Management of Patients With Post-Traumatic Wrist Flexor Contracture by Carpectomy and Wrist Fusion.

Post-traumatic wrist flexor contracture is most commonly seen in major trauma affecting the hand, wrist, and forearm. It produces debilitating complications affecting the quality of life, often requiring multiple staged surgeries, and prolonged rehabilitation with physiotherapy to yield functional improvement. Wrist flexion contracture correction is the first surgery performed to reduce the deformity and improve the functional status of the hand. Releasing the wrist flexion contracture due to stretch on the contracted structures could cause a vascular compromise of the hand and skin deficit, which needs flap cover. On the other hand, removing the carpal bones reduces the length of the extremity and makes the existing skin adequate, with the wrist in the neutral position. This procedure avoids the need for a flap and avoids the stretch of blood vessels in bringing the wrist to the neutral position. A retrospective study was performed on three patients who presented to our institution, i.e., Sri Ramachandra Institute of Higher Education and Research, Chennai, India, and underwent carpectomy and wrist fusion for correction of post-traumatic wrist flexor contracture between December 2019 and July 2021, with follow-up extending to a maximum of 18 months. The three patients underwent prior surgeries at different hospitals following injury and later presented at our institution for further management and subsequently underwent surgeries and extensive rehabilitation to improve wrist and hand function. The patients underwent a staged procedure for correction of wrist contracture by soft tissue release and carpectomy, followed by wrist arthrodesis. Postoperatively, none of the patients had neurovascular complications or complications related to wound healing. Hence, carpectomy and wrist fusion are safe procedures to correct the wrist flexion contracture without complication and motivate the patient to undergo further surgeries to improve hand function.

The Demography of Traumatic Brachial Plexus Avulsion Injuries.

Background and objective Brachial plexus injuries more commonly affect the younger generation who constitute the productive workforce. The patients who sustain avulsion injuries of the brachial plexus are more often involved in high-velocity accidents. The avulsion injuries are surgically managed by nerve transfers. This study aimed to evaluate the demography of brachial plexus avulsion injuries. Materials and methods This retrospective study was conducted in January 2013 and included 21 patients treated from January 2007 to December 2011. Results Of the 21 patients, 20 were male and the most commonly affected patients were in the age group of 21-30 years. The mean age of the affected patients was 27.24 years. Six of the patients had pan palsy (C5-8 and T1), nine had C5-7 injury, and six had C5-6 injury. Twenty patients underwent spinal accessory to suprascapular nerve transfer, nine patients underwent ulnar nerve fascicle to nerve to biceps branch transfer, and one patient underwent intercostal nerve to musculocutaneous nerve transfer. Of note, 40% of the patients regained more than M3 power for abduction and external rotation of the shoulder, and 30% of the patients regained more than M3 power for elbow function. Conclusions Road traffic accidents are the most common cause of brachial plexus injuries. Nerve transfers for shoulder and elbow function play a significant role in improving the function of the upper extremity.

Second-Layer Palmar Graft for Fingertip Reconstruction: An Analysis of Aesthetic and Functional Outcomes.

BACKGROUND:  Fingertip injuries are very common and require a stable and durable cover. The end result after reconstruction must be a painless finger with good aesthetic appearance. Skin loss in fingertip, with or without partial loss of pulp fat, is often managed with a split-thickness skin graft, which causes a poor aesthetic result due to color mismatch of the grafted skin in the glabrous volar skin of fingertip. The full-thickness and partial-thickness skin graft harvested from palmar skin provide color match but may cause donor site morbidity in the form of painful scar or contour deformity. Harvest of the second layer from the palm (intermediate part of dermis) allowed the first layer (epidermis with superficial part of dermis) to be reposed over the remaining dermis in palm, thus allowing closure of donor defect without any tension. This technique provides a good color match for the primary defect, along with reduced donor site morbidity. AIM: The study aims to analyze the outcomes of second-layer palmar graft (SLPG) in patients with fingertip injuries. MATERIALS AND METHODS:  The retrospective study was conducted in January 2012 on 40 patients who underwent SLPG. RESULT:  The graft take was 100% in 36 patients with an average static two-point discrimination (2PD) of 6 mm. The average cosmetic visual analog score for the donor area was 100 and recipient site was 80. CONCLUSION:  The SLPG is a good surgical procedure for reconstructing fingertip defects, providing excellent aesthetic appearance and optimal function.

Giant Cell Tumor of Tendon Sheath: A Rare Peri-carpo-metacarpal Location Masquerading as a Recurrent Ganglion Cyst-a Diagnostic Conundrum.

Introduction: Giant cell tumors of tendon sheath (GCTTS) are benign soft-tissue lesions commonly affecting the digits, which occasionally cause pressure atrophy of an adjoining bone; but perforating the cortex to expand into the medullary canal is quite uncommon. We report such a case of suspected recurrent ganglion cyst with eventually manifested as a GCTTS with an intra-osseous involvement of the capitate and hamate bone. Case Presentation: A 28-year-old lady had been diagnosed as a case of recurrent ganglion cyst of the dorsum of the left wrist - 6 years ago and 4 years ago - both of which were confirmed histopathologically and were surgically excised. The patient had now presented in July 2021 with similar complaints of pain and swelling over the same site, for 1 year. Our initial clinical diagnosis was a case of recurrent ganglion cyst. Patient also presented with occasional bouts of fever for the past 2 weeks, which made us suspect osteomyelitis as well. Routine blood parameters showed that an elevated ESR and CRP, blood, and urine cultures were negative and magnetic resonance imaging showed features suggestive of osteomyelitis-involvement of capitate and hamate bone. However, to our surprise, intraoperatively, there were no features suggestive of osteomyelitis and the lesion was excised in-toto and the gross specimen resembled a classic ganglion cyst, which was sent for histopathological examination. To our surprise yet again, it was reported as a case of Giant cell tumor of the tendon sheath, which in retrospect, clinically and radiologically correlated with an intra-osseous involvement of the capitate and hamate. The patient is on regular follow-up to pick up any further recurrences. Conclusion: "Once a ganglion, always a ganglion" should not be taken as the Gospel truth. Histopathological diagnosis continues to remain as the gold standard, especially in cases of soft-tissue swellings of the hand. Correlation and integration of clinical features, Imaging modalities and histopathological diagnosis are the cornerstone in the management of GCTTS.