The Use of an Adipofascial Flap to Prevent Extensor Tendon Adhesions After Plating of the Proximal Phalanx of the Fingers: A Comparative Study.

BACKGROUND: Extensor tendon adhesions occurring after proximal phalangeal (P1) fractures are not uncommon. A previous report described the use of an adipofascial flap (AFF) to prevent adhesions after dorsal plating of the P1. The purpose of the study is to examine the results of open reduction and internal fixation with the use of an AFF (F group) and without (N group, that is, no flap used) in a larger group of patients. METHODS: A retrospective study involving a period of 11 years was conducted involving results of 21 unstable fractures of the P1 of the fingers in 18 patients. In all, 12 fingers were treated without any flap (N group) and 9 fingers were treated with the AFF (F group). For each patient, the total active motion (TAM) ratio, and the grip strength (Jamar) ratio were assessed, and adverse effects and the 10-point visual analogue scale (VAS) score were recorded. For statistical analysis, sample characteristics were described using mean ± standard deviation and median, and a Bayesian approach was used for inferential analysis. RESULTS: In the F group, the TAM ratio (84% ± 13% vs 65% ± 17%) was higher with a lower rate of adverse effects (OR: 0.067, 95% CI, 0.0035-0.58,) and a lower VAS score with evidence of the positive effect of the AFF. The Jamar ratio was similar in the 2 groups (F group 80% ± 25% vs N group 79% ± 19%) with no associated effect of the AFF on grip strength. CONCLUSIONS: The AFF is a reliable tool to reduce adhesions between plates and the extensor apparatus of the P1 and may be useful to improve finger function after plating of P1 fractures. TYPE OF STUDY/LOE: Therapeutic, Retrospective, Level IV.

Sonographic Follow-Up of Patients With Cubital Tunnel Syndrome Undergoing in Situ Open Neurolysis or Endoscopic Release: The SPECTRE Study.

Background:The measurement of cross-sectional area (CSA) is a diagnostic tool to detect entrapments syndrome. The aim of this study was to compare the clinical outcome in elbows undergoing endoscopic and "in situ" open cubital tunnel release for cubital tunnel syndrome (CuTS) using ultrasound-related changes in the largest CSA of the ulnar nerve. The purpose is to determine the association between clinical outcome and CSA. Methods: From May 2011 to April 2016, 60 patients with CuTS were prospectively followed and not randomly divided in two groups: 30 patients undergoing an endoscopic release (ER) and 30 patients with "in situ" open neurolysis (OR). A sonographic examination was performed by the senior authors at baseline and 3, 6, and 12 months after surgical decompression. Results: CSA values were statistically significantly lower in the ER. Hand grip strength difference with Jamar test was not statistically significant a 12 months (39 kg vs 27 kg). Static-2 point discrimination test difference was only statistically significant lower in the endoscopic group at 3, 6 and 12 months but not clinically relevant (5 mm vs 6 mm). The American Shoulder and Elbow Surgeons-Elbow questionnaire (ASES-e) function score, ASES-e Pain score, and ASES-e Satisfaction score were not statistically significant different between the two groups at 3, 6, and 12 months post operatively. Conclusions: The study confirms that in spite of lower values of CSA in the ER, there is not a statistically significant difference between the two techniques in terms of subjective outcomes. Ultrasound (US) measurements seem to have a limited value in clinical results of patients treated for entrapment neuropathy of the ulnar nerve.Type of study/LOE: Prognostic Level III.

Skeletal Muscle Metastases to the Flexor Digitorum Superficialis and Profundus from Urothelial Cell Carcinoma and Review of the Literature.

Urothelial cell carcinoma (UCC) metastases to skeletal muscle are extremely rare and usually found in patients with advanced stage cancer. The most common sites of bladder cancer metastases are lymph nodes, lung, liver, and bones. Muscle is an unusual site of metastases from a distant primary cancer, due to several protective factors. We present a rare case of 76-year-old patient with metastases in the flexor digitorum superficialis (FDS) and flexor digitorum profundus (FDP) muscles, 2 years after a radical cystectomy for invasive UCC of the bladder. This case is the first description of a forearm lesion, with an extensive infiltration of the volar compartments of the forearm, and the first one with a clear functional impairment.

Fifth metacarpal neck fractures treated with soft wrap/buddy taping compared to reduction and casting: results of a prospective, multicenter, randomized trial.

INTRODUCTION: The majority of fifth metacarpal neck fractures (boxers fracture) are treated conservatively without surgery. The purpose of this prospective, randomized, multicenter trial was to determine if the outcomes of soft wrap and buddy taping (SW) was noninferior to reduction and cast (RC) in boxer's fracture with palmar angulation ≤70° and no rotational deformity. MATERIALS AND METHODS: Sixty-eight patients with similar characteristics were prospectively enrolled and randomized at four institutions. Our primary outcome was measured by the shortened Disabilities of the Arm, Shoulder and Hand (quickDASH) questionnaire at 4 months. Noninferiority was claimed if there was no more than +10 points difference in the quickDASH. Other secondary radiographic and clinical outcomes were measured. RESULTS: At 4 months, mean difference in the quickDASH between the two groups was -10.4 (95 % confidence interval, -27.0; +6.2) which was under the pre-specified margin. There was no significant difference between both groups' secondary outcomes of pain, satisfaction with the esthetic appearance, mobility of the metacarpophalangeal-joint at flexion and extension, or power grip. Increased fracture angulation, as measured on follow-up radiographs, was not significantly different between both groups. The degree of palmar fracture angulation was not related to work leave or profession. Duration of time off from work was 11 days shorter in SW compared to RC (P = 0.03). CONCLUSION: This study supports the use of soft wrap and buddy taping for treatment of boxer's fracture with palmar angulation ≤70° and no rotational deformity. Although there was no statistical difference in satisfaction with the esthetic appearance, the patient must be willing to accept the loss of the "knuckle" with this treatment method.

Fracture dislocation of the pisiform bone in children: a case report and review of the literature.

Simultaneous fracture and dislocation of the pisiform is a rare condition, and only two cases have been reported in children. We retrospectively collected and reviewed clinical and radiographic data of a child with a type II Salter-Harris fracture of the distal radius, associated with fracture dislocation of the pisiform. In addition, we performed a systematic review of the literature available to date.

[Is it necessary to remove the whole trapezium in thumb osteoarthritis]. / Muss das Vieleckbein bei der Sattelgelenksarthrose immer entfernt werden?

Carpometacarpal (CMC) arthritis of the thumb is a common condition seen in GP consultation. This disease can cause significant disability and affected patients often need a surgical intervention. Up to recently, surgical treatment included the resection of the whole trapezium in different possible modifications. In this article, we review mini-invasive procedures for treatment of thumb carpometacarpal joint arthritis.

Should aspirin be stopped before carpal tunnel surgery? A prospective study.

AIM: To determine whether patients taking aspirin during carpal tunnel release had an increase of complications. METHODS: Between January 2008 and January 2010, 150 patients underwent standard open carpal tunnel release (CTR) under intravenous regional anaesthesia. They were divided into three groups: groups 1 and 2 were made of 50 patients each, on aspirin 100 mg/d for at least a year. In group 1 the aspirin was never stopped. In group 2 it was stopped at least 5 d before surgery and resumed 3 d after. Group 3 acted as a control, with 50 patients who did not take aspirin. The incidence of clinically significant per- or post-operative complications was recorded and divided into local and cardio-cerebro-vascular complications. Local complications were then divided into minor and major according to Page and Stern. Local haematomas were assessed at 2 d (before resuming aspirin in group 2) and 14 d (after resuming aspirin in group 2) postoperatively. Patients were reviewed at 2, 14 and 90 d after surgery. RESULTS: There was no significant difference in the incidence of complications in the three groups. A total of 3 complications (2 major and 1 minor) and 27 visible haematomas were recorded. Two major complications were observed respectively in group 1 (non stop aspirin) and in group 3 (never antiaggregated). The minor complication, observed in one patient of group 2 (stop aspirin), consisted of a wound dehiscence, which only led to delayed healing. All haematomas were observed in the first 48 h, no haematoma lasted for more than 2 wk and all resolved spontaneously. A major haematoma (score > 20 cm(2)) was observed in 8 patients. A minor haematoma (score < 20 cm(2)) was recorded in 19 patients. All patients at 90 d after surgery were satisfied with the result in terms of relief of their preoperative symptoms. Major and minor haematomas did not impair hand function or require any specific therapy. CONCLUSION: Our study demonstrates that continuation of aspirin did not increase the risk of complications. It is unnecessary to stop aspirin before CTR with good surgical techniques.

Treatment of type III middle phalangeal neck fractures through a palmar approach: a case report.

Phalangeal neck fractures occur almost exclusively in children. We present the case of a 49 years old man with a dislocated fracture of the neck of the middle phalanx with the distal fragment rotated at 180? due to a traumatic circular saw injury to the left index, which was solved by anatomical reduction and bone fixation with two 1.5 mm Synthes screws and a temporary transarticular K-wire at the distal interphalangeal joint. Zone I flexor digitorum profundus repair was performed using a modification of the Kessler 4-strands core suture and a full-thickness skin graft from the hypothenar eminence was taken to cover the skin gap. At 6-month follow-up the patient was pain-free and with a total active movement equivalent to 190? No radiological signs of avascular necrosis of the head of the middle phalanx or nonunion of the distal fragment was detectable with recovery to the previous manual work. Owing to the position of the phalangeal head maintained in position by the collateral ligaments an anatomic reduction from dorsal approach is difficult to be performed and a longitudinal traction can render the reduction harder too. The volar approach permits an easier reduction of the fracture through a derotation of the distal fragment facing palmar.

Patients' point of view on informed consent: a prospective study in carpal tunnel surgery.

Patients' perception of consent form (CF) is not well known and many patients tend to view the CF as an administrative act. As part of a prospective study, a questionnaire was sent to 188 consecutive patients within 1 month after carpal tunnel release. Questions focused on patients' recall about risks, benefits, alternative options, preferences about decisions process and global satisfaction with CF. Patient's understanding of the legal consequences of the CF was analysed. Risk's recall rate was 59%. CF reduced preoperative anxiety in 65% and the influence in patients' decision was relevant in 55% of cases. Patients have limited understanding of the legal consequences of the consensus and 29% of patients believed that primary function was to protect hospital. Ten percent believed that CF expunges patients' right to compensation in case of claims. Patient involvement in medical decision-making is a key aspect of patient centred care. A substantial uncertainty exists about legal implication of CF, leading to potential discord.

Fracture of the radial sesamoid bone of the thumb: an unusual fracture.

The hand consists of five sesamoids. Two of them are present at the metacarpophalangeal (MCP) joint of the thumb. Fracture of the sesamoid bones of the thumb is a rare injury and the literature on the radial side is seldom reported. We reported a case of a patient with a fracture of the radial sesamoid at the MCP joint of the thumb in order to increase attention regarding this type of injuries. A 44-year-old male, high level gymnastic trainer, was helping one of his athletes during an exercise while he reported a hyperextension trauma to the MCP joint of the right thumb. One week after trauma, he presented to the hand surgeon complaining of a painful thumb at the MCP joint level on its palmar aspect. Standard A-P and lateral X-rays revealed a fracture of the radial sesamoid and the fracture was treated with a splint for 3 weeks. He was able to resumed his entire work 6 weeks after the injury. The sesamoid fractures is an indicator of the magnitude of the hyperextension injury and sometimes associated with tears of the volar plate ligament of the MCP joint. And a failure to recognize the ligament injury may lead to a long-term hyperextension instability on pinching.

Transient bone resorption following finger replantation: a report of 3 cases.

Radiographic changes consisting of alterations in mineral content, osteopaenia or destructive neuropathy that occur following successful finger replantation have already been described. We report our experience about four fingers in three individuals in whom bone changes developed in the first three months postoperatively with complete "restitution ad integrum". Three patients, 21-49 years old (average 36 years) sustained a clean-cut amputation of four fingers. The first patient had an amputation at the base of the middle phalanx of the index finger and the second patient at the base of the proximal phalanx of the ring finger. The third had an amputation at the base of the first metacarpal bone and the proximal phalanx of the small finger in a five finger amputation. In the first case, two dorsal veins and two palmar digital arteries and nerves were repaired. In the second case, one palmar artery and one dorsal vein were reanastomosed. In the third case at the thumb, two dorsal veins and two palmar digital arteries and nerves were reconstructed. At the small finger, one dorsal vein, one palmar digital artery and two digital nerves were reconstructed. Bone fixation was achieved with two and three K-wires or tension-band wiring. Replantation was successful in all cases. Three weeks after replantation, the X-rays showed rapid development of osteopaenia in the juxtaarticular region and metaphyses of the bone. These changes were followed by subperiosteal, intracortical and endosteal bone resorption. No further surgical procedures or splintage were needed and hand therapy was not discontinued. At 10-13 weeks (average 12 weeks) postoperatively, the X-rays showed a complete recovery with new periosteal bone formation. We suggest that the radiographic changes after finger replantation are transient, first evident subperiosteally and progressing centrally. They may reflect small-vessel compromise and microinfarction and transient hyperemia secondary to neurovascular damage or to sympathetic progressive recovery.

Post-traumatic combined flexion of the thumb, index and middle finger after intrinsic muscles reconstruction of the hand: a case report.

We report a case in which simultaneous flexion of the thumb, index and middle finger occurred 6 months after the surgical reconstruction of the adductor (AM) and first dorsal interosseous (IO) muscles. An anomalous connection in the form of tendon slip associated to fibrous adhesions between the flexor pollicis longus (FPL) tendon, flexor digitorum profundus indicis (FDPI) and middle finger (FDPM) tendons were found. Either ultrasound (US) examination or magnetic resonance imaging (MRI) were unable to detect the site of adhesion. Excision of the slip and radical tenosynoviectomy led to early functional recovery.

False aneurysm of the common digital artery. Is reconstruction with an arterial graft worth the efforts? A case report.

False aneurysms in the hand are rare. A false aneurysm of the common digital artery in the palm for the second and third finger is reported, illustrating our experience with arterial graft reconstruction after excision as a valid alternative surgical therapy to a vein graft, when ligation or end-to-end anastomosis are not indicated or feasible. The superficial palmar branch of the radial artery was chosen as donor vessel based on the similarity in vessel diameter and wall thickness to the common digital arteries. Ease of harvesting and performing the microvascular anastomosis using an arterial graft allows for a viable reconstruction after false aneurysm excision in the palm.

Occult fractures of the scaphoid: the role of ultrasonography in the emergency department.

OBJECTIVE: To evaluate ultrasonography (US) performed by an emergency radiologist in patients with clinical suspicion of scaphoid fracture and normal radiographs. MATERIALS AND METHODS: Sixty-two consecutive adult patients admitted to our emergency department with clinical suspicion of scaphoid fracture and normal radiographs underwent US examination of the scaphoid prior to wrist computed tomography (CT), within 3 days following wrist trauma. US examination was performed by a board-certified emergency radiologist, non-specialized in musculoskeletal imaging, using the linear probe (5-13 MHz) of the standard sonographic equipment of the emergency department. The radiologist evaluate for the presence of a cortical interruption of the scaphoid along with a radio-carpal or scapho-trapezium-trapezoid effusion. A CT of the wrist (reference standard) was performed in every patient, immediately after ultrasonography. Fractures were classified into two groups according to their potential for complication: group 1 (high potential, proximal or waist), group 2 (low-potential, distal or tubercle). RESULTS: A scaphoid fracture was demonstrated by CT in 13 (21%) patients: eight (62%) of them belonged to group 1 (three in the proximal pole, five in the waist), five (38%) to group 2 (three in the distal part, two in the tubercle). US was 92% sensitive (12/13) in demonstrating a scaphoid fracture. It was 100% sensitive (8/8) in demonstrating a fracture with a high potential of complication (group 1). CONCLUSIONS: Our data show that, in emergency settings, US can be used for the triage to CT in patients with clinical suspicion of scaphoid fracture and normal radiographs.

Analysis of the inter- and intra-observer agreement in radiographic evaluation of wrist fractures using the multimedia messaging service.

BACKGROUND: Orthopaedic surgeons are often asked to evaluate X-rays of patients admitted to the Accident and Emergency Department with the suspicion of a wrist fracture or, in the case of an evident fracture, to decide the correct treatment. The aim of this study was to evaluate the feasibility of a correct interpretation of the images of injured wrists on the screen of a last generation mobile phone, in order to evaluate if the specialist could make the right diagnosis and choose the correct treatment. METHODS: Five orthopaedic and one hand surgeons have evaluate the X-rays of 67 patients who sustained an injury to their wrist. In the case of fracture, they were asked to classify it according to the AO and Mayo classification systems. The evaluation of the images was accomplished through the PACS and using a mobile phone, at a different time. In order to check the inter- and intra-observer reliability, the same pattern was followed after a few months. RESULTS: The mobile phone showed basically the same agreement between the observers highlighting the worsening of the inter- and intra-observer reliability with the increment of the variables considered by a classification system. CONCLUSIONS: The present paper confirms that a last generation mobile phone can already be used in the clinical practise of orthopaedic surgeons on call who could use it as a useful device in remote or poorly served areas for a rapid and economic consultation LEVEL OF EVIDENCE: The level of evidence of this case is economic and decision analysis, level 2.

Unstable mallet fractures: a comparison between three different techniques in a multicenter study.

OBJECTIVE: Management of mallet fractures is still a matter of discussion throughout the literature. For some authors, mallet fractures involving more than 1/3 of the articular surface and palmar subluxation of the distal phalanx require surgical treatment. In this study we retrospectively compared three different techniques for mallet fractures: Kirschner wire fixation with extension block pinning (EBP) of the distal interphalangeal joint, Kirschner wires used as joysticks (KWJ) and interfragmentary mini-screws for open reduction and internal fixation (ORIF). METHODS: Fifty-eight mallet fractures with palmar subluxation in 58 patients were treated with the aforementioned surgical techniques. Twenty mallet fractures in 20 patients 18 to 70 years old (average 42 years) were operated upon by EBP, 16 patients 22 to 56 years old (average 56 years) were operated upon using KWJ and 22 patients 22 to 54 years old (average 36 years) received ORIF. Follow-up time was 6 to 58 months (average 21 months). The following intraoperative parameters were considered: intraoperative time, number of Kirschner wires/screws and technical problems. Postoperative parameters included work absence and complications. The radiological evaluation was based on A-P and lateral views preoperatively and interviews at follow-up time. Bone union was defined by radiological evidence of bone trabeculae crossing the fracture site on at least one view. Clinical evaluation involved range of motion (ROM) test with a goniometer. Based on these measurements, a functional Crawford score was established. RESULTS: All fractures healed. In the KWJ group, intraoperative time was shorter and total ROM was wider (72 degree vs 58 degree and 54 degree; in the ORIF group, return to work was faster (2.7 weeks vs 7.2 weeks and 6 weeks) but a little higher complication rate due to screw positioning has been found. Functional results as to total ROM, distal interphalangeal lag extension and Crawford classification were similar. CONCLUSIONS: We demonstrate the advantages of the use of the three techniques and bone consolidation in all cases with no signs of osteoarthritis. Screw fixation is more technically demanding (longer intraoperative time and more complications) but allows earlier mobilization and faster returning to work. EBP and KWJ techniques are faster to perform with no complications but require a careful management of the pin tracts. There is no statistically significant difference as to functional results.