A Rare Case of Bilateral Spaghetti Injuries in Children due to Assault by Mother and Analysis of Functional Outcome at Three Years.

Management of child abuse with flexor tendons, neurovascular injuries, and life-threatening conditions is challenging. It needs a multisectoral coordinated and synchronized team effort for successful outcomes. We present a case series of children abused by a parent with a sharp object. The children sustained multiple flexor tendon injuries, neurovascular injuries in upper limbs, and tracheal injury compromising respiration. We performed a tracheostomy to save a child and subsequently repaired numerous flexor tendons, nerves, and arteries. During follow-up, these children required secondary reconstruction (tenolysis, tendon lengthening, nerve reconstruction) for flexor contractures, stiffness, and sensory loss in distal forearms. We measured the range of movements and assessed the children's functional outcome using the Strickland score at 3-year follow-up. The range of movement and functional outcome was excellent in both children in our series. A timely performance of surgery, aided with efficient intensive care, therapy, and consistent posttraumatic psychosocial rehabilitation, produced excellent results in our series.

Chronic Neglected Scapho-capitate Syndrome: A Rare Case Report with Management.

Introduction: Scapho-capitate syndrome is a rare variety, usually occur during high-energy trauma leads to fracture of scaphoid and capitate with 180 rotation of proximal fragment of capitate. Case Report: We present a unique case of chronic neglected scapho-capitate syndrome, in which the rotated proximal fragment of capitate along with the early degenerative changes in capitate and lunate. Result: Exploration of the wrist by dorsal approach, fracture fragment was resorbed and non-amenable for fixation. The scaphoid and triquetrum were excised. The cartilage between the lunate and capitate was denuded and arthrodesis was performed by 2.5 mm headless compression screw. The articular branch of the posterior interosseous nerve (PIN) was excised for pain relief. Conclusion: Accurate diagnosis in acute injury is essential for functional outcome. In chronic cases, magnetic resonance imaging is necessary to know the status of cartilage for planning of surgery. Limited carpal fusion with neurectomy of articular branch of PIN can give adequate pain relief and improvement in wrist function.

Tuberculosis of hand and wrist: Varied clinical presentation and functional outcome by surgical intervention in 13 cases.

A prospective study of 13 cases with tuberculosis of hand and wrist was presented with mean age of patients being 42.7 years (range 18 months to 84 years). Pain, swelling and difficulty in movement of adjacent joints were the most common presenting complaints. The discharging sinus, abscess & nerve compression were also observed in some cases. Out of 13 cases, bone involvement was seen in one case, joint involvement in five cases, soft tissue involvement in five cases and two cases had both soft tissue and joint involvement. All patients had undergone operative intervention for confirmation of diagnosis and improvement in function. Surgeries like open biopsy, debridement and tenosynovectomy were performed. Depending upon drug sensitivity on culture and histopathology report, standard anti-tuberculous treatment (ATT) was commenced under supervision of Infection Disease expert. Hand function was evaluated by modified Green and O'Brian score. The mean score was 58.84 (35-70) before any intervention and it improved to 89.23 (60-100) at 6 months follow up after surgical intervention and ATT. In conclusion, surgery may help for early functional recovery and for encouraging patient to use their hand for activities of daily living.

Staged Reconstruction of Chronic Constriction of Thumb Caused by a Stuck Ring - A Case Report.

We report the management of a 45-year-old man with a ring stuck in his dominant thumb for 3 weeks causing vascular and neural compromise and deep-seated infection. Previous reports have described rings embedded in the digits, though we were not able to find any reports of such rings causing ischaemia. We performed staged reconstruction to salvage the thumb. The thumb viability was confirmed after ring removal and the infection was treated as per culture sensitivity report. Both digital nerves were reconstructed with sural nerve graft and the circumferential soft tissue defect was covered with bilobed first dorsal metacarpal artery flap from index and middle finger. At the 6-month follow-up, the patient had useful function of the thumb with well-settled donor site on index and middle finger. Level of Evidence: Level V (Therapeutic).

Treatment of Ruptured Meningocele Post-Brachial Plexus Surgery: Potential Life-Threatening Complication-An Unique Case Report of Management of Ruptured Meningocele Post-Brachial Plexus Surgery to Avoid Dreadful Complication.

INTRODUCTION: Formation of meningocele in brachial plexus injury is known and can be diagnosed on magnetic resonance imaging (MRI). It is mainly reported in brachial plexus root avulsion injuries and does not require specific treatment. We report accurate diagnosis and management of dreadful complication due to rupture of meningocele post-brachial plexus exploration. CASE REPORT: A 23-year-old engineer presented at 4 months post-bike accident right side extended brachial plexus injury involving C5, C6, and C7. On MRI, he had meningocele in C6-7 root region. We performed supraclavicular exploration of brachial plexus and distal nerve transfers for shoulder abduction and elbow flexion. During surgery, the meningocele was ruptured. As the cyst was deep and extending toward apex of lung, the diagnosis of fluid drained had to be distinguished from pleural fluid with cerebrospinal fluid (CSF). We found hemo-glucose test and beta-2-transferrin levels are mandatory to confirm the diagnosis. Post-surgery, the patient had drainage of almost 500 cc of CSF from wound every day for 3 days. This was managed by repeat MRI and finally lumbar puncture drainage helped to seal the meningocele in neck. CONCLUSION: Meningocele in brachial plexus injury is common but rupture of cyst can be fatal. To confirm the origin of fluid, beta-2-transferin level is more specific test than the hemo-glucose test. Lumbar puncture and drainage away from neck can be more reliable modality of treatment in case of intraoperative rupture of such cysts if drainage is excessive postoperatively.

A Rare and Unique Complication of Pins and Rubbers Traction System (Suzuki frame) while Managing Simple PIPJ Fracture-dislocation.

Introduction: The management of acute proximal interphalangeal (PIP) joint fracture-dislocation by dynamic external fixator is widely practiced method. The complications such as pin loosening or non-union or stiffness are known and can be treated well. The over distraction causing vascular compromise and calcification of volar plate jeopardizing the function and viability of the affected digit is not reported so far. Case Report: We report a case of 2 weeks post-traumatic ring finger PIP joint fracture-dislocation in a 21-year-old male which was treated by pins and rubber dynamic traction method. The affected digit was found cold and lengthened at 3 weeks of distraction causing vascular compromise. The X-ray showed over distraction by 1.5 cm at PIP joint. The digit was salvaged by removing distractor and applying splintage. Later, at 6 weeks, X-ray showed volar plate calcification causing joint stiffness. This was tackled by volar plate arthroplasty. At 2 months, the patient got 20-80° movement without pain. Conclusion: The dynamic pins and rubber traction system for acute PIP joint injury can result in complication like over distraction leading vascular compromise. The clinical and radiological assessment with such technique is mandatory once a week to avoid missing such disasters. Even if such complication occurs, immediate fixator removal and splintage can save the digit. Once it survives, secondary procedure for gaining movement or stabilizing the joint like volar plate arthroplasty can be considered.

Evaluation of results of various tendon transfers in high and low radial nerve palsy.

BACKGROUND: Various combinations of tendon transfers are available for radial nerve palsy. However, the choice of which set of transfer to be performed in a patient remains an issue of varied opinions among surgeons. The study attempts to evaluate the results of various tendon transfers for radial nerve palsy quantitatively and subjectively. It also identifies which set of transfer is suitable for particular groups of patients. MATERIALS AND METHODS: The study was conducted between 2005 and 2007. A total of 15 tendon transfers were performed using various combinations and evaluated according to Bincaz's criteria, Kapandji scale and effect of tendon transfers on activities of daily living. RESULTS: 13 patients had excellent to fair outcome according to Bincaz's criteria. 2 patients had poor outcome. There was no hindrance in the activities of daily life in all patients. 93.4% of patients were satisfied with the results. CONCLUSION: Every combination of tendon transfers has its own set of merits and demerits. Selection of donor tendons as per occupational need of patients is utmost important. Patients in our series were satisfied with set of transfers using Pronator teres(PT) for wrist extension, Flexor carpi radialis (FCR) for finger extension and rerouted Palmaris longus (PL) for extension of thumb. Flexor carpi ulnaris (FCU) is important for power grip.

An approach to the supraclavicular and infraclavicular aspects of the brachial plexus.

The surgical approach to the brachial plexus is of great importance during surgery for brachial plexus injuries--obstetric or traumatic. A number of different approaches have been described over the years for these injuries, with each 1 having its own advantages and disadvantages. We describe a novel approach to the supra-clavicular and infra-clavicular aspects of the brachial plexus, which has been used by senior author successfully for the past 15 years. It involves creation of 2 windows, 1 above and 1 below the clavicle in case of adult traumatic plexus injuries. A slight variation of joining the 2 incisions and creation of a laterally based cervicopectoral flap is used for obstetric brachial plexus injuries along with the use of clavicular osteotomy. The advantages of this approach are that it gives rapid access to the brachial plexus; wide exposure can be obtained for all regions of the plexus and donor nerves such as the spinal accessory nerve can be harvested in the same incision.