diagnosis. This case reinforces the lung as a frequent origin of hand metastases and the significance of elevated EGFR expression in facilitating metastatic spread. CONCLUSION: The rarity of hand metastasis in patients with genetic predispositions like Lynch syndrome calls for heightened vigilance and an integrated management approach. It highlights the critical role of histopathology in diagnosis and the need to consider genetic factors in treatment planning. Further research is encouraged to understand the mechanisms enabling certain cancers to metastasize to the hand and the role of genetic conditions in these processes.

Extensor tendon rupture and preoperative mri confirmations of suture anchor prolapse: a case report and literature review.

BACKGROUND: While suture anchors are widely used in medical procedures for their advantages, they can sometimes lead to complications, including anchor prolapse. This article presents a unique case of suture anchor prolapse at the base of the distal phalanx of the little finger after extensor tendon rupture reconstruction surgery. CASE PRESENTATION: A 35-year-old male, underwent extensor tendon rupture reconstruction using a non-absorbable suture anchor. After seven years the patient visited our outpatients complaining of stiffness, pain, and protrusion at the surgical site. Initial X-ray imaging suggested suggesting either a fracture of the distal phalanx or tendon adhesion but lacked a definitive diagnosis. Subsequent magnetic resonance imaging (MRI) revealed bone connectivity between the middle and distal phalanges with irregular signal shadow and unclear boundaries while maintaining a regular finger shape. MRI proved superior in diagnosing prolapsed suture anchors, marking the first reported case of its kind. Surgical intervention confirmed MRI findings. CONCLUSIONS: Suture anchor complications, such as prolapse, are a concern in medical practice. This case underscores the significance of MRI for accurate diagnosis and the importance of tailored surgical management in addressing this uncommon complication.

Fracture or Not: An Easily Mistaken Benign Finding in a Tuberous Sclerosis Patient.

Tuberous sclerosis (TSC) is a rare autosomal dominant disorder that can affect multiple organ systems, including the brain, heart, lungs, and skin. Cutaneous manifestations are common, including ungual fibromas, however, these may be mistaken for other pathologies. Here, we present the case of a 14-year-old with TSC complaining of traumatic left little finger pain. Radiographic evaluation revealed cortical scalloping of the nailbed, concerning for a non-displaced fracture. Given the history of TSC, however, this defect may have also represented a periungual fibroma. The patient subsequently underwent conservative management and an eight-month radiographic follow-up showed no osseous remodeling, supporting the diagnosis of periungual fibroma. It is imperative for clinicians to understand the cutaneous manifestations of TSC to aid in proper diagnosis and avoidance of unnecessary treatment. In this case, interval follow-up confirmed the diagnosis and excluded fracture.

A 3D-Printed Dummy for Training Distal Phalanx Amputation in Mice.

The development of realistic dummies for training the distal phalanx amputation (DPA) technique in mouse pups is a promising alternative to reduce and replace animals in training for research and teaching. To test this, we obtained micro-CT data from postnatal day-five mouse pups, meticulously segmented them, and converted them into a 3D mesh format suitable for 3D printing. Once the dummy was printed, it was evaluated during actual training courses in two different groups: in the first group, users received no dummies to train the DPA, and in the second group, users were trained with three dummies. To assess the effectiveness of the dummy, we conducted a survey followed by an expert veterinarian evaluation. Our results showed that DPA is a complex procedure, and it is commonly poorly performed. When implementing the dummies, users who were not provided with dummies to practice only had an 8.3% success rate in DPA, while users provided with three dummies had a 45.5% success rate, respectively. Despite additional research being needed, our dummy offered improved practical training by providing a safe and effective alternative in line with ethical considerations while demonstrating the feasibility of using 3D printing technology to promote the 3Rs in experimental research.

Radiographic assessment of normal parameters of forelimb distal phalanx in Turkmen horses.

The Turkmen horse is one of the oldest breeds in the world with unique characteristics in agility, endurance and jump, being publicly acclaimed. Laminitis affects the limbs and decreases athletic performance. Radiographic evaluation is essential to confirm the sinking diagnosis in every breed of a horse suffering from laminitis. Since no information about distal phalanx radiographic measurements in this breed has been reported, the current study was designed and conducted. In the present study, 24 clinically sound registered Turkmen horses of both sexes (15 mares and nine stallions) were selected. Lateromedial radiographic views of both front distal phalanges were taken, focusing on the distal phalanx. After magnification correction, images were used to measure founder distances (FD) and other distal phalanx radiographic measurements using an image processing program. There was no significant difference between radiographic measurements of the left and right front feet. The FD had a significant positive correlation with weight. The horses under 3 years of age had a significantly greater U angle than the horses over the age of three. Also, palmarocortical length (PCL) in the Turkmen stallions was significantly higher than mares. In this investigation, PCL in horses under the age of three was significantly lower than horses over 3 years of age. The values determined in this study can be used as baseline data of front feet in Turkmen horses.

Development of a simplified new method of bone age estimation using three bones of the hand and wrist.

Though the Greulich and Pyle (GP) method is easy, inter-observer variability, differential maturation of hand bones influences ratings. The Tanner-Whitehouse (TW) method is more accurate, but cumbersome. A simpler method combining the above, such that it utilizes fewer bones without affecting accuracy, would be widely used and more applicable in clinical practice. OBJECTIVES: 1. Devising a simplified method utilizing three bones of the hand and wrist for bone age (BA) assessment. 2. Testing whether the 3 bone method gives comparable results to standard methods (GP,TW2,TW3) in Indian children. METHODS: Developmental stages and corresponding BA for radius, hamate, terminal phalanx (left middle finger) epiphyses combining stages from GP,TW3 atlases were described; BA were rated by two blinded observers. 3 bone method ratings were compared with the same dataset analyzed earlier using GP,TW2,TW3 (4 raters). RESULTS: Radiographs analysed:493 (Girls=226). Mean chronological age:9.4 ± 4.6 yrs, mean BA 3 bone:9.8 ± 4.8 yrs, GP:9.6 ± 4.8 yrs, TW3:9.3 ± 4.5 yrs, TW2:9.9 ± 5.0 yrs. The 3 bone method demonstrated no significant inter-observer variability (p = 0.3, mean difference = 0.02 ± 0.6 yrs); a strong positive correlation (p < 0.0001) with GP (r = 0.985), TW3 (r = 0.983) and TW2 (r = 0.982) was noted. Bland-Altman plots demonstrated good agreement; the root mean square errors between 3 bone and GP,TW3,TW2 ratings were 0.6,0.7,0.6 years; mean differences were 0.19,0.49,-0.14 years respectively. Greatest proportion of outliers (beyond ±1.96 SD of mean difference) was between 6 and 8 years age for difference in 3 bone and GP, and between 4-6 years for difference in 3 bone and TW3,TW2. CONCLUSION: The 3 bone method has multiple advantages; it is easier, tackles differential maturation of wrist and hand bones, has good reproducibility, without compromising on accuracy rendering it suitable for office practice.

Radiological features of arterial channels in the equine third phalanx measured using a novel customized software represent changes of laminitis.

OBJECTIVE: To identify and measure radiolucencies at the solear margin of the distal phalanx in radiographs of healthy and laminitic hooves. SAMPLE: Clinical records and dorsoproximal-palmarodistal radiographs of equine forelimbs with radiological diagnoses of either laminitis (n = 40, L) or navicular syndrome (n = 40, NS). METHODS: Outlines of the radiolucent structures at the solar margin were drawn in ImageJ, and a customized novel plugin "Arteries Analyzer/ImageJ" was used for measurements. The diverging radiolucencies outside the terminal arc of the distal phalanx were differentiated as arterial channels (open at the solear margin) and ellipses (closed at the solear margin). Comparisons between L and NS, between distal phalanges with and without ellipses, and of arterial channels and ellipses in areas were compared using Wilcoxon and the Mann-Whitney U tests, respectively. The reliability and repeatability of the method were tested using Friedman's test. RESULTS: Fewer arterial channels but more ellipses were identified in L than in NS. In phalanges with ellipses (n = 47), the number of ellipses and the number of arterial channels were negatively correlated (PCC -0.181, P = .224). The number of ellipses correlated positively with the severity of laminitis (PCC 0.495, P < .001; n = 80) and with the degree of rotation of the distal phalanx (PCC 0.392, P < .001; n = 80). CLINICAL RELEVANCE: The software tool successfully measured arterial channels and ellipses outlined by the evaluators. Results indicate that healthy arteries develop into pathological ellipses in laminitic feet. This may be used to complement the interpretation of radiographs and support clinical decision-making.

Subungual Hematoma.

The authors present the case of a 64-year-old male who presented to the emergency department due to foot trauma. He sustained a large subungual hematoma, which was drained. Following the procedure, the patient achieved complete resolution of his pain. He also reported no complications at two-week phone follow-up. The management of subungual hematoma, including the trephination procedure, is discussed. Potential complications, although rare, are reviewed.

Distraction Osteogenesis for the Brachytelephalangic Thumb - A Case Report.

Brachytelephalangy is a congenital condition characterised by the shortening of the distal phalanges, which affects appearance but does not cause severe functional disability. Therefore, most hand surgeons do not consider it to require surgical treatment, and there are limited options to improve the appearance of the affected digits. We present the case of a 55-year-old male patient with congenital brachytelephalangy of the thumb, who underwent a bone lengthening procedure using distraction osteogenesis with the Ilizarov minifixator. The distal phalanx was carefully osteotomised and gradually lengthened up to 5 mm with no adverse events observed. The patient was satisfied with the natural appearance of his thumb after the surgery. This gradual callus distraction method is a radical solution for people with brachytelephalangy, particularly after epiphyseal closure and can manage the external fixator on their own. Level of Evidence: Level V (Therapeutic).

Fractures of the phalanges.

Fractures of the phalanges encompass a wide range of injury patterns with variable articular and soft tissue involvement. The goals of treatment whether conservative or surgical are the restoration of function while limiting the risk of complications. An armamentarium of fixation options allows the surgeon to appropriately treat these fractures with the intention of initiating early postoperative mobilization. Previous publications report variable rates of complications following internal fixation of phalangeal fractures which represents an unsolved problem. It is incumbent on the surgeon to utilize meticulous surgical technique, achieve anatomic reduction with stable fixation and initiate early postoperative mobilization where indicated. In the following text, we review the management of most types of phalangeal fractures, except fracture-dislocations of the proximal interphalangeal joint. These injuries comprise a wide spectrum of presentation; thus, an understanding of anatomical and mechanical principles is integral to achieving a successful outcome.

Transmural Ultrasonography in the Evaluation of Horse Hoof Internal Structures: Comparative Quantitative Findings-Part 2.

The transmural ultrasound allows for the definition of the normal appearance of the hoof tissues and internal structures. Determining such measurements and proportions could contribute to evaluations of the normal spatial distal phalanx-hoof relationship. The objective was to describe the hoof's dermis and epidermis measurements using the transmural technique, in comparison with DR and anatomical sections. Sixty-two healthy hooves without digital radiographic abnormalities, made up of 30 anatomical pieces (phase 1) and 32 alive horse hooves (phase 2), and 16 sagittal sections of the first ones were used. The proximal and distal planes were compared, defining the following measurements: coronary band-extensor process, distal phalanx apex-hoof wall, sole dermis, middle stratum, parietal dermis, lamellar layer, the sublamellar dermis, and ratios between them. Most of the measurements were consistent among methods. Some showed measurement differences and a minority was impossible to determine. The transmural technique allowed for the observation and replication of measurements of the hoof structures, described with other diagnostic aids. It also allowed for the implementation of new measurements that would help to determine the spatial location of the distal phalanx. Additionally, it contributes to the visualization of normal findings, which will be useful to compare variations in the different phases of laminitis.

Zone 1 Flexor Tendon Repairs: Laceration and Avulsion Injuries.

In contrast to other zones of the hand, zone 1 flexor tendon injuries include laceration as well as avulsion mechanisms. Although zone 1 tendon lacerations are treated similarly to other zones, with various suture configurations and techniques, zone 1 avulsion injuries often require repair of tendon to bone. Proximity of the repair site to the distal interphalangeal joint often results in persistent flexion contracture and stiffness. Despite these differences in injury mechanism and location, zone 1 flexor tendon repairs are well tolerated and often lead to fair-high patient satisfaction.

Intraosseous Schwannoma of the Distal Phalanx.

Intraosseous schwannomas are extremely rare and only a few cases involving the proximal phalanx and metacarpal of the hand have been reported. We report a patient with an intraosseous schwannoma of the distal phalanx. Radiographs showed lytic lesions in the bony cortex and enlarged soft shadows of the distal phalanx. The lesion was hyperintense to fat on T2-weighted magnetic resonance imaging (MRI) and strongly enhanced after gadolinium (Gd) administration. Surgical findings revealed that the tumour had developed from the palmar side of the distal phalanx and the medullary cavity was filled with a yellow tumour. The histological diagnosis was schwannoma. A definitive diagnosis of intraosseous schwannoma using radiography is difficult. In our case, a high signal was observed on Gd-enhanced MRI and histological findings showed areas with a high cellular area. Thus, Gd-enhanced MRI may help in the diagnosis of intraosseous schwannomas of the hand. Level of Evidence: Level V (Therapeutic).

Incidental finding of a hidden central polydactyly: A case report.

Congenital hand anomalies are common, and must always be considered as a differential diagnosis in patients with hand pathology. We report the case of a child who sustained a fingertip injury to highlight an unusual presentation of central polydactyly.

Metastases to the nail unit and distal phalanx: a systematic review.

Metastases to the nail unit/distal phalanx (NU/DP), although rare, carry a poor prognosis and are frequently misdiagnosed due to variable clinical presentation. Metastases to the NU/DP may be the initial presenting sign of a new or recurrent malignancy. Since the most recent systematic review of case reports (133 patients total) was conducted in 2001, we conducted a systematic review from 1900 to 2021 (244 patients total) to assess any changes in trends in demographics, clinical presentation, and morphology and to report on more updated differential diagnoses. We also examined cases for age, sex, race, ethnicity, Fitzpatrick skin type, laterality, distribution, and diagnostic methods. The PubMed database (1900-2021) was used to detect case-level data per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We found that the most common primary tumors were lung, kidney, and esophagus. A NU/DP metastasis was the presenting sign of malignancy in 31.00% of patients without a former cancer diagnosis. Male to female ratio was 2:1, with average age at diagnosis 58 years. Metastases most often affected a single digit (79.91%), particularly the thumb, followed by the fourth digit. This systematic review corroborates that metastases to the NU/DP may be the initial presenting sign of a new or recurrent malignancy and provides updated diagnostic guidelines. NU/DP metastasis should be considered in both healthy patients and patients with a former malignancy diagnosis presenting with nail changes involving a single digit. Prompt diagnosis and treatment may improve prognosis.

Giant Cell Tumor of Tendon Sheath of the Distal Phalanx.

Giant cell tumor of tendon sheath (GCTTS) is a benign proliferative disorder of the synovial joints and tendon sheaths that typically manifests as a painless, firm, localized, and slow-growing mass. Commonly seen among women in the third to fifth decades, GCTTS can be diagnosed clinically; however, histopathological confirmation is required. The tumor is primarily removed surgically. Recurrence after excision is possible and occurs in up to 45% of cases.

Use of a Fascial Reverse Dorso-Ulnar Metacarpal Bone Flap for Non-union of the Distal Phalanx of the Thumb: A Case Report.

Reports describing the treatment of non-union of the distal phalanx of the thumb are limited. We present the case of a 45-year-old man who developed a symptomatic non-union after an open fracture of the distal phalanx of the thumb. He was treated with a reverse dorso-ulnar vascularised fascial metacarpal bone flap. Bone union was achieved 3 months post surgery, and he was well at 7 months post surgery. The reverse dorso-ulnar fascial metacarpal bone flap is an alternative to consider in patients with non-union of the distal phalanx of the thumb. Level of Evidence: Level V (Therapeutic).

Identifying Predictors of Radiographic Distal Phalangeal Nonunion After Fingertip Replantation.

PURPOSE: This study aimed to estimate the risk factors for distal phalangeal nonunion in cases involving Kirchner wire fixation after successful fingertip replantation. METHODS: This study retrospectively analyzed 116 digits of 111 patients, including 74 and 42 digits with replantation in Tamai zones I and II, respectively. Univariate and multivariable analyses were performed to assess the influences of 15 independent variables on nonunion, including age, sex, medical history of diabetes mellitus, history of smoking, injured hand and digit, injury type (clean, blunt, and crush-avulsion), amputation type (complete or incomplete), length of the distal bone fragment (mm), fracture type (simple or comminuted), presence of a bone defect, length of the fracture gap after fixation (mm), number of Kirchner wires used, evidence of venous repair, and the occurrence of pin tract infections after fixation. RESULTS: At 12 months after replantation, 100 digits showed bony union and 16 (13.8%) digits showed radiographic nonunion or equivalent complications, including 9 digits with asymptomatic nonunion without a secondary operation, 5 that underwent an additional operation for nonunion or a complication, and 2 with distal bone resorption. A multivariable analysis indicated that the postfixation fracture gap was the only significant predictor influencing nonunion (odds ratio, 3.30; 95% confidence interval, 1.92-5.68). CONCLUSIONS: The extent of the postfixation fracture gap had the greatest influence on preventing distal phalangeal nonunion, indicating the importance of reducing the fracture gap in primary fixation as much as possible. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Osteotomies of the second phalanx of the great toe: A clinical experience.

BACKGROUND: At the time of the first report on the feasibility of corrective osteotomies of the distal phalanx (DP) of the great toe there were no published studies addressing this type of surgery. Along this line, and throughout our clinical experience, this paper tries to show the clinical benefits of hallux DP osteotomies when correcting interphalangeal valgus deformities (IHV) of the great toe, either with open or percutaneous procedure. MATERIAL AND METHODS: This is a review of 18 cases in which a DP osteotomy was performed in 2 different institutions, 8 cases were performed using open technique and 10 cases percutaneously. The correction obtained was analyzed by measuring the distal articular set angle (DASA), obliquity angle (AP1), asymmetry angle (AP2), and global distal phalanx deviation (GDPD) angle before and after the surgery on dorso-plantar weight-bearing radiographs in all cases. Clinical results were also recorded. RESULTS: Excellent clinical and radiological results were achieved with both techniques in all patients with no complications. The average DP angular deformity correction in terms of AP1, AP2 and GDPD angles were 4.58º ± 5.55º, 8.95º ± 4.77º and 16.53º ± 7.26 respectively. In 10 cases an Akin osteotomy was associated. CONCLUSION: In cases with valgus deviation in the hallux DP, a corrective osteotomy of the DP alone or associated to osteotomy of the PP should be considered as a useful tool. The technique is feasible and has no technical difficulties for an orthopedic surgeon with experience on feet surgery.

Masson's Tumor of the Distal Phalanx May Present Like a Felon, Report of a Rare Case.

Also known as intravascular papillary endothelial hyperplasia, Masson's tumor is a relatively rare soft-tissue vascular tumor that usually arises in the hand. Felon is an abscess formation in the distal phalanx that usually occurs following a penetrating microtrauma. We present a 30-year-old patient who was referred to our clinic with a palpable mass in the distal phalanx of the index finger after a needle stick injury. At first, the lesion was treated as a felon but finally and after treatment failure, a complete reevaluation revealed the lesion to be a Masson's tumor of the distal phalanx.