Reversible median nerve neuropathy and local muscle irritation resulting from blind removal attempts of etonogestrel contraceptive implant: a case report.

Nexplanon is an etonogestrel contraceptive implant that comes with an applicator, making it easier to insert and remove. Complications related to insertion and removal procedures, such as neural-vascular injuries, are rare. We describe a case of reversible median nerve neuropathy and local muscle irritation resulting from blind removal attempts of an iatrogenically migrated implant. The patient presented with an unusual pain at the surgical site along with abnormal sensations and numbness in her left hand that worsened after blind attempts to remove the implant. Radiographs revealed that the rod was 3 cm from her insertion scar and deeply embedded in her left arm. The patient then underwent left arm exploration and implant removal under fluoroscopic guidance by an orthopedic surgeon. The rod was placed intramuscularly, adjacent to the median nerve under the basilic vein. The abnormal sensations and numbness in her left hand could be attributed to median nerve involvement, while the atypical pain at the surgical site could be a result of local irritation from the intramuscularly migrated implant from attempts at removal. The symptoms gradually resolved after surgery. This indicates that patients with impalpable contraceptive implants should be referred for implant removal by specialists familiar with the procedure to prevent further deterioration of adjacent structures from iatrogenic implant migration.

Effect of delayed distal radius fracture fixation on the difficulty of surgical operation.

Purpose: The effect of delayed distal radius fracture (DRF) fixation by volar locking plates (VLPs) on the operative time, rate of bone graft use and need for additional surgical incisions was analyzed. Short- and mid-term outcomes were compared between early and delayed DRF fixation. Methods: A retrospective cohort review of DRFs treated with VLPs was performed. The effects of delayed fixation were analyzed by 1) comparing intraoperative and radiographic parameters and follow-up outcomes between early fixation (EF, 1-10 days) and late fixation (LF, ≥11 days), 2) predicting the prolonged operative time using linear regression analysis, and 3) predicting the rate of bone graft use and additional incision using odds ratios. Results: Of 104 patients, 51 and 53 were in the EF and LF groups, respectively. EF showed a significantly shorter operative time, lower rate of bone grafting and fewer additional incisions (94.80 vs. 123 minutes, 3.92% vs. 26.18% and 2% vs. 20.45%, respectively). Radiographic parameters, immediate postoperative pain and wrist range of motion were significantly better in the EF group. However, the visual analog scale (VAS) pain and Patient-Rated Wrist Evaluation (PRWE) scores were not different at the 12-month follow-up. For every day of delay, the operation was prolonged by 2.17 min, the rate of bone grafting increased by 8%, and the chance of additional incisions increased by 8%. Conclusion: Delayed DRF fixation affects intraoperative and postoperative outcomes. We encourage internal fixation for DRFs as early as possible to reduce surgical complexity and improve postoperative outcomes.

A proximal interphalangeal joint custom-made orthosis in trigger finger: Functional outcome.

Introduction: Trigger finger is a common and functionally limiting disorder. Finger immobilization using an orthotic device is one of the conservative treatment options for treating this condition. The most common orthosis previously described for trigger finger is metacarpophalangeal joint immobilization. There are limited studies describing the effectiveness of proximal interphalangeal joint orthosis for treatment of trigger finger. Methods: This study was a single group pretest-posttest design. Adult patients with single digit idiopathic trigger finger were recruited and asked to wear a full-time orthoses for 6 weeks. The pre- and post-outcome measures included Quick-DASH score, the Stages of Stenosing Tenosynovitis (SST), the Visual Analogue Scale (VAS) for pain, the number of triggering events in ten active fists, and participant satisfaction with symptom improvement. Orthotic devices were made with thermoplastic material fabricated with adjustable Velcro tape at the dorsal side. All participants were given written handouts on this disease, orthotic care and gliding exercises. Paired t-tests were used to determine changes in outcome measures before and after wearing the orthosis. Results: There were 30 participants included in this study. Evaluation after the use of PIP joint orthosis at 6 weeks revealed that there were statistically significant improvements in Quick-DASH score from enrolment (mean difference -29.0 (95%CI -34.5 to -23.4); p < 0.001), SST (mean difference -1.4 (95%CI -1.8 to -1.0); p < 0.001) and VAS (mean difference -3.4 (95%CI -4.3 to -2.5); p < 0.001). There were no serious adverse events and patient satisfaction with the treatment was high. Conclusions: Despite our small study size, the use of proximal interphalangeal joint orthosis for 6 weeks resulted in statistically significant improvements in function, pain and triggering, and also high rates of acceptance in patients with isolated idiopathic trigger finger.

Treatment of Chronic Severe Flexion Contractures of Fingers with Bilateral Side-Finger Flaps (Wing Flaps) and Full-Thickness Skin Graft.

Background: Severe flexion contractures of proximal interphalangeal joint of fingers can significantly impair hand function, typically after burn injury recovery. Extensive surgical release exposes deep vital structures, which subsequently requires significant skin coverage. The author presents the results of using bilateral side-finger flaps (wing flaps) and full-thickness skin graft for coverage of the defects. Methods: Seven patients (8 fingers) with chronic severe flexion contractures of fingers resulting from burn injury were included. Results: Mean flexion contracture and full flexion angles of the joints were improved from 84.4°/93.7° to 4.7°/92.5° at the last follow-up visit. No major complications were observed during the postoperative follow-up period (range, 6-16 months). Conclusions: This alternative surgical technique can be successfully applied for the treatment of chronic severe flexion contractures of fingers. The advantages of this approach are the use of local flaps from injured digit, and that it can be performed as a one-session procedure.

Glomus tumors of the fingers: Expression of vascular endothelial growth factor.

Glomus tumors are uncommon, benign, small neurovascular neoplasms derived from glomus bodies in the reticular dermis. Glomus bodies are found throughout the body to regulate body temperature and skin circulation; however, they are concentrated in the fingers and the sole of the foot. The typical presentation is a solitary nodule in the subungual or periungual area of the distal phalanx. The primary treatment of choice is surgical removal. We investigated expression of vascular endothelial growth factor (VEGF) using immunohistochemistry in glomus tumors of the fingers. All five glomus tumor samples were positive for VEGF expression. VEGF immunoreactivity was largely localized to the cytoplasm of tumor cells, suggesting a contribution of VEGF to the vascularization of glomus tumors.