Hand Surgery

Recessive dystrophic epidermolysis bullosa (RDEB) is an uncommon and severe disorder characterised by trauma-induced blisters, intractable skin ulcers, scarring, milia, and nail dystrophy. We report the good result of both surgical release of fingers allowing spontaneous epithelisation without skin grafting and post-operative meticulous skin care without splinting, followed-up for one year.

Calcium deposition in the skin, known as calcinosis cutis, is an uncommon disorder caused by an abnormal deposit of calcium phosphate in the skin. We report a case of idiopathic calcinosis cutis in fingertip treated with surgical excision followed by the occlusive dressing using aluminum foil, and obtained significant pain relief and round-shaped fingertip which looked normal.

We present a patient with an asymptomatic painless medial elbow swelling of one year's duration, which was diagnosed as a ganglion originating from a non-united avulsion fracture of the medial epicondyle with a pseudarthrosis. Medial elbow ganglia are unusual lesions typically arising from the medial aspect of the ulnohumeral joint capsule, often in combination with symptoms of cubital tunnel syndrome. To our knowledge, a ganglion arising from a pseudarthrosis has not been reported in the literature, and should be considered in the differential diagnoses of lesions encountered over the site of fracture non-union in proximity to a joint.

Fractures of the proximal end of the radius in children are uncommon. A case of fracture through the articular surface of the radial head (Salter–Harris type IV) in a 12-year-old boy is presented. Our paper recommends bone peg fixation in the treatment of Salter–Harris (S–H) type III or IV injuries in nearly skeletally mature.

Isolated volar dislocation of the fifth carpometacarpal joint is a very rare injury. We present two cases of isolated volar dislocation of the fifth carpometacarpal joint treated successfully with percutaneous skeletal fixation.

We report on the case of a 14-year-old patient with bilateral avulsion of flexor digitorum profundus (FDP) in both ring fingers. This was noted four days after a basketball match. At surgical exploration both FDP were ruptured with the ends located at A2 and A3 pulleys. These were repaired with excellent functional results. While FDP avulsions can often occur affecting the ring finger this is the first reported case of a patient presenting with a bilateral injury affecting the ring finger on both sides.

We describe a unique case of a 44-year-old gentleman who presented to our hand department with a history of a lump within his right palm that spanned several decades. Its gradual increase in size together with pain on palpation merited further investigation and subsequent surgical excision. Extensive tumour emanating from both ulnar and median nerves was resected, the histopathological diagnosis of which was plexiform neurofibroma. We believe this is the first description of an isolated plexiform neurofibroma of the hand with dual nerve origin.

Fracture dislocation of the wrist is a rare injury in adolescents, and therefore it is easily ignored at the initial treatment. Once ignored, an alternative treatment such as proximal row carpectomy is indicated, but surgical outcome is not as good as that of an early reduction. We have experienced a chronic case of fracture dislocation in a 15-year-old, skeletally immature boy and treated it by scaphoid osteotomy, associated with bone grafting, screw fixation and ligament repair. The patient had no difficulties in daily activities nine years post-operatively, however the X-ray showed slight deformity of the scaphoid. Even for a chronic case, late reduction with ligamentous repair should be considered in adolescents.

We describe our experience of using a volar locking plate for corrective osteotomy and bone grafting combined with early mobilisation in the treatment of distal radius malunions. Corrective osteotomy of the distal radius was performed through a volar approach, and fixated by a volar locking plate associated with corticocancellous iliac bone grafting in three patients aged 16, 71 and 75 years. Two patients had had volarly displaced malunion and one dorsally displaced malunion. Wrist motin was started immediately after surgery. The average follow-up was 15 months (range, 12–20 months). All osteotomies healed at an average 5.7 weeks post-operatively, resulting in a total arc of wrist motion of 133°, forearm rotation of 167°, and grip strength of 70% of that of the contralateral side. This treatment method proved to be effective and safe.

Achieving coverage after digital injury is crucial, because simple skin defects can expose essential structures such as tendons or bones. This is particularly true on the dorsal surfaces of the digits, where the skin provides the only protection for the tendons. However, longitudinal skin defects of the digit have not been specifically identified in the literature and there have been few reports focusing on longitudinal dorsal skin defects. Here we report on the use of a bipedicle flap for reconstruction of complex longitudinal dorsal tissue defects of the digits, including those associated with tendon or bone damage.

Loss of median nerve function or a neuropathic pain syndrome may occur in around 20% of distal radius fractures if post-traumatic oedema in the carpal canal generates excessive pressure on the median nerve. No method currently exists to reliably distinguish which patients may benefit from a concomitant carpal tunnel release. This case series details the results of following a prospective plan designed to minimise median nerve related complications associated with distal radius fractures by measuring Semmes-Weinstein monofilament scores in 374 radius fracture patients who underwent surgical stabilisation. One hundred and sixty-nine patients with the clinical symptoms of median nerve compression, a decrement in monofilament score of grade 1 (out of 5) compared to the contralateral side or at least 4.31 g underwent concomitant carpal tunnel release. The remaining 205 patients did not have carpal tunnel release. There were no cases of neuropathic pain or loss of median nerve function.

Segmental carpal tunnel pressure was measured in 12 hands of 11 idiopathic carpal tunnel syndrome patients before and after two-portal endoscopic carpal tunnel release. We aimed to determine at which part of the carpal tunnel the median nerve could be compressed, and to evaluate whether carpal tunnel pressure could be reduced sufficiently at all segments of the carpal tunnel after the surgery. Pressure measurements were performed using a pressure guide wire. The site with the highest pressure corresponded to the area around the hamate hook; the pressure in the area distal to the flexor retinaculum could be pathogenically high (more than 30 mmHg) before the surgery. The two-portal endoscopic carpal tunnel release achieved sufficient pressure reduction in all segments of the carpal tunnel when the flexor retinaculum and the fibrous structure between the flexor retinaculum and the palmar aponeurosis were completely released.

Non-union at the metaphyseal level is rare following a fracture of the distal radius. When a non-union does occur, it is usually easily treated with cancellous bone graft from the iliac crest. Resistant and multiply operated atrophic non-unions more frequently occur at the diaphyseal level of long bones. A corticoperiosteal free flap based on the articular branch of the descending genicular artery has previously been described to treat such difficult non-union cases in various sites, but not at the distal radius. At the distal radius metaphysis, the close relationship with the extensor tendons raises concern regarding the ability to fit this free flap to the non-union site without significant interference with tendon function. By careful technique of crumbling the cortex of the flap without tearing the periosteal continuity, the flap can be contoured and snugly fit to this particular site while preserving tendon function. A unique case is presented of a multiply operated resistant atrophic non-union of the distal radius metaphysis in a heavy smoker that was rapidly healed using the genicular corticoperiosteal free flap.

Subungal glomus tumours are uncommon; the only treatment is complete surgical excision. Transungual approach is often preferred; however, secondary nail deformity may occur. Lateral periungual approach is used to avoid this complication, but this approach provides limited exposure and is used for peripheral lesion only. We describe a modified periungual approach which can be applied to central lesions. This approach can provide adequate exposure for complete excision of the subungual tumour while avoiding incision of the nail bed.