Palanisamy Arul Murugan 1, Foo Tun Lin 2

1 Tan Tock Seng Hospital, Singapore, Singapore 2 National University Hospital, Singapore

Introduction: Collar stud abscesses are characterized by presence of infection in volar and dorsal extent of the web space. Usually, incisions are made over both dorsal and volar aspects of the web space to ensure adequate drainage. However, this risks further embarassment of the tenuous blood supply to the comissure. In a series of cases, a volar only approach was used to treat these abscesses with encouraging results.
Materials and Methods: 13 consecutive cases of collar stud abscess were treated in this manner. Contraindications were necrotic web space skin, and extensive infection requiring extensile incisions along the digit or dorsum of the hand (extensor zone 6).
Results: 10 patients were successfully treated with an index procedure followed by delayed closure. One patient required a dorsal incision to drain sub-aponeurotic infection emanating from the web space. Two patients with first web space pantaloon abscess and ischemic skin on presentation required reconstruction of the webspace with posterior interosseous artery flap. At the end of their follow up, all patients regained about 90 percent of digital motion. Conclusion: In selected cases, a volar only approach may be indicated to avoid morbidity of skin necrosis, and unsightly dorsal hand incision.

Kevin J. Renfree, Karan Patel, Ishan Ranjan, Ryan McLemore

Mayo Clinic Arizona

Objectives: To determine factors for and incidence of implant-related symptoms and removal after olecranon fixation.
Methods: This is a retrospective review of 36 patients (28 female, 8 male; average age 65) treated with olecranon fixation by a single surgeon over 16 years at a large, tertiary-care institution. Average follow-up was 5.3 years. Fixation was tension band (n=28) or plates (n=8). Average body mass index (BMI) was 26 (range 18-39). A published survey questionnaire assessed current implant related symptoms. Logistic and ordinal logistic regression and Fisher exact test were used to analyze responses and frequency relations.
Results: Final average motion was 9-134° (tension band) and 17-138° (plates). Average fracture healing was 95 days (range 41-185). Four complications occurred (11%)- 3 implant related. Logistic and ordinal logistic regression and Fisher’s exact test analyzed survey responses and frequency relations. 11% (4/36) of patients had implants removed for pain. 63 % (20/32) with retained implants reported no pain, 34 % (11/32) reported occasional irritation, and 3% (1/32) reported frequent irritation. 13% (4/31) would now opt for implant removal, which was highly related to level of irritation (p<.001, Fisher’s exact test). Longer follow-up (p=.0143) and men (p<.001) were associated with less implant irritation. There was a tendency for irritation with lower BMI irrespective of gender (p=0.150).
Conclusions: Actual implant removal rates (11.4%) and theoretical (22.9% including patients opting for hardware removal) are lower than previously reported (63-82%). Our study is the first to identify patient related factors associated with implant symptoms and removal. There was no association between implant removal and fixation type or age, and maintained implants are reasonably well tolerated (84% currently satisfied with implants in elbow).

Pobe Luangjarmekorn, Pravit Kitidumrongsuk

Department of Orthopaedic , King Chulalongkorn Memorial Hospital , Chulalongkorn university , Bangkok , Thailand

Objective : Free flap surgery was the important tool for limb reconstruction. These complex operations usually followed by some complications and many times required additional procedures. The purpose of this study was to analyze acute and long-term complications with additional surgeries that found after free flap surgeries during 10 years follow up.
Materials and Methods : Data of patients who were operated by free flap surgery for limb reconstruction during 2004-2015 were retrospectively reviewed.
Results : 34 free flap surgeries( in 28 patients ) were studied.Mean follow up time was 6.42 years. Type of free flap surgeries were including ; 7 gracilis transfers , 7 toe transfers , 5 latissimus dorsi flaps , 5 fibular transfers , 4 anterolateral thigh flaps , 2 lateral arm flaps , 2 radial forearm flaps , and 2 venous free flaps.Acute postoperative complications were classified into 4 groups ; Group 1: Total flap loss ( 20.6% , 7/34 flaps ) , Group 2 :Major complications ( that need additional operations within the first week ) ( 32.4% , 11/34 flaps ). Example of major complications were partial flap necrosis (6 cases) ,wound swelling with delayed closure (3 cases ), arterial occlusion (1 case), bleeding ( 1 case),infection (1 case ), and fail implant fixation (1 case ) , Group 3: Minor complications ( which no need for additional operation ) ( 23.5% , 8/34 flaps ) ; For example : minimal flap necrosis( 3 cases) ,wound dehiscence ( 1 case ),wound drainage( 2 cases ) ,bleeding ( 1 case ), nerve injury ( 1 case ) ,and rhabdomyolysis ( 1 case ) , and Group 4: No post-operative complication ( 23.5% , 8/34 flaps).Overall rate of additional operation within the first week was 52.94% ( 18/34 flaps ). The example of additional procedures were anastomosis revision( 3 cases ) , stop bleeding (1 case) , debridement with flap coverage (6 cases ) , amputation( 2 cases ) , skin graft ( 7 cases ) , implant revision (2 cases) , antibiotic beads insertion (2 cases) , vacuum dressing (1 case) .Long term complication was found 22.22% ( 6/27 flaps). For example; chronic osteomyelitis (4/6 cases ) and implant failure 2/6 cases ).
Conclusions : Free flap surgery was a valuable tool for limb reconstructions. But these complex procedures were not free of complications. Our study showed several types of complications that might occur after surgery including total flap loss (20.6%) , major complications (32.4%) , minor complication (23.5%).Only 23.5% was free of complication. Moreover , 52.94% of cases needed additional surgery.Because of this reason , physicians who performed free flap surgeries should be prepared for these complications and advice their patients about risks with possible additional procedures after the free flap surgeries.

Deborah A. Schwartz

Orfit Industries America Jericho, NY USA

Therapists today need low cost solutions for activities in the clinic and for the creation of home programs that will encourage clients' active participation. Innovations that incorporate inexpensive items from local markets into activities to promote hand function are promoted. It is possible to create an attractive, yet inexpensive, low cost home program that your patient can easily follow! Each home program can be custom designed and client- centered. This presentation will offer many ideas for designing activities that promote full range of motion, active grip and pinch, desensitization fine motor and more. Suggestion on how to engage patients in actualization of the activities is also presented. The current evidence supporting the use of everyday items in hand rehabilitation is offered.

Jennifer Innamorato, Marlee McNerney, Jennifer Petrilla, Hillary Prozzillo

Alvernia University, Reading, Pennsylvania, USA

The purpose of this study was to determine if there was a perceived sports performance benefit of KT, as compared to placebo tape or no tape, in healthy collegiate athletes. Kinesio Tape® is used to increase sports performance; however, there is a lack of existing evidence supporting the claims of KT. Despite the lack of evidence, KT is frequently used in the treatment and prevention of sports injuries.
Therefore, this study aimed to explore KT in the realm of sports, as well as to address gaps in the literature regarding the benefits of KT. If evidence from this research study supports the benefits of KT, then therapists have reason to use KT as an intervention, or a preparatory method, to promote and enhance individuals’ participation in meaningful occupations, such as sports. The following research question was proposed: Is there a perceived sports performance benefit of KT, as compared to placebo tape or no tape, in healthy collegiate athletes? The null hypothesis was: There is no perceived sports performance difference between KT, placebo tape, and no tape.
Materials and Methods
This quantitative pilot study utilized a convenience sampling method. Participants included eighteen healthy men’s and women’s lacrosse players, from a small division III university. A crossover design was used and consisted of three trials: Kinesio Tape®, placebo tape, and no tape. Perceived sports performance was measured using an eight-item, self-made questionnaire, which allowed the researchers to analyze the data through inferential and descriptive statistics, such as a one way analysis of variance (ANOVA) with a Bonferroni post-hoc test, t-test, Cronbach’s alpha, mean, and standard deviation.

There were a total of 8 men and 9 women lacrosse players who participated and completed the study. Results indicated that there were no significant differences between the Kinesio Tape® and no tape trials. However, there were statistically significant differences found between the placebo tape and no tape trials. While placebo tape was the only tape that yielded significant differences, participants perceived their sports performance to be better when wearing either placebo tape or KT, than when wearing no tape.
Based on the findings, the null hypothesis was rejected. However, while a perceived sports performance difference was found between the three trials, the difference was found in favor of the placebo tape. While this research study attempted to address gaps in the literature, there is still a need for future research to be conducted on the effects of other types of adhesive tapes.

Takashi Ajiki, Yuki Iijima, Akira Murayama, Katsushi Takeshita

Department of Orthopedic Surgery, Jichi Medical University, Tochigi, Japan

Objective: Autologous nerve grafting remains the gold standard for repairing peripheral nerve defects. However, this method causes several donor-site problems, such as the development of painful neuromas or permanent sensory loss. The limited amount of nerves that can be harvested from the patient’s own body is a critical issue for long-distance nerve gap bridging or treating multiple nerve injuries. Several types of artificial nerve conduit have been used for bridging peripheral nerve gaps as an alternative to autologous nerves. On the other hand, in the clinical setting, peripheral nerve defects are often accompanied by damage to the surrounding tissues (e.g., bone or muscle defects, vascular injuries). The efficacy of artificial nerve conduit in repairing nerve injuries accompanied by surrounding tissue damage remains unclear. In the present study, we fabricated a novel nerve conduit vascularized by superficial inferior epigastric (SIE) vessels, and evaluated whether it could promote axonal regeneration in a necrotic bed.
Materials and Methods: Adult male LEW rats (280–320 g) were used for this study. A 15-mm artificial nerve conduit (NerbridgeTM ) was implanted beneath the SIE vessels in the groin of a rat to supply it with blood vessels 2 weeks before nerve reconstruction. We removed a 13-mm segment of the sciatic nerve and then pressed a heated iron against the dorsal thigh muscle to produce a burn. The defects were immediately repaired with an autograft (n = 10), nerve conduit graft (n = 8), or vascularized nerve conduit graft (n = 8). Recovery of motor function was examined using a digital force gauge for 18 weeks postoperatively. The regenerated nerves were evaluated electrophysiologically and histologically.
Results: Two weeks after conduit implantation under the SIE vessels, the nerve conduit was covered with fat and connective tissues, which were vascularized by the SIE vessels. Observation of longitudinal frozen sections of the nerve conduit revealed SIE vessels adhered to the outside of the tube and abundant capillary vessels within the conduit. The vascularized conduit group showed significantly better motor function than the nonvascularized conduit group but worse motor function than the autograft group from 14 to 18 weeks following surgery. Electrophysiological evaluations revealed that the vascularized nerve conduit improved nerve function more effectively than the nonvascularized conduit but less effectively than reinnervation after an autologous nerve graft. Toluidine blue staining of the regenerated nerves showed that the total number of myelinated axons in the conduit group was significantly less than that in either of the other groups. The gastrocnemius muscle weight ratio showed that whereas muscles in the autograft group were resistant to atrophy, those in both the conduit and vascularized conduit groups were not
Conclusions: We demonstrated that vascularization of an artificial nerve conduit could promote axonal regeneration in a necrotic bed in which the tissue surrounding the graft was damaged. Although this tissue-engineered conduit did not achieve the level of reinnervation attained by an autograft, further studies may improve the quality of nerve regeneration beyond that of autologous nerve grafting.

O Samarah, Kamil M. K Ahmad, A Khanfar, M Hamdan, TM Tareq, S El-Hadidi

University of Jordan, Amman, Jordan

Simple decompression of the first extensor compartment is commonly used for treating de Quervain’s disease, with the possible complication of subluxation of the tendons of the abductor pollicis longus (APL) and extensor pollicis brevis (EPB) over the radial styloid. To prevent this rare but serious complication, several surgical techniques have been proposed in the literature
The purpose of our study was to evaluate the results of Littler’s technique for reconstructing the first extensor compartment following the release for de Quervain’s disease.
Patients and Methods 
A retrospective study was performed in 58 patients. The outcome assessment involved a questionnaire to assess for complications including tendon subluxation.
None of the patients required reoperation. None of the patients experienced clicking around the radial styloid after surgery. Eight patients experienced transient paresthesia in the superficial radial nerve distribution; all have been resolved spontaneously in 1-24 weeks.
We believe that Littler’s technique for treating de Quervain’s disease is an effective, safe and simple method that prevent possible tendon subluxation following simple release of the first extensor compartment.

Takakazu Hirayama, Masaaki Shindo, Kazuhiro Ozawa,

Department of Orthopedic Surgery, Shindo Hospital, Asahikawa City, Hokkaido, Japan

To evaluate the results of reconstruction of the thumb after traumatic loss with use of traumatized index finger on-top-plasty.
Materials and methods
Surgical technique
An injured or severed index finger in conjunction with traumatic amputation of the thumb creates an ideal situation for on-top-plasty of the index finger stump to the thumb remnant.
This surgical technique is one of the several modifications of the classic pedicle island transfer. A palmar approach is used to transfer the segment of index finger. After identification and dissection of the neurovascular bundles of the index finger and resectioning of the second metacarpal shaft at the desired level, the traumatized index finger with its neurovascular pedicle is transferred and fixed to the thumb at the desired position. The skin defect of the web space is covered by a dorsal flap or skin grafting as necessary.
Eight patients who were treated by this technique included 6 men and 2 women with ages ranging from 19 to 65 years. Five were injured in the right hand and 3 in the left. The period between the injury and thumb reconstruction ranged from 3 weeks to 6 months. The level of the thumb amputation was at or near the metacarpophalangeal joint in 7 patients and at the proximal phalanx in 1. All the patients had intact carpometacarpal joints and good thenar musculature function. The level of index finger amputation was at or near the proximal interphalangeal joint in 6 patients and near the metacarpophalangeal joint in 2. Two palmar neurovascular bundles of the injured index finger were available in 6 patients and 1 in 2. The nails of the index fingers were absent in all the patients.
The average follow-up period was 6 years (range, 1 to 19 years). In all the cases, patients were able to perform the function of opposition and pinch that required the use of thumb. None of the cases required secondary operation. Pinch strength averaged 85.3% and grasp strength averaged 68.5% of the contralateral side. Static two-point discrimination ranged from 3 mm to 10 mm. Four patients had intolerance to cold and 3 had good reorientation. The patients with preservation of 2 neurovascular bundles showed excellent sensibility. This technique provides one-stage lengthening, stability and excellent sensibility in the thumb, however, cortical reorientation is not good enough. Transfer of the damaged index finger widens the web space by removing the hindering nonfunctioning index finger to enhance the length of the injured thumb. All patients reported some difficulty in gripping smaller objects (coin, tablets, etc.), especially chopsticks. All were satisfied with the daily functioning activities of their reconstructed thumbs and the aesthetic appearance of their reconstructed hands, despite a decrease in the number of digits and the absence of nails.
Despite all the available options, traumatized index finger on-top-plasty for thumb reconstruction provided satisfactory, functional and cosmetic results. However, severity of the initial injuries to the thumb and index finger determined the final outcome.
Keywords: traumatized index finger, on-top-plasty, thumb reconstruction

Vázquez Alonso Ma. Francisca, Viñas Silva Alberto

Unidad Medica de Alta Especialidad en Traumatología y Ortopedia "Lomas verdes" IMSS, México México

Key Words: Four corner fusion; SNAC/SLAC wrist arthritis.
Scapholunate advance collapse (SLAC) and scaphoid nonunion advance collapse (SNAC) are the two most common patterns of postraumatic wrist arthritis. SLAC wrist develops after attenuation, either traumatically or atraumatically, of the scapholunate ligament. Atraumatic causes of SLAC wrist include calcium pyrophosphate dehydrate deposition disease, reumathoid arthritis, neuropathic diseases, and b2-microglobulin asociated amyloid deposition diseases. On the other hand, SNAC wrist develops following a scahpoid fracture that has progressed to a nonunion. Both of these processes lead to abnormal joint kinematics, since the lunate is unrestrained by the distal scaphoid and, therefore, assumes an extended posture. Over time, this may result in a dorsal intercalated segment instability (DISI) deformity, which invariably progresses to degenerative arthritis as the radioescaphoid articulation, followed by carpal collapse and midcarpal arthritis. The purpose of this retrospective, longitudinal and observational study is to evaluate the functional outcome and pain relief in SLAC/SNAC wrist, after four corner fusion. Matherial and Methods: This study was made in 52 patients of the IMSS (Instituto Mexicano del Seguro Social) UMAE (Unidad Médica de Alta Especialidad) HTO (Hospital Traumatologia y Ortopedia) Lomas Verdes, these patients undergone four corner fusion surgery, in a period january 2007 to december 2014. We used Quick Dash Questionary to evaluate functional outcome and pain relief in these patients. Results: 50 patients showed minimum functional disability (96.2%) and two patients with moderate (3.8%); only three patients had complications related to surgery (3.8%); the average of laboral reinstatement was 85 days after surgery. We made a Wilcoxon sign test, variable pain before surgery related to pain after surgery had a improvement and statistic value p<.001. Discusion and Conclusions: the most of the patients had a improvement of the pain after surgery, 96.2% of patients studied had a minimum functional disability, similar results compared with the study made by Dacgo A. and Baumeister S. (3) with 21 patients treated with four corner fusion with a follow-up tof three years. The most of the patients showed a functional improvement of the wrist after surgery, SNAC/SLAC wrist arthritis is more common in young and productive patients, the average of laboral reinstatement was 85 days after surgery.

Rodríguez Sammartino Mario Alberto, Mussini Daniel Oscar, Rodríguez Sammartino Juan Martín, Day María Candela

Clínica de Fracturas y Ortopedia Mar del Plata Argentina

We report a case of displaced isolated triquetral body fracture that resulted in non-union, treated successfully with open reduction and internal fixation using compression screws and bone grafting, and with early mobilization of the wrist.
Clinical Case
A 71 year old female suffered a hyperextension trauma on her right wrist on November 5, 2009. After some days, the patient was assisted at an emergency department and an x-ray was taken which showed no osteoarticular lessions. A diagnosis of soft tissue injury to the wrist was suspected and our patient treated with wrist immobilization. Our patient continued to remain symptomatic with tenderness over the ulnar aspect of his wrist for four months after the injury, despite the treatment. At this point a magnetic resonance imaging (MRI) scan was carried out, which suggested a non-union and minimally displaced fracture of the triquetral body. A computed tomography (CT) scan confirmed the diagnosis. Our patient finally underwent an open reduction and surgical fixation at five months after the injury due to persistence of symptoms. A dorsal approach was used to access the triquetrum between the fifth and the sixth extensor compartment. Dissection was carried out to expose the triquetrum and the non-union fragments were visualized. The fragments were reduced under direct vision and fixed with onemini-compression screws (Trimed Ltd) and bone graft from the Lister tubercle was use. Our patient was followed-up at two weeks, six weeks, and 12 weeks post-operatively to union. The fracture went on to complete union radiographically.
Although non-union of triquetral body fractures is rare, such cases can lead to considerable disability. After extensive systematic review of the literature, searching Embase, Medline, Cochrane, Cinhal, and Google search engines, we could identify only three previous reports of non-union of triquetral body fracture [1-3]. This low incidence could be attributed to the rich vascular supply of the triquetrum, which may explain the low risk of developing avascular necrosis in these fractures. Durbin [2] reported treating triquetral non-union with immobilization in plaster cast, which was unsuccessful and the patient remained symptomatic. Abboud et al. initially treated the non-union with cast immobilization, which did not respond, and subsequently carried out an open reduction and internal fixation using headless compression screws, with iliac bone autograft [1]. Kawakami et al. also achieved successful bone union of the triquetral fragments with open reduction and internal fixation using headless compression screws and iliac bone graft [3]
Given the morbidity associated with non-union of triquetral body fractures we encourage a high index of suspicion for these fractures in people who have fallen on an outstretched hand with ulnar sided wrist pain. We recommend that patients with persistent ulnar sided pain and disability should be further investigated for this injury. CT and MRI have a high sensitivity in allowing visualization of both bony and soft tissue injury and morphology of the fracture to determine the need for early fixation and to reduce morbidity in this group of patients.

Seiji Nishimura1, Katsuyuki Shibata1, Kaoru Tada2, Shou Horie3, Yuki Matsui4

1 Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University, Japan; 2 Department of Orthopedic Surgery, School of Medicine, Kanazawa University, Japan; 3 Department of Rehabilitation, Kanazawa University Hospital, Japan; 4 Shimada Hospital, Japan

Purpose: Using our original sensor equipped with a 3-component force transducer, we developed a muscle strength measurement system for the thumb based on 3-dimensional analysis to identify muscle strength in the four directions, i.e., flexion, extension, abduction, and adduction forces. Furthermore, we improved our original system to enable measurement of coordination ability of the thumb. The present study was performed to review coordination ability of the thumb in the four directions.
Methods: 32 thumbs of 32 healthy adults with an average age of 21.7 were studied. The subjects, who had no medical history of functional disorders in the arms, voluntarily participated in our experiment after being informed that there would be no negative after-effects caused by the measurement. In our measurement system, a 3-component force transducer was fixed to a custom-built sensor. This unit, which was connected to three strain gauge amplifiers, transmitted the data to an A/D conversion analyzer for recording on a personal computer. For measurement, the shoulder joint angle was fixed to 60° flexion and the wrist joint angle was fixed to 40° dorsal flexion. The proximal phalanx was pressed onto the prescribed position of the sensor. We measured thumb flexion, extension, abduction, and adduction forces. And we measured all directions of coordination ability in the thumb, too. We did the coordination ability of the thumb with the ability that we could keep movement with the power of 50% of maximum muscular strength at the objective position.
Results: The average thumb forces in flexion, extension, abduction, and adduction were 42.1 N, 12.7 N, 13.7 N, and 35.3 N, respectively. Thumb adduction and flexion forces were significantly greater than those of extension and abduction were. The average thumb coordination ability in flexion, extension, abduction, and adduction were 6.92, 15.88, 14.46, and 9.98, respectively. Thumb adduction and flexion coordination ability were significantly smaller than those of extension and abduction were. In other words, this means that thumb coordination ability of flexion and adduction is high. Furthermore, in the measurement of the coordination ability, a coefficient of correlation showed high reproducibility with 0.71-0.90.
Conclusions: This technique will be useful in evaluating muscle strength and coordination ability in the field of applied hand surgery by allowing examination of various positions of the thumb.

D. Wessing, Y. Bachour, M.J.L. Berkhout, M.J.P.F. Ritt

VU University Medical Center, Amsterdam, The Netherlands.

Purpose: Resection of the distal pole of the scaphoid is one of the surgical techniques applied for the treatment of painful scaphotrapeziotrapezoid osteoarthritis (STT-OA) and non-union of fractures in the distal part of the scaphoid. Very few studies report on the outcome of this technique. The purpose of this study is to evaluate the midterm outcomes in a consecutive series of patients.

Methods: This is a retrospective study in which we evaluated 13 patients (15 wrists) with a mean follow-up of 4.1 years. The indication for surgery was in all cases a STT-OA. We evaluated objective functional outcome measures (range of motion and grip strength) and patient reported outcome measures (VAS for pain, Michigan Hand Questionnaire and Quick-DASH). The degree of dorsal intercalated segmental instability (DISI) and the postoperative complications were also assessed.

Results: Extension and flexion averaged 61.6 and 74.3 degrees, while radial and ulnar deviation averaged 16.7 and 27.8 degrees respectively. Grip strength at position 1-5 respectively averaged 16.0, 23.6, 21.5, 18.3 and 15.6 kg. Reported pain averaged 2.1/10, MHQ 76.4/100 and Q-DASH 25.2/100. A mild postoperative DISI deformity was observed in thirteen wrists with an average lunocapitate angle of 22.1 degrees (range 0-44) on radiographic evaluation without a correlation with reported pain scores. None of the opposite wrists, whether with or without STT-OA, displayed a DISI deformity. The only observed complication was a complex regional pain syndrome in one case.

Discussion: The mid-term results for distal pole resection of the scaphoid in the treatment of STT-OA and scaphoid non-union are satisfactory. Almost all patients develop a mild degree of DISI deformity, but this does not affect the outcome.

Type of study/Clinical relevance: Therapeutic III

Keywords: STT-OA, distal pole resection of the scaphoid, midterm-outcomes

Leanne Miller, Christina Jerosch-Herold, Lee Shepstone

University of East Anglia, Norwich, UK

Oedema after trauma or surgery is a normal part of the healing process, however prolonged oedema, which is more viscous resulting in elasticity and thickening of the tissues, has a negative impact on joint range of motion, soft tissue mobility, quality of scar tissue formation, function, strength, and appearance of the hand.
Prolonged hand oedema can cause delays to the recovery of the patient which has consequences on service delivery, return to work and functional ability resulting in cost implications for the individual, NHS and the wider economy.

Although the treatment of hand oedema is a core component of the hand therapist’s management no systematic reviews on effective hand oedema treatments exist. There is also a lack of consensus on how the treatments are delivered.
There is a need to describe and define oedema management and develop oedema management guidelines before the interventions can be evaluated through primary studies.

The aims of this study are to identify and describe current assessment methods of hand oedema among hand therapists in the UK and to develop consensus on best practice for hand oedema interventions including the frequency, duration and instructions given to patients.

Materials and Methods;
A web-based cross-sectional survey of practising hand therapists was be conducted with members of the British Association of hand Therapists (BAHT). The questionnaire was made available to members on the BAHT website and social media pages and e-mailed to members in an E-Bulletin.
Following this, an internet-mediated Delphi study was conducted with ‘experts’ who completed the online questionnaire and volunteered themselves as an ‘expert’ in the field of hand oedema. Consensus will be based on an a priori level of agreement if 75% with at least 2 rounds expected to take place.
Data collection is ongoing and analysis will be completed by July 2016

Data from the survey will be analysed using summary statistics for closed questions and thematic content analysis for open question. The results will be used to begin to define and describe current oedema treatment and assessment methods which will be further refined through the Delphi consensus methods.

This study will describe current practice in the UK and the results compared to a recent systematic review of oedema management techniques completed by the author. Trends in service delivery will be established based on professional background and grade of staff. Details on the management of oedema including; frequency, duration, modality and advice to patient will be amalgamated into a consensus based oedema treatment guideline.
Results of both studies will be discussed in terms of their implications for local and national service delivery, cost, impact on patient outcomes and future development.

Andrzej Zyluk, Agnieszka Mazur-Grzesiuk

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin, Poland

Tumours of the upper extremity are common and mostly benign. The most commonly diagnosed are ganglion cysts: specific, non-neoplasmatic swellings localized mostly around the wrist. The objective of this retrospective study was to determine the proportion of various types of hand tumours, that were not ganglions, operated on in the authors’ institution in 2014.
Results. A total of 246 patients, 141 women (57%) and 105 men (43%), aged a mean of 53 years with tumours within the upper extremity, were identified and treated in the authors’ institution within 2014. Almost half of the lesions were localized in the fingers - 119 (48%), followed by the wrist - 49 (20%), metacarpus - 40 (16%) and more proximal parts - 38 (16%). The time between noticing of the lesion by the patients and operation was a mean of 4 years (range 1 month - 30 years). The most common lesion was giant cell tumour of the tendon sheath - 58 cases (23%), followed by lipoma - 40 (16%), epidermal cyst - 23 (9%), enchondroma - 16 (6%), hemangioma - 14 (6%), fibroma - 11 (4%), glomus tumour - 10 (4%) and rheumatoid nodule - 10 (4%). Two cases of malignant fibrosarcoma were diagnosed accidentally in this material.

Andrzej Zyluk, Katarzyna Skala, Zbigniew Szlosser

Department of General and Hand Surgery, Pomeranian Medical University in Szczecin

The objective of the study was a comparison of outcomes of K-wire vs plate fixation for distal radial fractures with regard to patients’ quality of life.
Materials and Methods. One hundred and two patients, 79 women and 23 men with displaced distal radial fractures, were non-randomly allocated for either K-wire (n=72) or palmar plate (n=30) fixation. In general, simpler fractures were fixed by pins, while plates were used for those that were more severe.
Results. No statistically significant differences were seen at 3- and 6-month follow-up assessment in any of the analyzed variables: wrist range of motion, total grip and key-pinch strength, and the DASH and SF-36 scores.
Conclusion. We conclude that being guided by the postulated algorithm in treatment-choice of distal radial fractures is a reasonable balance between clinical- and cost-effectiveness. We also failed to find any advantage in health-related quality of life as an outcome measure in distal radial fractures compared to standard measures.

Sang Ki Lee 1, Youn Moo Heo 2

1 Eulji University College of Medicine, Daejeon, South Korea 2 Konyang University College of Medicine, Daejeon, South Korea

The purpose of our retrospective study was to evaluate the outcomes of scaphoid fracture nonunion treated with a pronator quadratus pedicled vascularized bone graft and a headless compression screw with regard to early wrist and thumb mobilization. From January 2008 to June 2011, 27 patients (20 men, 7 women; mean age, 24 years; age range, 15–32 years) with scaphoid fracture nonunion were treated with a pronator quadratus pedicled vascularized bone graft and a headless compression screw, and who met our inclusion criteria, including symptomatic scaphoid waist fracture nonunion with or without compromised vascularity and carpal instability. We evaluated radiologic assessment (correction of carpal instability, union rate). And, overall clinical results were also graded using the wrist range of motion, the modified Mayo wrist score, and Disabilities of the Arm, Shoulder and Hand (DASH) score. All patients achieved bony union in a mean of 11.5 weeks (range, 8–18 weeks). The mean radiolunate and scapholunate angles improved from –12.3° (range, –38.0° to 4.5°) and 62.8° (range, 50.0°–72.5°) preoperatively to –1.4° (range, –14.5° to 6.5°) and 48.5° (range, 40.5°–63.5°) at the follow-up. The final average range of motion was as follows: wrist flexion, 73° (range, 65°–85°); extension, 69°(range, 60°–80°); ulnar deviation, 36°(range, 15°–50°); and radial deviation, 22°(range, 10°–35°). The average postoperative modified Mayo wrist score and Disabilities of the Arm, Shoulder and Hand score were 92 points (range, 78–100 points) and 11 points (range, 0–32 points), respectively. Our results suggest that a pronator quadratus pedicled vascularized bone graft and internal fixation with a headless compression screw can yield satisfactory functional and radiographic outcomes in the treatment of scaphoid fracture nonunion.

Ronit Wollstein 1,2, Olga Polovinets 2, Alon Wolf 2

1 University of Pittsburgh School of Medicine, Pittsburgh, PA, USA 2 Technion Israel institute of technology, Haifa, Israel

The patterns of load on the wrist, elbow and shoulder during push-up performance may cause overload on certain areas of the upper extremity with pain and injury. Clinically patients with wrist or elbow injury are incapable of performing push-ups. In a previous study we evaluated the forces passing through the wrist during the performance of push-ups in 2 different styles and found that during enactment of a push-up on a hyperextended wrist the forces travel more ulnarly, more dorsally and in a less organized fashion than the forces travelling through the wrist when the push-up is executed on a neutral wrist. The forces passing through the elbow and shoulder during push-ups in the different methods may change accordingly. The purpose of this study was to compare the trajectory of the forces through the elbow and shoulder during push-ups on a hyperextended wrist (military style pushups) and during push-ups performed on a straight wrist (knuckle pushups). We hypothesized that knuckle push-ups differ from push-ups on a hyperextended wrist in force distribution through the elbow and shoulder.
Materials and Methods:
Fourteen healthy right-handed male volunteers performed push-ups on a neutral wrist (knuckle push-ups) and on a hyperextended wrist (military- style). The push-ups were performed in a gait analysis laboratory using a Vicon motion capture system to follow the kinematics. The force vectors were measured using force plates and computed using Matlab software. We evaluated the uniformity of the forces passing through the shoulder and elbow using a reflective marker on the elbow and markers in the shoulder area.
In both methods, the force was not uniform throughout the push-up experience. In both styles the right and left upper extremity (all joints) moved equally in the vertical plane.
The forces passed through a larger area in the shoulder than in the elbow regardless of push-up style. In knuckle push-ups the force passed through a more focused area in the elbow than in the hyperextended wrist. In knuckle push-ups the forces were distributed over a larger area in the shoulder than in the hyperextended wrist position.
The forces through the wrist elbow and shoulder are distributed differently during the different styles of push-up. It seems that while push-ups in hyperextension load the wrist and elbow in a more diffuse fashion with force dissipating through more structures, the opposite is true for the shoulder. This knowledge can be translated clinically to differentially strengthen and load certain areas in the upper extremity in rehabilitation and training. Further study is necessary to delineate the differences between both types of pushups especially in regards to the anatomical location of force transmission and the amount of load being transmitted. This can affect our use of these exercises in the rehabilitation of the injured upper extremity.

Young Hak Roh, Jong Ryoon Baek, Do Hyun Moon, Beom Koo Lee

Department of Orthopaedic Surgery, Gil Medical Center, Gachon University School of Medicine, Incheon, Korea.

Objective/hypothesis: Patients with hand fractures often have pain, swelling, and stiffness in the joints of the hand, which may lead them to protect their hands, resulting in more stiffness and in delayed recovery. However, the effects of pain-coping strategies on functional recovery after hand fractures have not been investigated in depth. We hypothesized that preoperative catastrophization and anxiety in patients with hand fractures would be associated with a (1) decrease in grip strength; (2) decreased ROM; and (3) perceived hand-specific disability at 3 and 6 months after surgical treatment for a hand fracture.

Materials and Methods: A total of 93 patients with surgically treated hand fractures were enrolled in this prospective study. Preoperative assessments measured coping strategies evaluated by measuring catastrophic thinking with the Pain Catastrophizing Scale and pain anxiety with the Pain Anxiety Symptom Scale. At 3 and 6 months postoperatively, grip strength, total active range of motion, and disability (Quick Disabilities of the Arm, Shoulder, and Hand score) were assessed. Bivariate and multivariate analyses were performed to identify patient demographic, injury, and coping skills factors that accounted for outcomes of strength, motion, and disability.

Results: Decreased grip strength was associated with catastrophic thinking (beta = -1.29 [95% confidence interval, -1.67 to -0.89], partial R2 = 11%, p < 0.001) and anxiety (beta = -0.83 [-1.16 to -0.50], partial R2 = 7%, p = 0.007) at 3 months, but by 6 months, only anxiety (beta = -0.74 [-1.04 to -0.44], partial R2 = 7%, p = 0.010) remained an important factor. Decreased total active range of motion was associated with pain catastrophizing (beta = -0.63 [-0.90 to -0.36], partial R2 = 6 %, p = 0.024) and anxiety (beta = -0.28 [-0.42 to -0.14], partial R2 = 3%, p = 0.035) at 3 months but not at 6 months. Similarly, increased disability was associated with pain catastrophizing (beta = 1.09 [1.39-0.79], partial R2 = 12%, p < 0.001) and anxiety (beta = 0.93 [1.21-0.65], partial R2 = 11%, p = 0.001) at 3 months; these factors failed to be associated for 6-month outcomes.

Conclusions: Preoperative poor coping skills as measured by high catastrophization and anxiety were associated with a weaker grip strength, decreased range of motion, and increased disability after surgical treatment for a hand fracture at 3 months. However, poor coping skills did not show persistent effects beyond 6 months. More research may be needed to show interventions to improve coping skills will enhance treatment outcome in patients after acute hand fractures.

Young Hak Roh, Jong Ryoon Baek, Do Hyun Moon, Beom Koo Lee

Department of Orthopaedic Surgery, Gil Medical Center, Gachon University School of Medicine, Incheon, Korea.

Objective/hypothesis: Diffuse peripheral nerve impairment is common in metabolic syndrome (MS), and high prevalence of hyperlipidemia and hypertension in patients with peripheral neuropathy has been reported. We hypothesized that patients with MS would show decreased functional scores on both objective and subjective measures of function compared to those without MS for 24 weeks after corticosteroid injection for carpal tunnel syndrome (CTS).

Materials and Methods: In consecutive patients with CTS treated with corticosteroid injection (10 mg triamcinolone acetonide), 55 patients with co-occurrence of MS were age- and sex- matched with 55 control patients without MS. Grip strength, perception of touch with Semmes-Weinstein monofilament, and Boston Carpal Tunnel Questionnaires (BCTQ) were assessed at baseline and 6, 12, and 24 weeks follow-up.

Results: Patients with MS had more severe electrophysiologic grade of CTS than those without MS, but the two groups had similar preoperative grip strength and BCTQ scores. The BCTQ symptom and function scores of the MS group were significantly greater than the control group at 12 and 24 weeks follow-up. There was slightly weaker grip strength in patients with MS throughout the 24-week follow-up, but the differences did not reach statistical significance, except for significantly greater grip strength at 12-week follow-up in the control group. Semmes-Weinstein monofilament sensory index for the control group was significantly greater than that of MS group throughout the 24-week follow-up. After 24 weeks, 5 patients (13%) in the control group and 13 patients (27%) in the MS group had carpal tunnel surgery (p = 0.04).

Conclusions: CTS patients with MS are at risk for poor functional outcome and failure of treatment after corticosteroid injection, as considerable improvements in symptom severity and hand function will likely occur only within 6 weeks after injection for MS patients. These results could help guide initial treatment and counsel patients about prognosis after corticosteroid injection.

Young Hak Roh, Jong Ryoon Baek, Do Hyun Moon, Beom Koo Lee

Department of Orthopaedic Surgery, Gil Medical Center, Gachon University School of Medicine, Incheon, Korea.

Objective/hypothesis: A limited health literacy is common among patients who are seeing a hand surgeon. However the effects of health literacy on treatment outcomes and satisfaction after an acute hand injury, such as a mallet finger injury, have not yet been thoroughly investigated. We hypothesized that a low health literacy in patients with an acute mallet finger would be associated with (1) poor compliance and follow-up loss and (2) treatment outcomes both in terms of objective measures and self-reports of hand function.

Materials and Methods: A total of 72 patients that had been treated with a splint for an acute mallet finger injury were enrolled in this prospective study. Health literacy was measured according to the Newest Vital Sign (NVS) during the initial visit, and compliance according to the treatment protocol was rated at week 7 when the splints had been worn out. At 6 months a follow-up visit was conducted to assess the extensor lag, treatment satisfaction, and disability (through the Quick Disabilities of the Arm, Shoulder, and Hand score). Bivariate and multivariate analyses were performed to determine whether patient demographics, injury characteristics, and health literacy factors accounted for outcomes in the extensor lag, satisfaction, and disability.

Results: The NVS scores were significantly correlated with patient compliance. Extensor lag was associated with an increase in age, poor compliance, and low health literacy, and these three factors accounted for 28% of the variation in the extensor lag. An increased disability was associated with poor compliance, which accounted for 12% of the variance in disability. A decrease in treatment satisfaction was associated with a low health literacy and poor compliance, and these two factors accounted for 21% of the variation in treatment satisfaction.
Conclusions: A limited health literacy was associated with poor compliance in splint care for mallet finger injuries and led to poorer treatment outcomes in terms of extensor lag and treatment satisfaction. More research is needed to show whether an improvement in patient comprehension through an informational intervention will improve the treatment outcomes in patients after an orthopedic injury, such as for an acute mallet finger injury.

Conclusions: A limited health literacy was associated with poor compliance in splint care for mallet finger injuries and led to poorer treatment outcomes in terms of extensor lag and treatment satisfaction. More research is needed to show whether an improvement in patient comprehension through an informational intervention will improve the treatment outcomes in patients after an orthopedic injury, such as for an acute mallet finger injury.

Andres Alejandro Dogliotti

National Children Hospital Juan P. Garrahan, Buenos Aires, Argentina.

Introduction: Duplication of an upper limb or "triplication of the upper extremity", is a rare malformation, with no known cause, and with very few cases reported in the medical literature. Each case represents a challenge and great interest for surgical reconstruction by the hand surgeon. Treatment is focused on the resection and reconstruction of the upper extremity, seeking to achieve acceptable functional and aesthetic results.

Objective: The purpouse is to present the case of a patient with a duplicated right limb, expose the clinical findings, reconstruction strategy and show the surgical treatment with its results.

Methods: We report a 2-year-old girl, bringed with her parents because of multiple congenital malformations. On physical examination, the left dominand limb was normal, but she presented right polythelia, right upper limb duplicated (polymelia) as a posterior accessory limb, very hypoplastic and with a short forearm; rigid elbow, stiff wrist and a single non-functional digit in her hand. The “anterior” right limb, was larger but also hypoplastic; and had limited active movements; an extended elbow, with reduced passive flexion, and a radial polydactyly in an arthrogryposys-like hand. Vascular studies revealed the presence of all major arteries in the resectable extremity. The surgery strategy consisted of resection of the extra limb, and spare a skin flap in order to increase the volume of the remaining anterior arm; use a proximal functional muscle (pseudo-triceps) for transfer to the shoulder (lateral aspect of the humerus as external rotator) and to the biceps for reforcing elbow flexion. On the upper limb preserved, we resected the radial polidactily, opened the first interdigital space and coveraged with a dorsal bilobed flap from the extra thumb. Also we performed a posterior elbow release (distal triceps elongation and posterior capsulotomy).

Results: The postoperative period was very satisfactory, since the aesthetic result immediately delighted the parents. Two years after surgery and without phisical therapy, the parents were very satisfied because the shoulder increased its mobility; the child used her hand better and got active elbow flexion up to 90°.

Conclusions: The purpose of the reconstructive surgeon must be not only to resect the more hypoplastic extremity; but also to take advantage of the disposable structures of the extra limb in order to increase cosmetic and function of the remaining limb, such is the case of the transfer of a posterior two head muscle to improve shoulder movement and the skin flap to give better contour of the arm.

Claudia Lamas, Antonio Garcia, Laura Velasco, Ignacio Proubasta, Camila Chanes

Hand Unit and Upper Extremity, Orthopaedic Surgery Department, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain

Introduction: Dislocations of the lunate with or without fractures of the scaphoid are uncommon injuries. The defining characteristic of these injuries is dislocation of the capitate head from the lunate concavity. Perilunate dislocations (PLDs), are referred to as lesser arc injuries, whereas perilunate fracture dislocations (PLFDs) are referred to as greater arc injuries. We showed three patients of a variant described by Viegas with a transscaphoid PLFD with a dorsal dislocation of the proximal fragment of the scaphoid associated with scapholunate dissociation.
Methods: We prospectively have treated three patients with this specific variant between January 2008 and September 2015. The characteristics of the injury were described radiologically with AP, lateral and scaphoid views, and with TC scan. Surgery treatment and outcome were analysed. Functional outcomes evaluated were pain with the visual analog scale (VAS), range of motion, grip strength, Disabilities of the arm, Shoulder and Hand (DASH) score, and Mayo wrist score.
Results: We treated three patients, all of them men, with a mean age of 46 years (42-52). The associated fractures were a distal radius fracture in one case and trapezoid plus capitate in other case. The lunate was stabilized with a K-wire to the scaphoid in one case, to the capitate in other case and to the capitate and to the triquetral plus capitate in the last case. The scaphoid fracture was synthesized with a Mini-Acutrak screw in two cases and stabilized with a K-wire to the capitate in the other case. Reinsertion of scapholunate ligament with an anchor was performed in one case. Follow-up time averaged was 12 months (range, 12-54 months). Of the patients, 2 were pain-free and 1 had pain with activity. Mean preoperative VAS pain score was 7 (4-9) and 1 (0-2) postoperatively. Postoperative average wrist range of motion was 65º in extension, 62º in flexion, 12º in ulnar deviation, and 14º in radial deviation. Mean grip strength was 12 Kg preoperatively, 54 Kg postoperatively, and 62 Kg contralaterally. All cases showed union at the plain radiography at the final of the follow-up, confirmed by CT scan. Complications included one case of extensor pollicis longus tendon rupture. Preoperative Mayo Wrist Score was 52 and a postoperative value was 92 (80-100). DASH functional scale improved from 75 (56-82) to 8 (0-10).
Conclusions: It seems that the optimal treatment of this injury is open reduction and internal fixation of the scaphoid fracture, and open reduction and K-wire fixation of the lunate dislocation.
A review of the literature reveals only a few cases of this combination of injuries. This particular injury complex may be added to the list of various wrist injuries.

Justin C.R. Wormald 1, Matthew D. Gardiner 1,2, Hawys Lloyd-Hughes 2,3, Sonya Gardiner 3, Abhilash Jain 1,2

1 Department of Plastic and Reconstructive Surgery, Imperial College Healthcare NHS trust, St Mary’s Hospital, Praed St, London, W2 1NY 2 Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Roosevelt Drive, Oxford, OX3 7FY, UK 3 Royal Free Hospital, Pond Street, London, NW3 2QG

K-wire fixation is commonly performed for upper limb fractures. K-wires are buried or non-buried depending on surgeon preference. We performed a systematic review of the literature comparing buried and non-buried K-wires in all upper limb fractures to determine the difference in post-operative infection rate. A thorough search was performed to identify all studies relating to management of K-wires in upper extremity fractures in both paediatric and adult populations (Embase, Medline, Cochrane Database, etc.). Eight studies met the inclusion criteria. There was one prospective RCT and seven case series ( 3 studies examined adults and 4 in paediatric populations). Two studies looked at hand, one wrist, three lateral condyle elbow and two at forearm fractures. The rate of post-operative infection was calculated for each group (buried versus percutaneous). Six studies reported a higher post-operative infection rate in non-buried K-wires compared to buried K-wires. We synthesized data for post-operative infection across all studies in a forest plot. There is a lack of high quality evidence to support the use of buried K-versus non-buried wires in upper limb surgery, nonetheless our review suggests a trend to higher infection rates associated with non-buried wires.

Weiwen Zhang

Department of Hand Surgery, Ningbo No.6 Hospital, Ningbo, 315040, China

Objects Review all cases of different stages avascular necrosis of lunate bone suffered the wrist arthroscopy technology, analyze the curative effect , investigate the advantages and disadvantages of wrist arthroscopic technique in different stages and different surgical procedures. Methods 33 cases of lunate bone in patients with different stages avascular necrosis undergoing wrist arthroscope from Match 2013 to June 2015,.All cases accepted preoperative wrist X-ray, CT and MRI examination, according to the Lichman/Stahl stage, the stage I (3 cases), the stage II (11 cases), the stage IIIA(7 cases), the stage IIIB (5 cases), the stage IV (7 cases). Assessed pre-operative wrist ROM, grip strength and degree of pain,performed a functional evaluation using the modified Mayo wrist scoring system. All 3 cases of stage I and 11 cases of stage II accompanied ulna  plus variation, according to the ulna length, 6cases suffered Wafer’s ulna shorten underwent arthroscopic surgery, and 8 cases went under ulna shorten by opening osteotomy; The 7 cases of stage IIIA, suffered "wrist synovial cleaning and the second metacarpal dorsal artery implantation under arthroscope"; 5 cases of stage IIIB and 7 cases of stage IV , went under "wrist synovial cleaning and  excision of lunate bone and scaphoid-capitatum fusion". Results Followed up for 6 to 28 months postoperatively, Assessed postoperative wrist ROM, grip strength and degree of pain,performed a functional evaluation using the modified Mayo wrist scoring system. The pain when resting had decreased ,and the pain when wrist motion had also reduced, grip strength obviously improved, the postoperative ROM improved or hold the line of pre-operation, except the 12 cases that suffered the excision of lunate bone and scaphoid-capitatum fusion,the postoperative ROM decreased. Conclusions The wrist arthroscopy technology is  minimal invasive, rapid recovery, and the postoperative curative effect is satisfied. Suit different stages avascular necrosis of lunate bone; can check-up the lunate bone directly , assess the osteonecrosis degree more precisely; According to stage of avascular necrosis of lunate bone, offer  personalized operative procedures .

Xin Wang

Department of Hand Surgery, Ningbo No.6 Hospital, Ningbo, 315040, China

Objective Introduce the procedure using the extensor retinaculum flap to reconstruct the DRUJ dorsal ligament, and analyse the clinical efficacy。 Methods 11patients were included in the study based on: chronic symptoms of DRUJ instability, demonstrable instability on examination, MRI evidence of RUL deficiency, or arthroscopic findings of TFCC ulnar tears. 4male, 7female; mean age was 41.4ys old; 9cases had a history of wrist injury; a pre-operation functional evaluation was performed using the modified Mayo wrist scoring system for all patients; 10 patients suffered arthroscopic confirmation of TFCC tear. During the operation a extensor retinaculum flap was designed about 4cm long by 1cm wide, the pedicle of flap based on the distal ulnar. Raised the flap and revealed the DRUJ, reduct the DRUJ by supinating the forearm, then transferred the flap to the dorsal-ulnar aspect of the radius and fixed by an anchor. Postoperatively, the upper extremity were kept in a long plaster in the position of elbow flexion 90°and forearm supination for 6 weeks. Results Patients were followed-up for 4-18months. The rotation of wrist was improved and the handgrip strength was increased significantly. A functional evaluation was performed using the modified Mayo wrist scoring system. All patients satisfied with the final result. Conclusion The DRUJ dorsal ligament reconstruction using the extensor retinaculum flap should be a promise surgical modality for the DRUJ instability.
[Key words] DRUJ; RUL; Extensor retinaculum; Ligament reconstruction; Instability

Xin Wang

Department of Hand Surgery, Ningbo No.6 Hospital, Ningbo, 315040, China

Twisted toe flap saves the great toe but sacrifices the second toe in thumb
reconstruction. It involves harvesting a compound flap from great and second toes on
one vascular pedicle, either the plantar or dorsal system. Wrap around flap is raised
from the great toe and a vascularized joint is harvested from the second toe on the
same vascular pedicle. A soft tissue fillet flap is harvested from the second toe to
reconstruct the soft tissue defect of the great toe and the second toe is sacrificed. We
describe a technique that saves both great and second toes. After the twisted toe flap is
harvested, the secondary cutaneous defect of the great toe and osseous defect of the
second toe are reconstructed with an Osteocutaneous superficial circumflex iliac
artery perforator flap. This procedure was successfully performed in two patients
preserving great toe and second toe.
Keywords – twisted toe flap, second toe, osteocutaneous

ZHOU Dan-ya

Department of Hand Surgery, Ningbo Sixth Hospital, Ningbo, 315040, China.

Objective To investigate the clinical effects of reparing the complicated soft tissue defects of limbs with free thoracodorsal artery perforator(TDAP) flaps. Methods From April 2009 to March 2014, ninteen limbs (including 8 upper limbs and 11 lower limbs) soft tissue defects with bone and tendon exposure were repaired with free TDAP flaps in the secondary stage. There were 5 polyfoliate perforator flaps, 1 chimeric muscle flap, and 1 chimeric muscle polyfoliate flap. The sizes of the flaps ranged from 5cm×6cm~20m×11cm. Seventeen wounds of the dornor site were closed directly, and the other two were closed with skin grafts. Results Sixteen flaps survived successfully. Two flaps had venous congestion and survived at last after taking the stitches out. One flap had partial necrosis and repaired by skin graft finally. The clinical results were satisfactory after 3~15 months following-up, and the scars of the dornor sites of all but 3 patients were not obvious. All the shoulder function were normal. Conclusion The TDAP flap has dependable blood supply, good texture, less dornor site morbility. The polyfoliate TDAP flap can be used for repairing irregular defect. The chimeric latissimus TDAP flap can be used for the function reconstruction. The free TDAP flap is suited for repairing soft tissue defects of the limbs.
【Key words】Perforator flap; Polyfoliate flap; Soft tissue defect; Thoracodorsal artery; Transplantation

Hideki Tanaka

Niigata Prefectural Yoshida Hospital, Niigata, Japan

Ulnar nerve transposition at the elbow is frequently indicated for severe cubital tunnel syndrome. External neurolysis, if done in the long segment, could cause regional nerve ischemia, resulting in poor functional recovery.
The purpose of this study is to evaluate the intraneural blood flow during vascularized transposition of the ulnar nerve in patients with cubital tunnel syndrome.

Materials & Methods
In the last 8 years anterior submuscular transposition of the ulnar nerve was performed in 18 elbows of 17 cases who had cubital tunnel syndrome with intrinsic muscle atrophy. There were 10 men and 7 women. The average age was 65 years ( range: 24 to 79 years).
The nerve was elevated 10 cm in length with the extrinsic nutrient vessels; posterior ulnar recurrent vessel (PURV), superior and inferior ulnar collateral vessel (SUCV, IUCV) under the surgical microscope. Tissue blood flow was measured by laser Doppler flowmetry before and after elevation of the nerve.
Regional blood flow were measured on the ulnar nerve at the level of medial epicondyle (E) and 2 cm (P2, D2), 4 cm (P4, D4) proximal and distal to the epicondyle, and 6 cm proximal (P6).

The nutrient vessels developed anatomically uneven among specimens. SUCV existed in all cases, while IUCV was absent in 17%, and PURV in 6%, respectively.
Quantitative blood flow measurement after elevation of the nerve revealed 13.7+/-28.0 at D4, 16.8+/- 24.8 at D2, 18.3+/- 11.9 at E, 24.9+/- 29.8 at P2, 13.1+/- 9.6 at P4, 9.3+/- 8.0 at P6 (Mean +/- SD ml/100g/min.). Once the IUCV was clamped, nerve blood flow at P2 was down 2.3〜92.7 (mean 23.4) ml/100g/min.
IUCV was relatively bigger in diameter than the others, and supposed to be a main vessel to the entrapment portion. Preservation of PURV needs microsurgical technique. SUCV could be restored easier technically, though it contributed the fewest blood flow among the 3 nutrient vessels.

The results of the present study demonstrate that regional blood flow of the ulnar nerve within the cubital tunnel is relatively maintained by preservation of the 3 extrinsic nutrient vessels. IUCV is the main vessel to the entrapment portion of the nerve. Ulnar nerve should be mobilized with nutrient vessels kept intact under microsurgical dissection.

Qi Jianwu

Department of Hand Surgery, Ningbo No.6 Hospital, Ningbo, 315040, China

【Abstract】 Objective To explore the clinical application and effects of free superficial circumflex iliac artery perforator flap for skin and soft-tissue coverage of the hand defects in end-to-side anastomosis. Method From January 2012 to June 2015, 21 cases of the hand defects were treated with free superficial circumflex iliac artery perforator flaps which ranged from 5.0cm×8.0cm to 10.0cm×15.0cm. As the diameter of the superficial circumflex iliac arteries are less than 1 mm, they were anastomosed with the dorsal branches of radial arteries in end-to-side anastomosis. All superficial circumflex iliac veins were anastomosed with the cephalic veins in end-to-end anastomosis. The accompanying veins of radial artery were anastomosed with the superficial veins of free flaps in 15 cases, including 11 cases in end-to-side anastomosis and 4 cases in end-to-end anastomosis, and not anastmosed in other 6 cases. Results 21 cases of all flaps survived with no occurrence of vascular crisis . Follow-up from 3 to 18 months, All flaps recovered with satisfying appearance and quality. Conclusion As the vascular diameter of superficial circumflex iliac artery perforator flaps are relatively small, the superficial circumflex iliac artery could be anastomosed with the dorsal branches of radial arteries in end-to-side anastomosis. It was nothing serious about inconsistency of the blood vessel diameters in the donor and recipient site. The surgery is simple and reliable without sacrificing the primary arteries and veins. It’s especially suitable for free superficial circumflex iliac artery perforator flap with small pedicle vessels.
【Keywords】superficial circumflex iliac artery;perforator;free flap;anastomosis;end-to-side;

Christian Allende, Luciano Gentile, Fernando Vanoli, Cesar Bartolomeo, Natalia Gutierrez.

Instituto Allende de Cirugía Reconstructiva. Sanatorio Allende. Hospital de Niños de la Santísima Trinidad. Córdoba. ARGENTINA.

Introduction: Posttraumatic diaphyseal nonunions with bone loss are rare in children, they are frequently secondary to complex lesions or result from fracture treatment complications. We evaluate the result of their treatment.
Methods: We retrospectively evaluated eight children with upper extremity long bone fractures that got infected and resulted in segmentary bone defects. Children’s age averaged 10.1 years (range, 8 to 14). Four bone defects were located at the humerus, three at the ulna, and one at the radius. All patients had had previous surgical procedures, averaging 3.9; originating segmentary bone defects that averaged 4 centimeters. Time between initial trauma and definitive surgical procedure averaged 22.7 months. Treatment was open reduction and internal fixation with a plate and autologous cancellous iliac crest bone graft in seven cases, a free fibular non-vascularized graft was associated in one reconstruction, and cement spacer with antibiotics in another.
Results: Follow-up averaged 3 years (range, 2 to 5). Bone continuity, stability and union, without pain, was achieved in all cases. Five had some degree of functional limitations.
Conclusions: There are few reports in the literature on traumatic diaphyseal bone defects in children, and they are focused in lower extremity lesions. In our series we report eight cases of upper extremity bone defects in children; in which union, stability and absence of pain was achieved in all cases, autogenous bone graft and a plate bridging the defect was used in seven cases; and one infected case united after debridement and the placement of a cement spacer.

Steffen Löw, Alexandra Herold, Christoph Eingartner

Caritas-Krankenhaus, Bad Mergentheim, Germany

Whereas arthroscopic central resection of the TFCC is well accepted for TFCC perforations, treatment of ulnar impaction syndrome with superficially intact TFCC remains controversial. Both, ulnar shortening and wafer resection can compromise the integrity of the distal radioulnar joint. We suppose that central resection of the TFCC is sufficient to decompress the ulnocarpal joint and to alleviate symptoms.
For this prospective study, we included 33 patients with ulna impaction syndrome, presenting with isolated positive fovea sign. Two of them presented an ulnar-sided TFCC tear and were excluded. Central TFCC perforations were arthroscopically debrided. However, even if there was no central lesion detected from ulnocarpal view, ulnar impaction syndrome was suspected and the TFCC was centrally resected and debrided if there was no other explanation for the ulnar-sided wrist pain. All patients could be evaluated 3, 6 and 12 months post-operatively, with the results being compared to those of the pre-op evaluation.
15 patients did show a central lesion. 3 of them needed ulnar shortening osteotomy 2, 8 and 14 months post-op. These patients pre-operatively complained of a mean pain of 7.4 ± 1.6 on exertion and of 3.2 ± 2.7 at rest. Pain was significantly reduced to 3.5 ± 3.0 respectively 0.3 ± 0.8 after 3 months, to 2.8 ± 2.6 and 0.5 ± 1.3 after 6 months, and to 2.6 ± 2.6 and 0.6 ± 1.6 after 12 months. Krimmer and DASH score significantly improved from 70.5 ± 14.8 and 45.7 ± 14.9 pre-operatively to 86.4 ± 13.5 and 20.1 ± 18.4 after 3 months, to 87.9 ± 11.8 and 15.6 ± 15.6 after 6 months and to 87.9 ± 10.5 and 10.4 ± 7.7 after 12 months.
16 patients had a superficially intact TFCC. In 4 of these patients, ulnar shortening was performed 5, 10, 12 and 16 months post-op. One further patient asked for re-arthroscopy 19 months later, because initial arthroscopic TFCC debridement alleviated his symptoms for more than one year. These patients initially complained of a mean pain of 7.1 ± 1.6 on exertion and of 2.1 ± 2.0 at rest. Pain was significantly reduced to 4.6 ± 3.3 respectively 0.4 ± 1.2 after 3 months, to 3.0 ± 3.1 and 0.3 ± 0.7 after 6 months, and to 2.8 ± 3.3 and 0.0 ± 0.0 after 12 months. Krimmer and DASH score significantly improved from 73.2 ± 10.3 and 36.5 ± 15.0 pre-operatively to 85.6 ± 10.3 and 21.0 ± 13.7 after 3 months, to 88.5 ± 16.6 and 17.4 ± 15.7 after 6 months and to 83.0 ± 30.5 and 9.7 ± 12.9 after 12 months.
According to the present results, central resection of the TFCC can be recommended to decompress the ulnocarpal compartment in clinically diagnosed ulna impaction syndrome in both cases with and without central TFCC lesion. The risk of an ulnar shortening or wafer resection does not need to be taken.

Claudia Lamas, Antonio Garcia, Camila Chanes, Ignacio Proubasta, Laura Velasco

Hand Unit and Upper Extremity, Orthopaedic Surgery Department, Hospital de la Santa Creu i Sant Pau. Universitat Autònoma de Barcelona, Barcelona, Spain.

Introduction. Nondisplaced or minimally displaced scaphoid fractures can be traditionally treated by immobilization. In an attempt to decrease immobilization and wrist stiffness, some authors have described the percutaneous screw fixation (PSF). The purpose of the study was (1) to evaluate the frequency of scaphotrapezial (ST) and radiocarpal osteoarthritis at medium-term follow-up in patients with acute scaphoid waist and proximal pole fractures that had been treated with PSF using a dorsal or volar approaches; (2) to assess the union rate and implant failure.
Methods. Prospective study from June 2006 to January 2014. Eighty-one patients were operated for minimally or nondisplaced acute scaphoid waist and proximal pole fractures with a mini-acutrak PSF. There were 3 female and 78 male with mean age 26 (18- 54 years). The average follow-up was 51 months (24-96 months). Wrist radiographs includes PA, lateral, 45º supinated oblique, a 45º pronated oblique views, as well as a PA view in ulnar deviation. Scaphoid fractures have been classified by Herbert and Fischer´s classification. Degenerative changes at the ST joint were staged according to the modified Eaton and Glickel classification. Functional outcomes evaluated were pain with the VAS, range of motion (ROM), grip strength, DASH score, Patient-Rated Wrist Evaluation (PRWE) and modified Mayo wrist score.
Results The mean patient age was 26 years (range, 18- 54 years). Follow-up time averaged 51 months (range, 12-96 months). Mean preoperative VAS pain score was 6 (4-9) and 1 (0-2) postoperatively. Postoperative average wrist ROM was 68º in extension, 70º in flexion, 20º in ulnar deviation, and 14º in radial deviation. Mean grip strength was 53 Kg postoperatively and 61 Kg contralaterally. All the cases (100%) achieve union in an average of 7 weeks (6-13 weeks). In 31 out of 81 patients CT was obtained and confirmed union. PSF was indicated for 55 Herbert type B2, 11 type B1 and 15 type B3. Screw lengths were a mean of 22 mm (18-26 mm). The mean preop scapholunate angle was 51º (49-57º) and postop value was 48º (32-54º). The mean preop radio lunate angle was 15.5º (10-22º) to 5º (0-10º). Screw protrusion into the ST joint was noted in 5 cases (6,2%). Three patients showed stage 2 osteoarthritis of the ST joint (3,7%). We did not observe osteoarthritis signs in radiocarpal joint. Eccentric screw was seen in 6 patients (7,4%) and in all cases the union of the fracture was achieved. In one patient the guidewire was broken (1.2%). DASH functional scale improved from 56 (12-78) to 7 (0-10). Mean postoperative PRWE score was 8. Preoperative Mayo wrist score was 52 and the postoperative value was 92.
Conclusions. PSF minimally injured the articular surface in the ST and radiocarpal joint having a minimum incidence of osteoarthritis at medium-term follow-up. The percentage of union of the scaphoid was 100% without appreciating implant failure. We recommended the technique of PSF in minimally or nondisplaced scaphoid fractures in young and active patients to allow shorter time to union and time to return to work.

Issei Nagura1, Takako Kanatani1, Masatoshi Sumi1, Atsuyuki Inui2, Yutaka Mifune2, Takeshi Kokubu2

1Department of Orthopedic Surgery, Kobe Rosai Hospital, Kobe, Japan 2Department of Orthopaedic Surgery, Kobe University of Medicine, Kobe, Japan

Quantitative evaluation of thenar musculature by ultrasonography is possible and this was applied in evaluating thenar atrophy in patients with carpal tunnel syndrome (CTS).
Materials & Methods
Forty six patients with thenar atrophy due to CTS (14 males and 32 females) with a mean age of 70.4 years (range, 35-92 years) were included in this study. Thenar atrophy was classified by visual grading scale: (+) or (++). Ultrasonographic examination was performed to evaluate abductor pollicis brevis (APB) and opponens pollicis (OPP) muscles. The transducer was applied onto the palmer surface of the hand perpendicularly to the longitudinal axis of the first metacarpal bone. Both muscles were analyzed by measuring their thickness; the “APB depth” (from the inserted prominence of the OPP muscle above the first metacarpal bone to the palmar surface) and the “OPP depth” (from the ulnar prominence of the first metacarpal bone to the palmar surface of the OPP). A control group was comprised of twenty healthy volunteers with a mean age of 34.5 years (range, 30-39 years). The “APB depth” and“OPP depth” were analyzed by Mann –Whitney U test (P<0.05).
The averages of the “APB depth” and “OPP depth” in the control group were: male; 9.3±1.3mm and 4.7±0.9mm, female; 7.9±1.3mm and 3.9±0.8mm. The averages of the “APB depth” and“OPP depth” in the patients graded (+) were: male; 8.5±2.0mm and 4.7±1.0mm, female; 6.9±2.0mm and 3.9±0.8mm, and in the patients graded (++) were: male; 3.5±1.4mm and 2.9±0.4mm, female; 4.3±1.2mm and 3.1±0.6mm. Compared to the control group, the “APB depth” and “OPP depth” in the patients graded (++) demonstrated significant decrease (p<0.05). Both the “APB depth” and“OPP depth” were decreased significantly parallel with the progression of muscle atrophy; graded (+) →(++)(p<0.05).
In this study, the quantification of thenar atrophy in CTS by ultrasonography was demonstrated and could be useful to evaluate not only thenar atrophy level but also postoperative recovery objectively.

Jaime Ernesto Forigua Vargas, Rafael Arturo Brunicardi Hurtado, Carlos Morales Vela, María del Pilar Archila, Diana Marcela Chaparro Rivera,

Hospital de San José – Sociedad de Cirugía de Bogotá. Fundación Universitaria de Ciencias de la Salud. Bogotá, Colombia

Brown Tumors (BT) are highly vascular lytic bone lesions found in the primary and secondary hyperparathyroidism. The brown term is given by red-brown tissue, as by the accumulation of hemosiderin. Currently are most often as a result of Secondary Hyperparathyroidism, its pathophysiology is due to a decreased phosphorus excretion by the kidney failure, leading to a decrease in the active form of vitamin D (Calcitriol) and serum calcium. Apart from hyperphosphatemia, hypocalcemia, Cronic Kidney Disease (CKD) causes a decrease in the activity of the 1-alpha-hydroxylase, which decreases intestinal calcium absorption. Hypocalcemia, therefore induces an increased secretion of parathyroid hormone (PTH) and bone resorption. In some patients, there may be severe Secondary Hyperparathyroidism, with the consequent appearance of lytic bone lesions knowns as BT. These can compromise axial and / or appendicular skeleton, on radiographs look like cystic images as they generally do not compromise cortical bone, however, can also appear multiple or unique lytic lesions, rarely found on the hands, let alone the fingers.

Materials and Methods:
In the following article, we present a male patient of 29 years of age with chronic kidney disease who presents with 4 months of onset of mass after trauma of the tip of the left ring finger, which has increased in size and pain progressively. He was treated surgically, by amputation preserving healthy margins.

Currently, the patient is being treated for their underlying conditions for the services of Nephrology and Endocrinology, and so far, has no recurrence of the BT.

We consider very important the publication of this case, as in the literature, there are few reported cases of BT in hand, and is the first to take into account the chronicity and patient's condition to give management the tumor.

Juan M. Patiño, Fernando Zicovich Wilson, Ignacio M. Abdon, Alejandro J. Ramos Vertiz, Alejandro E. Michelini

Hospital Militar Central, Ciudad de Buenos Aires, Argentina

Objective: The aim of this study is to determine if there are differences in functional results in patients presenting fractures of the distal radius treated with volar locking plates and, secondarily, to compare this results according to age and fracture type (AO).

Methods: 39 patients treated between January 2010 and December 2012 were evaluated. They were 19 women and 20 men, with an average of 60 years old and a range between 18 and 86 years old. The average follow up was of 46 months. We made radiographic postoperative measurements of the ulnar tilt angle of the radius, the volar tilt angle of the radius and stiloid height. We evaluated residual pain with VAS (Analogue Visual Scale). The objective and subjective function was evaluated with the DASH inquiry (Disabilities of the Arm, Shoulder, and Hand) and Mayo wrist score.

Results: The mean flexion was of 51º , extension was 55º , pronation was 80º , and supination was 75º. The mean ulnar tilt angle was 19, 66°, the mean volar tilt angle was 2.07°, and the mean stiloid height was 8.97 mm. The average DASH was 14.38 and the average Mayo was of 78.58. There was no significant statistical correlation between the fracture complexity and the age, and the analyzed variables.

Conclusions: In this series, volar locking plates were a valid option for the resolution of unstable distal radius fractures in its different patterns and in a wide age range.

Rong Khaw, Obi Onyekwelu, Anuj Mishra

University Hospital of South Manchester, Southmoor Road. Wythenshawe, Manchester, United Kingdom

Introduction and Aims
The recommended treatment for Giant cell tumour of the tendon sheath (GCTTS) in the hand is surgical excision. The recurrence rate varies from 4% to 44%. Dissection is often incomplete as the tumour is often diffuse; poorly encapsulated; presents with satellite lesions with a predilection for a distal location in the digit; involves extensor, flexor tendons and joint; involves the periosteum or underlying phalanx; and is associated with degenerative joint disease. We present the case of a GCTTS in a 38 year old right hand dominant female patient enveloping the three branches of the ulnar digital nerve to the right little finger. These branches have been previously described but rarely demonstrated.

Materials and Methods
MRI demonstrated the GCTTS displacing her flexor tendons volarly. There was abutment against the ulnar neurovascular hundle. In order to mitigate against the risk of further recurrence, we elected for microscopic excision.

Key Results
The GCTTS was identified and dissected from the three branches of the ulnar digital nerve to the right little finger: volar, articular, and dorsal branches. These branches were meticulously visualised and protected with the GCTTS enucleated from the underlying periosteum. The tumour did not invade bone, but compressed against it.

These three small branches of the digital nerve (volar, articular, and dorsal) have previously been described but rarely visualised. We demonstrate their presence and preserve them all during the microscopic dissection of the GCTTS. Adjuvant radiotherapy also reduces the risk of further recurrence. This remains controversial.

Rong Khaw, Obi Onyekwelu, Fouzia Choukairi, Anuj Mishra

University Hospital of South Manchester, Southmoor Road, Wythenshawe, Manchester, United Kingdom

Introduction and Aims:

Mannerfelt syndrome refers to the attritional rupture of the flexor pollicis longus

tendon secondary to osteophytes in the carpal tunnel and predominantly affects

females. This article reports a case of attritional rupture of the flexor digitorum

profundus (FDP) tendon of the little finger, termed ‘reverse’ Mannerfelt lesion.

Material and Methods:

A 58 year old female sustained a closed rupture of the FDP tendon of the right

dominant little finger whilst lifting. The patient previously received steroid injections

for carpal tunnel syndrome. Initial exploration under wide awake local anaesthetic

revealed the distal stump of FDP to be frayed in the mid-palm at the level of the

superficial palmar arch. Re-exploration under general anaesthetic revealed the

proximal end of the FDP tendon in the carpal tunnel. There was evidence of severe

tenosynovitis in the carpal tunnel with signs of early arthritic changes. Therefore the

carpal tunnel was decompressed and tenosynovectomy undertaken. FDS was

attenuated, therefore we elected for end-to-side little to ring finger FDP repair. The

A1 pulleys for both little and ring fingers were vented and good excursion was



Rupture of one or more of the deep flexor tendons at the palm or wrist is best

treated by suturing the distal tendon ends to the adjacent intact tendon. Small

bridge grafts can be used with poor results. We describe the repair of ‘reverse’

Mannerfelt lesion to the adjacent intact tendon. The patient was able to start early

active mobilization.

Jie Lao, Yudong Gu.

Department of Hand Surgery, Huashan Hospital, Shanghai, China

Early release of multiple bands in amniotic band syndrome.
Yousheng Fang, Jie Lao, Yudong Gu.
Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China

Amniotic band syndrome(ABS) can result in loss of limb function, even amputaion, espescially in the severe cases. We tried to release the severe bands in early stages which were done within three months after birth. The outcomes of the surgery were evaluated.

Material and Methods:
Retrospective chart review of patients with severe ABS referred to our hospital from 2007-2015. A total of 22 cases, 52 extremities were investigated. All the cases in this group were classified into type 3 according to Weinzweig classification. Of 22 cases, both upper and power extremity were involved in 13 cases, upper extremity involved in 5 cases, lower extremity involved in 4 cases. Multiple bands involved in single lower leg or forearm in 5 cases. All the cases were released within three months after birth. A transverse ring incision was made to release the bands. All the cases, including multiple bands were released in one stage surgery.

Results: The patients were divided into 4 groups: group 1A, single band in single limb; group 1B, multiple bands in single limb; group 2A, band in toes or fingers without circulation problem; and group 2B, toes or finger bands with circulation problem. All the patients were followed-up with a period ranges from 6months to 8 years, all the limbs, toes and fingers were survived, and the lymphoedma was reduced remarkably, the scar was less compared to the zigzag incision.

Early release of the bands in one stage with a transverse incision is a safe and effective technique for severe ABS, especially for multiple bands in unilateral limb involvement.

Maria Laura Frutos 1, Micheline Isel 2

1 Hospital Privado Universitario de Córdoba, Argentina; 2 Institut Européen de la Main. Hôpital Kirchberg, Luxembourg.

Arthroplasty for rheumatoid arthritis requires multiple surgical procedures in soft tissue to reduce the volar dislocation of the proximal phalanx, the correction of the ulnar deviation and realignment the extensor tendon dislocated in intermetacarpal valley.
In the case of the degenerative osteoarthritis, MPs are the least affected joints, but the painful clinical picture pushes the patient to require a surgical solution.
The consensus was reached for silicone implants, the most powerful.
The implant MP Neuflex silicone is preformed with a bending of 30 °.
Objective: Present the rehabilitation protocol and orthoses used after joint replacement MP Neuflex.
Materials and Methods: Rheumatoid arthritis: To allow early mobilization compatible with soft tissue repair is essential to use a dynamic orthosis low profile of MP extension. The patient actively engages in bending arthroplasty MP 30 ° the 1st week 45 ° the second, the third 60 °. The return to the extension to 0 ° is passive. Beyond the 4th week a dynamic orthosis with extension component (Levame type) reduces the flexion contracture of 30 ° incorporated into the prosthesis.
Degenerative osteoarthritis: the protocol is simplified. The only protection that is necessary to ensure the suture of the webbing of the extensor mechanism. A static orthosis placing MP quasi extension is used for 4 weeks, leaving free the IP joints. The patient is released of Velcro on the palmar surface to achieve an active flexion limited to 30 ° the first week, the second 45 ° and 60 ° 3rd. In case of flexion deficit beyond the fourth week a direct traction orthosis on P1 complete the result.
Results: Rheumatoid Arthritis: In a series of 151 prostheses the mobility area (ROM) is 56 °, the average active flexion of the MP is of 69 ° with an average deficit extension of 11 °. This protocol allows the patient to be in the relevant sector to increase its gripping ability.
Degenerative osteoarthritis : In a series of 15 implants the active bending of the average mobility is 72 ° with a MP extension deficit -9 °.
Conclusions: This protocol allows to resume unprotected manual activity, without force, after 6 weeks.

Asami Abe, Hajime Ishikawa

Niigata Rheumatic Center, Shibata, Niigata, Japan

The prevalence of the rheumatoid arthritis (RA) in wrist joints is high, and the bone destruction progression of the wrist joints often gets worse. By the progress of the RA treatment, it is to be able to suppress the bone destruction progress, but the ratio of patients performed the wrists arthroplasty do not decrease. The ulna stump stabilization using the flexor carpi ulnaris (FCU) tendon performed for the prevention to rise to the end side of the ulna stump at the time of ulnar head excision in our center. I examined the laborer of the operation method, usefulness.
The stabilization of the ulna stump with the FCU tendon was performed 58 wrists in 354 wrists that received a wrist operation in our hospital since January 2007 to March 2014. It was 36 cases to have been accompanied by an extensor digiti minimi (EDM) tendon tear at the operation time. In ten wrists (2.8%)of reoperation, two cases were with a creak sound on forearm rotation, eight cases were with rupture of the EDM tendon. Ten male, 43 female, average age were 62 years old. It was 45 right wrist joints, left wrist joint 13, and the case of both wrists was five. It was mean DAS28 4.21, MMP-3 188.4, CRP 1.30 in preoperation. The biological preparation use example was by for each one case of IFX, ETN, ADA, CZP in four cases.
(evaluation method) photographed 3DCT in forearm maximum pronation rank after art in all cases preoperation, and measured a rise of the distal ulna edge back side using Dorsal Subluxation Ratio (DSR), and compared it after art in preoperation.
(result) DSR 53.7% were 7.6% after art, and the stabilization effect of the ulna stump was seen clearly in preoperation of the all cases average. DSR was 9.2% after preoperation DSR 56.1%, art in -1.2%, a first operation example after preoperation DSR 38.8% of examples to reoperate, art. As for the first operation example with the extensor digitorum muscle tendon tear, 12.7%, the first operation example without the tear were 4.6% after DSR48.1%, art after art DSR 61.7% in preoperation in preoperation. The tendon tear happens after art neither.
(consideration) When DSR exceeded 30%, according to the Ishikawa and others, it became the risk of the extensor tendon tear, but which group went over this value this time in preoperation. When I use an extensor carpi ulnaris muscle (ECU) tendon when I use pronator quadratus muscle, the stabilization of the ulna stump may use FCU tendon, but FCU tendon use is useful most to stabilize the ulna stump which projected into the back side. All cases do not fit it at the time of a wrist operation, but I think about the risk of the postoperative extensor digitorum minimi tendon tear, and it seems that it is useful as the method for the prevention.

Zhang Jun Pan, Xiang Zhou, Shu Guo Xing, Jun Tan, Jin Bo Tang

Jiangsu Clinical Medical Research Center (Tendon, Nerve and Bone), Jiangsu, China

Purpose: To summarize and analyze more recent experience of wide-awake hand surgical procedures under local anesthesia without tourniquet in different units of our center.

Methods: From 2014 to 2016, in four hand surgery units within Jiangsu Clinical Research Center (Tendon, Nerve, and Bone Surgery) we performed hand surgical procedures in 120 patients with the patient wide-awake, using local anesthesia without tourniquet. The wide-awake surgery was most frequently used in carpal tunnel release (53 patients) and flexor tendon repair (25 patients). Among less frequently used are digital nerve repair, cubital tunnel release, release of compression of tendon sheath to the tendons, and open reduction and internal fixation of the metacarpal bone. 1% lidocaine with 1:100,000 epinephrine was used for all these procedures. The amount of injected anesthetics ranged from 10 to 20 ml, and the local anesthetics was given 15-20 minutes before surgical incision. We obtained satisfactory bloodless surgical field and the patients were pain-free during the surgery. Resistance-free motion of the flexor tendons were confirmed during surgery after either carpal tunnel release or primary repair of the flexor tendons. After digital nerve repair, we also confirmed that the nerve is tension-free during intra-operative active motion of the hand.

Discussion. We found that tendon repair, carpal tunnel release, and digital nerve repair are particularly benefited from the wide-awake non-tourniquet surgical setting, which allow the patient to move the fingers to confirm resistance-free tendon motion or tension or restriction to nerves. The anesthetic methods are easy to use and patients are very satisfactory with this approach.

Xavier Gueffier, Georges Delalu, Philippe Pernot

Clinique Saint Vincent de Paul, Bourgoin Jallieu, France

Chondroma management is complicated in the fracture or pre-fracture stages and the common procedure is to await fracture consolidation before surgical management of the chondroma.
Applying a dynamic external fixator could it improve functional prognosis in chondroma-related pathologic fractures of the base of the second phalanx ?
Between January 2011 and February 2013, we treated 2 patients with pathologic chondroma-related fractures of the second phalanx of long digits. Pre-operative assessment to select therapeutic action systematically included X-ray and CT scans. Post-operative follow-up included clinical examination and X-ray.
Follow-up covered 13 months and 39 months. One case involved cancellous bone grafting by anterior approach together with placement of the dynamic external fixator as part of the same surgical procedure. The external fixator was removed on day 35. Full mobility was achieved at 3 months. In the other case, the dynamic external fixator was applied early so that rehabilitation could begin without delay. The bone graft (harvested from the anterior iliac crest) was performed on day 54 at the same time as the external fixator was removed. Full mobility was complete at 3 months. There were no major complications, such as nonunion, malunion, infection or tumour recurrence.
These cases demonstrate the possibility of using a dynamic external finger fixator for the management of second phalanx chondroma at the fracture stage. With early rehabilitation, prolonged immobilisation and resulting stiffness can be avoided.

Christian Allende, Federico Paganini, Fernando Vanoli, Cesar Bartolomeo, Bernardo Murillo.

Instituto Allende de Cirugía Reconstructiva de los Miembros. Sanatorio Allende. Córdoba. ARGENTINA

Introduction: Multiple flaps can be used to cover soft-tissue defects of the upper extremities. But, in large combined defects, in which fasciocutaneous coverage is needed few options that allow adequate coverage with low donor site morbidity are available. We report our results with the use of parascapular flaps in these large posttraumatic defects located in the forearm and wrist.

Methods: We report 11 parascapular flaps performed for the reconstruction of posttraumatic massive combined soft-tissue loss at the forearm and wrist, between 2005 and 2015. The size of the defects to be covered by the flap averaged 24 x 10 centimeters. Patient’s age averaged 29 years (range, 19 to 42). Ten patients were male and one female. Time from injury to flap coverage averaged 7 days (range, 1 to 23). All patients had significant muscle and tendon loss; seven had associated fractures (two with segmentary bone loss at the ulna); three patients had segmentary nerve traumatic loss (average 11 centimeters); two patients had electrical injuries with severe nerve compromise.

Results: Follow-up averaged 29 months (range, 12 to 56). Ten flaps survived with no complications, and in those ten cases the extremity could be saved. In one case, a defect resulting from an electrical burn, the flap failed and the patient had a below elbow amputation. Donor site closed primarily in all cases. One case with segmental bone loss was reconstructed using Masquelet’s technique. A termino-lateral ulnar to median nerve transfer was performed in one segmental nerve loss; nerve grafts were performed in two cases. Tendon grafts were performed in two cases, and tendon transfers were associated in two cases. Patient’s aesthetic satisfaction averaged 8 points (subjective scale 0 to 10). DASH score averaged 56 points (range, 22 to 92). Pain score VAS averaged 2 points (range, 0 to 7). One patient developed a seroma at the donor site that solved spontaneously.

Conclusion: The parascapular flap was first reported by Santos, it is a fasciocutaneous flap derived from the subscapular artery axis, it can be harvested individually or combined as conjoint flaps, and it is used mainly for head and neck reconstructions. This flap is a versatile and robust flap that can be tailored to reconstruct a wide variety of defects in the extremities, and its use avoids the need to sacrifice functionally important muscle. It reduces donor site morbidity when compared to the anterolateral thigh flap, but site positioning is a drawback. All injuries included in this report were massive, and the decision on weather to save or amputate the extremity was always performed after thoroughly discussing with the patients the different options available, possible complications, and expected results.

Jaime Forigua, Alvaro Fiorillo Gonzalez, Rafael Brunicardi, Ricardo Becerra

Hospital de San Jose FUCS, Bogota, Colombia


Severe upper limb injuries with skin defect represent a surgical challenge, the posterior interosseous flap is one possible reconstructive option. This flap has the advantage of being versatile and reliable and it does not require sacrifice of any vessel that is essential for perfusion of the hand. The posterior interosseous flap is frequently used in the reconstruction of dorsal and first web space defects, seldom used to cover de palmar aspect of the wrist subcutaneously around the cubital border of the ulna. We performed an anterior transposition through the interosseous membrane of the flap to create a longer pedicle and reducing tension.

Materials and Methods

We present a 30 year old male patient which presented with a compartmental syndrome in the left upper extremity after a high energy trauma which produced fractures in the index, middle, ring and fifth metacarpal, distal radius y ulna. Fasciotomies were performed, with multiple surgical debridement and internal fixation of the fractures. Fasciotomies were closed persisting a skin defect in the palmar aspect of the wrist measuring 10 x 6cm with exposure of flexor tendons. A retrograde posterior interosseous flap was designed and transposed thru a tunnel measuring 2 x 2cm in the interosseous membrane of the forearm, thus reducing the tension over the pedicle and improving the contribution of the anterior interosseous artery to the flap through a perforating branch.


The patient was followed for a mean time of 12 months with adequate viability of the flap throughout all the follow up. Hand function returned to normal ROM of the fingers and normal grip and pinch.


This modification in the transposition of the posterior interosseous flap creates a longer pedicle that runs in a straight line to the receptor area reducing the strain over the pedicle and the risk of ischemia.

Christian Allende, Santiago Iglesias, Javier Nuñez, Javier Jabif, Luciano Gentile

Instituto Allende de Cirugía Reconstructiva. Sanatorio Allende. Córdoba. ARGENTINA

Introduction: The purpose of this study was to evaluate the results achieved after the use of minimally invasive percutaneous plate osteosynthesis (MIPPO) in oligotrophic humerus nonunions.

Methods: We retrospectively evaluated 11 patients with humerus nonunion treated by MIPPO between 2009 and 2013. Nonunions were diaphyseal in eight cases, and located in the proximal humerus metaphysis in three cases. All nonunions were oligotrophic. The three cases affecting the proximal humeral metaphysis had no previous surgical treatment, and the eight diaphyseal nonunions had previous surgical treatment with antegrade locked endomedullary nails. Two lateral approaches were used: one proximal transdeltoid approach, lateral to the tip of the acromion, and another distal approach in which the radial nerve was released and protected, the length of the approaches ranged from 4 to 6 centimetres; the plates were slide from proximal to distal. In the three nonunions located in the proximal humerus metaphysis stabilization was achieved using locked 90º blade-plates, and in the eight diaphyseal nonunions long 3.5mm LCP plates were used.

Time between initial surgery and revision surgery averaged 11.4 months (range, 7 to 21). Preoperative DASH score averaged 32 points (range, 12 to 64). Preoperative Constant’s score averaged 67 (range, 36 to 94). Preoperative visual analog scale of pain averaged 4 points (range, 0 to 7). The three patients with proximal metaphyseal nonunions had some degree of loss of active motion, but no patient had shoulder or elbow passive range of motion loss. In diaphyseal nonunions the intramedullary nails were left in-situ; the nails were not dinamized in 5 cases, and they were dinamized by removing the locking screws in 3 cases. Bone graft was associated through a third lateral approach (average 4 cms) in three diaphyseal nonunions.

Results: Follow-up averaged 17.4 months (range, 12 to 38). Union was achieved in ten cases, after an average of 4.5 months (range, 3 to 6). One diaphyseal nonunion with delayed union needed the addition of bone graft 6 months after the placement of the plate. DASH score at last follow-up averaged 14 points (range, 0 to 26), and final Constant’s score averaged 89 points (range, 78 to 100). The analog scale of pain averaged 0.5 points (range, 0 to 2). Time from definitive surgery to work return averaged 17 weeks (range, 3 to 24). There were no infections or postoperative nerve compromise. None of the patients needed implant removal.

Conclusion: Different alternatives have been reported for the treatment of humerus nonunions. Plates are the treatment of choice for these lesions according to the literature. Good results have been reported with the use of MIPPO in humerus fractures. In our series of patients we achieved bony union and had good functional results using this MIPPO technique in selected oligotrophic humerus nonunions.
We used long locked plates in diaphyseal oligotrophic nonunions in which a locked nail failed and was not removed; and 90o blade plates in methaphyseal oligotrophic nonunions; the addition of bone graft can be avoided if alignment is restored and good bone contact can be achieved.

Jun Tan, Jin Chen, Jinbo Tang

Affiliated Hospital of Nantong University, Nantong, China

Objective Wide-awake technique does not need a tourniquet because epinephrine can provide local vasoconstriction. Using lidocaine with epinephrine for most hand surgery is deemed to be safe. The present study is to evaluate wide-awake surgical intervention without tourniquet to treat the carpal tunnel syndrome.
Materials and Methods From March 2014 to November 2015, 42 patients with carpal tunnel syndrome (55 wrists) were treated by wide-awake surgery without tourniquet. Pain during the procedure of the anesthesia and the operation, bleeding control of the surgical area, degree of clear visualization, and overall patient satisfaction were assessed.
Results All patients were satisfied with the entire operative procedure. There was clear visualization of surgical area for exposure of nerve and surrounding without any exudates interfering. For the VAS scores, the result was excellent (n = 30) and good (n = 12) during and all were excellent during the surgical procedure. Pain perception in the surgical area gradually recovered the feeling of pain three hours after surgery. The VAS score was between "2-6", no patient needed to take analgesics for pain. All incisions healed well after surgery, there was no phenomenon that was delaying healing or wound dehiscence.
Conclusions Wide-awake surgical treatment of the carpal tunnel syndrome without tourniquet is a convenient, safe and cost-effective manner. It is worth of wide application.

Stefan Johansson, Ingela Carlsson, Birgitta Rosèn, Sven Abrahamsson

Department of Hand Surgery Skåne University Hospital Malmö, Sweden

Objective outcome measures are an important element in hand therapy in order to follow recovery and facilitate clinical decision making. However, traditional chronologic patient records are less suitable for following such measures in an effective way. Therefore, our aim was to create a non-commercial software system where outcome measures for hand therapy patients were easy and time-efficient to register, retrieve and display.

Materials and Methods
The software system was developed at the Department of Hand Surgery at Skåne University Hospital. In a first step an expert group of hand therapy professionals specified which measures to include, need of interface and display of data. In a second step a professional programmer developed a software system according to the specifications. In a third step the software system was pilot tested and adjusted and in a fourth step the program was implemented at our hand therapy unit.

The software system developed, DIGMA®, is linked to the digital patient records of the university hospital. The outcome measures included are: joint motion for shoulder, elbow, wrist, thumb and all finger joints measured by a goniometer; hand grip strength measured with the Jamar dynamometer and pinch strength with a Pinch gauge; the Sollerman Hand Function Test and the Rosen score. The data input is done via a user friendly interface and measures of joint motion and strength are registered via integrated electronic goniometers and dynamometers. The outcome measures can be retrieved and displayed in accessible figures and diagrams in different points over time.

The development of DIGMA® has enabled easy and time-efficient digital registering, retrieving and displaying of important outcome measures used for hand therapy patients. This facilitates communication in the hand therapy team and thereby supports efficient clinical decision making and increased patient safety.

Ronit Wollstein1,2, Purnell Traverso 3, Anselm Wong 3, Lois Carlson 3, Duffield Ashmead 3, H. Kirk Watson 3

(1 ) University of Pittsburgh School of Medicine, Pittsburgh, PA, USA;2Technion Institute of technology, Haifa, Israel; (3 ) The Hand Center, Glastonbury, CT, USA

Scapholunate advanced collapse of the wrist (SLAC) is the most common degenerative condition of the wrist. Treatment includes salvage procedures such as proximal row carpectomy and partial wrist fusions. Often treated by four-corner-fusion (4CF), there is limited information on long-term results of this operation. We hypothesized that four-corner-fusion is a durable surgery with good clinical long-term function.
Materials and Methods:
Fusion was obtained using K-wires and a splint for 6 weeks following surgery. A retrospective chart review of patients undergoing 4CF as well as an interview and recent radiographs were obtained. Patients with a follow-up period of less than 10 years were excluded from the study. Long-term evaluation included standard wrist radiographs, wrist range of motion (ROM), and the QuickDASH questionnaire. Radiographs were evaluated and described by the Kellgren-Lawrence classification system for osteoarthritis of the radiocarpal joint.
Four hundred –and- seventy patients underwent a four-corner fusion for SLAC wrist from 1982 to 2003. Only twelve patients (15 wrists) were available for follow-up. Average age at surgery was 49.1 (range 25-67 years). Average follow-up period was 18 years (11 – 27 years). Scapho-lunate advanced collapse was the etiology in 13 wrists and scaphoid non-union advanced collapse in 2 wrists. One wrist was converted to a full wrist fusion (6.7%).
Average extension/flexion arc was 68.6 degrees (0 to 96) and radial/ulnar deviation arc was 32.9 degrees (0 – 55). QuickDASH scores averaged 7.8 (range 0-32.5), with only one score above sixteen. Seventy-three percent of radiographs showed minimal to moderate joint destruction of the radiocarpal joint and 27% showed severe joint destruction.
A very small percentage of patients were available for follow-up at long-term in our practice. This limits the conclusions available from this study. However, scaphoid excision and four-corner fusion seems to be a reliable, durable procedure for patients with advanced wrist arthritis. Functional results were good at long-term follow-up despite significant radiographic changes in the radio-lunate joint in 73% of patients. Patient satisfaction was high and functional impairment was low.

Sun Yucheng1, Sheng Xiaoming2, Tang Jinbo3, Chen Jing4

Department of Hand Surgery, Affiliated Hospital of Nantong University, Nantong, Jiangsu, China,

Objective: The collateral ligaments are major stabilizers of the metacarpophalangeal joint. The aim of this study was to investigate the change in length of collateral ligament during digital flexion and the each portion of the collateral ligament components change during digital flexion in vivo.
Method: Twenty fingers of five hands of five healthy adult volunteers were used. We obtained computed tomography scans of the index, middle, ring and little fingers at flexion 0°, 30°, 60°and 90°of the metacarpophalangeal joint. Radial and ulnar collateral ligament of each metacarpophalangeal joint were measured and analyzed with computer modeling.
Results: The results showed that from flexion 0° to 90°, there's no difference between the radial and ulnar collateral ligament in length in general. The length of dorsal and middle portion of collateral ligament lengthened progressively during flexion and reached the maximum at 90° flexion, but the length of volar portion increased and then decreased, and reached a minimum at flexion 90°.
Conclusion: Three portions of collateral ligament play different roles at different positions by change in tension and length to coordinate flexion and lateral motion in proper scope, thus stabilizing metacarpophalangeal joint.

Mohammad javad Fatemi1,Kamal seyed Foroutan2,Arash Najafbeigi2, Yousef Shafaeie1, Tooran Bagheri1

1 Burn Research Center,Iran University of Medical Sciences,Tehran,Iran;2 Hazrat Fatemeh Hospital, Iran University of Medical Sciences,Tehran,Iran

Background: Tendon injuries are common and it take a long time for an injured tendon to heal. Adverse phenomena such as adhesion and rupture are associated with these injuries. Finding a method to reduce the time required for healing and improve the final outcome will lead to decreased frequency and intensity of adverse consequences. This study was designed to investigate the effects of basic fibroblast growth factor on the healing of the Achilles tendon in rabbits
Methods: In 10 New Zealand white rabbits, Achilles tendon was cut at the intersection of the distal and middle thirds on both hind legs. One microgram of recombinant basic fibroblast growth factor (bFGF) was injected in the proximal and distal stumps of the cut tendon on the right side (study group). Normal saline of equal volume was injected on the left side in the same way (control group). Then the tendons were repaired with 5/0 nylon using modified Kessler technique. A cast was made to immobilize each leg. On day 42, rabbits were killed and both hind legs were amputated. Tensometry and histopathologic examination were done on specimens.
Results: In tensometric studies, more force was required to rupture the repair site in study group (p =0.008). In histopathologic examination, collagen fibers had significantly better orientation and organization in the study group (p =0.01). No difference was noted regarding number of fibroblast and fibrocytes, and degree of angiogenesis in the two groups.
Conclusion: Application of basic fibroblast growth factor at tendon repair site improves the healing process through improvement of collagen fiber orientation and increase in biomechanical resistance.

Keywords: tendon repair, fibroblast growth factor, tensometry, tendon injury

Mohammad javad Fatemi1,Hossein Akbari1,2, Fatemeh Khodaei1,Siamak Farokh Forghani1, Tooran Bagheri1,Mitra Niazi1

1 Burn Research Center,Iran University of Medical Sciences,Tehran,Iran;2 Hazrat Fatemeh Hospital,Iran University of Medical Sciences,Tehran,Iran

Background: Treatment with stem cells, new approach to the repair tissue is created. Adipose tissue is one of the most abundant and accessible source of stem cells is to evaluate the effect of this study stem cells become fat increase the power of an Achilles tendon repair in rats were studied.
Methods: This study was a Experimental study in 1392 in the Burn Research Center of Iran University of Medical Sciences. 36 Sprague-Dawley male rats, weighing 250 to 300 g were randomly divided into three groups. Inguinal fat a dozen animals to produce autologous stem cells were used.0 suture was struck. After 30 days, the mice were killed and Achilles tendon of 6 rat of each group send to pathology and 6 of each group was measured by the strength of tendons.
Results: The results showed a significant difference in power tensometry tendon stem cells to grow and control groups there. (P-value = 0.0 95) The results showed that no significant difference in the time variable There have been three studies. (P-value = 0.44) .the results of the biopsy samples showed that the difference between the rate of collagen, fibroblasts, collagen orientation , vascularization, inflammatory cells and foreign body reaction was not significant, and only difference in metaplasia is significant. (p-value = 0.024)
Conclusion: This study showed that stem cells could improve biomechanics and is significantly different from other groups. There were no significant differences in histological characteristics.
Keywords: Adipose derived stem cells, Achilles tendon

Jing Chen, Jun Tan, Qing Zhong Chen, Yu Cheng Sun, Jin Bo Tang

Affiliated hospital of Nan Tong University, Jiangsu, China

Objective: Destruction of articular cartilage may occur after intra-articular distal radius fractures, predispose to secondary osteoarthritis (OA). This study was to directly determine the thickness and volume of the articular cartilage at the distal radius via magnetic resonance imaging (MRI) in vivo.
Materials and Methods: Six asymptomatic volunteers without known history of previous wrist injury were enrolled in this MRI-based study. The cartilage was segmented from each image of a set of MR images using a semi-automatic B-spline snake method. Boundaries from the initial segmentation were manually corrected to increase accuracy. The boundaries obtained from the segmentation were reconstructed into a 3-dimensional polygon model to directly measure the articular cartilage volume and thickness.
Results: The average cartilage thickness in the distal radius is 0.74±0.09 mm. The average cartilage volume in the distal radius is 415±83 mm3. And, in all samples the thickness is less than 1 mm. The maximum recorded thickness was 0.91 mm.
Conclusions: The applied technique can be used for accurate determination of cartilage volume and thickness in wrist. Our study quantifies the thickness of the articular cartilage at the distal radius.

Shosuke Akita, Shigeyoshi Tsuji, Akihide Nanpei, Jun Hashimoto, Masanobu Saito

Osaka Minami Medical Center, Kawachinagano, Japan

Silicone metacarpophalangeal (MP) joint arthroplasty is a valuable option for the treatment of ulnar drift in the hands of patients with rheumatoid arthritis (RA). There are two designs for silicone MP joint arthroplasty. One is the straight type (Swanson or Avanta/Sutter), and the other is the preflexed type (NeuFlex or Avanta Preflex). There are many reports of the results with each implant. However, to the best of our knowledge, there have been no previous reports about the results of the Avanta Preflex implant. The purpose of this study was to evaluate the short-term outcomes when the Avanta Preflex implant was used to treat RA patients with ulnar drift.
Materials and Methods
A retrospective review of Avanta Preflex silicone MP joint arthroplasties was performed in 20 patients (26 hands, 94 implants) with RA. Patients were evaluated at an average of 48 months (minimum follow-up period, 24 months). Objective results included grip strength, ulnar drift, extensor lag, and arc of motion measurements at the MP joints. Preoperative and postoperative data for grip strength, ulnar deviation, and finger motion were compared using the paired two-group t-test. The level of significance was set at p<0.05. Anteroposterior and lateral radiographs were obtained at the time of latest follow-up for all fingers. The radiographs were reviewed for erosions adjacent to the silicone implant and implant fractures. Subjective results were evaluated with visual analogue scale (VAS) scores, which measured pre- and postoperative pain at rest and during use, hand function, and cosmetic appearance. Patient satisfaction was noted.
The mean grip strength improved from 0.5 kg preoperatively to 1.2 kg at the time of final follow-up (p < 0.001). The mean ulnar drift improved from 33° preoperatively to 7° at the time of final follow-up (p < 0.001). The mean arc of motion of the MP joints improved from 33° preoperatively to 52° at the time of final follow-up (p < 0.001). The mean extension deficit of the MP joints improved from 46° preoperatively to 14° at the time of final follow-up (p < 0.001). There were no erosions adjacent to the silicone implant and no implant fractures in any of the fingers. The VAS assessments (0-10) showed overall decreases in pain at rest and with use and improvements in hand function and cosmetic appearance. Statistical analysis showed a significant improvement in cosmetic appearance (P = 0.01). Eighteen patients (90%) were satisfied with their results.
Arthroplasty of the MP joints with the Avanta Preflex implant provides a more functional arc of motion and improvement of grip strength and appearance without any bone reaction adjacent to the silicone implant in short-term follow-up. The Avanta Preflex implant appears to give similar results to those obtained with other silicone implants in RA patients.

Arvind Mohan, Justin CR Wormald, Chang Park, Gillian Smith

Chelsea and Westminster NHS Hospital Trust, London, United Kingdom

We present an extraordinary case of finger necrosis following prolonged external compression from a ring in a chronic hoarder. A 72-year-old unkempt male presented to the emergency department with a grossly necrotic left little finger. The patient described a four-week history of increasing swelling and discolouration affecting the little finger following a minor injury. On examination, the finger was swollen and necrotic secondary to increasing venous congestion from a tight ring. The whole hand was visibly soiled with the presence of faecal matter under the fingernails. A fifth ray amputation was performed under general anaesthesia preserving the base of the metacarpal and the extensor carpi ulnaris attachment. Post operatively, the patient was discharged on oral antibiotics and followed up in the dressing clinic ten days later. He attended his clinic appointment and with partial wound dehiscence. He did not attend any further appointments despite repeatedly contacting the patient, and eventually social services were contacted, due to safeguarding concerns as a venerable adult. In this report, due to the patient’s social circumstances and psychiatric condition a vicious cycle of increasing congestion and ischaemia led to irreversible tissue necrosis of the entire digit.

Sergi Barrera-Ochoa 1,2, Sergi Rodríguez-Alabau 2, Eva Correa 2, Xavier Mir-Bullo 1,2

1 Hospital Universitari Vall Hebron, Orthopedic Surgery Department, Hand and Microsurgery Unit, Barcelona, Spain; 2 Hospital Universitari Quiron-Dexeus, ICATME. Hand and Microsurgery Unit, Barcelona, Spain

Objective: The authors propose a new treatment technique in II-IIIA Lichtman stages lunate ostheonecrosis. Eleven patients with stages II-IIIA of Kienböck´s disease had combines dorsolateral biplane closing radial osteotomy associated with minimally lunate internal fixation.

Material and Methods: From 2012 to 2014, 11 patients have been treated (9 women and 2 men) with a mean age of 27 years old (24y.o.-32y.o.). Mean follow up of 12 months (9m-24m). In all cases the wrist affected was the dominant one. In 3 cases they have a sedentary occupation while in the other 8 they have an active occupation. The time to diagnosis goes from 3 months to 13 months, this delay in the diagnosis was due in most cases to a first normal X-ray, and the diagnosis was confirmed later on with CT-scan or MRI staging Kienböck in II-IIIA Lichtman stages. In all cases radial and sagital tilt angles are over the standard angles (radial tilt 20º and sagital tilt 10º). There is no case of cubitus minus and all patients present a lack of lunate coverage by the radial articular surface. Fragmentation pattern combines a stress fracture in frontal plane and lateral corner comminution of lunate, associating pain, grip strength loss and limitation of the range of motion.

Results: The results show that the biplanar closing wegde radial in dorso-lateral plane leads to a negative variance in frontal angle (radial tilt ≤15º) and lateral angle (sagital tilt ≤5º), recentering lunate under the protection of the radial cupule and modifying the radiocarpal loading pressures. Afterwards, in the same surgical procedure, the stress lunate fracture is stabilized with a dorsal mini invasive technique of internal fixation with cannulated screws (dorsal mini-open with capsular preservation avoiding damages on volar lunate vascularization). These changes do not affect distal radiocubital joint. The combination of these two procedures leads in most cases to stress fracture consolidation and an improvement of pain. However the improvements in grip strength and range of motion are limited.

Conclusion: In conclusion, the combination of decompression-recentering of radiocarpal joint and lunate stabilization provides ideal biomechanical conditions to overcome the necrosis phase and early leads to reparation and remodeling phases. Surgical technique and clinical and radiological preliminary results in the first 11 cases performed are exposed. Advantages and disadvantages are discussed and compared with other surgical techniques currently used.

Martín F. Caloia, Diego González Scotti

Hospital Universitario Austral Pilar Argentina

The incidence of the distal radius fractures (DRF) is increasing and associated with a significant socio-economic cost and has a global impact on:- the patient, - the healthcare systems, and –high demand centers of health care. Recent studies about operating costs in the treatment DRF with volar plates, have demonstrated that the only predictor of costs is time and the kind of healthcare center, being the ambulatory type which have more advantages on potential cost savings and global resources. The purpose of this study was to determine whether using a disposable "kit" locked volar plates for single use in replacement to traditional systems, can produce savings in operating times, specifically evaluating the "start time" within the overall surgical process of treating module DRF.
Material & Methods:
From December 2014 to December 2015 we evaluated prospectively 76 cases of unstable DRF treated surgically with standard volar plates which were previously sterilized in the institution. The "start time" (period from the arrival of the patient to the pre-anesthesia room to the "checklist" time before the surgery) was determined. Each time was taken prospectively and a theoretical simulation was made taking the differences between the use of the disposable single-use set and the standard sterilized plates, evaluating the potential benefits of time saving resource for improvements in surgical module costs. To determine the global costs the average value of operating room was taken, which was AR$ 5.000.
The of "start time" average was 20.45 minutes (16-40). Three cases were dismissed, one because sterilization problems (wrapping paper tear), another because of the lack of drill bit and the lastone because the set was not the appropriate to treat a DRF. In those proceedings two were canceled and the other was rescheduled in the same day five hours later. In all cases the operating room line was interrupted an average of 55 minutes.The theoretical simulation using the disposable set results in a time delay "start time" 0 minutes.Over time cost of “starting time” causes an average of AR$ 1745.00 additional economic cost ($ 800 - $ 2,500). generating a decrease in the cost effectiveness of operating room time by 34.9%.
As the cost of health care continues rising, the development of strategies to contain costs has become an increasingly important tool.The new trends promote the ability to provide high quality care at lower costs and find new sources of potential economic resources.
Surgical operating costs are analyzed in detail during the start time in the surgical treatment of fractures of the distal radius. Potential advantages of saving costs in “the start time”are described using a disposable osteosynthesis set and, therefore, the operating cost after an internal theoretical simulation at a high demand healthcare center.
In the theoretical simulation, the “single use set” of volar plates for distal radius fractures showed a potential economic resource for the surgical module saving an average of AR$ 1745.00 which represents a 34.9% of the total module costs described.

Francisco Javier Garcia Garcia, Juan Blanco Blanco, David Pescador Hernandez

University Hospital of Salamanca, Salamanca, Spain.

Cat scratches are a very common infection via on the hand and Pasteurella Multocida causes most of them. A good management include an early diagnosis, empiric antibiotic therapy with Penicillin even before we have microbiological diagnosis, and correct wound care, all are critical issues faced by a surgeon in dealing with such patients, because despite most cases are benign and self-limited the nature of all of these injuries can be very deceptive. Complex cases are those in which this injury goes unnoticed for the patient and come in a few days, even weeks later, with a clinical presentation of swelling, pain and fever resulting in deep tissue infection that may compromise the function of the hand. We report an immunocompetent 36-years-old male who was scratched by a cat on the right hand dorsum one week ago, now the physical examination reveals clear signs of cellulitis, with great swelling, erythema extending proximally to the wrist and pain with passive motion, paresthesias and difficulty moving the fingers. Fasciotomies of the adductor pollicis and interosseous compartment were necessary to relieve the compartment syndrome established due to the scratch infection as well as hospitalization and intravenous antibiotic therapy. Microbiology identified Pasteurella Multocida.

Yoo-Joon Sur, Ho-Youn Park, Youn-Tae Roh, Dong-Uk Min, Seok-Whan Song

Department of Orthopedic Surgery, Uijeongbu St. Mary’s Hospital College of Medicine, The Catholic University of Korea 271 Cheonboro, Uijeongbu, Gyeonggi-do, 11765, Republic of Korea

- Background
Detection of dorsal cortical penetration of distal locking screws is difficult owing to the irregular shape of the dorsal surface of the distal radius. This study was designed to analyze two-dimensional morphological characteristics of the distal radius on axial magnetic resonance image, and to suggest a guideline for evaluation of screw length in distal radius fractures on the fluoroscopic or plain X-ray true lateral image.
- Methods
Anteroposterior length and lateral width of the distal radius, distance between the highest and the lowest point of the dorsal cortex (deceptive length), and widths of the first to second (hazard zone) and the third to fifth extensor compartments (safe zone) at the Lister tubercle level were measured on 104 axial magnetic resonance images by two hand surgeons.
- Results
The mean length and width of the distal radius at the Lister tubercle level were 22.96 mm and 30.42 mm, respectively. The mean hazard zone and safe zone widths were 8.72 mm and 19.43 mm, respectively. The mean deceptive length was 4.07 mm and the deceptive length did not have a relationship with height, sex, and age of subjects.
- Conclusions
We suggest that 4 mm be used as a reference value for the evaluation screw length at the safe zone. If the vertical distance between a distal screw tip and the most prominent dorsal cortex is lesser than 4 mm on a fluoroscopic or plain X-ray true lateral image, dorsal cortical penetration should be suspected. When dorsal cortical penetration at the hazard zone is suspected, both oblique or pro-supination views should be checked.

Jae Sung Lee1, Min Jong Park2, Jong Pil Kim 3

1 Chung-Ang University Hospital Seoul, KOR 2 SungKyunKwan University Samsung Medical Center Seoul, KOR 3 Dankook Univeristy Hospital, Cheonan, KOR

We conducted a prospective randomized, multicenter study to compare short arm and long arm casts for the treatment of stable distal radius fracture in elderly patients. We randomly assigned patients over the age of fifth-five who had stable distal radius fracture to either short arm cast group or long arm cast group. Radiographic and clinical follow-up was conducted at one, three, five, twelve, and twenty-four weeks. Also, degree of disability caused by each cast immobilization was evaluated at the patient`s visit to remove cast. There were no significant differences in radiological parameters between the groups except for volar tilt. Despite these differences in volar tilt, neither functional status as measured by the DASH, nor VAS was significantly different between the groups. However, the mean score of disability caused by cast immobilization and the incidence rate of shoulder pain were a significant difference. Our findings suggest that short arm cast is as effective as a long arm cast for the stable distal radius fractures in the elderly. Furthermore, it is more comfortable and introduced less restriction on daily activities.

Luke S Robinson 1, Mitchell Sarkies 2, Ted Brown 1, Lisa O'Brien 1 3

1Department of Occupational Therapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University – Peninsula Campus, Frankston, Victoria, Australia 2 Department of Physiotherapy, School of Primary Health Care, Faculty of Medicine, Nursing and Health Sciences, Monash University – Peninsula Campus, Frankston, Victoria, Australia 3 Department of Occupational Therapy, Alfred Health, Melbourne, Victoria, Australia

Injuries sustained to the hand and wrist are common, and account for approximately 20% of all emergency department presentations. The economic burden of these injuries, comprised of direct (medical expenses incurred), indirect (value of lost productivity) and intangible costs, can be very extensive and rise sharply with the increase of severity.
This paper systematically reviews cost-of-illness studies and health economic evaluations of acute hand and wrist injuries with a specific focus on direct, indirect and intangible costs. It aims to provide economic cost estimates of burden and discuss the cost components used in international literature.
Materials and Methods:
A systematic search of cost-of-illness studies and health economic evaluations of acute hand and wrist injuries in the databases of MEDLINE, AMED, EMBASE, Cochrane Central Register of Controlled Trials, SCOPUS, and CINHAL was conducted. Data extracted for each included study were: design, population, condition, intervention, and estimates and measurement methodologies of direct, indirect and intangible costs. Reported costs were converted into US-dollars using historical exchange rates and then adjusted into 2015 US-dollars using an inflation calculator. Where median data were presented, an estimated mean was calculated for data analysis. Additionally, national-cost estimates were converted into costs per case.
The search yielded 764 studies, of which 21 met inclusion criteria. The studies reported on data from Austria, China, Denmark, Ireland, Netherlands, Slovenia, Sweden, Switzerland, Turkey, and the United States of America. Investigated injuries included non-specific acute hand injuries, scaphoid fractures, osteoporosis related wrist fractures, digit amputation, ulnar and/or median nerve repair, digital nerve injury and zone II flexor tendon repair. Twelve studies were cost-of-illness studies and seven were health economic evaluations. The methodology used to derive direct, indirect and intangible costs differed markedly across all studies. Indirect costs, which account for lost productivity, represented a large portion of total cost in both cost-of-illness studies [64.5% (IQR 50.75-88.25)] and health economic evaluations [68% (IQR 49.25-73.5)]. The median total cost per case of all injury types was US$6,951 (IQR $3,357-$22,274) for cost-of-illness studies and US$8,297 (IQR $3858-$33,939) for health economic evaluations. Few studies reported intangible cost data associated with acute hand and wrist injuries.    
Several studies have attempted to estimate the direct, indirect and intangible costs associated with acute hand and wrist injuries in various countries using heterogeneous methodology. Estimates of the economic costs of different acute hand and wrist injuries varied greatly depending on the study methodology but by any standards these injuries should be considered a substantial burden on the individual and society. Further research using standardised methodologies could provide guidance to relevant policy makers on how to best distribute limited resources by identifying the major disorders and exposures resulting in the largest burden.

Isam Atroshi 1,2, Anna Lauritzson 3

1 Department of Orthopedics Hässleholm-Kristianstad-Ystad Hospitals, Hässleholm, Sweden 2 Department of Clinical Sciences - Orthopedics, Lund University, Lund, Sweden 3 Department of Occupational Therapy, Hässleholm Hospital, Hässleholm, Sweden

Although a multicenter study that evaluated the efficacy of collagenase clostridium histolyticum (CCH) injections for Dupuytren’s contracture (DC) has reported 2 to 5 years outcomes, it had substantial follow-up attrition and the treating surgeons themselves measured outcomes. Besides, the injection and manipulation procedures currently used are not identical to those used in that study. No other prospective studies have reported outcomes of CCH beyond 1 year. We aimed to study the 2-year outcomes of a modified injection method using higher CCH dose injected in multiple sites in the cord.

Material and Methods
Patients with DC, a palpable cord and extension deficit of ≥20º in the metacarpophalangeal (MCP) and/or proximal interphalangeal (PIP) joint treated with CCH were eligible. A hand surgeon injected 0.80 mg CCH into multiple sites in the cord and performed finger extension under local anesthesia after 1 or 2 days. A hand therapist measured joint contracture before injection and at 5 weeks and the first 29 patients completed the QuickDASH. Of 57 consecutive patients (59 hands), 48 patients (50 hands; 85% of the treated hands) underwent follow-up physical examination at a mean of 26 (median 25, range 24 to 35) months after injection and another 4 patients agreed to a telephone interview. A hand therapist measured joint contracture and inquired about satisfaction with treatment results. The patients completed the QuickDASH.

Mean MCP active extension deficit was 54° before injection, 6° at 5 weeks and 9° at 2 years and corresponding values for the PIP joints were 30°, 13° and 16°, respectively. Mean total (MCP+PIP) AED had worsened by 5° from 5 weeks to 2 years. In joints with a pretreatment deficit ≥10°, mean improvement in AED from baseline to 2 years for the MCP joints was 49º (95% CI 41-54) and for the PIP joints 25º (95% CI 17-32).
Between 5 weeks and 2 years, AED had worsened by at least 20° in 7 MCP (14%) and 7 PIP (14%) joints. In the treated joints, a passive extension deficit of 0° to 5° at 2 years was recorded in 39 MCP (83%) and 15 PIP (48%) joints. The median QuickDASH score (25th, 75th percentiles) improved from 11.4 (2.3, 21) at baseline to 2.5 (0, 9.1) at 5 weeks (p<0.001) and to 2.3 (0, 18) at 2 years (p=0.034). Of all treated patients 83% were satisfied with the results.

This study shows good outcome after CCH injection with contracture correction maintained at 2 years in the majority of the treated fingers and a high rate of patient satisfaction. Up to 2 in 10 patients may have recurrent contracture in the treated finger.

Neha Dewan1, Joy C MacDermid1,2,3,4, Norma MacIntyre1, Ruby Grewal2,3,4

1 School of Rehabilitation Sciences, McMaster University 2 Hand and Upper Limb Center, St. Joseph’s Hospital, London, Ontario, Canada 3 Department of Physical Therapy, University of Western Ontario 4 Department of Surgery, University of Western Ontario

Objective: The objective of our study was to describe therapist’s knowledge, clinical practice patterns, barriers and facilitators for assessment, treatment, referral and education with respect to secondary falls/osteoporotic fracture prevention (SFOFP) for patients with distal radius fracture (DRF) over 45 years of age. Additionally, we aimed to examine therapist’s preferences in terms of content and delivery format for KT tools that would support implementation of SFOFP

Methods: A cross-sectional, multi-national (Canada, USA and India) survey was conducted among 272 therapists from August-October 2014.

Results: 157 completed surveys were analyzed descriptively. The majority of therapists were from the USA (59%), certified hand therapists (54%) and females (87%). Most therapists’ (65-90%) believed they had knowledge about assessment, treatment and referral options about SFOFP for patients with DRF. However, the majority of therapists reported never using fracture risk assessment tool (90%) and lower-extremity (LE) muscle strength testing (54%). Instead, medication history was most commonly assessed (82%). With respect to treatment, ~33% of therapists always used upper-extremity muscle strengthening exercises. Most therapists’ did not use balance (79%), LE muscle strengthening (85%), bone strengthening (54%) or community–based physical activity (72%) programs (responses rating from sometimes to never). Similarly, when surveyed about patient education, therapists were less inclined (responses rating from sometimes to never) to advise their patients about web–based resources (94%), regular vision testing (92%), diet for good bone health (87%), referral for bone density evaluation (86%), footwear correction (73%), and hazard identification (67%).

The majority of therapists (36% and 29%) reported lack of time as one of the most commonly reported barrier for assessment and treatment respectively. 23% of therapists identified lack of their expertise as one of the top most barrier for referring patients with DRF to other health care professionals for SFOFP. Context of care, followed by the expertise were the two most commonly reported facilitators for assessment (35%, 34%), treatment (41%, 29%) and referral (53%, 18%) of patients with DRF for SFOFP.

79%, 69% & 55% of therapists, respectively showed their interest for more information on assessment, treatment and referral of their patients with DRF. More than 50% of therapists were in favor of web based information for patients and therapists. 40% of therapists also recommended using pamphlets for patients. Fewer (15-25%) therapists preferred to have apps and online workshops for therapists, apps for patient self-assessment, and you tube videos. Less than 15% of participants showed their preference for apps for patient self-treatment, hands on educational workshop at conferences, educational webinars for patients, textbook chapter in entry level physical therapy education curriculum, or electronic reminders to therapist.

Conclusion: The SFOFP practices revealed care gaps and limited implementation in the routine clinical practice of therapists. Future research should focus on educational/knowledge translation strategies to improve therapist’s awareness about multi-factorial fall risk screening and engagement in SFOFP for patients with DRF.

Christian Allende, Javier Nuñez, Fernando Vanoli, Luciano Gentile, Bernardo Murillo.

Instituto Allende de Cirugía Reconstructiva. Sanatorio Allende. Córdoba. ARGENTINA

Introduction: Treatment of distal humerus nonunion with bone loss and extreme osteoporosis is a challenge. Mainly because they present in elderly patients, frequently with immunosuppression, a stiff elbow joint and insufficient neighbor joints (shoulder and wrist). We report a case in which the association of severe rheumatoid arthritis and chronic metaphyseal distal humerus nonunion resulted in chronic upper extremity disuse, bone loss, joint stiffness and subsequent extreme osteoporosis.r
Methods: We present a 63 years old female, who consulted with a right dominant side supracondylar distal humerus nonunion with 12 years evolution. The patient presented severe instability at the nonunion site, and complete functional impairment of her dominant upper extremity, which made the extremity useless. Examination also evidenced advanced wrist and shoulder rheumatoid involvement; pain during passive motion at the nonunion site and no motion at the elbow joint. There was no neurovascular compromise. Preoperative DASH score 100 points; VAS pain score 7 points. Radiological evaluation showed extreme osteoporosis, six centimeters bone loss, and dynamic x-rays confirmed that there was no motion at the elbow joint. Intraoperative findings were: an extremely thin and fragile cortical bone, with cancellous endomedullary bone replaced by fatty tissue. A Conrad-Morrey prosthesis was placed after resection of the distal humeral epiphysis; and, as to increase and extend the humeral component of the prosthesis, a Kuntscher nail was countersinked in the humeral stem of the prosthesis, which was then cemented. Then the ulnar component was placed and the components were assembled.
Results: Follow-up is 3.5 years. Dash score 56 points. VAS pain score 2 points. The patient can write, eat and take care of her self, using the affected extremity; activities that she could not do before the procedure. No radiographic signs of implant loosening are evidenced. Functional evaluation shows a loss of 25 degrees in extension. Humeral length is three centimeters shorter than the contralateral side. Most of the actual functional limitation of the patient originates from her advanced gleno-humeral arthritis, and severe hand deformity resultant from her advanced rheumatoid disease. She can flex the elbow elevating up to 2.5 kgs with no pain. She refers that time and use, are still progressively increasing the strength of her extremity. The contralateral non-dominant upper extremity is also severely affected by her rheumatoid disease and was not useful for comparison.
Conclusion: In cases of distal humerus severe bone loss, with elbow joint involvement (that can not be reconstructed using open reduction, internal fixation and bone grafts), reconstructions can be performed using adapted conventional prosthesis, alloprosthesis, or non-conventional prosthesis. In cases in which extreme osteoporosis is associated to bone loss, the use of Kuntscher’s nails countersinked in the humeral stem allow extending the proximal stem as much as needed, increasing implant-bone contact surface; and working length and strength distribution of the construction. kuntscher nails are hollowed, they have trebolled shape and they can expand; and the shape of the humeral stem of Conrad-Morrey’s prosthesis is triangular, these qualities allow achieving excellent pressfit between both implants when countersinked.

Saranjeet Singh Jagdev, Subodh Pathak

Shree Krishna Hospital, Karamsad, Anand, Gujarat, India

Complex forearm injuries involve multiple tissue and often associated with contamination, crushing and loss, arrives at odd hours when specialists are not available can lead to serious complications. 16 such patients were treated aggressively by single orthopaedic reconstructive surgeon. The patients having multiple tissue injuries of forearm associated with curshing and contamination treated right from beginning at our center were included.The patients with sharp cut injuries, those underwent replantation or amputation and referred to us at middle of staged treatment of such injuries were excluded. They were called for functional assessment, satisfaction with salvage and disability. The average MESS score of the series was 4.26.The average number of surgery of the series was 3.8 with average hospital stay of 30.9 days. 10 patients underwent primary internal fixation of both bone, external fixator in 1patient , delayed fixations in 2 patients, primary bone grafting in 3 patients and in 1 patient delayed bone grafting was done. Muscultendinous repair was done in 5 , loss were left unrepaired in 7and tendon transfers were done in 2 patients. Primary nerve repairs were done in 2 and nerve graftings were done in 2 patients. Vascular repair was done in one and ligated in 2 patients. 6 skin graftings,2 emergency flaps, 5 early flaps ,5 delayed flaps were done for wound closure. During the treatment phase, one had superficial infection and one had implant infection treated with local wash and antibiotics and removal of implant after bony union respectively during treatment period. One had superficial flap necrosis treated with excision and suturing and stiffness of elbow treated with radial head excision. All the patients were followed up and assessed for function and disability using DASH score. Average duration of follow up was 47.2 months with average tip pinch strength gain was 62.24%, key pinch strength gain 58.48% , grip strength gain 54.75 % of other limb. Average DASH score was 10.24 and all of them were back to same job except for one had to change the dexterity but was in same job. Nobody had severe or extreme pain ,3 had mild pain and 2 had moderate pain. 10 patients had no restriction and 1had quite a bit restriction in social life. All were satisfied with their salvage and preferred limb over amputation despite of residual deformities.The patients with nerve injuries scored average DASH score of 17.66.The patient with brachial artery repair scored 4. All the injuries are different from each other and needs expert care right from beginning. The presence of major nerve injury is the most significant predictor of functional outcome. Timely repair of important vessels can salvage the limb. Emergency and early wound coverage can improve functional outcomes. So,Training in plastic coverage of wounds using pedicle flaps and skin grafting, microsurgical nerve and vessel repairs for orthopaedic surgeon can be of great help for the patients coming to rural centers with complex forearm injuries.

Katarina Mortazavi, Ingela K Carlsson, Lars B Dahlin

Skane University Hospital, Department of Hand Surgery - Rehabilitation dept, Malmö, Sweden

Fear of movement after a finger fracture - what is the problem?

Objective/hypothesis. Rehabilitation following finger fractures is often uncomplicated, but can sometimes cause long lasting problems in function and give activity limitations that are not directly related to the structural impact of the injury. Our aim was to investigate hand function six weeks following conservatively treated proximal phalangeal fractures and to identify personal and behavioural factors related to hand function.
Materials and Methods. A cross-sectional design was used with data-collection and measurements of patients’ hand function six weeks after the trauma. At this point, twenty-four patients [16 women, 8 men, median age 50 (18-82)], have completed the Tampa Scale questionnaire regarding fear of movement, the Quick-DASH as well as estimated their pain intensity on a Visual Analogue Scale. In addition, their hand function was assessed with grip strength and total active motion (TAM).
Results. Preliminary results indicated significant correlations between fear of movement and reduced grip strength six weeks after a finger fracture. Pain intensity during activities also seemed to be associated with reduced grip strength and so did a higher Quick-DASH score. There were no significant correlations shown between fear of movement and TAM and pain intensity during activities did not tend to be related to fear of movement.
Conclusions. We conclude that it would be of great importance if patients with a finger fracture, in need of more guidance, information and support, could be identified at an early stage so that rehabilitation time could be shortened and the patients could return to their work/activities sooner.

Roman Wirtz 1, Silvia Pianigiani 2, Bernardo Innocenti 3, Frédéric Schuind 1

1 Campus Hospitalo-Facultaire Erasme, Bruxelles, Belgium; 2 IRCCS Istituto Ortopedico Galeazzi, Milano, Italy; 3 BEAMS Department, Université Libre de Bruxelles, École polytechnique de Bruxelles, Bruxelles, Belgium


Secondary displacement represents a frequent complication of conservative treatment of distal radius fractures. Patient and fracture related intrinsic factors play a major role, but presumably also the casting technique. The “gap space” between skin and cast allows movements to a certain degree and increased mobility might favor re-displacement.


This study aimed to use 3D imaging to measure the space between plaster and skin as one potential factor for secondary displacement and therefore failure of conservative treatment.


We developed and validated a new methodology to analyze and compare different forearm casts. On the subject’s CT scans, four reference bone-markers were identified to define the radius axis, as well as axial, frontal and sagittal planes. The same points were used to define a precise region of interest. Once the region of interest was located, 3D imaging reconstruction was used to calculate the volume of the arm, the plaster and the “gap space”, defined as the space between the internal surface of the plaster and the external aspect of the limb. After testing the reliability of the land-marks and the proposed methodology, a total of 15 patients have been analyzed. For each patient, not only the three volumes were calculated, but also the characteristic of the inner surface of the plaster. We furthermore compared two different casting materials, the Plaster of Paris (PoP) and the Fiberglass (FG).


We found the width of the “gap space” to average 4mm, being slightly inferior on the radial side. Comparing the two different casting materials, PoP and FG, we found a significantly larger variance of this space in casts made of PoP (p<0.05). A roughness analysis showed also a markedly significantly higher irregularity of the undersurface of PoP casts in comparison with Fiberglass.


These results represent interesting new information regarding the conservative treatment of distal radius fractures and the herein described methodology can be used to correlate extrinsic, cast related factors to failure of non-operative treatment due to loss of reduction.

Frédéric Degez 1, Mathilde Gerbouin 2, Manon Gorzelanczyk 2, Marina Ogeron2, Grégoire Mitonneau 3

1 PT, Centre de la Main, Village Santé Angers Loire, France 2 french student in physiotherapy 3 Ph.D, Laboratoire de Physiologie de l’Exercice, Université Savoie Mont-Blanc, France

The treatment of the épicondylalgia often associates treatment and brace. There are few evaluations of the only brace in the literature. We wanted to evaluate the effect of the brace on a population of patients suffering from épicondylalgia and to compare it on a control population.
In October 2014, we evaluated all our patients arriving for épicondylalgia. We measured the instantaneous force with the dynamometer of Jamar. In the same time, we took the same measures near a population without pathology of the upper limb. We included 83 people of median age 44 years, 43 men for 40 women. The 55 patients were reached of épicondylalgia (strictly tendinous: 27 cases; strictly neural (with irritation of the deep radial nerve): 5 cases; mixed: 23 cases). The brace was allowing the flexion of the elbow. Its tightening was felt during the time of contraction. Measurements were carried out in taut and bended position, without brace then with arm-brace. For each measure, we calculated the ratio: instantaneous force with brace/instantaneous force without brace.
The ratio of force in the control population is 1 for measurement in extension and 1.01 in flexion to 90°. The ratio in the population of the patients is 1.13 in extension and 1.07 in flexion. The ratio in the population reached of tendinous épicondylalgia is 1.08 in extension and 1 in flexion. The ratio in the population reached of neural épicondylalgia is 1.07 in extension and 1.03 in flexion. The ratio in the population reached of mixed épicondylalgia is 1.21 in extension and 1.15 in flexion. The force for the series of patients without pathology isn’t improved. One notes a clear improvement of the maximum force for the patients with mixed épicondylalgia and a relative improvement for the tendinous and neural epicondylalgia.
The arm-brace improved the maximum force only at one patient reached of épicondylalgia. The épicondylalgia with irritation of the deep branch of the radial nerve does not contra-indicate the brace. The increase in maximum force signals an improvement of the muscular efficiency. It allows to the patient to stay longer in his comfortable function during his recovery. We’ll have to confirm these results by anatomical and biomechanical explanations respecting the neural function.

Stephan F. Schindele 1, Christoph M. Sprecher 2, Stefan Milz 3, Stefanie Hensler 1

1 Schulthess Clinic, Zurich, Switzerland; 2 AO Research Institute, Davos, Switzerland; 3 Ludwig-Maximilians-University, Munich, Germany

Primary press fit and secondary osteointegration is a precondition for component anchoring in articular surface replacements of proximal interphalangeal (PIP) joints. However, this outcome is not achieved in many existing prosthesis designs. In order to improve osseous integration of the implant, the modular prosthesis CapFlex-PIP© (KLS Martin Group, Germany), a modern polyethylene-metal surface replacement consisting of a proximal and distal component, was developed.
We hypothesized that long-term cementless fixation of the CapFlex-PIP© could be achieved with initial press-fit technique allowing secondary osteointegration at the bone with the pure titanium pore backside of the components. However, it is difficult to obtain evidence of such osteointegration using standard radiographs. The most detailed and accurate statement can be made by histological analysis, but this requires retrieval of the implant-bone interface. We report such a rare case of an explantation of a CapFlex-PIP© implant due to a soft tissue complication.

Case Report
We present the case of an 84-year-old woman who suffered from severe osteoarthritis in the PIP joints with several operations in the past. After 11 months of CapFlex-PIP© replacement at the index finger, she had a traumatic rupture of the radial collateral ligament during manual work in her garden. Fixed ulnar deviation with functional limitations provided the indication for revision surgery with removal of the CapFlex-PIP© prosthesis and joint arthrodesis. Intraoperatively the proximal and distal components of the prosthesis showed mechanically stable integration and the polyethylene inlay (UHPW) was intact.
The removed implants and attached tissues were immediately fixed in 70% methanol for histological analysis of osteointegration. After dehydration, the blocks were cut in the transversal plane and selected sections were stained with Giemsa-eosin. The Bone-Implant-Contact (BIC) rate, as an quantitative indicator for osteointegration, was measured on all stained sections using a Zeiss Axioplan microscope. The average BIC value was 40.7% for the proximal and 46.5% for the distal implant part. The observed values were within the BIC range published for particular dental implants and higher than those reported for the humeral parts of resurfacing shoulder prostheses.

The present case demonstrates a successful osteointegration of an implant used for human finger articular surface replacement. The result supports the assumption derived from radiographic evaluation. Implants remaining in the correct position can be interpreted as sufficiently osteointegrated. The investigated CapFlex-PIP© implant shows osteointegration of both components, a result which is comparable to that of other load-bearing and articulating implants at different locations in the human body.

Ralph Murphy, Benjamin Baker, Anuj Mishra

University Hospital of South Manchester, Manchester, UK

Introduction and aims: Glomus tumours are rare, usually benign neoplasms of the neuromyoarterial structure known as a glomus body. We aimed to evaluate the role of imaging, recurrence rates and clinical trends within our tertiary hand-centre.

Material and methods: All patients undergoing surgical excision of glomus tumours from April 2005 – April 2015 were identified retrospectively from our coded online reporting system. Demographic data, clinical diagnosis prior to excision, macro- and microscopic, and radiological tumour characteristics were recorded.

Results: 48 patients had a histological-proven glomus tumour. The median age was 55 (IQR: 44.5-64) with no difference between males and females. 35 were found to be within a digit, most commonly from the left thumb (13%), with 20% from a nailbed. Nailbed tumours showed a strong female preponderance (71%).

Both USS (15%) and MRI (15%) were requested in equal numbers pre-operatively. Only 57% of the USS suggested the presence of a glomus tumour, whereas 71% of the MRI scans confidently demonstrated evidence of a glomus tumour.

We found a 6% recurrence rate from sites including: right forearm, left index finger and right middle finger. No pre-operative imaging was requested for these patients.

Conclusions: MRI is the gold-standard pre-operative imaging modality and should be used when recurrence is suspected, especially prior to further surgical treatment.

Keywords: gloms tumour, imaging, surgical excision, recurrence

Denise Casey, Daniel Harte, Lynn Wilson

Southern Health and Social Care Trust, Craigavon, Northern Ireland

In the Southern Health and Social Care Trust, implementation of hand therapy for elective post-operative care of orthopaedic patients begins approximately at 10-14 days. The therapy team consists of specialist occupational therapists responsible for post-op wound inspection, suture removal, commencement of therapeutic modalities (e.g. orthotic fabrication, exercise programme) and signposting (e.g. arranging review with the consultant or clinical outcome practitioner if appropriate and arranging follow up therapy or discharge). The therapist would dictate the treatment session for attention of the G.P and consultant.

Methods and Materials
A patient satisfaction questionnaire was designed using a Likert scale to ascertain patient views on being assessed by the hand therapist (as opposed to the surgeon) post-op. The questionnaire was anonymous and completed after the initial assessment with the hand therapist. The questionnaire also gathered data on the surgical procedure and gender of the patient.
37 questionnaires were completed (56.7% female; 43.3% male). Of these 65.7% were carpal tunnel releases, 17.1% were trigger finger/ thumb releases and 11.4% were palmar/ digital fasciectomies, 2.9% were joint arthrodesis and 2.9% were other (removal of growth).

All of the respondents indicated they were happy for the occupational therapist to be the first point of contact post operatively, confident in their knowledge, and in the advice and treatment provided in relation to their condition, they felt they received enough treatment to improve their condition.

The results from this study demonstrate that patients were unequivocally happy for the therapist to be the first point of contact post-operatively. This informs the clinical team that this model of care is valued by service users with associated health economic benefits i.e. cost savings with seeing therapist instead of consultant.

Bridget Salt, Daniel Harte

Southern Health and Social Care Trust, Craigavon, Northern Ireland

Health promotion is “the process of enabling people to increase control over and to improve their health” (World Health Organisation, Ottawa Charter, 1986). In contemporary life, health promotion is a key strategy to manage growing demands on healthcare services through preventing illness and injury. In 2014, our healthcare Trust set up a Facebook page to share information with service users. The Trust serves a population of over 300,000 people. Service users that typically present to our department have an upper limb injury or a condition that affects hand function. As social media is now a predominant method of information sharing in modern society, we planned to use the healthcare Trust's Facebook page for health promotion related to hand therapy.

Materials and Methods
A series of health promotion campaigns, relevant to the area of hand therapy, were identified. The Trust Public Relations department was contacted to seek advice on submitting such campaigns for inclusion on their Facebook page. The therapy team referred to a range of information sources to ensure any information was up-to-date and evidence-based. Articles were to be written in a fun, journalistic style.

In December 2014, our first campaign was posted on Facebook. This was a seasonal campaign to provide advice to the public on hand safety when carving turkey over the Christmas period. A second campaign on diabetes and the hand was posted on the 14th November 2015. This coincided with World Diabetes Day. This article reached over 6000 people and it was viewed by more than 600 people online.

Our goal is to devise a series of health promotion campaigns relevant to our clinical area for use on social media. This is a simple method of connecting with service users. Campaigns can be posted routinely to ensure the message reaches as many people as possible. Other themes have yet to be posted. These include advice on joint protection, preventing hand injuries in sports participation, life hacks to overcome functional limitations and seasonal advice on injury prevention such as fireworks and pumpkin carving.

Il-Jung Park 1, Hyoung-Min Kim 1, Soo-Hwan Kang 2.

1 Department of Orthopaedic Surgery, Bucheon St. Mary’s Hospital, The Catholic University of Korea 2 Department of Orthopaedic Surgery, St. Paul’s Hospital, The Catholic University of Korea

Background : Vascularized bone grafts for the treatment of Kienböck’s disease may facilitate revascularization and remodeling of the avascular lunate. The aim of this study was to evaluate the radiological and clinical results using a fourth extensor compartmental artery (ECA) bone graft for Kienböck’s disease.

Methods : Between May 2009 and June 2012, 13 patients (six men, seven women) with Kienböck’s disease were treated with fourth ECA vascularized bone grafts. The mean age was 39.2 (20-58) years, and the mean follow-up period was 19.8 (12-60) months. At the time of surgery, one patient was graded with Lichtman’s classification stage II Kienböck’s disease, 11 with IIIA, and one with IIIB. Pre- and post-operative range of motion, pain, grip strength, and radiological parameters, including carpal height ratio and radioscaphoid angle, were evaluated.

Results : At the last follow-up, pain was significantly diminished, and grip strength had improved from 60.5% to 88.6% of the strength of the unaffected side. Mean range of motion had improved from 39° to 51° flexion and from 41° to 55° extension of the wrist joint. There was little or no change in carpal height ratio and radioscaphoid angle (both p>0.05).

Conclusions : Fourth ECA vascularized bone grafting is a reliable alternative to other revascularization procedures for the treatment of Kienböck’s disease, as it is effective, less invasive, and has a low risk of pedicle kinking.

Keywords : Lunate, Kienböck’s disease, fourth extensor compartmental artery

Il-Jung Park 1, Yoon-Min Lee 2, Jae-Young Lee 1, Chang-Kyun Park 1, Soo-Hwan Kang 3

1 Department of Orthopaedic Surgery, Bucheon St. Mary’s Hospital, The Catholic University of Korea 2 Department of Orthopaedic Surgery, Yeouido St. Mary’s Hospital, The Catholic University of Korea 3 Department of Orthopaedic Surgery, St. Paul’s Hospital, The Catholic University of Korea

Background: Trigger wrist, a relatively unusual condition, is a triggering at the wrist produced by wrist or finger motion. We evaluated the clinical manifestations and surgical results of trigger wrist with multiple etiologies.

Methods: We retrospectively reviewed 15 patients diagnosed with trigger wrist from October 2008 to December 2012. The patients comprised six men and nine women with a mean age of 44.8 years (range, 29–86 years). The mean follow-up period was 16.2 months (range, 11–30 months).

Results: The causes of trigger wrist were an anomalous muscle belly of the flexor digitorum superficialis (n = 5), severe tenosynovitis of the flexor tendon (n = 4), fibroma around the flexor tendon sheath (n = 2), a rheumatoid nodule (n = 1), both anomalous muscle belly and tenosynovitis (n = 1), a ganglion (n = 1), and pigmented villonodular synovitis (n = 1). All of the patients showed mild to moderate symptoms of median neuropathy without thenar muscle atrophy. Postoperatively, all of the patients recovered well with resolution of median nerve symptoms, and the wrist triggering was absent.

Conclusions: Trigger wrist is a relatively rare condition compared with trigger finger, which is the most common disorder of the hand. Careful examination and proper diagnosis are required to avoid inadequate and ineffective treatment for patients with trigger wrist.

Key words : Trigger finger, trigger wrist, median neuropathy, flexor digitorum superficialis

Alvaro Baik Cho 1,2, Raquel Bernardelli Iamaguchi1, Gustavo Bersani Silva1, Renata Gregorio Paulos1, Leandro Yoshinobu Kiyohara1,2, Luiz Sorrenti1,2, Klícia de Oliveira Costa Riker Teles de Menezes2, Marcelo Rosa de Rezende1, Teng Hsiang Wei1, Rames Mattar Junior1

1 Hand Surgery and Reconstructive Microsurgery Group of the Institute of Orthopedics and Traumathology – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – São Paulo, Brazil 2 Hand Surgery and Reconstructive Microsurgery Group – Division of Orthopedic Surgery – Faculdade de Medicina do ABC, Sto André – São Paulo, Brazil

The purpose of this report is to critically evaluate our results of two intercostal nerve transfers directly to the biceps motor branch in complete traumatic brachial plexus injuries. From January 2007 to November 2012, 19 patients were submitted to this type of surgery, but only 15 of them had a follow-up ≥ two years and were included in this report. The mean interval from trauma to surgery was 6.88 months (ranging from 3 to 9 months). Two intercostals nerves were dissected and transferred directly to the biceps motor branch. The mean follow-up was 38.06 months (ranging from 24 to 62 months). Ten patients (66.6%) recovered an elbow flexion strength ≥ M3. Four of them (26.66%) recovered a stronger elbow flexion ≥ M4. One patient (6.25%) recovered a M2 elbow flexion and four patients (26.66%) did not regain any movement. We concluded that two intercostal nerve transfers to the biceps motor branch is a procedure with moderate results regarding elbow flexion recovery, but its still one of the few options available in complete brachial plexus injuries, especially in five roots avulsion scenario.

Raquel Metzker Mendes 1, Fernando Vicente de Pontes 2, Marisa de Cássia Registro Fonseca 3, Maria Candida de Miranda Luzo 4

1 University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo; 2 University Hospital, Faculty of Medicine of São Paulo, University of São Paulo; 3 Faculty of Medicine of Ribeirão Preto, University of São Paulo; 4 University Hospital, Faculty of Medicine of São Paulo, University of São Paulo

Background: Sensory changes occurred after a peripheral nerve injury in the hand affect significantly the performance of an individual in the activities of daily living, causing a great impact in quality of life. Early sensory reeducation of the hand aims to obtain better functional results after rehabilitation by applying strategies that use the cortical plasticity and sensory integration concepts. Objectives/ Hypothesis: The objective of this study was to review and update evidence about the use of early sensory reeducation protocols decribed in the literature. Materials and Methods: A literature search of PubMed, Scielo, BVS and PEDro for the following terms: “sensory reeducation” or “sensory re-education” or “early sensory reeducation” or “sensory relearning” and “hand” or “upper limbs” was undertaken. Studies were selected if they met the inclusion criteria: clinical trials that applied early sensory reeducation of the hand after a peripheral nerve repair. Results: A total of 37 articles were found, but only eight studies were included. A lack of controlled trials (two in the total eight), randomized or not, and a considerable variability in the interventions adopted were observed. In general, the studies used tactile stimulation with textures; mirror therapy and audio-tactile integration to early sensory reeducation of the hand both at supervised rehabilitation and at home. Different methods of assessment and follow-up periods were detected also. Conclusions: All the studies reviewed described good results in the sensory function of the hand (tactile gnosis) after early interventions; however, it was difficult to compare them and recommend a protocol due to the heterogeneity of the methods.

Alvaro Baik Cho 1,2, Renata Gregorio Paulos1, Marcelo Rosa de Resende1, Leandro Yoshinobu Kiyohara1,2, Luiz Sorrenti1,2, Teng Hsiang Wei1, Raul Bolliger Neto1, Rames Mattar Junior1

1 Hand Surgery and Reconstructive Microsurgery Group of the Institute of Orthopedics and Traumathology – Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo – São Paulo, Brazil 2 Hand Surgery and Reconstructive Microsurgery Group – Division of Orthopedic Surgery – Faculdade de Medicina do ABC, Sto André – São Paulo, Brazil

The purpose of this study was to observe if the results of the median nerve fascicle transfer to the biceps are equivalent to the classical ulnar nerve fascicle transfer, in terms of elbow flexion strength and donor nerve morbidity. Twenty five consecutive patients were operated between March 2007 and July 2013. The patients were divided into two groups. In Group 1 (n= 8), the patients received an ulnar nerve fascicle transfer to the biceps motor branch. In Group 2 (n= 15), the patients received a median nerve fascicle transfer to the biceps motor branch. Two patients with follow-up less than six months were excluded. Both groups were similar regarding age (p= 0.070), interval of injury (p= 0.185) and follow-up period (p= 0.477). Elbow flexion against gravity was achieved in 7 of 8 (87.5%) patients in Group 1, versus 14 of 15 (93.3%) patients in Group 2 (p= 1.000). The level of injury (C5-C6 or C5-C7) did not affect anti-gravity elbow flexion recovery in both groups (p= 1.000). We concluded that the median nerve fascicle transfer to the biceps is as good as the ulnar nerve fascicle transfer, even in C5-C7 injuries.

Raquel Metzker Mendes 1, Marisa de Cássia Registro Fonseca 2, Valéria Meirelles Carril Elui 3, Nilton Mazzer 4

1 University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo 2 Faculty of Medicine of Ribeirão Preto, University of São Paulo 3 Faculty of Medicine of Ribeirão Preto, University of São Paulo 4 Faculty of Medicine of Ribeirão Preto, University of São Paulo

Background: The recovery of sensibility of the hand after peripheral nerve injuries is often incomplete. The unsatisfying results are due to both structural changes related to neural regeneration process and to cortical changes in the hand map after injury. Thus, the implementation of early sensory reeducation techniques aimed to preserve the area of cortical representation of the hand becomes an important strategy to obtain a better function. The search for cortical audio-tactile integration, using sensor glove models is an example of these early methods. Objective/Hypothesis: The objective of this study was to evaluate and compare the sensory hand function in subjects submitted and not-submitted to an early protocol of sensory reeducation of the hand by using a sensor glove model. Materials and methods: For the participation in this research, 33 subjects were selected; 16 were excluded for not meeting the inclusion criteria or due to poor adherence to treatment. Thus, the final sample was composed by 17 subjects of both genders, aged 18 or older, submitted to surgical repair of median and/or ulnar nerves at the wrist level for a maximum of 15 days. The subjects were divided into two groups: the training group (TG), submitted for three months to a protocol for early sensory reeducation of the hand, with a sensor glove model, and the control group (CG), not submitted to this protocol. The sensory function of the hand was assessed at the first, third and sixth months after the nerve repair by the application of esthesiometry test (EST); static two-point discrimination test (2PD); Shape and Texture Identification test (STI™) and DASH questionnaire. Results: In the intragroup sensibility assessment, only TG subjects presented significant differences in the EST (p=0,001) results and DASH questionnaire score (p=0,02) over time. However, no significant differences were found between groups after six months. Conclusions: In this study, a better touch threshold and a patient-reported outcome were found in subjects submitted to an early sensory reeducation protocol with a sensor glove model, but further trials and a long term follow-up, are needed to appropriate evaluation of the effects of early sensory reeducation using this sensor glove model.

Jin-Rok Oh, Jun-Pyo Lee, Myoung-Gi On

Department of Orthopedic Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea

Objective: This study aims to compare and analyze the effects of surgical treatment in cases in
which the displacement of the fixating material was not corrected and mal-union took place.

Methods: The study was conducted from January 2010 to March 2015, and 21 Wonju severance
cristian hospital patients who received surgical treatment using basal plate internal fixating material
participated. Patients were divided into two groups – group A which received internal fixation after
osteoclasis as they received early surgery and thus showed soft callus formation and group B which
received internal fixation after osteotomy as they received late surgical treatment and showed hard
callus formation meaning complete enchondral ossification – and VAS scores, Mayo wrist score
before and after the treatment (post-surgery, 3 month, 6 month, 1 year respectively), grasping power
of the hand compared to the normal side, range of motion of hand before and 1 year after the
treatment were compared between the two groups.

Results: Out of 21 patients with chronic distal radius fracture (malunion), 10 patients were in group
A, and 11 were in group B. The average time to receiving surgical treatment was 7.75 weeks in
group A and 23.67 weeks in group B. Both group displayed positive outcomes in VAS score after a
year (both under three), and group A showed significant difference in 3 month follow-up of VAS
score. The grasping power of hand were both recovered to about 80% (A: 86% B: 78.3%) and there
was no significant difference between the two groups. Range of motion - in terms of flexion,
extension, radial side rotation and ulnar side rotation – improved in both groups compared to
pre-treatment, and group A showed bigger improvements than group B.

Conclusions: In conclusion, the study showed that performing earlier surgery when there is only soft
callus formation to distal radius fracture mal-union compared to performing late surgery when
enchondral ossification is already finished, bring about stastically significant differences in pain and
articular range of motion.

Jin-Rok Oh, Jun-Pyo Lee

Department of Orthopedic Surgery, Yonsei University Wonju College of Medicine, Wonju, Korea

Introduction: Distal radius fracture is very common, and there are a few cases in which scaphoid
fracture is accompanied with it. This study aims to compare and scrutinize the cases of distal radial
fracture injuries that accompany scaphoid fracture to those that do not.

Materials and methods: From Jan. 2011 to Dec. 2013, Yonsei Wonju Severance Hospital enrolled
212 distal radius fracture patients. Diagnosis was done by the use of computed tomography, and data
about 212 patients - age, sex, BMI, A0 classification of distal radial fracture - were collected and

Result: Twelve out of 212 patients had scaphoid fractures along with the radial injury. Age, sex, and
BMI did not display significant difference between the two group, and ten out of twelve turned out
to be C type in A0 classification of distal radius fracture.

Conclusion: 12 cases - out of 212 - turned out to have scaphoid fracture along side the radial injury.
The number might look small and trivial, but to note the difference is truly important: diagnosing it
at the time of injury is challenging, and misinterpreting scaphoid fracture as mere inflammation of
the wrist can result in serious complications such as nonunion or disunion. These complications can
cause progressive necrosis and worse. Likewise, complete and concrete diagnosis of distal radius
fracture with scaphoid fracture is very critical.

Saranjeet Singh, Subodh Pathak, Nisheet Dave

Pramukhswami Medical College, Shree Krishna Hospital, Karamsad, Anand, Gujarat, India

CMC joint of thumb is second common joint involved in arthritis in human body, which leads to pain,stiffness,deformity and weakness of the thumb. Patients with advanced disease who have failed conservative treatment modalities have multiple surgical options including ligament reconstruction with tendon interposition (LRTI), resection arthroplasty, arthrodesis, silicone implantation, vasculrised joint transfers, and total joint arthroplasty. Each surgical procedure has its own advantages and disadvantages. Ligament reconstruction with tendon interposition (LRTI) is one of the performed procedure for this problem. In LRTI the trapezium is excised and FCR is used to reconstruct to reconstruct beak ligament to prevent collapse of 1st ray and provide stability to thumb and rest of the tendon is rolled on itself and interposed between the space created between the 1st metacarpal and scaphoid and FCR is joined to EPB. At our institute LRTI procedure was performed in 11 patients with average age was 57 years. We wanted to check the functional results of this procedure in Indian patients. All patients included in the study were seen in the outpatient department and identified to have basal joint arthritis according to their clinical presentation and classified on the basis of radiological appearance. The patients underwent LRTI by single surgeon. The thumb was immobilized in a spica cast for 4 weeks, after which the cast was replaced with a removable protective splint, and physiotherapy was started. All the patients were followed up and assessed for function and disability using DASH score. Average duration of follow up was 24 months with average tip pinch strength gain was 75%, key pinch strength gain 80% , grip strength gain 80 % of other limb. Significant Improvement in active 1st web space angle was seen with average of 19.5 degree. Average DASH score was 4.14 ranging from 1.72 to 6.89. Nobody had severe or extreme pain ,3 had mild pain and 2 had moderate pain. All the patients were able to do their activities of daily living. All were satisfied with the cosmetic appearance of the hand after procedure. LRTI provides excellent relief of pain.. Based on our observation of DASH scores, the results have remained encouraging in most cases with restoration of beak ligament to provide a stable and functional thumb. There is no doubt that the debate over the treatment choice for the CMC arthroplasty will continue. LRTI is a useful procedure for pain relief and functional restoration in elderly patients of India.

Chihab Taleb1, Ahmed Zemirline2, Frédéric Lebailly3, Stéphanie Gouzou4, Sybille Facca4, Juan Hidalgo4,Philippe Liverneaux4

1 Department of Hand Surgery, Emile Muller Hospital, Mulhouse, France; 2 Department of Hand Surgery, Private Hospital Saint-Grégoire, Rennes, France; 3 Department of Hand Surgery, Saint Paul Clinic, Fort-de-France,France; 4 Department of Hand Surgery, University of Strasbourg, Illkirch, France;

Background: The rate of malunion after distal radius fractures is 25% after conservative treatment and 10% after surgery. Their main functional repercussion related to ulno-carpal conflict is loss of wrist motion. We report a retrospective clinical series of minimally invasive osteotomies.
Case description: The series consisted of 9 cases of minimally invasive osteotomies with volar locking plate fixation. All osteotomies healed. The average pain was 5.3/10 preoperatively and 2.1/10 at last follow-up. The mean Quick DASH was 55.4/100 preoperatively and 24.24/100 at last follow-up. Compared to the opposite side, the average wrist flexion was 84.11%, the average wrist extension was 80.24%, the average pronation was 95.33% and the average supination was 93.9%.
Literature review and clinical relevance: With similar results to those of the literature our short series confirms the feasibility of minimally invasive osteotomy of the distal radius for extra-articular malunion.

Jaime Ernesto Forigua Vargas, Omar David Dimian Mayorga, Rafael Arturo Brunicardi Hurtado

Servicio de Cirugía de la Mano, Hospital de San José – Sociedad de Cirugía de Bogotá. Fundación Universitaria de Ciencias de la Salud. Bogotá, Colombia.

Associated soft tissue injuries in distal radius fractures are common (30-98%) and cause adverse outcomes. The early identification by arthroscopy can document and treat such injuries. In our country there are no known studies documenting this type of injury and its effect on distal radial fractures.

To describe the arthroscopic findings in patients with distal radial fractures

Case series of adult patients who met criteria for surgical management of fractures of the distal radius with arthroscopic evaluation between January 2010 and September 2013 at the Hospital. Soft tissue injuries, articular steps and gaps were evaluated after the fracture reduction. Also, the measurements in the immediate postoperative radiographs were evaluated and the results according to radiographic measurements and joint gaps and steps were classified. Stata 10 statistical software was used to analyze the results.

We included 51 patients. Lesions of the triangular fibrocartilage injuries were most commonly associated with fractures of the distal radius with 19 patients (39.2%). Scapholunate ligament injuries often followed in 14 patients (27.4%). Also, we found 4 patients with osteochondral lesions, being the scaphoid the most affected bone (3.92%).

The associated ligament lesions in the distal radius fractures are common and often undiagnosed at the time of surgery. Arthroscopy allows to evaluate and treat not only these lesions but also gives us the opportunity to correct steps and joint gaps.

Jaime Ernesto Forigua Vargas, Omar David Dimian Mayorga, Rafael Arturo Brunicardi Hurtado.

Servicio de Cirugía de la Mano, Hospital de San José – Sociedad de Cirugía de Bogotá. Fundación Universitaria de Ciencias de la Salud. Bogotá, Colombia.

Associated soft tissue injuries in distal radius fractures are common (30-98%) and cause adverse outcomes. The early identification by arthroscopy can document and treat such injuries. In Colombia there are no known studies documenting this type of injury and its effect on distal radial fractures.

To describe functional outcomes in patients undergoing osteosynthesis of distal radius fractures assisted by arthroscopy in Hospital de San José, Colombia.

5 patients (6 women, 19 men) between 20 and 78 years with distal radius fractures were treated with open reduction and internal fixation with volar plate and assisted by arthroscopy. In total there were 30 distal radius fractures, 12.5% type B and 87.5% type C according to AO classification. Patients were followed on average for 20 ± 12 months.

Functional average from May Wrist Score was 79.4. 4 patients had excellent results, 16 good, 8 satisfactory and 2 poor results. The injury most frequently associated with Type C distal radius fractures was the lesion of the triangular fibrocartilage (30%). 23 patients recovered the strength by 75%, 4 patients reach 100% and one patient only 25% compared with the healthy limb. We did not find distal radioulnar symptomatic instabilities, although an increased range of mobility radiocubital in 8 patients (26.6%) was found. In the late postoperative they showed 3 patients with pain in the arthroscopic portals and one patient with ulnar dorsal branch neuritis.

Radiocarpal and Midcarpal arthroscopy is a useful tool for the management of osteosynthesis of distal radius fractures, as well as a tool for the diagnosis and treatment of injuries associated.

Tae-Kang Lim, Byoung-Hun Hwangbo, Jae-Hyun Park, Sang-Young Lee, Do-Hyun Lee

Eulji Hospital, Eulji University School of Medicine, Seoul, South Korea

Minimally invasive plate osteosynthesis (MIPO) for proximal or midshaft fracture of the humerus gained popularity, recently. However, a risk of axillary nerve injury is concern. The purpose of this study was to evaluate the incidence and risk factor of axillary nerve injury after MIPO procedure for humerus fractures by electromyography/nerve conduction velocity (EMG/NCV) study. This study prospectively evaluated consecutive 19 patients who underwent MIPO through anterolateral approach for humerus fractures. Of them, we included 16 patients who were examined by EMG/NCV study at 3-4 weeks postoperatively. An independent, well-trained physician from the department of rehabilitation medicine performed EMG/NCV studies in all patients. We excluded 3 patients because two of them were not compliant to EMG/NCV examination at that period and the remaining one died due to unrelated medial illness. There were 5 male and 11 female with mean age of 70 years (range, 52-89). Fractures involved in the proximal humerus in 14 patients (8 displaced two-part and 6 three-part fractures) and the midshaft humerus in 2. We correlated the presence of axillary nerve injury with the use of medial calcar support screw and patient’s body mass index (BMI). The mean follow-up period was 6 months (range, 3-11). As for the results, an EMG/NCV study revealed an incomplete axillary nerve injury in 4 patients and normal results in the remaining 8 patients. No complete nerve injury developed in this series. Nerve injury was found only in group with use of medial calcar support screw (four of 8 patients). Mean value of BMI was not significantly different between groups with nerve injury and without (25.6±2.1 versus 23.6±2.1, respectively, p=0.142). In conclusion, axillary nerve injury developed in four of 16 patients after MIPO procedures, all in an incomplete injury pattern. Use of medial calcar support screw to improve the stability of plate fixation can be a risk factor when used in MIPO technique.

Orlando Alberto Rodriguez, Carlos Savastano

1 Sanatorio Allende, Córdoba, Argentina; 2 Hospital Nuestra Señora de la Misericordia, Córdoba, Argentina

Most of the cattle in Latin America are found in areas where cases of tuberculosis can still be found. People living in those areas are more prone to get infected, especially where there is no adequate sanitary and veterinary control. The diagnosis is based on the microscopic exam of swab and on lab culture. However, most of the mediums used for the diagnosis contain glycerol, which inhibits the growth of strains of Mycobacterium bovis.
In these countries there are no programmes of diagnosis and eradication of M.bovis infection. Moreover, culture media with pyruvate is scarcely used (which is more appropriate to isolate M.bovis) and this contributes to underestimating the size of the problem.
Most of the cases are linked to Argentina, probably because Stonebrink medium, which is suitable for this mycobacterium, is used in our country.
The case of a female patient is presented with synovitis in the common flexor sheath and in the flexor tendon of the fifth finger of left hand secondary to Mycobacterium bovis.
OBJECTIVE: Our aim is to encourage diagnostic suspicion to infections caused by infrequent microorganisms based on the clinical-epidemiologic context of the patient and on macroscopic and microscopic examination of surgical specimens; and also to send samples for bacteriologic analysis periodically to reach an early diagnosis and administer an adequate treatment.
MATERIALS AND METHODOLOGY: Female patient, 48 years-old, native from the rural area of Tisino, Cordoba, Argentina. Antecedent of surgical decompression of the median nerve in left carpan tunnel (2012). Consultation for edema in anterior side of wrist, hypothenar region and fifth finger of left hand, pain 5/10 in the visual analog scale (VAS) and functional deficit in radiocarpal joint in flexion and in metacarpophalangeal and interphalangeal articulations of fifth finger. The clinical picture evolved progressively in a 9-month period. The patient made reference to several traumas caused by a needle in left hand (bovine leather seamstress). An extensive synovectomy was carried out with further development of M.bovis in culture. Infectology service started daily treatment with Rifampicin 600mg, Isionazid 300mg, Pyrazinamide 1600mg and Ethambutol 1600mg for two months and then six months with Rifampicin 600mg and Isionazid 300mg.
RESULTS: Patient responds well to treatment and recovers normal mobility in the affected segment without signs of relapse.
CONCLUSION: A successful treatment for infectious synovitis depends not only on the right surgical technique but also on the isolation of the germ to give a directed treatment. Presumptive diagnosis based on the clinical-epidemiological context plus an appropriate physical examination and a macroscopic evaluation of the surgical specimen should guide us towards an infectious etiology, which can only be confirmed later by the development of germs in culture.
Incidence of M.bovis infection in humans is less frequent than M.tuberculosis. The most important measures for control, elimination and possible eradication of this infection are food sanitation, pasteurization of milk, sanitary control, epidemiologic surveillance and an adequate treatment of patients.

Francisco Javier Garcia Garcia, Jose Maria Martin Enrique, Alberto Moreno Regidor, Carlos Marques Parrilla, Francisco Melchor Mencia

University Hospital of Salamanca, Salamanca, Spain.

Objective: Arthritis affecting trapezio-metacarpal joint of the thumb is a very common disease in our community. This joint is the second most common affected by degenerative processes in the hand after the distal inter-phalangeal joints. Condition predominantly affects women, especially those who are postmenopausal. Management of this arthritis initially starts with the use of conservative measures, but in some cases this treatment is not enough to mitigate pain and get an adequate mobility, then surgery is needed. The purpose of the study was to assess the clinical outcomes of the ARPE® arthroplasty in 62 patients at 5-year follow-up.
Methods: We present a retrospective study of 62 non-cemented total prosthesis of the trapezio-metacarpal joint in patients affected by arthritis with a minimum of 5-year follow-up.
Results: At the end of follow-up, 50 (80.5%) were considered a success, improving mobility and disappearing every, or almost every, pain. 4 (6.5%) prostheses do not improve the basal clinical situation or they worsened it, just after the surgery or during the period of evaluation, even having no remarkable radiological signs. We had 8 (13%) postoperative complications, 4 aseptic loosening, 2 recurrent partial prosthesis dislocation, 1 complex regional pain syndrome and 1 unnoticed metacarpal fracture. DASH score was obtained.
Conclusion: We consider ARPE® prosthesis as a good surgical option in advanced trepezio-metacarpal arthritis. We obtained during 5 years, an 80.5% percentage of success, improving the previous situation, 13% complications and 6.5% prosthesis with no clinical improvement.

Shibayama Hiroki, Morii Hokuto, Inui Takahiro, Ooae Kazunori, Inokuchi Koichi

Advanced critical care and emergency center, Saitama Medical Center, Saitama Medical University, Saitama, Japan

A free flap pedicled by the second dorsal metacarpal artery was reported by Earley at first in 1997 and there is only another report by Yu in 2005. Because this flap has some advantages for thin, aesthetic, sensate and less morbidity of the donor site, it is very useful for such a small defect of the fingers.

Materials and methods
41 year-old male was working in a truck factory and his right middle finger was crushed and amputated by solid metal blocks. He was transported to our hospital and the middle finger revealed crushed disarticulation at the distal interphalangeal joint and distal phalange was comminuted. The soft tissue around the middle phalange was damaged. He underwent replantation surgery at the same day but the finger became necrosis. After debridement, the middle finger was amputated at distal interphalangeal joint and middle phalange was explored with the soft tissue defect for 20 x 60mm. He selected a flap surgery for preservation of the finger length as a next treatment. At the day of 14th, We performed a free flap transfer with the second dorsal metacarpal artery and cutaneous nerve and veins for covering the middle phalange. We anastmosed the artery with the digital artery, the subcutaneous vein with the dorsal subcutaneous vein of the finger and the cutaneous nerve with the digital nerve. We needed full thickness skin grafting for volar aspect of the defect because the flap was located proximally different from the preoperative planning.

The flap survived without vascular troubles. Wound dehiscence and infection were not observed. One year after the operation, the patient had no pain and the range of motion of the proximal interphalangeal joint was 0/68. The moving two-point discrimination test showed 2mm. He returned to the previous working. The left hand as the donor site had full motor and sensory function, and the scar was inconspicuous.

The pedicle of this flap is the second dorsal metacarpal artery and subcutaneous vein. We can attach subcutaneous nerve from superficial branch of the radial nerve for the purpose of a sensate flap and/or, extensor tendon for the purpose of a tenocutaneous flap. Because this artery rarely has anatomical exceptional, the vascularity of this flap is very reliable. Advantages of this flap are thin, aesthetic, sensate and less morbidity of the donor site. Skin texture is very similar to the fingers. Disadvantage is small in both the flap size and the vascular pedicle. Totally, this flap is more useful for the small defect of the finger, except for volar aspect, than other thin flaps such forearm flap, dorsalis pedis flap and peroneal flap.

G. Demontis, E. Dapelo, A. Galuppi, A. Landolfi, S. Briano

IRCCS Azienda Ospedaliera Universitaria San Martino – IST Genoa - Italy UOC Ortopedia e Traumatologia d’Urgenza


Distal radius fractures represent 17% of all fractures. The incidence is higher in elderly population even due to low-energy trauma but it’s increasing in young patients due to high energy trauma with fractures at higher morphological complexity.
In the last few years, the evolution of the diagnostic means and the improvement of the materials in terms of biocompatibility has led to an increase of surgical treatment indications of this type of fractures.

The goals of the study are two. First to verify whether the increase of surgical indications in the treatment of wrist fractures is accompanied by a better radiological, functional and clinical outcome than in the past. Second to compare the data obtained with those of the same study conducted by the same authors between January 2007 and December 2010 to show how the improvement in materials influenced the clinical out-come.

Materials and Methods:
From January 2011 to December 2014 the Authors treated by means of volar plate 199 patients.
We re-evaluated 142 patients. The mean age was 47.4 years (age range 17-87 years) and there was an higher incidence in females with a ratio F: M of 1.26.
All patients were assessed clinically and radiographically at 1, 3, 6 and 12 months of follow-up and at the time of revaluation.
The clinical and functional outcome of patients was assessed according to DASH (Disabilities of the Arm, Shoulder and Hand) while an objective functional assessment was obtained by Gartland and Werley score as well as by radiographic evaluation.

The DASH score reported an average score of 5.3 with a minimum of 0 and a maximum of 37 showing satisfactory results (good-excellent) in 94% of patients evaluated.
The Gartland & Werley reported in 87% of cases a satisfactory result in line with the results obtained by the subjective evaluation.
Radiographic evaluation found satisfactory results in 85% of cases.

Comparing the data from the two studies we can say that the evolution of the materials used for the synthesis of wrist fractures led to an increase in primary stability even in complex fractures, resulting in an early return to daily activities and work, and improving quality of life. The study also showed that often the clinical results are better then the radiographic results.
According to literature in our experience the surgical treatment of wrist fractures by DVR represents the gold standard in treatment of these kind of injuries.

G. Demontis, E. Dapelo, A. Galuppi, S. Briano

IRCCS Azienda Ospedaliera Universitaria San Martino – IST Genoa - Italy UOC Ortopedia e Traumatologia d’Urgenza

Carpal dislocations are rare and usually a result of a high energy trauma and may be easily
overlooked or misdiagnosed, expecially in polytrauma patients.
We report a 3 years follow-up of a patient who sustained a bilateral volar lunate dislocation.
On the right side through a longitudinal palmar approach the lunate was reduced and
stabilized with three 2 mm k-wires ( scapho-lunate, luno-triquetral, scapho-capitate) and the
palmar capsule was repaired. The plurifragmentary distal radius fracture was reduced with
open reduction and stabilized with three k-wire and an external fixator for additional stability
of radius. The left wrist was treated with dorsal approach stabilizing the lunate with three 2
mm k-wires and below-elbow cast was applied.
The immobilization cast, the k-wires and the external fixation were removed after three
The authors report clinical findings and X-Rays after three years.
A literature review reports just nine cases of “bilateral lunate dislocation”.
Our report has been an unusual clinical and diagnostic finding and a rare treatment challenge.

E. Dapelo, G. Demontis, A. Galuppi, S. Briano

IRCCS Azienda Ospedaliera Universitaria San Martino – IST Genoa - Italy UOC Ortopedia e Traumatologia d’Urgenza

The rupture of the distal biceps tendon is a relatively uncommon lesion. In the past it was usually treated by immobilization with a loss of function untill 60% in elbow flexion and forearm supination. Now in the young and active people an early surgical reinsertion is the gold standard.
In this presentation we present our case series of surgical reinsertion with the single access by means of two suture anchors.

Materials and Methods
Between january 2010 and june 2014 we treated 55 patients, 54 men and just one woman who has a complex injury of the elbow . The avarage age was 41 yy. All patients were treated within 25 days from the traumatic event. No patients presented specific risk factor like cortisonic or antibiotic therapy or diabet.
The operation was made by loco-regional anesthesia and like a one day surgery procedure. We used the anterior single approach and suture anchors were used for tendon reconstruction in all cases.
Elbow range of motion (ROM), subjective strength recovery, time to return to work and sports activities, and complications were recorded. Disability of the Arm, Shoulder and Hand
Score (DASH), the Oxford Elbow Score (OES), and the Mayo Elbow Performance Score (MEPS) were obtained for all patients.
We revalueted 53 patients. ROM recovery was almost complete. Mean subjective strength recovery allowed full return to sports and work in 98.2 % of cases, within mean 3-month postoperative. Mean DASH, OES, and MEPS scores were excellent in the most of cases (MEPS: 98,87- OES: 46,7 - DASH: 1,3). We had not clinically relevant complications rate. There was just one case (1,8%) of partial rerupture (<1/3) that didn’t need for surgery again, just one case of superficial infection successfully treated by antibiotic therapy and one case of mild pain deep to the scar due to the fibrosis. We had no cases of nerve neuapraxia, heterotopic ossifications or complete rerupture.
On our opinion the reinsertion of the distal biceps tendon at its orthotopical site, the radial tuberosity, is the surgical solution that guarantees the best functional elbow results in recovery of flexion-extension and supination strength.
The use of the suture-anchors realizes a strong fixation with minimal bone exposition that means less etherotopic ossifications and low complication incidence.

S. Briano, E. Dapelo, A.Galuppi, G. Demontis

IRCCS Azienda Ospedaliera Universitaria San Martino – IST Genoa - Italy UOC Ortopedia e Traumatologia d’Urgenza

Metacarpal fractures are common injuries, in the most of cases composed and stable, and immobilization is sufficient to get good functional and esthetic results. However unstable fractures with any rotational or length deformity, if not adequately treated, can lead to malunion with stiffness and relevant functional and cosmetic deficits.
Intramedullary fixation of metacarpal fractures using small flexible rods provides stable fixation avoiding an extensive soft tissue trauma, increased surgical time and long immobilization.
Between 2010 and 2013 the Authors treated N 129 of extra-articular metacarpal fractures (112 patients) by intramedullary nailing, with SBSF Hand Innovation system. Under fluoroscopy closed reduction was obtained and, according to the technique, the nail was inserted with a percutaneous approach over the metacarpal bases. Then a proximal locking pin was inserted and a radiopaque plastic cap was applied over the cut end of the nail to minimize irritation to the adjacent soft tissue during the rehabilitation.
Immediately postoperatively motion was allowed with a dedicated dressing, positioned for one week, supporting the Mp joints in a flexed position while allowing free IP joint motion.
After one week all the patients started a rehabilitation program.
The nail was then removed between 5 to 12 week from surgery.
Follow-up (from 1 to 3 years) was performed using the DASH questionnaire and standard radiographs on 60 patients.
All fractures healed without complications. The patients reported a high degree of satisfaction with getting back to their normal activities. The MP ROM was complete in all of them. There were just of cases (5) those developed a slight cutaneous inflammation over the pin emergency but with a spontaneous healing.
The use of SBSF nailing system is rapid and reliable performed as a day-case procedure that minimizes the soft tissue trauma and allows early mobilization. The general outcome was good hand function with rare and secondary complications.

Chris Hasenkam 1, Gregory Hoy 2,3, Paul Soeding1,4

1 University of Melbourne Dept Anaesthesia 2 Melbourne Orthopaedic Group 3 Monash University Dept. of Surgery 4 Melbourne Anaesthetic Group

Surgical intervention for basal osteoarthritis of the thumb involves incisions across the wrist joint on either the volar or dorsal side. With the advent of ultrasound-guided regional anaesthesia, basal thumb joint arthroplasties can be performed using targeted peripheral nerve blockade, to avoid the morbidity of whole arm regional anaesthesia. Conventional belief dictates that anaesthesia can be achieved by solely blocking the Median and Superficial Radial nerves. This study focuses on the anatomical variation of the Lateral Cutaneous Nerve of Forearm (LCNF) where distal innervation to the dorsolateral thumb may also occur. This has important implications for achieving total surgical anaesthesia in thumb surgery, with regional blockade.
Following informed consent, patients were placed supine and each nerve was identified using surface ultrasonography (18MHz linear array probe B-K400, Denmark). The sonographic appearance of each nerve was identified and documented in relation to surrounding anatomy. The nerve was then blocked by circumferential injection of lignocaine 2% (3-5mL) and the cutaneous innervation mapped using loss of sensation to fine touch and thermal modalities. The extent of distal numbness was related to the radiocarpal joint.
Under ultrasonography, the LCNF was located deep to the Cephalic Vein in all cases (n=17). It was visualised and blocked 98.7mm ± 2.6mm distal to the Interepicondylar Line. The distal cutaneous distribution involved the Radiocarpal Joint and surgical field in 93% of cases (n=15). The Superficial Radial Nerve (n=3), and Median Nerve (n=3), followed typically understood patterns of cutaneous distribution.
The LCNF can be easily visualised and blocked using surface ultrasonography. In clinical practice, innervation of the cutaneous dorsolateral thumb by the LCNF must be considered when performing regional anaesthesia for thumb suspensionplasty and other basal thumb joint procedures.

Daniele dos Santos Scarcella, Maria Candida de Miranda Luzo, Marcelo Rosa de Rezende, Bruno Eiras Crepaldi.

Institute of Orthopedics and Traumatology – Hospital das Clínicas – Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.

Injury of upper roots of brachial plexus lead to loss or significant decrease in motion of the upper quarter and considering that internal rotation contracture of the humerus is a common complication due to lack of abduction and external rotation, this is a frequent concern among surgeons and hand therapists, because the patient with a normal hand function could have a better motor condition and increase independence and autonomy with elbow flexion and shoulder stability with good spatial positioning, that means the ability to external rotate the shoulder to at least neutral position. The findings in the literature related to this are some surgical procedures to restore external rotation, these procedures include neurological surgeries as nerve exploration, nerve transfers, combined nerve and muscle transfers. Muscle transfers are considered a good choice for late injuries. This prospective study included 10 patients with at least 1 year of injury that underwent surgery of ipsilatera lower trapezius muscle transfer to the infraspinatus tendon. Patients underwent screening prior to surgery considering as selection criteria passive range of motion (PROM) at least 90° of elbow flexion, PROM of at least 15° of external rotation, M4 biceps muscle strength or greater and free mobility of scapular-humeral joint. A progressive splint in abduction of 90 – 30 degrees and maximal external rotation was used after the surgery for six weeks. Rehabilitation protocol inicialized at two weeks and consisted of progressive reduction of abduction and external rotation limited to 30° untill 6 weeks. Evaluations consisted of goniometric measurement, manual muscle strength (Lovett Scale), Mallet’s classification and the Disabilities of the Arm, Shoulder and Hand (DASH) that were performed at 3 and 6 months post surgery. Results: The active movement of the shoulder had significant improvement in average gain of active and passive external rotation, 17 and 14 degrees respectively and gain of active and passive abduction of 13 and 14 degrees respectively. The DASH obtained initial average of 46.57 points decreasing to 26.74 after 6 months postoperatively. The Mallet’s classification and the manual muscle strength scale showed no changes with statistical significance. Conclusion: improvement of active flexion and abduction of the shoulder associated with the average gain of range of external rotation and abduction that associates showed improved clinical and functional assessment corroborated by the DASH was observed.

Nathalie Poirier Coutansais1, Frederic Degez 1,2, Bruno Cesari 1,2,3, Vinvent Casoli 1,2,3,4

1,2,3 Centre de la Main , Village Sante Angers Loire, France 4Laboratoire d'anatomie médico-chirurgicale appliquée ,université Bordeaux,France

Very few references are found in the literature. The aim of the study was to assess the frequency and the location of the buttonhole between the digital nerve and the artery in the palm.
Eight hands from six specimens were dissected under optical magnification, four of them had been previously injected with latex. Location of the buttonholes was noted according to the metacarpal space and proximal or close to the nerve division.
We found eight buttonholes in six hands. Only one of the specimens had buttonholes in both hands. We couldn't find any in the first space. At least, one feature was always located in the third space except one in the second. Two hands had two buttonholes, one in the third and the other in the fourth space. Five buttonholes were close to the nerve division, two were more proximal in the palm, one was double proximal and distal.
Hartmann's buttonholes are frequent, mostly located in the third metacarpal space as described in the literature. They are not always bilateral, buttonholes in the fourth space always seem to be associated to another one in the third space. A double buttonhole in the third space or a single one in the second space are uncommon. In the study no buttonholes existed in the first space.

Rosario Baladron, Michel Boutan

Bayonne and Dax, France


This study highlights the structural reality of the anatomical continuity of the arm to the hand. It shows the role of the fascias that insure the cohesion of motor elements and how the muscle chains link up at the hand. The author proposes to identify the key patterns of motor organization that underpin our motor reprogramming techniques, and the proprioceptive interest in soliciting the anatomical chains herewith described.


We performed a series of 48 dissections of the forearm and hand on fresh cadaver parts at the anatomy lab at the University of Bordeaux II. We highlighted the systematized anatomical structural continuities, based on a double longitudinal and transverse organization. The computer image processing enables a clear and structured presentation of these direct anatomical connections.


Longitudinally, continuities between extrinsic and intrinsic muscles are highlighted as:

- The PL muscle ends on the flexor retinaculum where the thenar and hypothenar muscle pillars are inserted.
- The ECRL muscle ending is close to the 1st DI muscle.
- The FCU muscle continues directly on from the ADM muscle.
- The FCU and ECU muscles show many connections along their route.
- The PT muscle exchanges a contingent of fibers with the FPL muscle.
- At the hand, we frequently find an expansion of the tendon of the APL muscle into the APB muscle.
- We note a direct motor connection of the lumbricals muscles that connect the flexor system to the extensor system.

Transversely, we find the circular fibers of the ante brachial fascia,
the retinacular system of the wrist and the palmar carpal ligament. At the hand, the transverse carpal and metacarpal arches maintain the continuity of the intrinsic muscles. The superficial palmar fascia is reinforced by the expansion of the PL and FCU muscles in continuity with the thenar and hypothenar fascia. On the dorsal side, the juncta tendinosum link up the extensor tendons.

Based on these elements, the author describes eight chains according to anatomical continuities:

1- The pronation chain consisting of PT-FPL-OP or PT-PQ-ADB continuities.
2- The short flexion chain formed by FCR - FCU transversely connected by the palmar carpal ligament.
3- The supination flexion chain consisting of the muscle sequence BB-FCU-ADM.
4- The long flexion chain consisting of the muscle sequence BB-FDP-Lb
5- The long extension chain consisting of the muscle sequence EDC-Lb.
6- The dorsolateral chain consisting of the muscle sequence ECRL DI-1. (first DI)
7- The supination-extension chain consisting of the muscle sequence S-APL.
8- The medial stabilization system set up by the muscular torque FCU-ECU.


This new anatomical approach to organizing in muscle chains enriches our understanding of motor mechanisms in order to offer our hand or wrist trauma patients, targeted exercises according to anatomical and functional continuity.

Jin Woo Park, Jihyeung Kim, Seung Hwan Rhee, Hyun Sik Gong, Goo Hyun Baek

Seoul National University Hospital, South Korea

Vascularized bone grafting has been regarded as standard surgical option for scaphoid nonunion with avascular necrosis, and the vascularized bone is commonly harvested from the dorsoradial aspect of the distal radius. However, we could not harvest adequate amount of bone from the distal radius, and the quality and strength of the bone are inferior to the iliac bone. The purpose of this study is to suggest surgical outcome of scaphoid nonunion with avascular necrosis using conventional nonvascularized iliac bone grafting.

Materials & Methods:
From 2002 to 2013, 32 consecutive patients with established scaphoid nonunion, proximal pole avascular necrosis, and no prior surgery were treated with open reduction, internal fixation with multiple K-wires or headless compression screw, and iliac bone grafting. Avascular necrosis of the proximal fragment was identified with computed tomography (CT) or magnetic resonance imaging (MRI) preoperatively, and also confirmed intraoperatively. The average time from wrist injury to the diagnosis was 41 weeks. Fracture nonunions were at the waist (n = 20), proximal third (n =11), and distal third (n = 1). Fisk-Fernandez technique were used in 15 patients who had humpback deformity of the scaphoid or severe DISI deformity, and Matti-Russe technique were used in 17 patients who did not have severe deformity of the scaphoid.

Of the 32 patients, bony union was achieved in 29 patients (91%). The average time to union was 11 (range, 9-13) weeks. The average radio-lunate angle was significantly changed from -6.7° to 1.2°, and the average scapho-lunate angle was also significantly changed from 61.7° to 54.3°. Although ranges of wrist motion and grip strengths were improved, there were no significant changes. The modified Mayo wrist score significantly improved from 48 to 82 points.

Nonvascularized conventional iliac bone graft can be applied for the surgical management of scaphoid nonunion with avascular necrosis. Although we did not evaluate revascularization of the proximal fragment after surgery, we can achieve bony union in most of our cases

Emma McPhillips, Daniel Harte

Southern Health and Social Care Trust, Craigavon, UK

The main purpose of the sense of touch is to protect and provide feedback to motor programmes and its tactile input is a code to describe the environment. Sensory re-education is based on vision-guiding touch with the use of attention and memory, focusing on several daily short practice sessions over weeks and months. The purpose of this project was to determine the most up-to-date evidence-based techniques used with people who have sustained upper limb nerve damage and use this to devise illustrations to educate both staff and patients.

Materials and Methods
A search for systematic reviews on sensory re-education for the upper limb was completed. Two reviews were found: one from 2007 and the other from 2012. A further study from 2014 was found relating to sensory re-education. These articles were then analysed to extrapolate the evidence on the recommended techniques and then produce appropriate illustrations on this treatment approach.

A photography session was arranged to gather a suite of photographs to illustrate evidenced-based sensory re-education techniques. A poster was designed and to be used as a study aid for students and therapists. Illustrations could also be used to help educate patients on these techniques in a visual method.

Learning through visual aids is a fun and interactive approach that can be included in therapy programmes and staff and student education. Using the current evidence-base as a foundation to devise ensures that such illustrations are relevant in this clinical area.

Aydin Yuceturk

Acıbadem University, Orthopaedics and Traumatology Department, Acıbadem Fulya Hospital , Hand Surgery, İstanbul , Turkey  

End to end nerve repair is the best choice of the treatment of nerve injuries. After trimming the nerve ends or neuroma excisions some amount of gap occur. Maintence of coaptain can be possible by joint positioning, nerve rerouting and transposition or bone shortening. Primary or secondary late nerve end to end repairs are gererally done under  tension.  We do not still know safe gap-tension for primary nerve suture but we know that end nerve repair always gives better result then other techniques. End to end nerve repair site has always the risk of rupture and nerve healing failure. Ultrasonography or MRI can be done to detect the nerve repair site but it is expensive and always not helpfull especially when peripheral nerve is deep or at brachial plexus site. To observe the  nerve healing site and  nerve anastomosis after the surgery, I define a new simple easy and cheap technique which is called “Nerve Repair Site Marking” (NRSM).
Methods: During the primary or secondary nerve repair to see the continuity of the repair site,  a new simple technique was used which is called NRSM. After coaptation of the nerve at any site of the body under tension, 1cm proximal and 1 cm distal of the suture site, the epineurium was marked with titanium hemoclip. In the first 6 weeks  periodically x-ray of the repair site was taken and the distance between the hemoclips were measured. Since 2006 during the end to end repair of the brachial plexus and peripheral nerve surgeries if there was the risk of rupture of the repair site. Between 2006 – 2015 23 patients 25 nerves which were end to end repaired under tension. All the nerves were repaired in between 1 week to 1 year secondarily. 16 were male and 7 were female. Age of the patients were between 3 months- 54 yeras (average 20.1 years). 9 brachial plexus, 3 siatic, 1 tibialis posterior behind knee, 2 peroneal (near knee joint), 1 musculocutaneus, 3 radial , 1 femoral, 2 median, 2 ulnar and 1 digital nerves were secondarly repaired.

Results: Only one patient had rupture of the repair site just after the surgery and repaired immediately again end to end. All other nerves nerve intact during follow up. There was no infection and foreign body reaction.

Conclusion: To get the better result after end to end nerve repair the nerve continuity must continue, but there is always the risk of rupture at the repair site. Since ultrasonography and MRI is helpful to examine the repair site this NRSM is a objective, simple and cheapest follow up technique. Early diagnosis of the rupture of the repair site still gives the surgeon and patient another option of treatment.

Shinya Maki

Watanabe Orthopaedic Hospital, Fukuoka, Japan

Purpose : To present the new MISF ( minimally invasive screw fixation ) technique for closed phalangeal oblique fractures, its indication and the postoperative results.
Materials and Methods : The study included eight patients( two women, six men ; age ranged 14 to 77 years, mean age is 36.5years ) with closed oblique (not comminuted )fracture of the phalanges. There were six proximal and two middle phalangeal fractures. Three cases were intra- and five were extra – articular fractures. One patient was operated at 17 days, but the rest were operated within seven days from the injury. 1.3 or 1.5 mm mini cortical screws were used in seven and micro Acutrak 2 screw in one patient. Follow up period is 3 to 35 months (av. 20.6 months )
MISF method ; The fracture displacement was corrected by manipulation and intrafocal technique using 1.0mm K-wire without skin incision, and some percutaneous 1.0 mm K-wires were used for temporary fixation. The ideal positioned K-wire was chosen and small incision was made at the insertion site. After measurement of the ideal size of the screw, K-wire was removed and replaced by the screw.
For the functional evaluations, we used union of the fracture, total active motion (TAM) and grip strength (measured by percentage to contralateral side ) in all the patients. Quick DASH (Disabilities of the Arm, Shoulder and Hand ) score was measured in five patients.
Results : Union was obtained in all the patients. TAM was 165° to 260°. Grip strength was 76 to 112 %. DASH score was 0 to 4.5. Excellent results were obtained in six cases which were operated within one week after operation. Re-operation was needed for loosening of the screw in one case. Each one good and fair result was obtained in re-operated and delayed operated case respectively.
Conclusions : This technique is low invasive and suitable for proximal phalanx simple oblique fresh fracture to prevent extensor system adhesion. The important points are precise location of the screw and to do the operation within one week after injury.

Pierre Desmoineaux 1, Tiphanie Delcourt1, Quentin Tribot Laspierre1, Pierre Luc Charlebois 1,2 , Nicolas Pujol 1

Centre hospitalier de Versailles , Le Chesnay , France 1 Hôpital du Haut Richelieu ,Saint Jean sur Richelieu, Canada 2

Basal thumb arthritis, unresponsive to conservative treatment, often leads to a surgical treatment. Different techniques have been described for this purpose: most of them include trapeziectomy, partial or complete, open or arthroscopic. It is often associated with ligament reconstruction or tissue interposition. Very little data has been published concerning the limits of such techniques, according to the pre-operative status of the patient. The aim of this study was to evaluate the prognostic factors associated with poor results in patients undergoing arthroscopic partial trapezial excision and ligament reconstruction, using a partial abductor pollicis longus (APL) graft.

We reviewed a consecutive case series of 76 procedures at a minimum follow up of twelve months, all performed by the same surgeon. Clinical and radiological preoperative factors were assessed. A good outcome was defined by the association of: absence of pain; increase in strength (key pinch and grasp); perceived satisfaction of the patient; and the result of the Nelson score. A bad outcome was defined by the absence of one of those variable.

21 patients had at least one criterion for a poor outcome. The only prognostic factor identified was male gender, with 7 male patients (87.5%) having a poor outcome. None of the other studied factors were significantly associated with failure: pre-operative functional demand; dominant or non-dominant side; presence or absence of metacarpophalangeal hyperextension; or association with carpal tunnel syndrome. Also, radiological staging (according to Eaton and Glickel classification), metacarpal subluxation, or peri-trapezial arthritis were not associated with the outcome of the procedure.

In conclusion, arthroscopic partial trapezial excision and ligament reconstruction with an APL graft was associated with poorer outcomes in men. Women seemed to benefit from surgery regardless of the severity of arthritis.

Pierre Desmoineaux 1, Matthieu Ferrand 1 , Jean David Werthel 1, Pierre Luc Charlebois 1 2 Nicolas Pujol1

Centre hospitalier de Versailles, Le chesnay ,France 1 Hôpital du haut Richelieu , Saint sur Richelieu , Canada 2

Cubital tunnel syndrome (CTS) is the second most frequent nerve compression syndrome. Although the most common diagnosis for CTS is idiopathic, it can be secondary to a great number of conditions. Many different therapeutic options exist however; none has been proven superior to the others. In situ neurolysis is thought to make the ulnar nerve unstable which could therefore make it more susceptible to dynamic constraints. In addition, results of this technique seem to be worse in case of severe compression.
We report the results of a retrospective monocentric study of endoscopic neurolysis. The purpose of this study is to evaluate the risk of complications and/or recurrence depending on the stability of the nerve intra- and post-operatively.

Materials and Methods:
All patients who had idiopathic CTS with a stable ulnar nerve were included and operated endoscopically. The nerve was released on 15 cm. Subjective and objective (McGowan grading system as modified by Goldberg) results were assessed. Complication rates and rates of recurrence were evaluated at the last follow-up.

A hundred and forty-three patients were included and 103 were assessed at a mean follow-up of 91 months (64-120). Thirty-six patients were lost to follow-up and 4 died before being reviewed. Ninety-three percent of the patients were better or completely asymptomatic. Seven percent of the patients were unchanged. They were all grade 1 in the McGowan classification. This technique did not provoke any aggravation of the symptoms. Only one patient had a painful scar. No other complications were found at the last follow-up and no recurrence was observed. Four nerves were unstable intraoperatively and 5 were unstable postoperatively but this did not have any consequence on the results.

Endoscopic treatment of CTS is efficient and good results can be expected when no motor lesions are present. In more advanced forms improvement can still be expected. Secondary instability of the nerve is rare and does not lead to a recurrence of the symptoms.

Jing Rui1,2, Yali Xu1, Xin Zhao1, Jifeng Li2,3, Yudong Gu1,2, Jie Lao1,3

1 Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai 200040, P. R. China 2 Key Laboratory of Hand Reconstruction, Ministry of Health, Shanghai 200040, P. R. China 3 Shanghai Key Laboratory of Peripheral Nerve and Microsurgery, Shanghai 200040, P. R. China

Objective: To compare the action potential of diaphragm, external intercostal muscles and latissimus dorsi in rat and to investigate the discharge patterns of phrenic nerve, intercostal nerve and the thoracic dorsal nerve.
Methods: Nine SD rats were randomly divided into three groups, diaphragm group, external intercostal muscles group and the latissimus dorsi group, three in each group. Action potential of diaphragm, external intercostal muscles and latissimus dorsi muscle were observed meanwhile the discharge pattern, amplitude, frequency and other parameters were record.
Results: 1.The diaphragm had a rhythmic clusters of discharge with the maximum amplitude around 0.3 ~ 0.4 mV and the interval between two discharges is about 1.0 ~ 1.2 s, which was consistent with breathing frequency under anesthesia. The duration of discharge is about 0.2 ~ 0.3 s, coincident to the duration of inspirer. 2. The external intercostal muscles also had rhythmic clusters of discharge and the patterns were similar which was observed from mid-axillary line and mid-clavicular line. The amplitude from first to the third external intercostal muscles was larger which the maximum amplitude was around 0.3 ~ 0.4 mV, but from the fourth external intercostal muscles, the amplitude decreased gradually, to the 6th external intercostal muscles, with the maximum amplitude around 0.1 mV. The 7th, 8th and 9th external intercostal muscles showed no obvious rhythmic clusters of discharge phenomenon, but the ninth external intercostal muscle showed similar rhythmic clusters of discharge phenomenon from mid-axillary line as affected by the rhythmic discharge of the neighboring diaphragm. External intercostal muscles had a similar discharge pattern as diaphragm, with the interval between two discharge was about 1.0 ~ 1.0 s which was consistent with breathing frequency under anesthesia. The duration of discharge is about 0.2 ~ 0.3 s, coincident to the duration of inspirer. 3. No independent rhythmic discharge was observed in latissimus dorsi under anesthesia. Conclusion: The phrenic nerve had rhythm clusters of discharge consistent with breathing frequency as well as intercostal nerves. From the first to the third intercostal nerves, the spontaneous discharge amplitude was larger, but from the fourth intercostal nerve the amplitude started to decrease, and till the seventh, eight, nine intercostal nerves, no obvious rhythmic clusters of discharge were observed, while the thoracic dorsal nerve didn’t show rhythmic discharge phenomenon.

C Pilbeam, A Duguid, M Arundell, LC Bainbridge

The Pulvertaft Hand Centre, Royal Derby Hospital, UK

The role of splinting after Needle aponeurotomy (NA), or percutaneous needle fasciotomy for Dupuytren’s Contracture is controversial. A UK Randomised Control Trial reported no significant benefit to splinting post fasciectomy but no evidence is available to guide practice post NA. We aimed to survey current splinting practice post NA among Hand Therapists and Hand Surgeons in Europe and North America.

Materials and Method
Web-based surveys were conducted for Therapists and Surgeons over a 6 week period. The Therapist survey included BAHT and EFSHT members. The Surgeon survey included BSSH members, members of the Dupuytren Foundation and Dupuytren online. Respondents were asked about their experience and case load, the indications for splinting, splint types and usage regimes.

203 Therapists responded with 133 treating NA patients, 35% were Physiotherapists, 63% Occupational Therapists and the remainder didn’t disclose. 99% of responses were from Europe with the remainder from North America. 102 had >5 years Hand Therapy experience and 96 >5yrs experience splinting Dupuytren’s.

171 Surgeons performed NA, 98% practicing in Europe or North America. 56% had > 5 years of experience performing NA, and 47% performed >1 per week.

96% of Therapists receive their referrals from surgeons for splinting post NA (the remainder from therapy practitioners), with referral to treatment reported as 43% 0-1day and 43% 2-5days. There is no consensus among Therapists on splint rationale (often historical, guideline or surgeon preference), indications or number of appointments.

70% of Surgeons refer for splinting post-procedure. There was little agreement as to splinting indications (i.e. joint(s) involved, extent of correction or cord division achieved) with different surgeons splinting in a different situations. Between 62% and 72% of Surgeons claimed to always splint for a specific combination of indications suggesting that the majority of patients were splinted across the survey.

Surgeons had no agreement regarding factors that make splinting need more likely, unlike the Therapists who believed that splinting was more likely for recurrent disease (73%) or rapid progression of deformity (53%).

Surgeons liked volar hand-based splints (65%) followed by volar based digit splints (32%) although splint type often followed therapist preference (38%). Therapists also preferred volar thermoplastic hand- based splints (72%). Splinting regimes were in agreement with Therapists and Surgeons recommending 1-3 months splint wear (46% Therapists, 54% Surgeons), at night only (52% Therapists, 61% Surgeons) or with additional intermittent day splinting (28% Therapists).

Of the Therapists that splint post NA they were discouraged from splinting by lack of research (34%), patient preference (24%) and personal experience of whether splinting makes a difference (21%). Of the 30% of Surgeons who didn’t refer for splinting, lack of evidence was cited by 65% and poor patient compliance by 26%.

Our surveys demonstrate marked variations in current practice. There is some consensus regarding splint type, duration and wear regime between Therapists and Surgeons. The decision to use splinting post NA at all remains controversial as the benefit is unknown. There appears to be significant equipoise and a multi-centre clinical trial is planned.

Hideki Tsuji, Hirotada Matsui, Natsumi Saka

Sapporo Tokushukai Hospital, Sapporo, Japan

[Introduction] Post-traumatic vessel disease (PTVD; Khouri1992) is known as a vascular disease associated with severe extremity trauma complicated with soft tissue damage. Blood vessels reached by edema and scar around "zone of injury" readily develop drug-refractory spasm, which generally occurs in patients with lower extremity trauma, and are not suitable for use as recipient vessels in free flap surgery. In this study, we retrospectively investigated recipient blood vessels selected and PTVD onset in acute-phase free flap surgery for severe upper extremity trauma. [Patients and Methods] 35 patients (27 men and 8 women; mean age, 45.0 years (18 -73)) were underwent acute-phase free flap surgery (+ composite tissue graft) for severe upper extremity trauma in our department between 2007.4 and 2014.8. The site of vascular anastomosis was in upper arm-elbow in two cases, forearm-wrist in 24 cases, in a hand in nine cases. Free flap surgery was performed 7.4 days (2 to 18 days) after injury on average. We investigated: 1.The state (disrupted/continuous) of the recipient vessel selected on the findings at the time of injury and CT angiography; 2. Relationship between PTVD onset and the number of days from injury to the operation; 3. Flap survival rate. [Results] 1. Disrupted, 17 cases; continuous, 18 cases. 2. PTVD occurred in 4/35 cases (11%), including 3/17 cases in the disrupted group (thumb reconstruction in all cases) and 1/18 cases in the continuous group. The mean number of days from injury to the operation was 11.0 days in the onset group, while it was 6.9 days in the non-onset group. 3. The survival rate was 34/35 = 97%. [Discussion] PTVD usually occurs in patients with lower extremity trauma, and has been considered a cause for a relatively high failure rate of flap surgery in free flap surgery. However, it was found in this study to occur in the upper extremity in thumb reconstruction cases. When a proximal portion of the blood vessel disrupted by injury is selected for anastomosis, the anastomosis is positioned sufficiently away from the affected area, but the PTVD onset seemed to be related to the number of days from injury to free flap surgery in addition to the location and extent of injury.

Fernando del Canto Álvarez, Manuel Sánchez Crespo, Higinio Ayala Gutiérrez, Mª Ángeles de la Red Gallego, Ciro Santos Ledo.

Hospital Universitario “Marqués de Valdecilla”. Santander -Spain-.

Aims. Because of the appearance in our consultation of five cases of malunión of fractures of forearm happened in paediatric age with important loss of the prono-supinación, we considered the possibility of practise corrective osteotomies. Previously we checked the related bibliography, specially concerning to the preoperative planning. Our aim was to value the functional results after carrying out several corrective osteotomies of this type.

Material and methods. We show five cases of malunión of ulna and/or radius after fractures happened in childhood, in which the degree of posttraumatic deformity did not correct with the bone remodelling, which caused major or minor aesthetic deformity close to a functional significant disturbance in the prono-supinación and / or incongruity radio-ulnar.

Results. We operated on five cases, one by means of isolated osteotomy on the radius, other four by means of combined osteotomies of both bones. In the five cases the consolidation of the corrective osteotomies was obtained in a better anatomical situation and they improved the ranges of mobility with regard to the preoperatives.

Discussion. It is known that ulna and radius form a real functional unit. When the forearm fractures happen in patients of infantile age, it is necessary to be demanding with the reduction and not to entrust everything to the bone remodelling since, according to the age of the child and the degree of deformity, marked angulations as well as malrotation cannot be sufficiently corrected, which may result in functional imapirment in prono-supinación, radio-ulnar incongruity and/or an aesthetic deformity. These three consequences are the main indications to carry out corrective osteotomies of the forearm. When the indication is the loss of mobility, most of patients wins prono-supinación. If it is corrected in the first year after the fracture, the profit is usually major that if it is done later. The profit also is usually major when the osteotomy is done below 10 years of age. If the reasons for the osteotomy are the radio-ulnar instability or the deformity, it may result in some loss of mobility.

Fernando del Canto Álvarez, Manuel Sánchez Crespo, Higinio Ayala Gutiérrez, Juan Ramón Sanz Giménez-Rico, Mónica Fernández Álvarez.

Hospital Universitario “Marqués de Valdecilla”. Santander - Spain

Introduction. Since we begin with the employment of collagenase from Cl. Histolyticum in the treatment of Dupuytren’s disease, we wonder on how would be the initial results after his employment, as well as the long-term permanence.

Material and Methods. We have practiced 92 infiltrations in 78 patients; 11 patients underwent double or even triple injection (5 because affectation was present in different fingers, 6 because of the MCP and PIP involvement).

We considered some personal data (age, side, dominance, work and level of manula activity), the presence of risk factors (alcohol, familiar precedents, diathesis, etc.), time of evolution of the disease, any previous surgery on it and the clinical evaluation of the disease (number of affected fingers and degree of retraction in every involved joint).

After the infiltration of the collagenase, we evaluated the success in finger extension (total, partial or null) and the presence of any complication.

Finally we have revisited the patients at 1, 6, 12 months and anually (maximum follow-up is 4 years) and we have measured the arch of movement in every joint and we have considered the presence of any recurrence.

Results. We have obtained good results after the administration of collagenase from Cl. Hystoliticum, with a rapid recovery and with low rates of complications and recurrence.

The results were better for the MCP (correction happens of 85 % of the retraction) than for the PIP involvement (55% of the retraction).

There was only two recurrences, one at 12 months affecting only IFP and another a complete recurrence in the early period of 3 months.

Conclusion. We believe that collagenase from Cl. Hystoliticum is a good option in the treatment of Dupuytren’s disease, specially when it mainly affects to the MCP joints and the PIP joint suffers from slight retraction.

Fernando del Canto Álvarez, Manuel Sánchez Crespo, Higinio Ayala Gutiérrez, M. Angeles de la Red Gallego, Laura Alonso Viana.

Hospital Universitario “Marqués de Valdecilla”. Santander -Spain-.

Introduction. Concerned about the early improvement in pain relief, range of motion, global function and strength recovery of our patients that underwent thumb carpo-metacarpal total replacement, we have compared the outcomes at 1, 3 and 5 years in order to understand when the results become stable.

Material and Methods. We compare the evolution of the results of 40 total trapecium-metacarpal prosthesis (34 ARPE®, 6 MAIA®) at 1, 3 and 5 years. We evaluate the pain level based on the VAS, the range of motion, the pinch and fist strength measured with the Jamar® dynamometer, and the global function related to the ability of develope five daily life activities. We also consider the radiological aspect to elude implant loosening or failure. For the measurement of the patient satisfaction we used a visual analogical scale. We compared statistically the results at 1, 3 and 5 years of follow-up.

Results. We have globally obtained good results in pain relief, range of motion, strength recovery, global function, and patient satisfaction. The improvement in every item is statistically signifiicant at 1 year, moreover pain relief, strength and patient satisfaction still improve significantly until the 3rd year. Furthermore, at 5 year of follow up, the outcomes are in the same satisfactory level.
The most frequent complications have been 3 dislocations; one of them happened 3 weeks after surgery and was managed with close reduction with good follow-up; the other two presented 6 months after surgery, one was caused by a bad cup orientation but both needed the revision of the trapecial implant.

Conclusion. We believe that the total trapecium-metacarpal joint replacement is a good option in the treatment of thumb basal osteoartritis because its fast functional results and level of patient satisfaction and their durability.

Marco A. Ardila R.

Hospital Orthohand, Bogotà, Colombia

Microvascular anastomosis end to end technique presented in this study, is the technique of graft cuff that combines the advantages of the technique with interrupted simple stitches but it decreases the required amount of them, to complement the graft cuff, both as described by others, thus reducing the time of an anastomosis without altering the results, or patency rates without significantly increasing the complexity of the technique.

Introduce a practice microsurgical intermediate difficulty, as a tool for training.
Recognize and implement a technique described that demands less surgical time and can be used in surgeries requiring multiple anastomosis.
Performing the technique in experimental animal model.

Materials and methods
A total of 10 Sprague-Dawley rats were used in the study with a body weight range of 200 to 300 gr. As implementation intraperitoneal anesthesia, the sutures were performed with 10-0, with standard surgical microscope.

Application peritoneal anesthesia and verification, the animal is placed on the work surface and secured there, the neck is shaved and skin incision is made in inverted T, the deep dissecting cervical plane and separating the sternomastoid muscles and completely exposing the carotid artery along its length, the clamping of the same is performed, the arteriotomy segment which must be of a minimum length equivalent to the diameter of artery is done, the graft super imposed on one of the stands to suture, and 4 stitches with intermittent simple technique applied to 90 ° away from each other, the graft slides until completely covering the area of suture, the distal and proximal clamp is removed in one motion, unlike the standard technique where the first clamp end is removed with retrograde flow, permeability is checked with anterograde and retrograde test, washing is performed with ssn 0.9% of the initial exhaust of the anastomosis.
Permeability reassessment is performed at 5 minutes and 15 minutes.
Skin closure and isolation protocol postoperative observation of the animal and it is carried out.
Verification 8 days after, a deep cervical approach is performed again to verify patency of the carotid artery, cuff graft integration.

All rats survived the surgical procedure, permeability: good permeability was found in 10 anastomosis, at 5 and 15 min after completion.
In a week review later, adequate permeability of the anastomosis was found in 9 of the 10 anastomosis.
Healing and proper integration of the graft within 8 days of the procedure were found.

The application graft cuff presents no technical difficulty.
It can be used whenever the length of the vessels to suture it possible to take of the graft.
As experimental practice is very useful to be able to verify the simplicity of the technique and can be used as a tool in microsurgery.
By requiring only 4 stitches the surgery time is reduced substantially.
There must be a new work by measuring comparatively time anastomosis with graft from the standard bracelet gold simple interrupted stitches.

Marco A. Ardila R.

Hospital Orthohand, Bogotà, Colombia

Describe a case of a low incidence disease in the general population. Review to literature regarding the case.

Schwannomatosis is genetic Disorder, recently recognized as third type of neurofibromatosis (NF) causing multiple schwannomas, without associated vestibular tumors, which are typical of the NF type 2.
Symptoms include pain and dysesthesia in the area of the nerve involved with the masses. Clinical treatment is aimed at controlling pain without a preferent favorite drug, surgery is very successful in solving the pain. However, the risk of complications such as nerve damage and high probability of recurrence means that surgery should be limited to the prevention of progressive neurological deficit.
Schwannomatosis (neurofibromatosis type 3)
Inheritance: autosomal dominant
Penetrance Complete
Frequency: Unknown
Features: schwannomas
Gen, Protein, Function: Unknown

Criteria for diagnosis of neurofibromatosis type 3
 Patient is 30 years or more, with 2 or more non-cutaneous schwannomas, at least one histologically confirmed without evidence of vestibular tumor on MRI, without mutation known neurofibromatosis.
 Schwannoma but non vestibular, and one a first degree relative with schwannomatosis possible.
 Patient is under 30, with 2 or more non-cutaneous schwannomas, at least one histologically confirmed without evidence of vestibular tumor on MRI without Neurofibromatosis known mutation.
 Senior patient 45, with 2 or more non-cutaneous schwannomas, at least one histologically confirmed without symptoms of dysfunction of cranial nerve VIII without NF2.
 Schwannoma but non vestibular and first degree relative with schwannomatosis.
 Segmental schwannomatosis: Patient with definite or possible diagnosis, but limited to one limb or <= 5 contiguous segments of the spine.

Case report
A 28 year male, with a history of 5 years of evolution, consisting of appearance of painless, slow growing mass in the left forearm associated with mild paresthesia hand. Without pathologic, surgical and family background.
Physical exam: Patient without skin lesions or masses, no lesions in the iris without hearing loss without visual disturbances without café-au-lait spots in the body.
Patient has painless and mobile hard masses on palpation in the left forearm, located in the proximal third (one) and from the middle third to the left wrist (three) without loss of strength or hand function. A electromyography was performed on the left forearm with normal results and further, magnetic resonance imaging forearm showing the four masses in ulnar nerve, one proximal and three distal in the forearm. A resection of the masses was practiced in twice surgical moments; in the first one the distal three masses was removed, and in the second time the proximal masses were remove. They were sent to pathology and are reported as: cellular schwannomas without necrosis or mitosis. Patient has satisfactory postoperative without nerve damage, which returns to normal daily activities.

It is a rare genetic disease, so it has been characterized and individualized from other Neurofibromatosis. It is not a malignancy disease, but may recur. The symptoms are associated with the location of lesions.

Karina Gonzalez Carta, Keith Bengtson, Michelle Kircher, Alexander Shin

Mayo Clinic, United States of America

Objective/hypothesis. There is no universally-accepted outcome measure for traumatic brachial plexus injuries. However, the Disabilities of Arm, Shoulder, and Hand (DASH) questionnaire is commonly used for this purpose. Unfortunately, the DASH may be highly influenced by many patient factors other than the impairments of the injured upper extremity.
Materials and Methods. We studied 138 patients who had flail arms from a brachial plexus injury. Each had the same neurological impairment -- 0/5 strength in all muscles of the affected arm. DASH scores at initial evaluation were correlated with age, BMI, gender, hand dominance, age at time of injury, VAS pain scores, and concomitant injuries.
Results. The mean age at the time of injury was thirty one years (range, twenty one to forty eight years). Hundred and twenty nine right arms and eighteen left arms were involved. Sixty four patients (46 %) had involvement of the dominant arm. Hundred and fifteen (83.33%) patients had associated injuries included ninety four (68.12%) closed head injuries. The total DASH scores averaged 48 ± 17 points (range 0 to 93 points). The total VAS score was 5 ± 2.87 points. A statistically significant positive weak correlation was found between the DASH and VAS score (p < 0.001, = rs 0,27) and there was no correlation between the DASH score and any other parameter.
Conclusions. Surprisingly, there is only a small correlation between DASH scores and VAS pain scores even in a large population with identical neurological deficits.

Tetsuya Nemoto1( 2), Hajime Ishikawa1, Asami Abe1, Hiroshi Otani1, Katsunori Inagaki2

1Niigata Rheumatic Center, Shibata, Japan 2Showa University, Tokyo, Japan

[Hypothesis] The boutonniere deformity of the thumb is the most common deformity of rheumatoid thumb and it accounts for 50 to 74% of the involved thumbs. Metacarpophalangeal(MP) joint arthroplasty is indicated for the deteriorated MP joint with preserved soft tissue stability. Feldon introduced to use flexible hinge toe implant for the MP joint reconstruction because of its better mechanical strength compared to finger joint implant. We hypothesized rheumatoid thumb reconstruction using flexible hinge toe implant would improve the clinical outcomes and radiological findings.

[Patients and Methods] Swanson implant arthroplasty for at the thumb MP joint was performed on the 68 cases (male 11, female 57) between November 2006 and December 2014. The average age was 64 yrs. old and the average follow-up period was 3 yrs. The duration of the rheumatoid arthritis at the time of surgery was 22 years. Combined with this MP joint arthroplasty, suspensionplasty at the CM joint (Thompson) was performed in 38 cases, arthrodesis at the IP joint in 20 cases, capsulodesis at the IP joint in 3 cases. Radiological assessments were performed in 68 cases, clinical evaluation was performed in 47 cases. We assessed range of motion, grip power, side pinch power, general health using visual analog scale (VAS) and DAS28-CRP. Wilcoxon rank sum test was used as a statistical analysis.

[Results] A painless stability was provided to the thumb in most of the patients. In the radiological assessment, the pre- and the postoperative flexion angles at the MP joint were 45 and 17 degrees, and extension angles at the IP joint were 41 and 0 degree(s). In the clinical assessment, the average arc of motion was 21 degrees, with 44 degree in flexion and -23 degrees in extension. The average grip strength changed from 110 to 121 mmHg (p=0.130) and the average side pinch power changed 1.7 to 2.0kgwf (p=0.094), they were not a significant change, the patients were satisfied with their appearance of the thumb. General health using VAS improved from 40 to 28 (p=0.006) and DAS28-CRP was decreased 3.3 to 2.3(p>0.001). In one case, postoperative infection occurred and implant was removal of required. No implant fracture of the implant occurred. Joint stability and prehension pattern improved by arthrodesis or capsulodesis.

[Conclusion] By the rheumatoid thumb surgery, deformity was corrected and hand function improved. The ratio of implant failure was lower than that in the previous reports.

Sang Ho Kwak, Young Ho Lee, Goo Hyun Baek

Seoul National University Hospital, Seoul, Korea

To compare clinical and radiographic outcomes of between two and three Kirschner wire(K-wire) intramedullary fixation for fractures in the neck of the metacarpal bone.
Material and Methods
A single institutional retrospective review identified 28 cases of metacarpal fractures between March 2010 and August 2014. Each of the cases met the inclusion criteria for closed, extra-articular fractures of the neck of the metacarpal bone. The patient groups were divided by the number of K-wire. Outcomes were compared for range of motion of the metacarpophalangeal joint, radiographic parameters, and period until union.
The fractures were treated with either 2 Kirschner wire fixation(n=10) or 3 Kirschner wire fixation(n=18). The active range of motion of metacarpophalangeal joint and radiographic result showed no statistically significant difference between the two groups. The mean union period was 5.9 weeks. However, four cases suffered distal head perforation in 2 K-wire fixation group and one case in 3 K-wire fixation group.
Multiple retrograde intramedullary Kirschner wire fixation is a good treatment of choice for fractures in the neck of the metacarpal bone. To prevent metacarpal head perforation, it is preferred to use three K-wires than two K-wires.

Ho Youn Park 1, Jin Sam Kim 2, Jun Bum Lee2, Jun O Yoon2, Wan Lim Kim2, Tae Hyoung Kim2, Sun Hwa Kim2.

1 Department of Orthopedic Surgery, Uijeongbu St. Mary’s Hospital, Catholic University, Gyeonggi-do, South Korea; 2 Department of Orthopedic Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea

Introduction: Carpal tunnel syndrome (CTS) is the most common type of entrapment neuropathy. According to the Health Insurance Review and Assessment Service Data in South Korea, the number of patients diagnosed with CTS is increasing and the total medical expenses for CTS are growing. As South Korea is a small country with a homogenous population, it is interesting locale to survey the factor patients consider when choosing a hospital for a minor operation, such as carpal tunnel release (CTR). Additionally, as the healthcare market of CTS is undergoing significant expansion, studies of the preferences of the patients are necessary. Conjoint analysis is a method for eliciting patient preferences, which has been recently applied in the medical field. This study aimed to investigate the preferences of patients scheduled for CTR using conjoint analysis and also introduce as an example of how to apply a conjoint analysis to the medical field. The use of conjoint analysis in this study is new to the field of orthopedic surgery.
Materials and Methods: A total of 97 patients scheduled for CTR completed the survey. The following four attributes were predefined: board certification state, distance from the patient's residency, medical costs and waiting time for surgery and two plausible levels for each attribute were assigned. Based on these attributes and levels, 16 scenarios were generated (2 x 2 x 2 x 2). We employed 8 scenarios using a fractional factorial design (orthogonal plan, SPSS version 22; Chicago, Il). Preferences for scenarios are then evaluated by ranking, in which patients list the 8 scenarios in their order of preference. Outcomes consist of two results: the average importance of each attribute and the utility score. We also calculated the average importance and utility according to the pain score (VAS) of the patients.
Results: The most important attribute was the physician's board certificate, followed by distance from the patient's residency to the hospital, waiting time and costs, respectively. The outcomes according to the VAS score also indicated that the board certificate state was the most important attribute. For patients with severe pain, waiting time was the second most important attribute. Utility estimate findings revealed that patients had a greater preference for a hand specialist than a general orthopedic surgeon. Patients with severe pain reported the lowest score on the "more than 4 weeks" criterion.
Conclusion: Patients considered the physician's expertise as the most important factor when choosing a hospital for CTR. Indeed, patients are increasingly seeking safety without complications as interest in medical malpractice has increased. The second most important attribute is the total distance from a patient's home to the hospital except in cases of severe pain in which it is the waiting time. This may indicate that patients are less willing to go to the hospital with long waiting time for surgery.

Elena Colmena Borlaff, Alexis Studer de Oya, Ignacio Roger de Oña, Andrea García Villanueva, Fernando García de Lucas

Fremap Hospital Majadahonda, Madrid, Spain


The fibula osteoseptocutaneous flap is an excellent option for the reconstruction bone and soft segmental defects. Since its first description in 1975 the free fibula flap has become the workhorse flap for head and neck reconstruction because of its suitability for mandible reconstruction. The purpose of our study is to evaluate the results of the free fibula flap for upper and lower limb reconstruction.

Material and methods

The case series was conducted at our Department of Hand and Upper limb surgery, from June 2013 to January 2016, and comprised 11 patients. Of the 11 fibula flaps, 5 were for tibia defects, 3 humeral defects, 1 radius defect, 1 double barrel for forearm reconstruction and 1 thumb reconstruction.

Every patient was treated at least two times (range 2 – 7) before the fibula transfer.

Patient demographics, size of the defect, skin paddle harvesting, complication rate, reoperation and satisfaction rate were evaluated. The outcomes measured were the flap success rate, the skin paddle survival and time to bone union.


The average duration of follow-up was 18 months (range, 8 to 30 months). The mean age of the patient cohort was 38 (25 to 52); 9 males and 2 females were included. Average segmental defect was 6,3 cm (2,5 to 15 cm). Nine patients had positive culture. Three patients with tibial nonunion, and one radius defect needed an arteriovenous loop previous to fibula transfer.

Results showed that flap survival was 90,9% (10/11 cases). One case of multioperated tibial defect presented venous congestion and could not be salvaged. Two flaps were re-explored for venous congestion with good outcomes. One case of humeral defect, presented a radial neuroapraxia, which resolved 6 months later.

Radiological evidence of bone consolidation was observed from 3 to 8 months (average 5,5 months) and no recurrence of nonunion was observed until the last follow up.

In lower limb defects, weight-bearing was allowed at an average of 4 months (range 3-8 months).


The free vascularized fibula graft is a viable method for the reconstruction of skeletal defects of more than 6 cm, especially in cases of recalcitrant nonunions or in patients with combined bone and soft-tissue defects. Theses difficult nonunion often involve extremities with several previous operations and fixations, bone atrophy and damage of the surrounding soft tissue, and frequently focal and active infection. In this case scenario vascularized bone transfer seems to be the best option.

This study proved that a microvascular free fibular flap heals rapidly, causes early functional recovery and it can be raised as an osteocutaneous flap, when soft tissue coverage is needed.

According to the complications rate, the free fibula transfer is a safe and reliable method.

In summary, we believe that the free fibula flap is an excellent option in difficult segmental bone defects with good outcomes and minimal morbidity.

Pierre Desmoineaux 1 Jean David Werthel 1 Pierre Luc Charlebois 1,2 Tiphanie Delcourt 1 Nicolas Pujol 1

1 Centre hospitalier de Versailles , Le Chesnay, France 2 Hôpital du haut Richelieu ,Saint sur Richelieu, Canada

Isolated scapho-trapezo-trapezoid (STT) arthritis is a different entity from trapezo-metacarpal arthritis which can lead to carpal instability by verticalisation of the scaphoid and Dorsal Intercalated Segment Instability (DISI). We had previously reported satisfactory results on function, pain and strength of an arthroscopic technique of resection of the distal pole of the scaphoid. However, longer follow-up of our patients has showed an evolution to carpal instability in some. The combination of an arthroscopic resection of the distal pole of the scaphoid with a ligamentoplasty has not been previously described to our knowledge. The purpose of this study was to describe this technique and to report short-term results in the treatment of STT arthritis.

Materials and Methods:
A cadaveric pilot study of feasibility was performed on 4 wrists (2 cadavers) followed by a clinical study on 9 wrists , 8 patients (mean age: 61.6 years). All patients had STT arthritis and had failed to respond to non operative treatment. All patients underwent the same surgical technique : arthroscopic resection of approximately 4 mm of the distal pole of the scaphoid through an optical RMC (radial midcarpal) portal and an STT instrumental portal ; ligament reconstruction and tendon interposition (LRTI) using a 4mm wide and 2cm long slip of flexor carpi radialis (FCR) inserted distally on the base of the 2nd metacarpal and passed from volar to dorsal through the STT joint space and fixed with a suture anchor on the dorsum of the scaphoid. No immobilization or physiotherapy were required postoperatively. Pre- and post-operative pain, range of motion, strength and radiographic carpal instability were evaluated.

Mean follow-up was 7 months. Pain was significantly improved in most cases. Grip strength was improved or stabilized however this did not reach significance and range of motion was unchanged. There were no intra- or postoperative complications and none of the patients was revised. At last follow-up no DISI was observed.

Discussion :
These satisfactory results encourage us to propose this outpatient minimally invasive surgery in first intention for patients with isolated STT arthritis rather than isolated resection of the distal pole of the scaphoid which could lead to carpal instability.

Trygve Strömberg, Anki Sundstedt

Department of Hand Surgery, Skåne University Hospital, Malmö, Sweden

The Social Thumb:
A Case of Aesthetics over Function after Traumatic Amputation


The complete or partial loss of a limb often results in significant disability. The psychological impact of the injury may result in poor self-esteem, a feeling of stigmatisation, and a reluctance to participate socially. Impaired dexterity and sensation, pain, and tenderness may limit autonomy and affect work. Choosing an optimised regimen requires paying keen attention to the patient’s psychological and physical needs. Here, we present a case of aesthetic preferences taking precedence over functional considerations.

Material and methods

A right-handed 17-year-old woman was injured in an automobile accident in July 2010. Her right thumb was amputated through the metacarpophalangeal joint. Multiple fractures of the hand and forearm were treated in part surgically, in part conservatively. Later, at the Department of Hand Surgery in Malmö, several treatment options for the thumb were considered:

1. To let things alone
2. An aesthetic partial hand prosthesis leaving the fingers free
3. A prosthesis attached to an osseointegrated titanium peg.
4. An aesthetic prosthesis preceded by a lengthening of the first metacarpal and a deepening of the first web space
5. A toe transfer

As the appearance of her thumb inhibited the patient socially, she desired a hand that looked normal. She did not feel any need for functional improvement. Also, she wanted to avoid additional disfiguration. After having received careful information, she opted for the fourth alternative.

A distraction osteotomy of the first metacarpal was done in December 2011 followed by a deepening of the first web space and a release the adductor pollicis and the first carpometacarpal joint in October 2012. The prosthesis was delivered in April 2013.

The outcome was evaluated with the Sollerman test, the SF-36, DASH, CISS, and SOC scores and in an interview. Grip strength, pinch, lateral pinch, sensibility and range of motion were registered.


Subjectively, our patient is satisfied. Her wish to regain a normal appearance was achieved and her social participation was improved. She regularly wears her prosthesis indoors and out, removing it only for sleep. It has become part of her body experience.

The main functional improvements pertain to light tasks such as writing, putting on makeup, brushing teeth, and using cutlery. The prosthesis also acts as a protecting buttress. It does not facilitate grasping large objects nor manoeuvres requiring strength.

The results of the tests and measurements comply with the patient’s narrative.


The loss of a thumb often leads to profound emotional, social, practical and professional consequences. The choice of treatment requires careful consideration of multiple factors such as individual preferences, compliance, aesthetic aspects and professional demands. Our patient was a high school student to whom aesthetics and social participation were of the utmost importance. She therefore found it easy to opt for a prosthesis and to decline a toe transfer. The chosen method is not universally applicable, but may - under the right circumstances - be a viable alternative.

Vitor Kinoshita Souza 1, Ameg Dalpiaz 1, Marisa de Cássia Registro Fonseca 2, Alexandre Marcio Marcolino 1, Rafael Inácio Barbosa 1,2

1 Laboratory of Assessment and Rehabilitation of Locomotor System, Campus Araranguá, Universidade Federal de Santa Catarina, Araranguá, SC, Brazil; 2 Clinical Research Laboratory of Hand and Upper Limb, Campus Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil.

Handgrip and lateral pinch, which need muscular synergism, for example, between finger flexors/wrist extensors and extrinsic/intrinsic muscles. Objective: To evaluate the effects of a wrist extensor muscles fatigue protocol at the handgrip and lateral pinch strength alterations, evaluated by dynamometry associated with surface electromyography (EMG). Methods: 40 subjects with mean age of 18 to 25 years, divided in to 2 groups (handgrip and lateral pinch), were included at the study. The fatigue protocol was based on the 1 Maximal Repetition (1- MR) test, followed by the wrist extension movement achievement, multiple times, with a load of 75% of 1-MR defined to each volunteer. The volunteers performed handgrip using a grip dynamometer (Jamar™) or lateral pinch using a pinch gauge™. Both groups performed the surface EMG (Miotec®) to analyze the behavior of median frequency (Fmed) during a fatigue protocol. It analyzed the muscles extensor carpi radialis, extensor carpi ulnaris, extensor digitorum, and flexor digitorum superficialis. The strength and EMG evaluations were realized before and after the fatigue protocol. Results: The fatigue protocol was effective on handgrip strength reduction (From 40.92 to 36.50) and lateral pinch strength reduction (From 10.11 to 8.47) (p<0.05, 95% IC). At the EMG analysis, using median frequency (Fmed), it was evidenced extensor carpi ulnaris muscle fatigue at the handgrip group. Conclusion: At the analyzed sample, the fatigue protocol was effective to reduce handgrip and lateral pinch strength, and the extensor carpi ulnaris muscle fatigue can be one of the factors to trigger this result.
Keywords: Handgrip, Lateral Pinch, Fatigue, Electromyography, Dynamometry.

Rodríguez Sammartino Mario Alberto, Mussini Daniel Oscar, Rodríguez Sammartino Juan Martín, Day María Candela

Clínica de Fracturas y Ortopedia Mar del Plata Argentina

Isolated ulnar translocation of the carpus is uncommon. In most of the patients described in published reports, the ulnar translocation occurs in association with fractures of the distal radius or ulna, fractures of one or more carpal bones or intercarpal ligament injury. The radiographic appearance is unusual and can be somewhat subtle. We present a case report in order to increase awareness of this injury and discuss management issues.
A 39 year old man injured his left wrist in a motor vehicle accident. The patient presented with pain, swelling and functional disability of his wrist. He had also clinical signs of radiocarpal instability. Radiographs demonstrated ulnar translocation of the carpus without associated fracture or intercarpal injury. The patient underwent surgery. The wrist was approached through a volar radial (Henry) exposure. There was an avulsion of the entire volar capsule and extrinsic ligaments from the volar articular margin of the radius. The carpus was realigned and stabilized to the distal radius using two kirschner wires. The capsule and ligaments origins were reattached to the volar margins of the distal radius using suture anchors. The wrist was inmobilized in a below elbow cast for 6 weeks, at this time the cast and the k wires were removed and the patient begun with rehabilitation under the supervision of an occupational therapist. The patient returned to work 4 months after the surgery. The range of motion at that time was: flexion 50°, extension 60°, radial deviation 15°, ulnar deviation 35°, forearm and digit motion were full. Radiographs showed good carpal alignment (no loss of reduction).
Traumatic ulnar translocation of the carpus is rare, with published accounts limited to case reports and small case series. The radiographic appearance is unusual and can be missed or misinterpreted. Ulnar carpal dislocation may be present when less than 50% of the lunate articulates with radius in the posteroanterior radiograph. The translation may also be evident as an increased in the distance between radial styloid and scaphoid, or positioning of the scaphoid in the lunate fossa. Also, the distance between a line, drawn through the central axis of the radius and the center of the capitate can be measured. The mechanism of injury appears to be hyperextension combined with pronation of the wrist, in wich the radiocarpal ligaments are ruptured. The stout radioscaphocapitate ligament normally prevents the carpus from sliding ulnarly and the radiolunate ligament is considered the most important structure in prevention of volar translation. These two ligaments must be disrupted to produce the ulnar translocation. Closed reduction and transarticular pinning is not sufficient to maintain anatomic alignment of the carpus. In our opinion, open reduction, repair of the radiocarpal ligaments and temporary transarticular kirschner wire stabilization is needed to ensure anatomic restoration of the carpus . Despite aggressive open treatment, maintaining normal radiocarpal relationships can be difficult. When these methods fail, a salvage procedure such as radioscaphoid, radiolunate, or total wrist arthrodesis becomes necessary.

Ryotaro Fujitani 1, Shohei Omokawa 2, Yoshihiro Dohi 1, Akio Iida 3, Yasuhito Tanaka 4

1 Ishinkai Yao General Hospital, Japan; 2 Nara medical university, Japan; 3 Hanna central Hospital, Japan

For peri-articular fractures of the proximal phalangeal base, most of cases are managed by conservative treatments. Nevertheless, there are two difficult patterns to treat by conservative treatment. At one, the extra-articular fractures with comminuted fractures of the dorsal side can be unstable and have a great tendency to dislocation. At the other, comminuted intra-articular fracture with a central depression fragment is difficult to achieve an accurate reduction of the articular surface with closed reduction by ligamentotaxis and to obtain a secure fixation.
Many techniques of treatment are reported, including casting, percutaneous pinning, external fixation and internal fixation with customized implants. Recently locking plate and screw system are available and good results can be expected in the patients treated with this system. But there is no report of using the locking plate fixation for peri-articular fractures of the proximal phalangeal base.
This study investigated the results of treating unstable peri-articular fractures of the proximal phalangeal base with volar locking plate fixation. We describe our surgical technique and report clinical and radiographic outcomes.
We performed a retrospective review of three consecutive patients with unstable fractures of the proximal phalanx. There were 4 women and 2 men with an average age of 50 years (range, 43-62 y). The finger injured was the, ring (4) and little (2). Of the four, 3 were comminuted fractures involving the articular surface of the proximal phalangeal base and three were unstable juxta-articular fractures.
Surgical technique
Access to the MP joint was achieved via a Bruner incision. The A1 pulley of the flexor sheath was incised on either lateral border to create a rectangular flap and A2 pulley was vented to a maximum of 50%. Next, the flexor tendon was retracted laterally. In the case with the need of articular exploration, the volar plate was sharply divided in the midsagittal line from the proximal volar edge of proximal phalanx to the proximal margin of the volar plate. Subperiosteal dissection of the edges of the divided volar plate was done to inspect the articular surface of the joint. The displaced and depressed fracture fragments were reduced. Once reduction was confirmed radiographically, the fracture was fixed definitively with a locking plate. The volar plate was repaired and the divided A1 and A2 pulley was placed under the flexor tendons. The bone graft was not carried out. Active and passive ROM exercise was initiated on the first postoperative day.
The average follow-up period was 12 months. All fractures went on to union within 3 months. Two plates were removed. There was no loss of reduction from initial postoperative to final follow-up radiographs. The final follow-up outcomes included averaged 96% of contra-lateral total active finger motion (TAM), 70°of MP flexion, 15°of MP extension and 9 of DASH score.
This preliminary study indicates that volar plating fixation using a fixed-angle plate system can successfully stabilize unstable peri-articular fractures of proximal phalangeal base of the finger. Early active range of motion was facilitated without compromising fracture reduction.

Samantha Piper 1, Lisa Lattanza 1, Lindley Wall 2, Charles Goldfarb 2

1 University of California, San Francisco, USA 2 Washington University, Saint Louis, USA

The effectiveness of open surgical release of post-traumatic elbow contractures in adolescents remains uncertain, and the benefit of post-operative continuous passive motion (CPM) devices in this population has not been investigated. We hypothesized that a significant improvement in active range of motion could be obtained and maintained after open contracture release in patients under 21 years old with post-traumatic elbow stiffness, and that outcomes would be unchanged by CPM.

A retrospective chart review identified 30 patients who had undergone post-traumatic open elbow contracture release by two surgeons at two institutions between 2006 and 2013. Non-traumatic contractures and arthroscopic releases were excluded. Capsulotomy, osteoplasty, excision of heterotopic ossification or hardware, ulnar nerve release or transposition, and/or ligament reconstruction, were performed through medial and lateral approaches as indicated. 30 patients were included; 17 were male and 18 used a CPM. Mean age at the time of injury was 12 years (5-19 years). 23 patients had a fracture of the radial head, proximal ulna, and/or the distal humerus, 17 had an elbow fracture dislocation, and 7 had a dislocation alone.
Outcomes included active range of motion and complications. A student T-test with P<.05 was used to determine significant differences between groups.

Mean time from injury to our contracture release was 28 months. Mean post-operative follow-up was 37 months. Elbow active flexion-extension and forearm rotation arcs both increased significantly by a mean of 48° and 63°, respectively, at final follow-up. A mean 86% of intra-operative motion was maintained at final follow-up. The use of a postoperative CPM did not significantly change these outcomes (P>.05). Complications included 2 patients that developed a recurrent contracture (one used a CPM and one did not), and 2 that developed post-operative ulnar neuropathy (one used a CPM and one did not).

Open contracture release for post-traumatic elbow contracture in an adolescent population can significantly improve and maintain active range of motion. Outcomes and complications occurring with and without the use of post-operative CPM are similar, however patient heterogeneity in our study population merits further investigation.

Claude Le Lardic

Institut de la Main Nantes Atlantique, Nantes, France

Our proposal is a protocol of rehabilitation of the wrist after ligaments injuries that we have tested in our department since few months.
This protocol is applied at patients after injury of the TFCC, after sprain of the scapho-lunate ligaments, after ligament surgery or also in many cases of pain of wrist without explicit injuries.
The aim of this rehabilitation is to obtain a muscular stabilization of the wrist for preventing all strains of the ligaments during the healing. It is also the way to teach a wrist management for preventing the arthrosis evolution.
We have the same indication than for the rehabilitation of the sprain of ankle, adapted at the wrist function, with physical exercises for strengthening the muscular stabilization.
After talking about the choice of assessments of the wrist, we explain our protocol and give the results of our study
10 cases has been selected and rehabilitated according to this protocol with only one Hand Therapist.
With have used the PRWE, the Quick Dash, The pain VAS and we have measured the grip, before and after the treatment.
All the measurements have been improved, less for the grip. Excepted for one patient who has revealed an associated Thoracic Outlet Syndrome
The results are very encouraging for this little sample and we continue this study with a bigger sample.
There are many scientific publications about the proprioception, everybody is agreeing with this rehabilitation treatment, but it is necessary to explain and to teach a protocol.

Koji Sukegawa 1, Kazuki Kuniyoshi 2, Takane Suzuki 3, Keisuke Ueno 2, Hitoshi Kiuchi 2, Rei Abe 2, Aya Kanazuka 3, Tomoyo Akasaka 2, Yusuke Matsuura 2

1 Department of Orthopaedic Surgery, School of Medicine, Kitasato University, Kanagawa, Japan 2 Department of Orthopaedic Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan 3 Department of Bioenvironmental Medicine, Graduate School of Medicine, Chiba University, Chiba, Japan

Hinged external fixators of the elbow are used to manage elbow instability and complex elbow fracture dislocations. They maintain elbow stability, facilitating early postoperative range of motion exercises; however, in extremely rare cases, radial nerve (RN) injury by half-pins has been reported (Baumann G. et al., JBJS Am., 2011; Caldwell JM. et al., JSES, 2013) that may cause serious complications. Although the zone where half-pins can be safely inserted has been investigated (Kamineni S. et al., Clin Anat., 2009; Clement H. et al., Surg Radiol Anat., 2010; Wegmann K. et al., JHS Am., 2014), no study has shown the RN course change during the motion of the elbow joint. The aim of this study was to investigate the RN course change in the upper arm when the elbow joint was passively flexed.
[Materials and Methods]
Six fresh-frozen cadaveric upper limbs were dissected. Before the dissection, the rotational center of each elbow at the distal humerus was identified in the lateral view using fluoroscopy and was marked with a 1.3-mm wire. In the lateral brachial region, the RN rotating the humerus from the dorsal to the ventral side was identified. The points at which the RN crosses over the anterior aspect, crosses through the lateral center, and crosses over the posterior aspect of the humeral shaft were defined in the lateral view as R1, R2, and R3, respectively. The distances between the rotational center of the elbow joint and each point on the RN were measured when flexion angle (FA) of the elbow was 10°, 50°, 90°, and 130°.
The distances between the rotational center of the elbow joint and R1, R2, and R3 were 78.2±5.8 mm, 97.3±7.7 mm, and 121.9±13.2 mm, respectively, when FA was 10°; 84.7±5.9 mm, 95.5±6.1 mm, and 117.3±11.7 mm, respectively, when FA was 50°; 87.6±5.3 mm, 96.4±7.8 mm, and 113.4±11.2 mm, respectively, when FA was 90°; and 92.6±6.5 mm, 98.3±7.9 mm, and 108.5±10.9 mm, respectively, when FA was 130°.
The distance between the rotational center of the elbow joint and R2 was constant regardless of the FA of the elbow. When the RN was tensed at the extension position, the distances between the rotational center and R1 and R3 increased. When the elbow joint was flexed, the RN was relaxed; consequently, the distances between the rotational center and R1 and R3 decreased (Figure 2). We recommend inserting half-pins within 70 mm from the rotational center avoiding the elbow extension position. Limitations of this study include measurements under exposure condition or condition without fracture, potentially resulting in difference from measurements at actual clinical practice.

Il-Jung Park 1, Soo-Hwan Kang 2

1 Department of Orthopaedic Surgery, Bucheon St. Mary’s Hospital, Catholic University of Korea; and the Department of Orthopaedic Surgery, St. Paul’s Hospital, Catholic University of Korea. 2 Department of Orthopaedic Surgery, St. Paul’s Hospital, College of Medicine, The Catholic University of Korea, Jeonnong-dong, Dongdaemun-gu, Seoul, 130-709, Republic of Korea

Purpose : Cubital tunnel syndrome caused by epitrochleo‐anconeus muscle is rare. The authors report clinical symptoms and the results of operative treatment of eight cases of cubital tunnel syndromes caused by epitrochleo‐anconeus muscle.

Methods and Materials : From November 2007 to October 2014, we performed surgery on 85 patients for Cubital tunnel syndrome (CuTS). Among 85 patients, 8 patients (Group 1) diagnosed with cubital tunnel syndrome caused by epitrochleo‐anconeus muscle and 77 patients (Group 2) with idiopathic cubital tunnel syndrome were evaluated retrospectively. In group 1, there were six males and two females, the mean age of the patients was 45.1 years (range, 23-65 years), 7 patients involved dominant hand, mean symptome duration was 6.5 months (range, 1-24 months), and the mean follow-up period was 18 months (12-32 months). Preoperatively, there were no ulnar nerve instability at the elbow, two patients with Dellon stage 2 and six patients with Dellon stage 3. All 8 patients received resection of the anomalous structure and ulnar nerve anterior subfascial transposition to prevent subluxation after complete release around the ulnar nerve. After postoperative 2 weeks, full range of motion was permitted and clinical results were evaluated using Dellon stage and Mowlavi scale at the postoperative 12 months.

Results : At the postoperative 12 months, symptoms were improved in all patients and no postoperative complications were developed. Compared idopathic CuTS group (n=77), anconeus group (n=8) showed significantly younger age, male, dominant hand, shorter symptom duration (p<0.05).

Conclusion : Cubital tunnel syndrome caused by epitrochleo‐anconeus muscle is rare, but it must not be ignored. For diagnosis, scrupulous physical examination with magnetic resonance imaging is needed and for treatment, resection of epitrochleo‐anconeus muscle combined with ulnar nerve anterior transposition is effective.

Tae-Kang Lim, Jae-Hyun Park, Byoung-Hun Hwangbo, Sang-Young Lee, Do-Hyun Lee

Eulji Hospital, Eulji University School of Medicine, Seoul, South Korea

Ulnar shortening is a recognized procedure for treating ulnar impaction syndrome. The most common site of the osteotomy is distal diaphyseal. However, this osteotomy carries a risk of nonunion because of limited contact area of cortical bones in the diaphysis and injury to the dorsal sensory branch of ulnar nerve (DSBUN). The purpose of this study was to assess the feasibility of proximal metaphyseal osteotomy for ulnar shortening procedure in cadaveric specimens. Twelve (6 matched pairs) fresh-frozen human cadaveric arms (mean 70 years, range 51-82) were used to simulate proximal metaphseal ulnar shortening osteotomy. The proximal posterior ulna was exposed through the extensor carpi ulnaris/flexor carpi ulnaris interval. The osteotomy was performed at proximal ulnar metaphysis, corresponding to the area just distal to the radial tuberosity. The level of osteotomy was determined under fluoroscopy uniformly in all specimens. The osteotomy site and the amount of bone resection (2 mm in all specimens) were marked, and two parallel osteotomy cuts were made by oscillating saw. After removing the resected bone, the plate (3.5 mm, dynamic compression plate, Synthes) was applied to fix the osteotomy. We checked the wrist posteroanterior images under fluoroscopy before the osteotomy and after fixing the osteotomy, and measured ulnar variances with those images using the method of perpendiculars. As for the results, the ulnar variances before and after osteotomy were compared with paired t-test. The mean value of ulnar variance decreased significantly from 1.8mm (1.3mm) before the osteotomy to -0.25mm (1.1mm) after fixing the osteotomy (p<0.001). The proximal metaphyseal ulnar osteotomy resulted in sufficient amount of shortening in the ulna in cadavers. This technique has theoretical advantages over the conventional osteotomy; more sufficient cancellous portion in the proximal ulnar metaphysis may provide more chance to heal the osteotomy site, and the risk of injury to the DSBUN can be avoided. This study showed that our technique can be an alternative option in treating the ulnar impaction syndrome.

Isidro Jiménez, Pedro J. Delgado, Sergio Martínez, Mario Gil de Rozas, Federico A. Figueredo, Juan R. Truan

Unidad de Cirugía de la Mano y del Miembro Superior, Hospital Universitario Madrid Montepríncipe, Boadilla del Monte, Madrid, Spain

Mucous cysts of the digits are a frequent and benign condition in hand surgery. Nonsurgical management is the rule if asymptomatic, but excision may be required if the overlying skin is thinned or if the patient reports disturbance. This skin covers a joint and a proper coverage is then required, therefore, numerous authors advocate flap covering, to bring good skin in to cover the previous cyst location

We report the use of the bilobed flap modified by Zitelli in a consecutive series of patients which underwent DIP mucous cyst surgery.

Materials and Methods:
From March 2014 to October 2015, 16 patients underwent surgery for DIP mucous cyst. They were eight men and eight women. Average age at surgery was 55 (40 – 68) years and follow-up was 15 (4 – 24) months. All surgeries were carried out by the same surgeon. The whole cyst was excised including the skin over itself. Capsulectomy was performed between the terminal slip and the lateral ligaments and DIP osteophytes were also excised when needed. The circular skin defect was covered by a Zitelli bilobed flap.
Time to wound healing, patient aesthetic satisfaction and complications were assessed.

The mean skin defect after resection of the cyst was 7 x 5 mm. All flaps survived and wounds healed in 13 days. There were no complications but one cyst reccurence was noted at final follow-up.
Eighty percent of patients rated the final esthetic outcome as excellent or very good and all patients would undergo the same surgery if necessary.

The Zitelli bilobed flap on skin coberture after mucous cyst excision is an optimal flap to provide good quality skin coverage over the DIP joint during surgery of digital mucous cysts. The final aesthetic outcome is excellent and geometrics landmmarks facilitate learning curve for young surgeons.

Yoshiaki Yamanaka, Yukichi Zenke, Kunitaka Menuki, Hideyuki Hirasawa, Takahumi Tajima, Akinori Sakai

Department of Orthopaedic Surgery, School of Medicine, University of Occupational and Environmental Health, Japan

Objective: In this study, we evaluated the clinical and radiographic outcomes after performing radial shortening osteotomy (RSO) and excisional arthroplasty with a palmaris longus tendon ball with bone core (PLTB) in patients with Kienböck’s disease at Lichtman stage III.
Materials and Methods: There were 6 subjects in each operation group (RSO group: 2 males and 4 females; mean age, 33.5 years and PLTB group: 3 males and 3 females; mean age, 51.3 years). The mean postoperative follow-up period was 15.5 months and 33 months in the RSO and PLTB groups, respectively.
We measured the carpal height ratio, carpal–ulnar distance ratio (CUDR), and radioscaphoid angle as radiographic parameters in each patient and evaluated the changes in each parameter preoperatively, postoperatively, and at the final follow-up in both groups. We compared the preoperative Mayo wrist score with that at the final follow-up in each group. We also evaluated the relationship between the difference in each radiographic parameter and the difference in the Mayo wrist score by comparing the preoperative and final follow-up values in each group.
Results: The Mayo wrist score significantly improved at the final follow-up compared with that measured preoperatively in each operation group (RSO group: mean score, 25 preoperatively and 75.8 at the final follow-up, p < 0.01; PLTB group, mean score, 38.3 preoperatively and 71.1 at the final follow-up, p < 0.01). CUDR was significantly higher postoperatively and at the final follow-up than that preoperatively in the RSO group (mean score, 0.22 preoperatively, 0.35 postoperatively and 0.35 at the final follow-up, p < 0.05). In the PLTB group, there were no differences among the radiographic parameters.
No differences were observed in the level of change in each parameter and the improvement of Mayo wrist score on comparing the preoperative and final follow-up values in both groups.
Conclusions: The Mayo wrist score significantly improved after performing RSO or PLTB in patients with Kienböck’s disease at Lichtman stage III. Radial deviation of the carpal bone was observed in the RSO group after surgery; however, this change was irrelevant with the improvement in the Mayo wrist score.

Essam ElKaref

Alexandria University , EGYPT

Objectives: To discuss the pros and cons of endoscopic scaphocapitate fusion in management of stage III Kienböck's disease.
Hypothesis: Recent literature has documented that scaphocapitate fusion, in treatment of Kienböck's disease, mechanically decompresses the lunate and prevents progressive carpal instability. It results in equal or relatively less loss of wrist motion when compared to other limited carpal fusions. Endoscopic surgery has the theoretical less morbidity and consequently better and easier rehabilitation.
METHODS: A prospective study was conducted on thirteen patients with stage III Kienböck’s disease; who underwent endoscopic lunate debridement, scaphocapitate fusion and excision of 3 to 4 mm of the radial styloid.
The mean period of clinical follow-up was 34 months (range, 15 to 57 months). Clinical outcome measures compared preoperative and postoperative data including wrist function scores, range of motion, grip strength, complications and also the radiographic parameters changes.
RESULTS: Radiological union was achieved in all 13 patients. The mean range of flexion extension arc of the wrist was improved to be 62% of the normal side postoperatively compared with 57% preoperatively.
A significant improvement in grip strength was also noted postoperatively (a mean of +23% of the normal side). Modified Mayo Wrist Scores were mostly fair to poor preoperatively and became good to excellent at the final assessment. Yet, 60% of patients has returned to their regular activities and the rest had to modify their work and / or sports.
Ulnar translocation of the carpus was noticed in most of the cases and was more evident in patients subjected to aggressive debridement or excision of the lunate. However, none of the patient's got attributable symptoms that necessitated further interface.

CONCLUSIONS: Although the results at the final assessment are almost comparable to open scaphocapitate fusion, yet the endoscopic approach still promising, as the post operative rehabilitation period was obviously shorter and the rate of improvement of motion and regain of grip strength was relatively faster.

Essam ElKaref

Alexandria University, EGYPT

Objective: Is to present the results of surgical management of fibrolipomatous hamartoma of the median nerve causing carpal tunnel syndrome in two childrenrnHypothesis: Neurogenic hamartoma is arare, slow-growing benign tumor of a peripheral nerve that designated by the WHO as nervous lipomatosis. It is most often occurring in the median nerve. In such lipofibromatous lesion, the epineurium and perineurium are enlarged and distorted by excess mature fat and fibrous tissue that infiltrate between and around nerve bundles. The distended median nerve may get entrapped within the limited space of the carpal tunnel.rnMaterials and Methods: Two young girls presented with a noticeable mass in the palm and in the distal volar aspect of their forearm with ever more pronounced symptoms of carpal tunnel syndrome and with wasting of thenar eminence. Tinel’s sign and Phalen’s test were positive all over the mass. MRI showed median nerve involvement on its length in the distal third of the right forearm and down into the palm, dissociating the nerve fibers, which were seen as low-intensity signal on T1- and T2-weighted images. The classical whirled appearance of the lesion and signs of median nerve compression within the carpal tunnel were also noticed.rnBoth cases were subjected to decompression of the carpal tunnel and neurolysis of the nerve bundles with excision of most of the tumour fatty tissue.rnResults: After more than five years of follow-up, there was no recurrence of the symptoms or the swelling. Although thenar muscles bulk improved, it is still smaller in size than normal side in both cases.rnConclusions: To protect the median nerve, both tunnel decompression and neurolysis of the nerve bundles should be performed. rn

Dawn Chia, Winston Chew

Hand and Microsurgery Section, Department of Orthopaedics, Tan Tock Seng Hospital, Singapore

The introduction of locking plate technology has increased the range of distal radius fracture types
amenable to fixation without the need for bone grafting as suggested by current literature. However, large bony defects in severely comminuted metaphyseal fractures may still compromise the results of locking plate fixation. Similarly, the locking plate may not adequately address small, unstable intraarticular fragments. In our study, we look at the outcomes of bone grafting used in severely comminuted distal radius fractures fixed with locking plates.

We reviewed prospectively collected data of patients who underwent surgical fixation of distal radius fractures in our institution from June 2009 to December 2010. Inclusion criteria were patients with comminuted distal radius fractures who underwent surgical fixation with locking implants, coupled with use of bone graft. Patients treated with non-locking implants were excluded from our analysis. After surgery, all patients underwent a standardized rehabilitation program consisting of four weeks of protected mobilization and progressive strengthening thereafter. Wrist motion, grip strength, and radiographic parameters – radial inclination, radial tilt, ulnar variance, articular step or gap, and fracture union were assessed at 3, 6, and 12months. At 12 months, the DASH (Disability of Arm Shoulder Hand) and Green-O’Brien scores were evaluated.

60 of 450 patients (13%) who underwent distal radius fracture fixation with volar locking plate systems required autologous bone graft (n=30) or synthetic bone substitutes (n=30). Bone grafting was indicated for maintenance of reduction in the setting of severely comminuted articular fragments or large volar-dorsal metaphyseal defects. No donor site morbidity was encountered. At final follow up, all fractures united with an average volar tilt of 4°, radial inclination of 18.8 °, and articular step or gap of 0.1mm. Based on Green-O’Brien criteria, the outcomes were excellent (10%), good (65%), fair (20%) and poor (5%).

The introduction of locking plate technology has increased the range of distal radius fracture types amenable to fixation without the need for bone grafting as suggested by current literature. The presence of large bony defects in severely comminuted metaphyseal fractures may still compromise the results of fixation with locking plates. Similarly, the locking plate may not be able to adequately address small, unstable intra-articular fragments alone. We recommend the incorporation of bone grafts as a valuable adjunct in maintaining the reduction position of articular fracture fragments, as well as for fractures with combined volar and dorsal metaphyseal comminution.

Tatsuki Ebata, Ikuo Nakai, Akira Kogure, Kenichiro Goto

Sakura Orthopaedic Hospital, Chiba, Japan

Objective: Carpal tunnel syndrome (CTS) is the most common upper extremity entrapment neuropathy. Nerve conduction studies are used for the diagnosis of CTS. As the severity of CTS progresses, the nerve conduction velocity in the carpal tunnel reduces. The compound muscle action potential of the abductor pollicis brevis (APB-CMAP) demonstrates progressively increased latency and decreased amplitude. In the most advanced stages of CTS, APB-CMAP finally becomes undetectable and the motor conduction velocity cannot be measured. The purpose of the present study was to investigate the epidemiology (risk factors) of CTS in relation to APB-CMAP.

Materials and Methods: Five hundred eighty-three hands of 398 idiopathic CTS patients whose latencies of APB-CMAP ≥4.5 ms between 2012 and 2015 were included in the present study. The diagnosis of CTS was established based on neurological and electrophysiological examinations. Secondary CTS patients, including those undergoing hemodialysis and those associated with other neuropathies or diabetes, were excluded. Patients had a mean age of 60.0 years. Among the 398 patients, 93 were men (23.4%) and 305 were women (76.6%); 377 patients were right-handed (94.7%) and 21 were left-handed (5.3%).

Results: Among 583 hands, 139 hands were of men (23.8%) and 444 were of women (76.2%). The number of hands of women was statistically significantly higher than that of men. Three hundred thirty-seven hands (57.8%) were dominant and 246 (42.2%) were non-dominant. The number of dominant hands was statistically significantly higher than that of non-dominant hands. In 190 patients with bilateral CTS, dominant hands had statistically significantly greater undetectable APB-CMAP rates (58 hands, 30.5%) than non-dominant hands (37 hands, 19.5%). In 115 patients with bilateral CTS and bilateral detectable APB-CMAP, the average latency of APB-CMAP of dominant hands (7.04 mV) was statistically significantly greater than that of non-dominant hands (6.25 mV). The number of hands of patients aged 50–59 years was the highest (175 hands, 30.0%), and the number of hands of patients aged 60–69 years was the second highest (161 hands, 27.6%). The number of hands of patients aged 60–69 years had the highest undetectable APB-CMAP rates (49 hands, 30.4%) and the greatest average APB-CMAP (7.02 mV). The number of hands of patients aged 70–79 years had the second highest undetectable APB-CMAP rates (24 hands, 28.9%) and the second highest average APB-CMAP (6.88 mV).

Conclusions: There are some possible risk factors of idiopathic CTS. Women were three times more likely to develop CTS than men. This may be because women have relatively smaller hands than men, or perhaps estrogen plays a part in the development of CTS. Dominant hands tended to develop CTS and were more susceptible to progression than non-dominant hands. The cause of CTS may be related to overuse of the hand, as repetitive motion at work. The age distribution curve of CTS peaked in the fifties and sixties when the most serious CTS occurred. Therefore, age is also an important factor of CTS. A combination of these risk factors appears to contribute to the development of CTS.

Mei-Mei Tang 1, Linda Maskill 2, Anna Pratt 2

1 Brunel university 2 Chelsea and Westminster Hospital, UK

A health profession should be underpinned by its evidence base, this is in line with increasing governmental policy. There is a shortage of hand therapy research, a potential solution to increasing the evidence base could be for increased engagement in research by practitioners, the reasons why research output is low is not clear.

A research tool was designed and piloted, then a cross sectional survey was conducted using an electronic questionnaire with 127 hand therapy clinicians. Goals included identifying items most frequently and to what degree were rated as barriers / facilitators. To identify any relationships between variables between research productivity and identify if any of the variables correlated significantly with one another.
The questionnaire was derived from emerging themes from the literature. Nominal and ordinal data were collected. A frequency count was conducted of which items and to what degree respondents agreed with statements were rated as barriers and facilitators. All the variables were correlated with one another.

Moderate correlations between research productivity existed between academic collaboration, having a research mentor, having ever collaborated in research and being currently active in research. The top five most frequently rated facilitators were personal factors – if funded to do so, research perceived as part of role, interest / enthusiasm, not concerned with challenging the status quo and belief that more hand therapy research was necessary. The top 5 most frequently rated barriers were environmental: insufficient time / protected time, not accessing clinical research groups and no appropriate space for conducting research.

There was a deficit of published literature exploring the perceptions of hand therapy clinicians regarding research production. An increased understanding of the potential barriers and facilitators to conducting research could lead to increased research productivity.

Mei-Mei Tang 1,2

1 Brunel university, UK; 2 Chelsea and Westminster Hospital, UK

The management of extensor tendon injuries is determined by the zone. Zones 3 and 5 are usually treated with different protocols given the variation in biomechanical features.
There are a number of protocols for zones 3 and 5 which vary from immobilisation, passive to early active regimes

Based on case study, explore available evidence for treating injury with extensor laceration in zones 3 and 5. Synthesise protocol features, biomechanics, healing, patient characteristics when deciding on protocol. Create safe and effective treatment regime for patient. Compare outcomes with available literature.

No specific evidence found on how to rehabilitate tendon lacerations in 2 zones. Strategy: combine 2 (active) protocols for zones 3 + 5, appropriate for patient.
Number of times seen: 6 Over: 10 weeks
Return to ‘work’: 1 week (unilateral, 4 weeks bilateral )
Note: no extension lag by week 10
Mild non-adherent, non-sensitive scar, no oedema.
Back to all adls, studies and leisure activities.
Patient reported satisfied with outcome and ready for discharge.

There was some evidence in zone 5 for effectiveness of early active protocols and zone 3 extensor tendon injuries. There was no evidence documenting the treatment of tendon lacerations in 2 separate zones simultaneously.
When a patient presented outside of the parameters of the available evidenced protocols, it was necessary to rely on clinical reasoning skills regarding biomechanics and healing and how they related to the patient and other clinical factors (surgery technique, time to presentation, hand therapist skill level).
With this approach, the patient achieved a better outcome compared to the most relevant literature in terms of range of movement, function and return to ‘work’ despite having the added complication of lacerations in 2 different zones.

Yoshiaki Tomizuka1, Soya Nago1, Yasuhiro Toyoizumi1, Taihei Yamaguchi2, Masahiro Nagaoka1

1Department of Orthopaedic Surgery, Nihon University Hospital, Tokyo, Japan; 2Department of Orthopaedic Surgery, Nihon University School of Medicine, Tokyo, Japan

The structures that stabilize thumb metacarpophalangeal(MP) joint are not only collateral ligaments but also the dorsal capsule. We report volar subluxation of the thumb MP joint in ten cases, and evaluated the collateral ligaments and dorsal capsule of the thumb MP joint.
Ten hands in ten cases were treated for volar subluxation of the thumb MP joint in our hospital between 2006 and 2015. There were nine male and a female, with a mean age of 38.0 years (range of 15-62 years). Injured hands were seven right hands and three left hands. Injuries caused by sports in four cases, the motor vehicle accident in three cases, the others in three cases. All cases were treated surgically, the average period from injury to operation was 28.5 weeks (ranged from 10 days to 4 years). We evaluated damage and procedure for the radial collateral ligament (RCL), ulnar collateral ligament (UCL) and the dorsal capsule (DC). The average follow up period was 9.1 months (range of 2-24 months).
All patients injured DC and required surgical repair. DC was repaired by suture anchor in eight cases and sutured directly in two cases. Injured ligaments were RCL in five cases, UCL in two cases and both RCL and UCL in a case. In two cases, both collateral ligaments were intact. These injured ligaments were repaired by suture anchor in six cases and sutured directly in two cases. We immobilized thumb MP joint temporally with a Kirschner wire in seven cases, with splint in two cases, with both Kirschner wire and splint in the remaining case postoperatively. Thumb MP joint was immobilized for 2-8 weeks and started ROM exercise. In two cases, severe extension lag (one is 30 degrees, another is 40 degrees) was remained.
Volar subluxation of the MP joint of the thumb highly combines DC injury, and it may cause severe extension lag of thumb MP joint. We consider that it is necessary to repair DC in volar subluxation of the thumb MP joint, and satisfactory results were obtained by repairing DC. RCL and extensor pollicis brevis cupsule contribute to stability against volar subluxation and rotation. In our cases, volar subluxation tends to increase by a result of RCL and DC injuries.

Sergi Barrera-Ochoa 1,2,3, Irene Gallardo-Calero 1,3, Alba López-Fernández 3, Cleofe Romagosa 4, Ramona Vergés 5, Marius Aguirre-Canyadell 1,3, Francisco Soldado 6, Roberto Velez 1,3

1 Hospital Universitari Vall Hebron. Orthopedic Surgery Department. Barcelona, Spain; 2 Hospital Universitari Quiron-Dexeus. ICATME. Hand and Microsurgery Unit. Barcelona, Spain;3 Vall d'Hebron Research Institute (VHIR). Musculoskeletal Tissue Engineering Group. Barcelona, Spain; 4 Hospital Universitari Vall Hebron. Pathology Department. Barcelona, Spain; 5 Hospital Universitari Vall Hebron. Radiotherapy Department. Barcelona, Spain; 6 Hospital Universitari Sant Joan de Deu. Pediatric Upper Extremity Surgery and Microsurgery Department, Barcelona, Spain

Objective: to compare the effect of neadjuvant irradiation on the microvascular anastomosis in cervical bundle using an experimental model in rats.

Material and Methods: One hundred forty male Sprague-Dawley rats were allocated into four groups: Group I, control, arterial microanastomosis; Group II, control, venous microanastomosis; Group III, arterial microanastomosis with previous irradiation (20 Gy) and Group IV, venous microanastomosis with previous irradiation (20 Gy). Clinical parameters, technical values of anastomosis, patency, and histopathological examination were evaluated.

Results: Irradiated groups (III,IV) and vein anastomosis groups (II,IV) showed significantly increased technical difficulties. Group IV showed significantly reduced the patency rates (7/35) as compared with the control group (0/35). Radiotherapy significantly decreased the patency rates of the vein (7/35) as compared with the artery (1/35). Group III-IV showed significantly reduced number of endothelial cells, and presence of intimal thickening and adventitial fibrosis as compared with the control group.

Conclusions: Neoadjuvant radiotherapy reduces the viability of the venous anastomosis in a preclinical rat model with a significantly increase of vein thrombosis.

Sergi Barrera-Ochoa 1,2,3, Irene Gallardo-Calero 1,3, Andrea Sallent 1,3, Alba López-Fernández 3, Cleofe Romagosa 4, Marius Aguirre-Canyadell 1,3, Jordi Saez 5, Roberto Velez 1,3

1 Hospital Universitari Vall Hebron. Orthopedic Surgery Department. Barcelona, Spain; 2 Hospital Universitari Quiron-Dexeus. ICATME. Hand and Microsurgery Unit. Barcelona, Spain;3 Vall d'Hebron Research Institute (VHIR). Musculoskeletal Tissue Engineering Group. Barcelona, Spain; 4 Hospital Universitari Vall Hebron. Pathology Department. Barcelona, Spain; 5 Hospital Universitari Vall Hebron. Radiotherapy Department. Barcelona, Spain

Objective: The aim is to create a new safe experimental model of radiation induced neurovascular histological changes with reduced morbidity and mortality for experimental microsurgical techniques.

Material and Methods: For this study 72 Sprague-Dawley rats weighing 350-400 g. were divided in the following manner: Group I: control group, 24 rats clinically evaluated during six weeks. Group II: evaluation of acute side effects, 24 irradiated (20 Gy) rats clinically evaluated during two weeks. Group III: Evaluation of subacute side effects, 24 irradiated (20 Gy) rats evaluated clinically for six weeks. The variables evaluated include clinical assessment, weight, vascular permeability (arterial and venous), mortality and histological studies.

Results: No statistically significant differences were observed between groups in clinical assessment, weight, vascular permeability and histological changes of larynx, trachea, esophagus and thyroid. Statistically significant differences were observed between groups I vs. II-III both in survival and histological changes of artery, vein and nerve. Rat body weight showed a progressive increase in all groups and the mortality rate of the presented model is 10.4% compared to 30-40% of the previous models.

Conclusions: The designed model induces selective changes by radiotherapy in the neurovascular bundle without histological changes affecting the surrounding tissues. This model will allow conducting new therapeutic experimental studies, including viability of microvascular and microneural sutures post radiotherapy in the cervical neurovascular bundle.

Sergi Barrera-Ochoa 1,2,3, Sleiman Haddad 2,4, Irene Gallardo-Calero 2,4, Eva Correa-Vázquez 2,3, Maria Merce Reverte-Vinaixa 2,4, Francisco Soldado 2,5, Xavier Mir-Bullo 1,2,3

1 Hospital Universitari Vall d’Hebron, Orthopaedic and Trauma Department, Hand and Microsurgery Unit, Barcelona, Spain; 2 Hospital Universitari Vall d’Hebron, Barcelona, Spain; 3 Universitat Autònoma Barcelona, Barcelona, Spain; 4 Institut Universitari Quiron-Dexeus. ICATME. Hand and Microsurgery Unit.

Objective: To (a) describe and evaluate a new diagnostic variable for chronic exertional compartment syndrome (CECS) of the forearm, TRest, and (b) analyze the sensitivity of the standard intracompartmental pressure (ICP) cutoff values.

Material and Methods: Ninety-seven patients identified from a database with clinical features compatible with forearm CECS. We retrospectively reviewed dynamic ICP of the flexor compartment in 97 successive patients (34 with bilateral involvement; 131 forearms) with clinical features compatible with forearm CECS. They all had resolution of CECS symptoms after fasciotomy of forearm compartments confirming diagnosis. Patients meeting the standard ICP diagnostic criteria were classified as a true positive group (TPG) whereas the rest were considered as false negative group (FNG). TRest was calculated in all of them. Main Outcome Measures: Preoperative standard ICP diagnostic criteria and TRest. Patient characteristics. Pain (Visual Analogue Scale (VAS) 100-point scale) and functional scores (Quick-Dash) at 3 months after surgery and at regular intervals during clinical visits. Surgical complications. Level of satisfaction with the outcome. Time to return to full activity after surgery.

Results: Mean ICP pressures for the TPG were: PRest 7.02 +/- 4.01 mm Hg, P1mn 32.29 +/- 3.71 mm Hg and P5mns 20.14 +/-2.31 mm Hg. Mean ICP pressures for the FNG were: PRest 6.74 +/- 3.45 mm Hg, P1mn 17.6 +/- 2.33 mm Hg, and P5mns 15.77 +/- 2.49 mm Hg. The current thresholds ICP values were analysed with a ROC curve, with an area under the curve (AUC) of 0.478 (IC 95% 0.371-0.586). Sensitivity of the current ICP criteria at detecting CECS was 67% (88/131). Comparing TRest between TPG (mean 19.68 +/- 3.05 minutes) and FNG (mean 19.86 +/- 2.84 minutes), no statistical difference could be found (p=0.761). Choosing 15mns as the cutoff (two standard deviations below the mean), the sensitivity of TRest >15 minutes at diagnosing CECS was 95%.
Conclusions: Current ICP criteria are not reliable at screening patients with suspected CECS of the forearm. Sensitivity of TRest at the 15 minutes cut-off was 95%, making it highly reliable at detecting CECS. We recommend its use in equivocal patients that do not meet standard ICP criteria. TRest could confirm CECS diagnosis and assist the surgeon at recommending surgical decompression.

Conclusions: Current ICP criteria are not reliable at screening patients with suspected CECS of the forearm. Sensitivity of TRest at the 15 minutes cut-off was 95%, making it highly reliable at detecting CECS. We recommend its use in equivocal patients that do not meet standard ICP criteria. TRest could confirm CECS diagnosis and assist the surgeon at recommending surgical decompression.

Jordi Canosa, Christian Gordo, Jaime J. Morales, Joan Domingo, José M. Illobre, Miguel de la Torre, Oscar Salgado

Orthopaedic Service, Hospital del Vendrell. Tarragona, Spain

- Context osteoporotic fractures are a major problem of Public Health for morbidity, mortality and increasing frequency.
- This type of fractures are often the first manifestation of osteoporosis was asymptomatic until this injury.
- However, it is often the presence of vertebral fractures diagnosed in patients who have suffered a fracture of the distal radius low energy trauma.
- Sometimes the diagnosis of vertebral fracture is difficult. The fact of finding them could be a sign of a more advanced or severe osteoporosis.

- We have reviewed prospectively and randomly a series of 40 patients diagnosed with distal radius fracture treated in our department in the last 12 months.
- In all cases the diagnosis been made by plain radiography in two projections.
- From a protocol and systematically we have made a simple X-Rays of lumbar spine in profile projection.
- The diagnosis of vertebral fracture we made them visually without using any kind of quantifier system.
- As inclusion criteria we have established:
1. diagnosis of fracture of the distal radius as the only injury
2. causal mechanism by low energy trauma.
- Arbitrarily we have set as an exclusion criterion higher age at 75 years.

- All patients in the review were women between 65 and 75 years.
- The radial fracture was treated conservatively in 25 and so surgery in the other 15.
- The profile lumbar spine has shown one or more fractures in 15 patients.

- According to our review the association between vertebral fractures and distal radius exceeds 30%.
- We consider necessary the systematic implementation of a lumbar spine radiology.
- We suspect that this frequency should be higher so the fact that we have not studied the dorsal spine and the fact that there are fractures that are not detected in a simple radiology.
- More studies are needed both to establish the actual frequency of vertebral fractures and to locate the actual severity of osteoporosis in cases of injury association, could reveal a more advanced stage of osteoporotic disease.

Francisco Javier Garcia Garcia, Iñigo Crespo Cullel, David Pescador Hernandez, Samuel Lopez Alonso, Carlos Marques Parrilla, Francisco Melchor Mencia, Juan Blanco Blanco

University Hospital of Salamanca, Salamanca, Spain.

Scedosporium apiospermum is a saprophytic filamentous fungus that can cause infections of the skin, respiratory system, central nervous system, and bones. It affects mainly to immunosuppressed patients, but also and more rarely to immunocompetent patients, in whom the condition usually has a traumatic origin and a localized nature, such as an area of tumescent or suppurating skin. It can also appear as septic arthritis or osteomyelitis.The early diagnosis for this fungus is essential and voriconazole is an effective antifungal treatment, together with aggressive and surgical debridement. To the best of our knowledge, there are 36 cases of musculoskeletal infections caused by the Scedosporium genus in immunocompetent patients described in the literature, and only 8 cases of infection caused by S. Apiospermum. We report a S. apiospermum infection in a 77-year-old man who suffered a rabbit scratch in his left hand.

Isidro Jiménez, Pedro J. Delgado, Marisol Nikolaev, Sergio Martínez, Mario Gil de Rozas, Federico A. Figueredo, Juan R. Truan

Unidad de Cirugía de la Mano y del Miembro Superior, Hospital Universitario Madrid Montepríncipe, Boadilla del Monte, Madrid, Spain

Scaphoid nonunion treatment should be done by debridement, corticocancellous bone graft (vascularized or non-vascularized) and estable fixation by open exposure that increased the morbidity of the procedure. Wrist artroscopy is a minimally invasive technique that preserve vascularization and neural propioception.

To assess our experience of arthroscopically assisted reconstruction in patients with unstable scaphoid nonunion.

Materials and methods:
A retrospective case series of chronic unstable scaphoid non-union treated with dry arthroscopic reconstruction using two midcarpal portals. DISI was corrected with a temporary Kw throught the dorsal radius. Scaphoid defect was packed with cancellous bone graft from the distal radius across the radial-midcarpal portal. Internal fixation was performed using a mini-Acutrak or HCS headless screw. Fusion rates, radiographic and clinical evaluation was performed, with a mean follow-up of 16,8 (12-36) months. All patiens were treated by the same surgeon.

13 patients (26 years mean age) were treated. 76% patients showed “humpback deformity” in preoperative radiological study. Union was achieved in all patiens at 6 (4-8) weeks. Range of flexo-extension arc improved after surgery, from 138,4º to 165º. Scapholunate angle (SLA) and radio-lunate angle (RLA) was significantly improved: SLA 67,7º to 47º; RLA 30,8º to 4º. Functional postoperativ evaluation: mean DASH-questionnaire was 8 and VAS 0,7. No complications was observed. No reoperations was needed.

Arthroscopic reconstruction can be a useful alternative for chronic unstable scaphoid nonunion. In our experience presents good clinical and radiological results, even in scaphoid waist nonunion with humpback deformity. Probably is limited for restoration of the normal carpal alignment but has positive effects on the recovery of clinical wrist function with comparable results to other open techniques.

Lívia Nahas Pinola, Flávia Pessoni F. M. Ricci, André David Gomes, Paulo Roberto Pereira Santiago , Marisa de Cássia Registro Fonseca

University of Sao Paulo, Ribeirao Preto, Brazil

Objective: To describe the development of the Brazilian version of the Functional Impairment Test-Hand, and Neck/Shoulder/Arm (FIT-HaNSA) and to evaluate its test-retest reliability on 10 volunteers.
Materials and Methods: In order to develop the Brazilian version of FIT-HaNSA Test device the following materials were needed: 2 adjustable aluminum rail units (200cm), 4 adjustable aluminum supports (26X3.8X2.5 cm) e 2 wooden shelves (60X30X1.5 cm). The rails were set in an iron frame and the aluminum supports screwed on the shelves to allow the slip on the rails allowing its adjustment at different heights. Finally, all this structure was fixed on an iron base to promote stability and to prevent unwanted movement. The device has been tested for its test applicability. The test consists of 3 tasks that simulate daily activities of lifting and sustained over-head work in the household or workplace. Instructions to perform each task were given according to MacDermid et al. (2007). The volunteers were instructed to use their affected arms in epycondiloalgia group or the dominant arm in asymptomatic group. The same stopping protocol was used for task 1, 2 and 3 and the time to complete the task was measured by a stopwatch. There was an approximately 30 second rest between the tests as the shelves were adjusted for the different tasks. This test was performed in 10 volunteers: 5 were asymptomatic (3 female, 2 male) and 5 had lateral elbow epicondyloalgia (3 female, 2 male). It was then performed in an interval of 7 days in order to measure the test-retest reliability.
Results: From the 5 asymptomatic, 2 did not complete all the tasks in the first test day. In the retest, one volunteer did not complete all tasks. From the 5 with lateral elbow epicondyloalgia, 4 did not complete all the tasks in the first test day. In the retest, the 5 volunteers did not complete all tasks. Statistical analysis was performed using SPSS version 20® for repeatability of measurements assessment of test-retest reliability by intraclass correlation coefficient (ICC), with a confidence interval (CI) of 95%. To check the level of correlation coefficient were adopted ICC values classified according to Wahlund et al. (1998): 1) excellent reliability for more values that 0.90; 2) good reliability between 0.80 and 0.89; 3) acceptable reliability between 0.70 and 0.79; 4) not acceptable reliability for smaller values that 0.70. The test-retest reliability for the tasks 1, 2 and 3 were respectively, 0.99 (0.91 – 0.99), 0.89 (0.02 – 0.98) e 0.95 (0.54 – 0.99).
Conclusion: The Brazilian version of FIT-HaNSA Test showed excellent reliability in repeated measurements over time by the same examiner in most tasks and it can be considered reliable for the studied sample. Future clinical samples are required to assess the validity of this test.

Flávia Pessoni F. M. Ricci , Lívia Nahas Pinola , Adriana da Costa Gonçalves , Elaine Caldeira de Oliveira Guirro , Marisa de Cássia Registro Fonseca

University of Sao Paulo, Ribeirao Preto, Brazil

Objective: To describe what are the main hand orthotic designs fabricated for patients with burning in upper limbs at a tertiary burns unit. Burns conditions generally imply severe functional impairment and hand orthoses play an important role during the rehabilitation process.
Materials and Methods: This work is part of a study approved by the Research Ethics Committee (HCFMRP-USP), according to the process n° 1354421/2015. It was a retrospective and descriptive study. Data collection was performed by the hand therapist responsible for making the orthoses. We included patients affected by burns in the upper limbs who were under treatment in the Physiotherapy section of the Burns Unit of the Clinical Hospital of Ribeirao Preto Medical School, from University of Sao Paulo. Data included all the orthoses fabricated in a period of six months, from January/2015 to July/2015, and the variables analysed were gender, involved joint, orthotic design and orthotic objective. These data were entered into an Excel spreadsheet, pre-prepared for further descriptive analysis.
Results: 7 patients (1 Female – 14,3%; 6 Male – 85,7%) needed orthotic device and 12 thermoplastic orthoses were fabricated. From all of the orthoses, 6 of them (50%) were static design and 6 (50%) were dynamic. Regarding the orthosis’ objective, 1 (8,3%) was for functional positioning post-surgery, 1 (8,3%) for ulnar claw correction and functional use during activities of daily living and 10 (83,4%) were for range of motion improvement, mainly metacarpophalangeal flexion. Apart from the positioning orthosis, all the other were for finger joints, with no wrist or elbow involvement.
Conclusion: Orthoses to regain range of motion are the main type fabricated for the studied sample, whether static or dynamic. Further studies are needed in order to optimize orthotic fabrication for the burned hand, with special attention to finger joints. Also, orthotic intervention in a preventive manner after surgery should also be considered.

Paula G. V. Cle 1, Rafael I. Barbosa 2, Marisa de Cássia Registro Fonseca 1, Diego Polizello 1, Nilton Mazzer 1

1Department of Biomechanics, Medicine and Rehabilitation of the Locomotor Apparatus, Medical School of Ribeirão Preto, University of São Paulo, Brazil. 2Federal University of Santa Catarina, Araranguá - SC, Brazil.

The use of locked volar plates for the stabilization of distal radius fractures (DRF) has been the most frequently used technique because it presents minor complications postoperatively compared to others approaches. In this surgical technique the pronator quadratus muscle (PQ), which plays an important role in the movement of pronation and stabilization of the distal radioulnar joint, is released from its insertion. The aim of the present study was to assess the effects of this intervention in pronation strength and wrist function. The sample consisted of 24 individuals underwent open reduction and internal fixation with the volar locking plate for DRF. The examinations included measurement of wrist range of motion (ROM) with a goniometer, grip and pinch strengths using a Dynamometer, functional assessment using the DASH score and the measurement of pronation and supination strengths using an isokinetic dynamometer. At 6 months the recovery of wrist ROM was partial, most of the evaluated amplitudes showed significant differences, except the passive extension and passive ulnar deviation. No significant differences were found in pinch strengths. Grip strength presented a 28.55% deficit of the operated side at 3 months, and this deficit decreased to 14.53% with significant difference at 6 months. An average of 9.27 in the DASH score was obtained at final evaluation. The mean values of peak pronation torque and total pronation work were lower in operated wrists, and the total pronation work presented significant difference at 6 months. This study suggests that the volar approach on DRF has a negative impact on wrist function and in pronation strength. Careful dissection of the PQ muscle in surgery, repair it whenever possible and longer follow-up periods over 12 months were recommended.

Sebastian Gallegos, Carlos Salinas, Paulina Salinas, Jennifer Carvajal, Luis Schnapp

Universidad de Chile, Santiago, Chile

Objetivo / Hipótesis
Different reporting methods, evaluation techniques and scoring systems have been used to quantify motor status of the distal median nerve. We present a new device for an easy, reliable and isolated clinical assessment of abductor pollicis brevis.

Materiales y Metodos
We used a custom made device for the isolated measurement (in kilograms) of palmar abduction of the thumb of adult healthy population at a our University Hospital. A single operator trained by the authors on the proper use of the device collected the data.

100 thumbs on 50 patients were assessed. Statistics calculated.

This new device is a valuable tool for objective assessment of the motor function of the distal median nerve both in neuropathies or recovery after nerve repair. After validation of its use in our local population this will most likely give more precision in research and clinical decision making.

Jeyamany Jacob 1, Yang Zixian 2, Andrew Chin Yuan Hui 2, Joshua Yong 2, Marc Garcia-Elias 3

1 Sengkang Health, Singapore, 2 Singapore General Hospital, Singapore, 3 Institute Kaplan, Barcelona, Spain

Injuries to the scapholunate (SL) ligament are the most frequent cause of carpal instability and account for a considerable degree of wrist dysfunction and interference with activities. Partial tears result in pain and reduced grip strength with current treatment being arthroscopy and debridement or surgical repair.However, following surgery, patients will need to be immobilised in cast or splint, which may result in further wrist dysfunction.
Studies in this area have been limited, and therapists tend to focus more on wrist flexion and extension exercises. However, even with full wrist flexion and extension ROM, they may still have difficulty with some functional activities that typically occur in an oblique plane as compared to that of a linear plane. Many tasks in daily lives are performed by moving the wrist from an extended and radially deviated position to a flexed and ulnarly deviated position, which was later termed the dart throwing motion (DTM). Kinematic studies demonstrated that this motion reduces strain on the SL interosseous ligament during wrist motion. This movement has been suggested as a possible treatment for partial SL injuries instead of surgery.

To investigate whether resisted controlled movements of the wrist in the radial extension and ulnar flexion movement will improve pain scores and grip strength of patients with partial SL tears. A secondary outcome to evaluate wrist ROM and participation in daily activities will also be investigated.

A total of 20 patients who meet the inclusion criteria (a diagnosis of partial SL dissociation injury, exhibits dorsoradial tenderness, negative Watson test, normal static and dynamic x-rays with no previous surgery or arthroscopy for the condition) would be recruited and randomized into 2 groups: control and intervention through the use of sealed, opaque envelopes. Both groups would be provided with conventional therapy weekly over 6 weeks, with the intervention group performing additional resisted dart throwing motion exercises. Outcome measurements include pain (using a 10-point Likert Scale) during wrist flexion, wrist extension and maximal grip as well as grip strength. Wrist ROM and participation in daily activities will also be measured. Demographic data would be analyzed with descriptive statistics, while pain score and grip strength would be analyzed using Student’s t-test, otherwise Mann-Whitney U test would be applied when data are not normally distributed. Demographic data would be analyzed with descriptive statistics, while pain score and grip strength would be analyzed using Student’s t-test, otherwise Mann-Whitney U test would be applied when data are not normally distributed

Data collection is in progress. Results and Conclusion would be updated by October 2016 at the International Federation of Societies for Surgery of the Hand congress. It is hypothesized that there would be an improvement in pain scores and grip strength amongst those in the intervention group compared to those in the control group. If the results of this study are able to establish this finding, it would provide a basis to form a protocol to be used with all future patients with partial SL dissociation injuries

Jeyamany Jacob 1, Yang Zixian 2, Andrew Chin Yuan Hui 2, Joshua Yong 2, Marc Garcia-Elias 3

1 Sengkang Health, Singapore 2 Singapore General Hospital, Singapore 3 Institute Kaplan, Barcelona, Spain

Injuries to the scapholunate (SL) ligament are the most frequent cause of carpal instability and account for a considerable degree of wrist dysfunction and interference with activities. Partial tears result in pain, reduced grip strength and limitations in range of motion (ROM) which have an impact on daily activity participation.

This case report explores the use of DTM on a patient with SL in improving range of motion and grip strength and reducing pain.

The study design is a retrospective case report of a 24 year old male with partial scapholunate injury.He presented at the Department of Occupational Therapy in January 2013 with complaints of pain in the right wrist following a fall. X-rays performed had ruled out any fractures and he was found to have a partial scapholunate dissociation. Occupational Therapy interventions were carried out weekly between Jan – Mar 2013. Therapy included heat, wrist exercises and gradual resisted dart throwing exercises on a specially designed device. This device was created in collaboration with engineering students from a local polytechnic. The device limited the wrist movement to the DTM action with adjustable weights which could be increased at increments of 100g. Before each therapy session commenced, pain scores were measured on flexion, extension, pronation and supination of the wrist as well as when taking grip strength. Maximal grip strength and ROM as well as pain free grip strength and ROM were also measured.

Preliminary results this single case study indicates improvement in grip strength and range of motion, as well as a reduction in pain score.

Victoria Jansen 1, Paul Hendrick 2, Jo Ellis 1

1 Pulvertaft Hand Centre, Royal Derby Hospital, Derby, UK; 2 University of Nottingham, Nottingham, UK

CMCJOA is a common and painful condition associated with ligament laxity, subluxation and joint instability. Instability in CMCJOA is only a theoretical concept, lacking satisfactory clinical assessments or objective data to confirm its presence. Despite little conclusive evidence for the presence of instability in the literature, therapy interventions aimed at reducing pain and improving function also include a number of exercise interventions which specifically target the symptoms associated with instability and subluxation. However, practitioners’ understanding of instability, and how a diagnosis might influence therapy management, have not previously been explored. This study aimed to explore the perceptions of experienced therapists who regularly treat patients with CMCJOA, in order to understand their perceptions of joint instability and its relationship with laxity, subluxation and strength, and its management (including the perceived effectiveness of exercise interventions).
To explore the views of therapists on the role of instability in the management of CMCJOA.
To describe the conceptual models of instability that guide practice, and the perceived relationship between function and: joint laxity; joint subluxation; and strength.
To describe the perceptions of therapists on the factors influencing their use of exercise in the management of instability.
A qualitative research design was chosen. Individual semi-structured interviews were conducted with nine therapists, who were recruited by web bulletins/emails from professional organisations, and interviewed using recorded telephone or video calls. Interviews were transcribed and analysed using a thematic analysis.


Three themes were identified:

1) Relationships between instability and laxity – for some participants the terms laxity and instability were used interchangeably. Participants found instability a hard concept to define, but generally described the joint as having inadequate support, or an imbalance in the support structures. Instability was associated with both laxity and subluxation, and also with disease progression. There was also agreement that in CMCJOA instability is a problem that includes the whole thumb column.

1) Stage of disease - influenced participants’ perception of whether instability might be present, but conflicting opinions were expressed ranging from instability being present in: pre-arthritic lax joints; to early disease; to all stages of disease.

3) Management - there was disagreement as to whether instability could be modified by muscle strength, or whether treatment should be focussed on compensating for instability. A number of factors were perceived to indicate that exercise was less likely to be effective for instability including significant: subluxation; muscle wasting; adduction contracture; uncontrolled pain and unmotivated patients.

Different perceptions of instability were reflected in the divergent opinions regarding the need to manage, and the potential for altering instability. There is a lack of clarity on the impact of instability on function, and a lack of consensus on the critical components that comprise the concept of instability. A clearer definition of instability would facilitate the development of assessment techniques, and the identification of mechanisms that affect function in CMCJOA, and critically the development and assessment of interventions for instability.

Hirokazu Tochigi1, Takeru Arai2, Okuyama Kunimasa1

1 Shizuoka municipal Shimizu Hospital,Shizuoka, Japan 2 Tokyo dental college of Ichikawa general hospital,CHiba, Japan

Introduction: In rheumatoid arthritis (RA), rupture of extensor tendons often occurs in multiple fingers. Direct repair was usually impossible because of retraction, shortening of the muscle. However, we tried to reduce the tendon gap and repair directly by using each reversed EDC half-slip tendons of proximal stump. In this study, we evaluated our surgical repair outcome.

Material and Methods: Of 4 RA patients (3 females, 1 male) who underwent surgery for total EDC tendon ruptures between 2012 and 2015. The mean age at surgery was 67 years (range, 59 to 71). The mean period from total drop finger to surgery was 58days (range, 29 to 97).The mean follow-up period after the surgery was 2.0 years (range, 1 to 3). Our treatment consisted of synovectomy, wrist arthroplasy by Sauve-Kapandi’s procedure, tendon end-to-end interlacing suture using each reversed 5cm EDC half-slip tendons of proximal stump, and repaired tendon was sutured side-to-side each other. Active exercise of the fingers was started immediately after the surgery. Surgical outcomes were evaluated on the basis of patient’s satisfaction and the range of motion (ROM) of the MP joint and wrist.

Results: Three patients (75%) were highly satisfied and one (25%) was satisfied with surgical outcomes. The mean MP joint active extension was 1.7°(range , 0 to 5). The mean MP joint active flexion 78.3°(range, 65 to 83). In all cases, wrist flexion ROM was limited more than 15°compare to non-surgical wrist, but no one complained of activity of daily living(ADL) disturbance.

Conclusions: For multiple extensor tendon ruptures of rheumatoid hand, our tendon reconstruction procedure led to almost full finger extension function without damage of other intact tendon and active finger ROM exercise could start soon after surgery. Full finger flexion also obtained in all cases. Although limitation of wrist flexion ROM were observed, no one complained of ADL disturbance. 

Kentaro Hayashi,Hirokazu Tochigi,Keita Kajikawa,Yusuke Oka,Taro Umezu, Mitsuru Hurukawa,Kentaro Kikuchi,Kunimasa Okuyama

Shizuoka city shimizu hospital,Shizuoka,Japan

Anterior dislocations of the elbow complicated with coracoid process fractures are rare. To our knowledge, only six cases have been reported in literature. We report a case of an elbow anterior dislocation complicated with a coracoid process fracture that required surgical treatment.
A ten-year-old girl was presented to our hospital with severe elbow pain, swelling and limitation in rage of motion after falling on her hand while running. Plain radiographs revealed an anterior dislocation of the elbow with “small avulsion like” fracture fragments near the coracoid process and the olecranon. There was no sign of nerve damage, as she did not experience any paresthesia or paralysis. Reduction was attempted under general anesthesia few hours after the time of injury However, reduction could not be achieved through closed measures and an open reduction was required. The dislocated joint was observed through a posterior approach. After opening the joint, an olecranon fracture with a relatively large proximal fragment displaced posteriorly was found. After distracting the proximal olecranon fragment, a fractured coracoid process fragment was found incarcerated between the ulnar shaft and the olecranon, preventing reduction of the anteriorly dislocated elbow joint. The coracoid process was reduced and fixed with K-wires prior to the reduction and fixation of the olecranon with tension band wiring. Four months post-operatively, union of the fractures sites and full range of motion as achieved.

Natalia Claro da Silva, Thais Cristina Chaves, Jacqueline Brazão dos Santos, Nilton Mazzer, Marisa de Cássia Registro Fonseca

University of Sao Paulo, Ribeirao Preto, Brazil

When the upper extremity is in a state of pain and/or reduced mobility, there is major damage on functional skills, work performance and quality of life, whose evaluation is critical to decision-making, monitoring progress and determining the disease prognosis. In addition to the objective instruments of clinical measurement (range of motion, muscle strength test, sensitivity and functional tests), the self-report questionnaires have been increasingly used for reflecting the patient's perception of the injury impact.
The Quick-DASH (QD) is a specific questionnaire and self-administered developed to evaluate the degree of symptom and dysfunction in patients with upper limb disorders. It is widely used in clinical practice and research throughout the world, already translated to Brazilian Portuguese, but yet not analyzed for its psychometric properties. The aim of this study was to conduct an analysis of the test-retest reliability of the Brazilian Version of the Quick-DASH (QD-Br) in Patients with upper limb disorders.
Methods: One hundred patients (mean age 44.27, SD 16.01) were interviewed in two opportunities (test and retest after 48-72 hours). Inclusion criteria were: patients of both sexes; aged over 18 years; with clinical and / or dysfunction of the upper limb due to musculoskeletal causes; released to use the affected limb after at least 1 week after any kind of immobilization or restriction to use due to pain and cognitive ability to understand written instructions. Exclusion criteria were: Neurological disorders of the central nervous system (CNS). They completed the QD-Br that consists of 11 items on symptoms and dysfunction on the upper limb, at first and second interview. Statistical analysis was performed using SPSS version 20® for repeatability of measurements assessment of test-retest reliability by intraclass correlation coefficient (ICC), with a confidence interval (CI) of 95%. The benchmark values considered of ICC were: less than 0.40 as poor reliability; between 0.40 and 0.75 moderate reliability and above 0.75 excellent reliability (FLEISS et al., 2003).
Results: 100 patients, 79 (42 men, 37 women; mean age = 45.17, SD 16.03) completed the QD-Br in the first and second interview. The ICC indicated that the test-retest reliability was 0.81 (0.72 - 0.87), suggesting excellent reliability.
Conclusion: The Brazilian version of Quick-DASH showed excellent reliability to evaluate patients with multiple upper limb disorders and it can be considered reliable for the studied sample. Future studies are necessary to conduct the analysis of the validity of this instrument, as well as its responsiveness to the Brazilian population.

Ruth Galtés 1, Susana Rodríguez 2, Aureli Oriol 2, Anton Rañé 2

1 Central University of Catalonia. Campus Manresa, Manresa, Spain 2 IAS Parc Hospitalari Martí i Julià, Salt, Girona, Spain

Background. The hand is an important area in the practice of physiotherapy. Since Physiotherapy studies were first established in universities in Spain, in 1990, the curriculum has undergone many changes. The most recent and significant of these are due to the impact of the harmonization of university studies within the European Higher Education Area, and to the upgrading of physiotherapy studies from diploma to degree status. Consequently, subjects and the corresponding credit-hours have been reorganised.
Aim. Our research describes the development of subjects related to the hand at Faculties of Physiotherapy in Spanish universities.
Two hypotheses are tested:
H1. The distribution of subjects allocated to the hand is homogeneous and progressive.
H2. The total number of credits allocated to the hand is sufficient in training expert professionals.

Methodology. Two types of research have been carried out: exploratory research into the deficient number of subjects to study the hand in Spanish universities; descriptive research into the specifications of curriculum development for subjects to study the hand.
The population for this study was 50 Faculties of Physiotherapy in Spanish universities. Documentary analysis was used for data collection. We analysed the curricula for first, second, third and fourth-year courses in degree programmes. These data were obtained from university websites between December 2015 and January 2016. In the first phase, subjects that studied the hand were selected. In a second phase, the number of credit-hours allocated to the upper-lower extremities and the hand were observed, with regard to the total number of hours and credits, per subject and per academic year. The total number of credits needed to complete a degree is 240, namely 60 European credits per academic year. The computer programme used to analyse the data was Numbers '09, version 2.3 (554).

Results. Valid values were obtained for 436 subjects from 47 universities; 112 for first year, 162 for second year, 123 for third year and 39 for fourth year. Three universities obtained missing values. The main types of subject are; Core, Compulsory and Optional. In first year, out of a total of 8,734.3 contact hours, 3,491 are allocated to the extremities, and 666.9 of these to the hand. In second year, out of a total of 11,708 contact hours, 4,899.6 are allocated to the extremities, and 847.3 of these to the hand. In third year, out of a total of 8,713.4 contact hours, 3,418.9 are allocated to the extremities, 592.3 of these to the hand. In fourth year, out of a total of 2,155.5 contact hours, 772.5 are allocated to the extremities, 132.3 of these to the hand.

Conclusions. Subjects that treat the hand are predominately included in the academic curriculum for a Degree in Physiotherapy during the first and second academic years. In fourth year, when the curriculum focuses on specialization subjects, a deficit in the number of credits precludes adequate expert training in physiotherapy of the hand.

Susana Rodríguez Paz 1, Aureli Oriol Segura 1, Ruth Galtés Fuentes 2, Antonio Rañé Tarragó 1, Francisco José Peris Prat 1

1 IAS Parc Hospitalari Martí i Julià de Salt, Girona, Spain; 2 Central University of Catalonia, Manresa, Spain

Lipomas are bening tumours uncommon in the hand and giant lipomas are extremely rare. We present a case of a large giant lipoma of the hand with neurological injury after surgery.
Material and Methods.
A 59-year-old man presented with a 2-year history of painless slow increasing in size mass in the volar aspect of the right hand. The mass was fluctuant and without inflamatory signs. No functional deficit non neurological symptoms were reported. A nuclear magnetic resonance was performed to reach a diagnosis, to assess the full extent of the lesions (75 cm in length, 65 cm width and 30 cm depth) and to aid in preoperative planning.
Elective excision of the lesion was underwent in two months and a half with a modified Brunner’s incision from the third interdigital space to the thenar area and with a carpal tunnel extension. The lipoma was located below the palmar fascia with occupation of the interdigital spaces, dissecting and engulfing the neurovascular bundles and tendons, but without infiltration. The mass was excised and the carpal tunnel was decompressed. Histology confirmed a lipoma with no evidence of malignancy. At postoperative assessment the patient had a well-healed scar without infection. Six moths of hyposthesia of the ulnar aspect of the third finger and the radial aspect of the fourth finger was fully recovered. There was good function and no clinical recurrence was observed after a mean follow-up of three years.
The giant lipoma of the hand presented is one of the largest reported to date. A radiological examination must be performed before surgery because any soft tissue mass greater than 5cm (defined as giant lipoma) must be considered malignant until proven otherwise. A carefully dissection must be performed to avoid neurovascular damage.

Carlos Eduardo Torres Fuentes, Rafael Arturo Brunicardi Hurtado, Ana María Sastre.

Hospital de San José – Sociedad de Cirugía de Bogotá. Fundación Universitaria de Ciencias de la Salud. Bogotá, Colombia.

Brachial Plexus tumors are rare and usually benign. Affecting patients ranging in age, finding reports from 19 to 71 years old. The clinic is characterized by 60% of cases as a palpable mass; 44% of patients report paresthesias; 44% state radicular pain, 16% of them have localized pain and 12% weakness. Type 1 Neurofibromatosis is an dominant autosomal disorder that affects about 1 in 3,500 live births and should be suspected in the presence of multiple neurofibromas, “café au lait” spots in the skin, Lisch nodules on the iris, optic gliomas , lipomas, sebaceous adenomas, intestinal tumors, kyphoscoliosis, nonunion of the tibia, among others. Although neurofibromas are commonly seen in many parts of the body, it is quite uncommon to find them in the Brachial Plexus.

We present a 22 years old male patient diagnosed with Neurofibromatosis type I, who visit our Hand Surgery Service with 7 years of evolution of the symptoms characterized by a progressive growth in the last 2 years of a tumor in the neck, axilla, lateral thoracic, and left arm. In addition, he refers pain and dysesthesia with palpation of the tumors. Previously, he had been taken to surgery for resection of other injuries, with positive plexiform neurofibroma histopathological report. We bring the patient to surgical resection of the tumors, with intraoperative find of a lobed, indurated, encapsulated injury, with significant infiltration of brachial biceps muscle. The motor branches of the musculocutaneous nerve and median nerve as the humeral vessels were identified and dissected. Then, dissection is continued to left chest, showing a mass of the same characteristics that infiltrates the pectoralis major, latissimus dorsi and axillary vessels, extracting total mass of 1,630 g weight

Postoperatively, the patient expresses great satisfaction with excellent postoperative course, without loss of function of the limb.

Neurofibromas have been reported in many parts of the body, however, are rare in the Brachial Plexus. The following case report shows a patient with a giant neurofibroma of 1630 grams, which makes it unique in the literature.

Danny Onzaga Barreto, Rafael Arturo Brunicardi Hurtado, Jaime Ernesto Forigua Vargas.

Servicio de Cirugía de la Mano, Hospital de San José – Sociedad de Cirugía de Bogotá. Fundación Universitaria de Ciencias de la Salud. Bogotá, Colombia.

Tuberculous osteomyelitis is rare, representing 3 to 5% of all types of tuberculosis and about 15% of extrapulmonary tuberculosis, ranking third after the Urogenital and Nodular. If the location at hand is rare, constituting a 2 to 4%, the location in carpal bones is exceptional.

It usually occurs in children younger than 4 years and in adults between 20 and 50 years old. Tuberculous osteoarthritis usually leads to a subacute or chronic stage, evolving progressively.

Generally, the time between the onset of symptoms to diagnosis varies on average between 8-21 months, which explains the delay in diagnosis and the destructive nature of the disease. As mentioned above, the symptomatology is insidious, besides present with nonspecific symptoms characterized by pain, swelling, and stiffness, associated with functional limitation. Edema may be due to joint effusion, synovial hypertrophy and / or abscesses that are up to 25% of cases.


We present a 73 years-old woman, with 18 months of edema and progressive pain in her right wrist. She was treated in another institution by Rheumatology as rheumatoid arthritis, which was infiltrated twice with corticosteroids in her wrist. Given the persistence and increased symptoms, was assessed by the Hand Surgery Department, and after observing lytic lesions in the distal radius and ulna, in the proximal two thirds of the metacarpals and carpal bones with structural collapse, and loss of the bone architecture, was taken a biopsy reported as a granulomatous infiltrate.

New biopsy and culture samples was taken and reported negative for BAAR, acute osteomyelitis and growth of Staphylococcus epidermidis, which perform surgical debridements, aplication of external fixator to prevent further collapse of the wrist bones and initiate intravenous antibiotics, with partial improvement for two months. Given the persistence of symptoms, a new biopsy was taken and granulomatous reaction is reported again. Blood markers (CRP) are taken where the diagnosis of tuberculosis is confirmed.

Because of the advanced progression of the disease, bone destruction and poor therapeutic response, limb amputation was proposed, which is not accepted by the patient, so limb salvage arises with the technique of induced membrane described by Masquelet.

In a first surgical time, complete resection of the carpal bones, the distal end of the radius and ulna, and the proximal part of the metacarpals was performed. The defect was filled with bone cement spacer with antibiotic for 6 weeks. Then the cement was removed and autologous cancellous bone graft taken from the core of both femurs. The wrist was fixed from the radio to the second and third metacarpal with two plates of 3.5 mm and the external fixator was removed.

After a year postoperatively, the patient is satisfied with the limb salvage with acceptable function of his hand and integration of the bone grafts.

The induced membrane technique described by Masquelet in 2010, can be an alternative in the treatment of large bone infections in the hand and wrist, saving the hand and preserving some function.

Chaoqun Yang, Yi Zhu, Jifeng Li, Jianguang Xu, Lei Xu

Department of Hand Surgery, Huashan Hospital, Fudan University

Introduction: To investigate the reliability of a newly electrodiagnosis method for rat’s Neurogenic Thoracic Outlet Syndrome (nTOS) by applying TES-MEP (Transcranial Electrical Stimulation Motor Evoked Potential) combined with PNS-CMAP (Peripheral Nerve Stimulation Compound Muscle Action Potential) technique.
Methods: Superior trunk model and inferior trunk model of nTOS were configured
on 72 male SD rats, divided into six experimental groups respectively. Latency, amplitude and isolateral amplitude ratio of TES-MEP and PNS-CMAP were recorded in the different intervals postoperatively.
Results: Latencies of TES-MEP and PNS-CMAP were firstly elongated in the 8-week group. Amplitudes of TES-MEP and PNS-CMAP were firstly attenuated in the 16-week group. Isolateral amplitude ratio of TES-MEP to PNS-CMAP was apparently decreased, and spontaneous activities emerged at 16 weeks postoperatively.
Conclusion: By analysing relativity between electrophysiological and histological study of rat’s compressed brachial plexus nerve, an electrodiagnosis criterion of rat’s nTOS was established preliminarily.

Mohammad Javad Fatemi1,zahra Orouji2,hesam Shobeyri1,Saeid Shafeiyan2,Ehsan Taghi Abadi2,Mitra Niazi1

1Burn research center,iran university of medical sciences,tehran .Iran;2Department of Regenerative Biomedicine at Cell Science Research Center, Royan Institute for Stem Cell Biology and Technology, ACECR, Tehran, Iran

Background: Epidermplysis bullosa (EB) is a genetic disease with skin fragility and instability at the junction of dermis to epidermis. Severe deformity of hands because of scars and adhesions leads to lose the proper function of hand which affects the quality of patients’ life. Covering the wound after opening adhesion is the major problem in the way of reconstructive surgeons. Our purpose in this study is to use allogeneic fibroblasts amnion after surgery as a cover in patients to prevent further adhesion.
Material and methods: this is an interventional study on 6 patients who suffer from Epidermplysis bullosa with deformity and adhesion. We took a skin sample from back of one of parents’ ear. Then fibroblast was separated, cultured and transferred to the amniotic membrane. After separating the full adhesion, all parts without skin were covered with the allogeneic fibroblast amnion. Furthermore, speed, quality, recovery time of wound were examined as well as range of motion in finger joints and the pressure on the skin.
Results: results showed us wound healing improved and time of healing varied between 15 to 29 days. The average time of treatment was 23.1 days with the standard deviation of 77.3. Restored skin could perfectly tolerate the pressure of rehabilitation activities and splint.
Conclusion: allogeneic fibroblast with a scaffold like amnion can reduce the need for skin graft in patients with Epidermolysis Bullosa. Normal allogeneic fibroblast and disability of releasing collagen seven in these patients can be considered as an effective factors in wound healing and show better results than autogenic fibroblasts.

Fernando Vanoli, Federico Paganini, Luciano Gentile, Marcelo Gastaudo, Christian Allende.

Instituto Allende de Cirugía Reconstructiva de los Miembros. Sanatorio Allende, Córdoba, Argentina

Introduction: Intraoperative C-arm fluoroscopy help surgeons achieve anatomical reduction, adequate stability, and less invasive approaches. Although there are clear benefits in their use, radiation exposure is still a problem and its use is associated to increased risk of cancer.
The objective of this study is to provide reference values of the doses of radiation absorbed by surgeons during open reduction and internal fixation (ORIF) of distal radius fractures and to compare surgeons radiation exposure at different sites (thorax, neck and wrist).
Methods: We prospectively evaluated radiation exposure in all distal radius fractures treated by ORIF with volar locked plates, by two surgeons, between May and December 2015. A Siemens Siremobil Compact L C-arm was used. Distance from C-arm tube to wrist was 25cms. Radiation exposure was measured using three AGFA dosimeters, one placed in surgeon’s thorax (covered by a lead vest), a second one in the neck (external to a thyroid lead protector), and the third one in the wright dominant wrist of the surgeons. Henry’s approach, AO classification and a volar locking plate were used. A relative radiation index (RI) for each surgery was constructed in order to identify differences among sites. RI was defined using the cumulative dose received and number of surgeries, weighted by fluoroscopy time of each surgery. All analysis were performed in the software Stata 14.0 (Stratacorp LP. College Station, TX: USA, 2014).
Results: We evaluated 50 patients. 64% were female, age averaged 53,16 years (SD 15,19) (range, 23 to 78). 54% of fractures were type A, 14% type B, 32% type C, according to the AO classification. Surgical approaches averaged 4,28 centimeters in length (range, 3 to 6,5).
Surgical procedure duration averaged 40 minutes (SD 2.06), and there was statistically significant difference between both surgeons (43 versus 36 minutes, p=0.0436). C-arm exposure time averaged 75 seconds (12 to 450); current used by the c-arm averaged 0,65 mA (SD 0,20).
Significant differences between surgeons (p=0.007), and among sites (p<0.05) were found, showing that there is less radiation in thorax compared to both other sites. In one surgeon, thyroid relative radiation index was the highest one (0.0071), while there were no significant differences in the other surgeon (p=0.545). Distribution pattern of relative and pondered doses, described through the total relative radiation index, was different between surgeons (surgeon 1: thorax 8, wrist 50, neck 42, surgeon 2: thorax 15, wrist 31, neck 54).
Conclusions: In ORIF of distal radius fractures surgeons are exposed to direct radiation during C-arm fluoroscopy, which is needed for indirect reduction techniques and less invasive approaches. This study evidenced that there is significant difference in the amount of irradiation exposure between surgeons and among body sites evaluated (Thorax, thyroid and wrist). The amount of radiation exposure received by surgeons in distal radius fractures cannot be associated to increased risk of cancer or malignancy development.

Marcella Rodrigues Costa, Tailsom Nunes Chaves de Queiroz, André Lourenço Pereira, Guilherme Ferreira Simões

1 Federal University of Minas Gerais (UFMG); 2 Risoleta Tolentino Neves Hospital; 3 Hospital da Baleia – Benjamim Guimarães Foundationl; 4 Hospital das Clinicas (HC- UFMG), Belo Horizonte, Brazil.

Objectives: Ray resections were first described about a hundred years ago and were used as salvage procedures. This surgical technique, when used properly, can enhance the function and aesthetics of the affected hand and thus reduce economic and social impact caused by a dysfunctional hand. The objective of this study was to analyze publications on fingers amputation and define the main indications and surgical techniques, contraindications, advantages and disadvantages, management, outcomes and complications. Materials and methods: This paper was based on a literature review of the topic in database, using the most popular searching tools, and reference books for the orthopedic community, totaling analysis of 40 publications between the years 1947 and 2015. Our experience with finger amputation is mainly related to cases of trauma received in a reference hospital in care of polytrauma patients. Results: Resections of the fingers ray are indicated for non-functional digits, usually limited by pain, stiffness, and important changes in length or lack of sensitivity, mainly due to trauma, infection, tumors, vascular insufficiency or Dupuytren's contracture. This procedure should only be performed in the absence of another that better preserve the hand function and of psychological patient barriers. The main advantages are elimination of pain and gaps between fingers, and functional improvement and aesthetics. The main disadvantages include loss of grip strength and pinch, reduction of the palm width and number of fingers. Resections are classified into the first ray amputation (thumb), resection of the central rays (third and fourth finger) and marginal rays (second and fifth finger). Indications for thumb ray resection are very limited due to the importance of this digit to hand functions and therefore the surgical reconstruction is preferred. Amputation of each ray has its own techniques. The resection of the marginal fingers is accomplished without the need for transposition and the proximal part of the metacarpal must be preserved. Furthermore, the technique that has shown more satisfaction to the central resection is the transference of a marginal finger to the remaining central basis. Postoperative care should focus on immediately begin of flexion and extension exercises, and as soon as tolerable, start physical therapy for rehabilitation. It is expected complete rehabilitation of the hand in 3 months. Most patients reaches hand strength about 70% to 85% compared to the contralateral side, although decreased dexterity is reported in some cases. The main complications are infection, wound dehiscence, nonunion, malunion, stiffness, neuroma, adherence of tendons and excess or shortage of skin. Conclusion: Ray resections of the fingers results in good aesthetic and functional outcome when the presence of an abnormal finger without reconstruction possibility interferes with the function of the hand. Typically, patients are satisfied with the surgery and return to their initial occupation in few months. Some patients could experience post-traumatic stress, depression, sleep disorders, and should be advised and assisted by psychologists or psychiatrists. We have registered cases of loss of substance and hand coverage, treated with the finger ray amputation, with excellent functional results, fast recovery and good visual appearance.

Isidro Jiménez, Alberto Marcos-García, Gustavo Muratore-Moreno, José Medina

Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain

Management and indications for surgery in the tetraplegic patient are highly complex because of the substantial functional deficits that they present and its effect on their daily activity.

To evaluate the functional outcome in tetraplegic patients who underwent biceps-to-triceps transfer surgery according to Zancolli’s modified technique in our center.

Materials and Methods:
This is a retrospective study of six biceps-to-triceps transfers using Zancolli's modified technique in four patients. All patients were assessed and followed by a multidisciplinary specialized spinal cord injury team.
Surgery was performed under general anaesthesia, with the patient in the supine position, without tourniquet, with the arm positioned on a surgical hand table and using magnification loupes. The biceps muscle and tendon were delivered into the posterior incision through a medial subcutaneous tunnel. The biceps tendon was sutured in a Pulvertaft fashion into the distal triceps tendon with a nonabsorbable suture keeping the elbow fully extended. We used an articulated elbow brace in extension and, from the fifth week, an active flexion rehabilitation programme progressively began.
We evaluated each patient's DASH score before surgery and 12 months later.

Average age of 28.2 years at the time of surgery. The average time from injury to the surgery was 27 (14-57) months and follow-up was 45 (18-92) months.
In the six arms, full and active elbow extension against gravity at 12 months after surgery was achieved. The mean DASH Score was 73.2 preoperatively and 20.8 12 months postoperatively. One patient reported loss of elbow flexion preventing thigh lift for transfers. This was resolved with a programme of rehabilitation and specific muscle strengthening. No other complications were notified.

Zancolli’s modified technique is simple and effective, with few complications whereby we can provide more autonomy for the tetraplegic patient.
We do not really know the validity and applicability of DASH questionnaire on these patients. We believe that validating a specific functional questionnaire on these patients is necessary.

Isidro Jiménez, Alberto Marcos-García, Gustavo Muratore-Moreno, José Medina

Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain

Lateral epicondylitis is a common injury in population. Most patients improve with conservative treatment but, a in a small percentage, surgery is necessary.

To analyze the clinical results obtained by a "four surgical tips" technique.

Materials and Methods:
This is a retrospective study of 35 operated elbows in 31 patients during 2004-2012 period. Mean follow-up was 5.3 years. In all cases epicondylar denervation, removing of the angiofybroblastic degeneration core, epicondylectomy and release of posterior interosseous nerve was performed. Surgery was done under regional anesthesia, preventive tourniquet, magnification loupes and using an outpatient surgery program. We evaluated each patient´s Broberg and Morrey Rating System (BMRS), Mayo Elbow Performance Score (MEPS), Visual Analogue Scale (VAS), DASH questionnaire and a survey of subjective assessment.

Using the “four surgical tips” technique, we obtained a clinical resolution of symptoms (VAS 0) in 80% of patients, VAS reduction >50% in 14% of patients and VAS reduction <50% in 6%. BMRS mean score was 97.2 points, MEPS of 95.71 points. The average reduction in VAS was 8.12 points (p<0.00) and average DASH score was 1.68 points. 94.3% of patients rated the result as excellent or very good. There was one recurrence solved by a new operation. Two neuroapraxia of the posterior interosseous nerve occurred that were completely recovered in 10 weeks.

We believe this “four surgical tips” tecnhique is an effective, reproducible and with few complications technique in surgical treatment of lateral epicondylitis resistant to conservative treatment. Our results, certainly satisfactory, should not make us forget that surgical treatment will remain insufficient while the pathophysiology of this lesion still unknown.

Isidro Jiménez, Gustavo Muratore-Moreno, Alberto Marcos-García, José Medina

Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain

Stiffness is one of the worst complications in Hand Surgery. Its conservative and surgical management is not easy and its results are usually unfortunately poor.

To analyze the results in surgical treatment of metacarpophalangeal stiffness by dorsal tenoartrolisis in our center and review the literature.

Materials and Methods:
This is a retrospective study of 21 metacarpophalangeal stiffness treated surgically. In all patients, dorsal tenoartrolisis was carried out. Rehabilitation programme started ten days postoperatively. Each patient was evaluated achieving the etiology, variation of active mobility pre and postoperatively, complications DASH questionnaire and a survey of subjective assessment.

Mean follow-up of 6.5 years and mean age of 36.5 years. The most common cause was a metacarpal fracture (52.4%) followed by complex trauma of the forearm (19%). Improvement in active mobility was 30.5º despite obtaining an intraoperative mobility 0-90º in 80% of cases. Mean DASH questionnaire score was 36.9 points. The result was described as excellent in 10% of our patients, good in 30%, poor in 40% and bad in the 20% remaining. Complex Regional Pain Syndrome type I in 9.5% of cases and intrinsic muscle injury in 14.3%.

Because of its difficult management and poor results, surgical treatment of metacarpophalangeal stiffness in extension is highly complex being the dorsal tenoartrolisis a reproducible technique according to our results and results reported in the literature.

Agustina Davalos 1 2, Lucia Pastorino 1,Elena Santamarina1, Paula Símaro 2, Gerardo Gallucci1

1 Hospital Italiano de Buenos Aires 2 Private hand therapy clinic Dávalos

The surgical alternatives for the treatment of this pathology give optimal results and provide the required stability to carry out an early rehabilitation. The aim is to evaluate the effectiveness of an early rehabilitation protocol in a patient with biceps repair.

Materials and Methods
9 Patients were treated from 2010 to 2015. 1 presented associated injuries. Average age was 47 years old. 8 males. 8 Patients with distal biceps suture treated by the same therapist were evaluated retrospectively. They were immobilized with an elbow thermoplastic orthosis during the healing period of 8 weeks, with the elbow in 60º of extension and the forearm in neutral position. 15 days post-surgery, active and passive controlled exercises without orthosis were performed during 8 weeks. After that, 15 days of progressive strengthening without immobilization orthosis. In the 10th week, pain was evaluated by Visual Analogue Scale, range of motion by goniometer, strength by dynamometer; function, daily life activities and personal satisfaction by Quick Dash. Wound and sensibility were also evaluated.

The average of initial pain measured by VAS was 5 (range 0-5). At the end of treatment an average of 2,5 (range 1-10) was achieved. Function showed a VAS average of 10.
The average of fist strength on the injured side was 58kg; and the one from the healthy side was 132kg. 100% showed satisfaction at the end of rehabilitation. Initial Dash score was 77, while at the end of treatment was 4,5. Goniometer outcomes did not show significant differences in comparison with the contralateral side.

The obtained outcomes demonstrate that a specific rehabilitation programme allows to control pain, improves function without producing any alteration in the healing process of the biceps suture, integrating it at their daily life with the maximum of motion as possible.

Filipa Santos Silva, Carolina Baptista, Ana Marta Coelho

Hospital Beatriz Ângelo, Loures, Portugal

Objective: Hemi-hamate arthroplasty was first described by Hastings in 1999 as an alternative treatment for the management of severe proximal interphalangeal (PIP) fracture-dislocation. This technique can be used for the reconstruction of the base of the second phalanx in acute PIP fracture-dislocations or as a salvage procedure in chronic fracture-dislocations.
The purpose of this retrospective study was to evaluate the clinical and radiographic results of hemi-hamate autograft for the comminuted PIP fracture-dislocations.

Materials and methods: Five patients (mean age 37 years) underwent hemi-hamate artroplasty for the treatment of an unstable PIP fracture-dislocation. One of them had a previous fixation of the fracture with a mini external fixator due to a comminuted fracture involving rupture of the dorsal cortex of P2.
The surgical technique involved debridement of the facture line and filling of the osseous defect with a size-matched autograft of the distal and dorsal portion of the ipsilateral hamate. The graft was then fixed to the dorsal cortex of P2 with mini-screws, thus re-establishing the proximal articular surface. Two of the patients were treated acutely (< 4 weeks) and in the remaining patients surgery was delayed (mean 31 weeks). The average middle phalanx volar lip destruction was of 59% (range, 45% to 80%) and it was measured in pre-operative x-rays.
Functional outcomes were assessed by objective and subjective measures: range of motion, grip strength, joint alignment and stability, Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score, visual analogue scale (VAS) of pain, satisfaction and return to work. The x-rays were evaluated for union, articular congruence and/or graft reabsorption or collapse. Complaints related to the donor site were also addressed. The mean follow up was of 24 months.

Results: The average PIP active motion was of 83º (acute 90º, chronic 70º) with a mean flexion contracture of 20º (range, 14º to 22º). Average active distal interphalangeal motion was 60º (acute 75º, chronic 52º). Grip strength averaged 85% of the other hand. There was no coronal or sagittal instability. The mean Quick DASH score was 2,3 (acute 3,4; chronic 1,2). Final X-rays were obtained at 12 months post-operative and union was observed in all patients. Mean VAS pain rating was 1, with higher values observed in chronic cases. None of the patients had complaints related to the donor site and all of them were satisfied with the result of the surgery. Three patients never interrupted work (one acute and one chronic) and the remaining returned to work in 60 days.

Conclusions: PIP fracture dislocations are extremely complex lesions and very difficult to address with the current ostheosynthesis techniques. The incapacity to adequately restore the joint surface can result in pain, stiffness, chronic instability and osteoarthritis. Hastings’s technique creates a joint surface very similar to the original one, reestablishing joint stability and allowing for early mobilization. The results with chronic cases are not optimal but patients show great satisfaction with the surgical treatment. Thus, our results seem encouraging when compared to the results of ostheosynthesis or other salvage procedures results.

Seungyong Sung, Whanyong, Jung

Catholic Kwandong University College of Medicine, International St. Mary's Hospital Incheon Metropolitan City Republic of KOREA

The purpose of this study was to investigate the clinical and radiological outcomes following open reduction and internal fixation of unstable or displaced distal ulnar (metaphyseal or articular) fractures that persists after reduction and fixation of the associated ipsilateral distal radius fracture. We retrospectively reviewed 48 patients(the mean age, 42 years) with unstable distal ulna and radius fractures. All radiuses were fixed internally with volar locking plates. The unstable displaced fractures of the distal ulna were treated with open reduction and internal fixation with Kirschner wire or with plates and screws. The mean final follow-up period was 36 months (range, 22–54 mo). Clinical outcomes were evaluated using a visual analog scale for postoperative pain; Disabilities of the Arm, Shoulder, and Hand scores; active range of motion; grip strength; and the radiological outcomes, including ulnar variance, were evaluated. There were no significant differences between the group fixed with Kirschner wire and the group fixed with plates and screws in any of the clinical outcomes and radiological outcomes. All distal ulna and distal radius fractures united at 12 weeks, and the mean VAS and DASH scores were 2 and 12, respectively. The average motion was: flexion 56°; extension 59°; pronation 64°; and supination 70°. Average grip strength was 97% of the opposite extremity. Final ulnar variance averaged −0.3 mm (ulnar negative), radial inclination was 22°, and volar tilt was 9°. All distal radioulnar joints were stable at the final follow-up. Open reduction and internal fixation of unstable distal ulna fractures, in the setting of an associated distal radius fracture, resulted in union, good to excellent alignment and motion, nearly symmetric grip strength, and minimal transient morbidity.

Jae doo Joo, Ja Hea Gu

Department of Plastic Surgery, Dankook University

For unstable fracture-dislocation of the fifth CMC joint, the authors prefer closed reduction and percutaneous pinning. Pin fixation methods are versatile in fracture fixation and there are various complications associated with the K-wiring procedure such as osteomyelitis, tendon rupture, nerve lesion, pin tract infection, pin loosening, migration and fractures through the pin site.
In our literature, a case of iatrogenic fracture after failed K-wire fixation in the management of a CMC joint fracture-dislocation has not yet been reported. We present a K-wire-related complication in the management of a CMC joint fracture-dislocation and would like to highlight the importance of planning K-wire placement and minimising the number of K-wire passes.
Materials and Methods
After having banged against the wall, a 22-year-old patient visited our clinic with a complaint of swollen and painful wrist. Computed tomography (CT) and x-ray were performed, and the diagnosis of posterior dislocation of the 4th and 5th metacarpal bases in the carpometacarpal joints (CMCJ) was made and fractured tiny bone fragments were found in the ventral side of the CMC joint. Although closed reduction was attempted, CMC joints were unstable. For unstable fracture-dislocation of the CMC joints, we prefer closed reduction and percutaneous pinning. According to our protocol, reduction was achieved by longitudinal traction and lateral pressure on the displaced bone. Firm fixation with a transarticular pin and transfixation pins into the adjacent metacarpal was performed to allow early motion. During these procedures, a junior surgeon from our team tried inserting transfixation pins with a 1.1 mm K-wire into the metacarpal shaft, but failed. The authors thought that it will heal and unite with splinting, and hence, they just follow their usual protocol. We reviewed him at 5 weeks, removed the K-wires and began mobilisation. Two weeks later, he noted acute onset of pain and swelling at the 5th metacarpal area. A radiograph of his hand was taken and it demonstrated a fracture through the metacarpal shaft where the K-wire had failed to enter the bone.
He was treated with an ulnar gutter splint for the second fracture and he made an uneventful recovery. However, his wrist needed to be immobilized for more than 8 weeks.
Multiple passes of the K-wire onto cortical and cancellous bone result in blunting of the K-wire and subsequent heat generation. A zone of necrosis around the pin site can lead to subsequent loosening and loss of fixation. Surgeons should be aware of the potential damage to bone during K-wire fixation. Preoperative planning, marking the K-wire route on the skin and appropriate K-wire thickness minimise complications. Patients should be told that following K-wire removal, the residual holes could subject to stress risers and that several weeks are needed before they can use their injured hand normally.

Michael Schenker, Sammy Al-Benna

Division of Plastic Surgery, Sheikh Khalifa Medical City, Abu Dhabi, United Arab Emirates

The free groin flap was used for the first successful microsurgical skin flap transfer in history. The use of this flap has now largely been abandoned giving preference to flaps with a longer pedicle and more constant anatomy. For cover of the hand and wrist, the antero-lateral thigh or lateral arm flap are considered more suitable and technically less challenging. The objective of this study was to examine whether the free groin flap remains a contender in the search for the best free skin flap to cover larger defects of hand and wrist.

Materials and Methods:
A retrospective case review of free superficial circumflex iliac artery skin flaps (SCIAF) from a single surgeon. Data are presented for patient characteristics, details of flap transfer and donor site morbidity. These data are compared to the use of the free lateral arm flap (LAF) and free antero-lateral thigh flap (ALTF) for reconstruction of defects to hand and wrist by the second author.

A total of 54 cases of free flap transfer to the hand or wrist were identified. Patient age range was from 8 to 77 years. Flap survival was 100% SCIAF; 89% LAF and 97% ALTF, respectively. LAF and ALT flaps needed more additional operations to the recipient site related to complications of the flap than the groin flap (44% vs. 28% vs 17%; p<0.01). In addition, 38% of ALT flaps underwent secondary thinning. Donor site complications only occurred with the ALTF with 8% undergoing scar revision. Neither of these procedures were required for SCIAF or LAF.

This study shows that the free groin flap contends well for hand and wrist cover, where a short pedicle length is not a problem. This is because the flap is naturally thin, rendering good contour of the hand. It rarely requires adjustment procedures. The free groin flap has a reputation for technical difficulty, but there was no failure to the hand or wrist. In the wider experience of the first author with this flap, only one failure was directly related to anatomical variation. In fact, this flap is ideal for a microsurgeon on his or her learning curve, because its donor morbidity is virtually non-existent. It may well be called a “disposable flap”, where the second available flap could be taken with impunity in case of failure.

Douglas Price Ana Laura, Torre Candelaria,Quispe Cintia, Blanchetiere Hernán, Pemoff Adriana

General Hospital Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina

Mercury is a chemical element commonly known as quicksilver and is the only metallic element that is liquid at standard conditions for temperature and pressure. The toxic effects of mercury after subcutaneous injection are not, at least initially as serious as those after acute inhalation. When the mercury penetrates the bloodstream, it is rapidly distributed, especially into the lungs. The local toxic effect of subcutaneous administration of mercury is an acute inflammatory reaction that progresses to granuloma formation, fibrosis, and necrosis of the subcutaneous tissue. In every instance, surgical excision, debridement of the accessible areas where mercury has accumulated is necessary, regardless of whether systemic symptoms are present.

The aim of our work is present a single case of self-injury with intravenous and subcutaneous injection of Mercury.

Material and Method:
We present a male patient of 21 years old who was referred to our hospital ten days after receiving self-inflected wounds by subcutaneous and intravenous injection of mercury in both forearms and left hand. He had obtained the mercury from his mother's work (dental mechanic). He was treated previously in to centres where they provide medical support but none surgical procedure was performed. At admission to our hospital, he presented erythema around multiple punctiform lesions caused by attempted intravenous injections. We also found presence of ulcerated lesions with erythematic halo in proximal third of the right forearm and ulnar fossa with serous and haematic debit, presence of multiple materials and silver beads, indurated lesion in the proximal third of the left forearm in ulnar side. In the dorsum of his left hand a fluctuating lesion was found, as well as perilesional erythema and redness. At the beginning no sistemic symptoms of mercury poisoning was detected. A full screening was performed including tomographic angiography, echocardiogram, renal ultrasound, where lesions consistent with mercury poisoning were found, as well as multiple lungs microembolism. In x-ray of both upper limbs radiopaque images with density of metal were seen. We performed a surgical procedure with extensive debridement guiaded by x-ray in both upper limbs. A second look was performed 48 hours later.

In the postop, the surgical wounds of left forearm evolved with dehiscence that requires daily care with silver sulphadiazine until the wound closure. In postop x-ray the extensive debridement with decrease of radiopaque material was checked. In the follow up the patient didn't show systemic symptoms of mercury poisoning.

In conclusion, when faced with this uncommon form of mercury intoxication, the emergency surgical approach should be based on preventing the metal from spreading by ligating the affected vessels and excising as many mercury deposits as possible from the subcutaneous tissue due to the certain possibility of spreading of mercury from the subcutaneous tissue to lungs and pericardiac.

Blanchetiere Hernán, Cuestas Nicolás, Torre Candelaria, Gomez Avellaneda Ivonne, Pemoff Adriana

General Hospital Juan A. Fernández, Ciudad Autónoma de Buenos Aires, Argentina

Supernumerary muscles in hand and wrist have been described in the literature, most frequently as casual discovery in imaging studies, cadaver dissections or surgical findings. One cadaveric dissection study talked about a prevalence of 12,8%. The most frequent anomalous muscles found are: palmaris longus (PL) and flexor carpi ulnaris (FCU). Variations and aberrant bellies in the abductor digiti mini (ADM) have also been encountered. When this muscles are present there is probability of ulnar nerve compression in cases of overuse syndrome and repetitive trauma due to muscle hypertrophy. However, idiopathic causes have been reported. We described an unusual case of ulnar nerve compression at the wrist by a supernumerary ADM muscle.
The aim of our work is to present a single case of a symptomatic anomalous abductor digiti mini in a child and the treatment performed.
Material and Methods: A 12 years old, right-handed female patient was evaluated to our centre, for 6 months of gradual onset of pain, misfunction and sensory disorders of fourth and fifth fingers of her left hand with positive Wartemberg´s Sign.
The clinical examination revealed hyperextension of fourth and fifth metacarpophalangeal joint, claw hand, hypoesthesia an hypotrophy of hypothenar eminency and positive Tinnel sign in Guyon´s canal.
The electromyography reported decreased ulnar nerve distal latency from Guyon´s tunel. Ultrasonography and conventional magnetic resonance (MR) scan did not show any space-occupying lesion or nerve disturbance. However a high-resolution MR scan revealed an aberrant muscle belly crossing the ulnar nerve in Guyon´s tunnel with nerve constriction and swelling signs.
We performed ulnar nerve release through a volar S shaped approach in the wrist. The anomalous muscle belly was origined from the flexor carpi ulnaris crossing the Guyon´s tunnel and the neurovascular bandle and ended in the hypothenar aponeurosis. We made the excision of the aberrant muscle and sent it to anatomo-patological study. The next day the patient referred an immediate improvement of the sensory symptoms. At 10 days, she started a rehab programme based on electrostimulation, active joint movement and strengthening. 4 weeks later, she regained hypothenar eminence tropism. At 6 weeks, the patient had total resolution of the sensitivity and function, with little finger adduction power of 5/5. She was able to return to full duty school activities.
There are many descriptions of wrist aberrant muscles in the literature. The abductor digiti minimi is the most variable hypothenar muscle. It can present one to three muscle bellies. Accessory abductor digiti minimi can originate from the tendon of the flexor carpi radialis, the palmaris longus, from the flexor carpi ulnaris or from the antebrachial fascia. In our patient we described the origin from de flexor carpi ulnaris and the end in the hypothenar aponeurosis. Although aberrant muscles in hypothenar region are uncommon, we should keep in mind when compression neuropathy appears. High resolution MR and electromyography are accurate studies to the confirmation of this etiology.

Gomez Avellaneda Ivonne 1,2, Torre Candelaria1, Blanchetiere Hernán 1,2, Douglas Price Ana Laura 1, Pemoff Adriana 2

1 General Hospital Juan A. Fernandez, Ciudad Autónoma de Buenos Aires, Argentina 2 Fundación las manos del músico, Ciudad Autónoma de Buenos Aires, Argentina

Parsonage Turner Syndrome, Neuralgic Amiotrophy or Idiopatic Brachial Plexopathy, is a painful clinical entity, non-traumatic, uni or bilateral, characterized by sudden onset of acute upper limb pain, most frequently shoulder pain. A progressive muscular atrophy with weakness, corresponding to the neural territory of the affected nerve is found.
It´s an uncommon entity and its diagnosis is made by exclusion of other common pathologies, such cervical spine disease, entrapment neuropathies, and primary shoulder disease. The etiology is still unknown.

The annual incidence reported in the literature is 1,64 -3 cases per 100.000, in USA and England. However, we did not find Latin-American reports with epidemiologic and outcome data.

The aim of our work is to give out incidence, anatomic prevalence and outcome of PTS patients in 2 medical centers of Buenos Aires, with the purpose of showing data in Latin-American population.

Materials and methods:
We performed a 4 years prospective study at 2 medical centers in Buenos Aires, Argentina.
In 4 years, we evaluated 12 patients with upper limb pain.
The inclusion criteria was: pain without other causes, weakness or muscle hypotrophy of the affected region. The exclusion criteria was lack of follow up, associated neurologic disease, previous musculoskeletal anomalies and low adherence to treatment.
There were 12 patients in this period, 2 were dismissed by lack of follow up and 10 met our criteria. All patients had a standard clinical report, EMG 4 weeks after the beginning of pain and gadolinium magnetic resonance (MR) of the affected region.
Patients diagnosed in acute pain period were treated with prednisolone and pregabaline immediately.
Outcome data was obtained with clinical exam every week since the first visit until 4 weeks, then monthly until 6 months, and then once a year.

A total of 10 patients, 6 men and 4 women were included. The average age varied between 18-73, with a median of 62.
The most frequent physical finding and EMG abnormalities were seen in the long thoracic nerve (6), suprascapular nerve (2), and superior trunk of the brachial plexus (2). The gadolinium MR showed hipercaptation on the involved muscle .Only 1 patient was identified in the pain period. Our protocolized treatment consisted of electrostimulation and passive mobilization until the patient gained full passive range of motion and the tropism improved. Afterwards, active mobilization with strengthening exercises and daily life activities integration was performed.

In our population we found an incidence of 0,04% annual. In our cases, 4 patients (44%) had a previous viral infection, more than the data reported in other studies (25%), but also we found a prevalence of the affection of long thoracic nerve (5 patient).
The early treatment with corticoid and pregabaline, according to Van Alfen, diminished the duration of pain.
Only one patient was diagnosed in the pain period: this data reflects the unawareness of this entity.

Nima Naghshineh 1, Kanu Goyal 2, Mithun K. Neral3, Glenn A. Buterbaugh 4, Joseph E. Imbriglia 4

1 Department of Plastic Surgery, University of Pittsburgh Medical Centers, Pittsburgh, PA, USA; 2 Department of Orthopedic Surgery, Wexner Medical Center, Columbus, OH, USA; 3 Department of Orthopedic Surgery, University Hospitals/Case Medical Center, Cleveland, OH, USA; 4Orthopedic Surgery, Hand & Upper Ex Center, Wexford, PA, USA

The proximal interphalangeal (PIP) joint is the third most common site of osteoarthritis arthritis in the hand. The related pain, limited joint mobility, and deformity can be disabling. Arthrodesis can provide pain relief and stability, but at the cost of loss of range of motion (ROM). Silicone arthroplasty was introduced as a method to relieve pain with preservation of function and ROM. We aim to report our mid-term clinical outcomes and patient satisfaction with the use of these implants

A cross-sectional review of subjects who had PIP arthroplasty for osteoarthritis arthritis was performed. Clinical assessment included range of motion, grip/key pinch strength, deformity, and DASH score. Subjective evaluation of function, satisfaction, and pain relief was assessed using a patient questionnaire.

47 fingers in 23 patients with a mean and median follow-up of 45 months were analyzed. Mean age was 62.8 years; 87% were female; with a mean duration of symptoms of 3.4 years prior to surgery.
The ring and long finger were most commonly affected. There was no difference in the pre (59.6°) and post-operative (59.8°) active ROM (p=0.97). Silicone PIP arthroplasty resulted in significant improvement in pain (7.5 to 2.2, p<0.001) and DASH (47.6 to 27.2, p<0.001) scores. There was no difference between the operative and non-operative hand with respect to key pinch (10.5 vs 11.8 lbs, NS) and grip strength (40.3 vs 47.6 lbs, NS).
Patient subjective reports were excellent. Eighty-five percent reported good to excellent pain relief while 93% said that they would have the surgery again. Two-thirds of the patients reported improvement in function greater than 50% and 63% reported significant improvement in deformity.
Most common complications were revision surgery and implant breakage at 20% and 14%, respectively. Univariate logistic regression models showed that pre-operative presence of non-insulin dependent diabetes nearly predicted a 10 times higher odds of revision surgery (p=0.07). Multivariate models did not yield any predictors of revision surgery. There was no correlation between objective grip or pinch strength and subjective strength reports (r=0.03, p=0.85), and no correlation between radiographic or measured deviations and the subjective deformity reports (r=0.20,p=0.45).

Our study has shown that silicone PIP arthroplasty provides considerable pain relief, near normal grip/pinch strength, improved function and high satisfaction for patients in the mid-term.

Mi Jing-Yi

Department of Hand Surgery, Wuxi 9th People's Hospital, Soochow University, Wuxi, Jiangsu 214062 China

Background: To report our experience with the use of modified great toe wraparound flap with preservation of a plantar triangular flap for reconstructing degloving injuries of the thumb and fingers.
Methods: Between 2007 and 2012, 31 patients underwent reconstruction with 37 flaps. 27 patients had 31 flaps for reconstruction of a degloved thumb and fingers, while 4 patients had reconstruction with 6 flaps for degloved fingers only. A modified great toe wrap-around flap with second toe medial toe hemipulp flap on a common pedicle was used for reconstruction of degloved fingers in 4 patients. Twelve patients had long-term follow-up, with a mean duration of 5 years (range, 2 to 8 years).

Results: All flaps survived. The contour of the reconstructed digits was similar to the contralateral one. In patients with long-term follow-up, mean two-point discrimination (2PD) of reconstructed digits was 6.2 mm (range 3 to 8). Mean DASH score was 0.8 + 1.0. Mean Michigan Hand Outcomes Questionnaire (MHQ) score was 87.3 + 3.7. Mean Foot and Ankle disability index (FADI) score was 95.5 + 2.7. The width of the preserved plantar triangular flap expanded from 35% to 67% of the width of the great toe and completely covered the weight bearing area.

Conclusions: Reconstruction of degloved thumb and fingers with a modified great toe wrap-around flap, preserving a plantar triangular flap results in excellent contour and functional outcome. Donor site morbidity in the foot was minimal.

Rose Biggins, David McCombe

The Royal Children's Hospital, Melbourne, Australia

Isolated camptodactyly, a non-traumatic flexion deformity of the PIPJ/s, is reported to be present in 1% of the population with various anatomical structures being implicated.
To treat this condition, wide variation in assessment and intervention approaches have been reported, resulting in confusion as to which approach should be used, or the evidence for these approaches.

This review aimed to examine the evidence for surgical and conservative approaches for camptodactyly and use this evidence, in conjunction with clinical experience, to inform an algorithm for assessment procedures and treatment guidelines.

Materials and Methods
Electronic databases were searched for studies published from 1994 that reported surgical and non-surgical interventions for non-syndromic camptodactyly. Validity and reliability of study findings were evaluated using the appropriate checklist according to the Critical Appraisal Skills Program (CASP). Level of evidence was assigned according to the NHMRC guidelines.

Analysis of the study findings included classification method, primary and secondary outcome measures, interventions used and outcomes achieved, length of follow up and complications. Studies detailing surgical interventions had additional comparisons of preoperative splinting, surgical technique and postoperative regime.

Findings from the literature review were combined with clinical expertise to develop an algorithm for assessment and intervention of children with camptodactyly.

A search of 3 electronic databases yielded six studies that fit the inclusion criteria. All were retrospective case series (NHMRC Level IV) of mixed methodological quality. Numbers of participants ranged from 12-57. Five different methods for classifying camptodactyly were identified. Passive range of motion (PROM) was the primary outcome measure in all studies. Interventions included passive stretch, splinting and surgery. Complications in the splinting and surgery groups included loss of flexion, skin/pressure issues, non-adherence and the need for further procedures.

Direct comparisons of outcomes was difficult due to variable classification methods, age at presentation, variety of intervention methods, and length of follow up.

Stretching in young children yielded promising improvements after 5-13 months: albeit with an intensive protocol. Splinting resulted in mean improvement in passive extension ranging from 9-36°, however treatment time was not detailed. Splint design and wearing regimes varied widely. Surgical intervention was generally completed after failed conservative approaches, with various combinations of release of structures. Postoperative splinting and therapy regimes were detailed in one recent study with a small sample size.

Results from these studies and the authors’ clinical experience were combined to formulate an algorithm for assessment and intervention. Assessment recommendations include: measures of function, pain and cosmesis in addition to bony changes, PROM, AROM and extrinsic/intrinsic contributors to contracture. Intervention recommendations will be detailed: conservative interventions require educating families regarding risks/complications, potential for improvements and expected outcomes. Surgical recommendation include meticulous planning and intensive postoperative therapy.

Limited evidence exists to guide the treatment of isolated camptodactyly in the paediatric population. Following a review of the literature and based on clinical expertise, an algorithm is proposed to guide assessment and intervention for this condition. Further research is required to assess the validity of this algorithm and results achieved from the recommendations.

Martín Caloia, Eduardo Lois, Diego González Scotti, Federico Noguera, Hugo Caloia

Hospital Universitario Austral Pilar, Buenos Aires, Argentina

The ganglion is the most common soft tissue tumor of the hand and wrist. In recent years, this entity has shown a greater tendency of arthroscopic treatment, due to the potential advantages of this technique: aesthetic, less morbidity, lower complication and recurrence rates, a quick recovery and the possibility of assessing intra-articular coexisting lesions. Although recent comparative studies with open techniques reveal that arthroscopic techniques show a lower percentage of recurrence, there is still a problem unsolved: postoperative pain that demonstrate certain patients and recurrence. Despite that pathogenesis is not well defined and therefore the causes of recurrence and postoperative pain, we believe that identifying the pedicle could be a key factor, that determines the appearance of these complications. The hypothesis of this study was to determine, in a group of patients, if the previous dyed ganglions with methylene blue under assistance of high-resolution ultrasound, facilitate visualization of the pedicle, making a more effective arthroscopic resection and reducing the post-operative pain and recurrence.

Material and method
A retrospective evaluation of a series of 21 patients, 18 women and 3 men performed, with a mean age of 36.4 years (range 18 -73), diagnosed with symptomatic ganglia (pain-aesthetic), refractory to medical treatment which they were operated surgically. They were previously studied with clinical examination and Rx- RNM. All patients were prospectively dialing ganglion by injecting 1-3 ml of methylene blue with high-resolution ultrasound assistance, as added to arthroscopic surgical procedure treatment. The average follow-up was 16.3 months (range 12- 27). Exclusion criteria: scapholunate ligament injuries, other locations and ganglion on pediatric population. Postoperative evaluation included: range of motion, pain by visual analog scale (VAS), strength of grip, pain in the scar, recurrence and asked patients, if they were satisfied with the results of surgery and if the return to use if necessary.

Pedicle was shown in 20 patients, 1 case was dismissed by extravasation of contrast outside the cyst due to an error in technique. Twelve patients had the ganglion cyst on her left wrist, 9 on the right side. Recovery of strength fist average 95.71%, full range of motion without recurrence at the end of the evaluation, and also a frank remission of pain (VAS score 7 to 0.2) was recorded. All manifest themselves very satisfied with the results and return to adopt this method of treatment again if it would be necessary. Findings: in 6 patients laxity of the scapholunate ligament was identified and there was 1 case of IB stable TFCC injury. Both lesions were treated simultaneously.

The prior staining with blue methylene under ultrasound assistance proved to be, in the short term follow-up, an essential adjunct procedure for arthroscopic resection of symptomatic wrist ganglion. The rate of recurrence, postoperative pain and patient satisfaction confirm the previously proposed hypothesis.

Martín Caloia, Santiago Lamarca, Diego González Scotti, Hugo Caloia, Federico Nogueira

Hospital Universitario Austral, Pilar, Buenos Aires, Argentina

Preiser's Disease [PD] or Idiopathic Avascular Necrosis of carpal scaphoid is a rare condition of unknown etiology without treatment guidelines to date. Recently, G. Bain et al. have introduced a useful classification and management of the Kienböck disease, using arthroscopic approach. This entity has pathophysiological parameters, like to PD. The purpose of this study was a retrospective evaluation of a number of cases, which were prospectively treated, by cartilage evaluation and decompression of the scaphoid, beneath arthroscopic assistance, adding, as an associate surgical procedure, the metaphyseal core decompression of distal radius, for the purpose of revascularization.
Materials and Methods
They were treated 6 cases of PD of which, 4 patients were retrospectively evaluated with a minimum follow up of 1 year. All were female, two dominant hand. Average age was 31.5 years (range 23-41). Mean follow-up time was 46 months (range 14-96). Preoperative evaluation was made by clinical examination of the wrist, scaphoid 's X-rays projections, and MRI. According to the radiological classification of Herbert & Lanzetta modified by Kalainov, we recorded Stage I: one case, Stage II: 2 cases and only one patient as stage III. We have adapted, the arthroscopic classification of Kiënbock to PD disease, to decide if was possible to make arthroscopic treatment. All cases have received arthroscopic treatment with the following sequence: evaluation the status of the cartilage + synovectomy + decompression of the scaphoid with biopsy and metaphyseal core decompression of distal radius. Postoperative evaluation included VAS score, range of motion, grip strength and X-ray exam to determinate the progression or not have the osteoarthritis of radio-scaphoid joint.

According to arthroscopic classification, of cartilage changes of the scaphoid, we have observed and classified, two cases in stage 0, one as stage I, and another as stage II. Among the arthroscopic findings, we registered synovitis, attenuation/partial rupture of the scapholunate ligament and fragmentation of the proximal pole; all were treated simultaneously, by debridement. Histopathology confirmed osteonecrosis in all cases. In the final functional evaluation a marked improvement was assessed, from the average 8.2 VAS in the preoperative, to a 0.3 in the postoperative, a motion range of 150 ° and grip strength 90 % compared to the healthy side respectively, and a high patients satisfaction rate, with remission of mechanical symptoms. Further Rx studies showed no progression of collapse of the scaphoid or acceleration of degenerative changes in the wrist.
The debridement and drilling of the scaphoid, by arthroscopy assistance, plus the metaphyseal core decompression of distal radius, it constitutes a minimally invasive technique that seems to provide functional encouraging results in early stages of this condition, especially when the necrosis is located in the proximal pole (Kailanov 2). To our knowledge in the early stages of this rare affection, arthroscopy is mandatory for assessment of cartilage and surrounding tissue, since the findings do not match with of images information’s. The core decompression, as in the initials stages of the Kienböck disease, would have the same beneficial effects in this condition.

Hua-Wei Yin, Yu-Tong Chen, Jing Xu, Yun-Dong Shen, Jian-Guang Xu, Yu-Dong Gu, Wen-Dong Xu

Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China

Purpose TFCC is particularly important in maintaining the distal radioulnar joint and the ulnar part of the wrist joint. TFCC injury can cause ulnar wrist pain, severely limiting the wrist function. MRI has been widely employed in diagnosis of TFCC injury. However, literature suggests low diagnostic value of MRI in TFCC injury and its classification. Our aims were to characterize the MRI appearance with new coil and to assess diagnostic accuracy.
Methods All the 53 patients had MRI examination with wrist specific coil, and had wrist arthroscopy after MRI examination. The scanning sequence was T1, T2, T2*, 3DMerg. One senior musculoskeletal imaging radiologists interpreted the examinations independently without prior knowledge of patients’ clinical history. Clinical classification of TFCC injury was implemented by a senior wrist surgery on the basis of the operation note and operation video record. Sensitivity, specificity, and accuracy are presented as percentages with 95% confidence intervals.
Results Sensitivity for TFCC injury detection on MRI was 89.2%. Specificity was 81.3%. Sensitivity was 79.2% for type I TFCC injury detection and 100% for type II. Specificity was 82.8% for type I TFCC injury detection and 89.7% for type II.
Conclusions 3.0T MRI examination with 8 channel wrist specific coil has high sensitivity and specificity for diagnosing TFCC injury, especially for type II TFCC injury.
Keywords TFCC injury; Arthroscopy; Magnetic Resonance Imaging.

Orkun Tahir Aran, Burcu Semin Akel, Çiğdem Öksüz

Hacettepe University, Faculty of Health Sciences, Occupational Therapy Department

Objective: Anxiety in musicians may be reason for musculoskeletal problems according to literature. Increase in muscle tension, alteration in pain perception and exhaustion may lead these problems which can be seen in anxiety. Our aim is to investigate the performance anxiety of musicians in a sample of Turkish musician population.
Method: Forty-eight professional musician were recruited to the study. Inclusion criteria of the participants were to attend at least 1 live performance per week for each musician. Performance anxiety of musicians (PerfAIM) were used to evaluate anxiety. PerfAIM is a 30 item questionnaire which evaluates anxiety about performing, its effect to general health, memory and symptoms related to anxiety like dizziness, muscle spasms, hand sweating, tingling fingers and/or lips etc.
Results: Mean age of participants was 27.17±6.7 years. Forty-four of the participants were playing string instruments, 2 of the participants were playing keyboards, 1 of the participants was playing reed and 1 of the participants was playing rhythms. Mean performing count was 1.2±0.6 days per week. Forty two or the participants were showed right hand dominance and other 2 were left hand dominance. Mean score of PerfAIM was 112.52 ±26.42 which means our sample had normal amount of musician performance anxiety.
Discussion: Anxiety in performing arts is an exhausting issue regarding to problem solving of the musicians. Our sample was consisted of healthy musicians with regular performance in weekly basis. However, further study with musicians in a bigger sample size might show more eligible results. Being a musician, physical and psychological stresses may corrupt hand function while performing. Effects of anxiety in disorders like focal hand dystonia, muscle pain,

Xavier Gueffier, Georges Delalu, Philippe Pernot

clinique saint vincent de Paul, Bourgoin jallieu, France

Intra-articular second phalangeal fracture of the thumb is a rare injury and, in the absence of displacement, is treated orthopaedically. The main complication is secondary displacement. Late-stage management is particularly problematic. The following reports on a case of delayed management of such injury at the fracture-dislocation stage, using a dynamic external fixator.

The patient is a 40 year old municipal employee, right-handed. Injury to his left thumb was sustained while playing football. Clinical examination evidenced a comminuted anterior face fracture at the base of the second phalanx. There was no interphalangeal dislocation. Orthopaedic management was initiated using a thermoformed Stack splint. Radiographic examination was performed on days 10 and 31. A dorsal fracture-dislocation of the second phalanx was observed when the patient was seen at one month. Surgical treatment involved closed reduction under image intensification, using a dynamic external fixator. Post-operative rehabilitation therapy began immediately. The external fixator was removed on day 45.
The patient recovered full passive and active mobility. At 6 months, radiographic verification showed favourable development, with fracture consolidation and no evidence of dislocation relapse.

The management of articular fractures is highly complex, particularly when the fracture is comminuted and observed tardily.
In the event of secondary displacement observed at one month, reduction of the fracture-dislocation is often difficult and sometimes impossible as a closed procedure, so that open reduction may be seen as a possible solution. Surgical access to the interphalangeal articulation of the thumb is difficult due to the tendinous environment (thumb extensor and flexor longus). Reconstruction of the articular surface and its stabilisation represent the second phase of the surgical procedure. It is particularly difficult if the fracture is comminuted and extensive. Faced with complex injury and late-stage management, the non surgical option is often given preference.
In the event of after-effects to interphalangeal articular fracture of the thumb, arthrodesis in the position of function is most frequently preferred. In some cases, thumb arthroplasty is considered.
An external fixator with transfixing pins is a possibility despite the second phalanx bone stock issue. Closed reduction of the injury was achieved in the case under discussion by the use of a dynamic distraction system. Our patient’s functional recovery outcome leads us to suggest this course of action for displaced interphalangeal articular fractures of the thumb, even when observed at a late stage.

Fracture of the second phalanx of the thumb is a rare injury. One of the main complications is secondary displacement. A dynamic external fixator to repair even late-stage articular interphalangeal fracture-dislocation of the thumb is a viable option.

Xavier Gueffier, Georges Delalu, Philippe Pernot

Clinique Saint Vincent de Paul, Bourgoin Jallieu, France

Phalangeal pathologic fractures due to chondromas are particularly unstable. Treatment involves curettage and bone grafting after consolidation of the fracture. We are reporting on a case of early management with curettage and filling protected by a dynamic external fixator subsequent to a fracture of the base of the second phalanx.
The object of the study is to report on the outcome of this treatment allowing for early rehabilitation.

We were treating a chondroma-related pathologic fracture on the second phalanx base of the index finger. Pre-operative assessment included X-ray and CT scan.
Curettage and cancellous bone graft filling as well as the application of a dynamic external fixator were part of the same surgical procedure. Post-operative follow-up included clinical, radiological and functional evaluation.

Results of the pre-operative scan led to preferring an anterior cortical window approach for curettage and cancellous bone grafting harvested from the iliac crest. The dynamic external fixator was placed in the course of the same surgical procedure and was then retained for 33 days. Rehabilitation began immediately after the operation. Full mobility was achieved. The fracture was pronounced to be consolidated at 3 months. There were no major complications, such as nonunion, malunion, infection or tumour recurrence.

The study demonstrates the advantages of surgical management with curettage and filling protected by a dynamic external fixator in the event of osseous chondroma fracture at the base of the second phalanx. With the placement of a dynamic external fixator, the fracture is stabilised so that early rehabilitation can prevent the tendon adhesions causing stiffness.

Yong Jin Kim, Young Suk Suh, Young Seok Lee

Centum Institute for Hand and Microsurgery, West Busan Centum Hospital, Busan, South Korea

Objective : Interthenar ( IT ) flap is based on perforators of the superficial palmar branch of the radial artery and its venae comitantes. This flap is particularly practical for using the palmar cutaneous branch of the median nerve. The authors evaluated the surgical outcomes of using interthenar perforator free flaps with special emphasis on flap design and harvesting technique.
Materials and Methods : One hundred forty-three interthenar perforator free flaps for finger soft tissue reconstructions were performed at Centum Institute during last 6 years. The flaps were used for soft tissue reconstruction of fingertip large volar oblique amputations, finger stump coverage procedures, salvage procedures after replantation, and soft tissue reconstruction of fingers had failed with bone, tendon or joints having been exposed. Forty cases were used as sensible flaps anastomosing between the digital nerve and the palmar cutaneous branch of the median nerve. The mean size of flaps was 2.5 x 4 cm ( range 2 x 2 to 3 x 8 cm ) The donor site was always closed primarily.
Results : The overall survival rates was 91.6%. Anatomic variation of the superficial palmar branch of the radial artery was found in 4 of all cases ( 2.8% ). All survived flaps provided well padded tissue with glabrous skin and touch sensation. Donor site morbidity was neglectable. There was no limitation in thumb motion.
Conclusions : Interthenar perforator free flap is useful with reliable vascular anatomy, and is a suitable option for moderate ( 2 x 2 to 3 x 8 cm ) sized finger soft tissue reconstruction where local or island flaps are not suitable.

Jorge Valero 1, José Vicari 2, Pedro Quiñonez 3, Igor Indriago 4, José Viamonte 4

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Sor Juana Inés de la Cruz, Mérida, Venezuela; 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Vicente Salías Sanoja, Caracas, Venezuela; 3 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Cnel. Elbano Paredes Vivas, Maracay, Venezuela; 4 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Complejo Hospitalario Universitario Dr. Luis Razetti, Barcelona, Venezuela

Background: Raynaud's Syndrome, described by Maurice Raynaud in 1862 to observe the color changes occurring in the hands of women during winter days. This study demonstrates the effectiveness of sympathectomy Henle nerve as an alternative treatment. Material and Methods: 4 female patients are presented with pain in the fingers of both hands was exacerbated during exposure to cold, not improved with conventional treatments; The test of the bucket with cold water, produced signs of pallor, cyanosis, and flushing. Electromyography was normal; The echo doppler reflection Indemnity flow and vascular disorder showed capilaroscopia microcirculation peri-nail fold. They underwent peri-arterial and peripheral neuro-adhesiolysis sympathectomy nerve Henle 2 to 3 cm in its path on the ulnar artery. Results: Patients who, we make them peri- ulnar peripheral arterial sympathectomy (nerve neurectomy Henle), evolved successfully referring their clinical picture. One year after sympathectomy, no trophic changes in the skin of the fingers and the test of the bucket with cold water showed, was negative for signs of Raynaud's syndrome. Conclusions: Treatment should be individualized and peri-arterial peripheral sympathectomy is an effective tool for the management of this disease alternative due to the low complication rate compared with stellate ganglion block and limited thoracoscopic sympathectomy.

Jhohana Mata, Nathaly Guevara, José Marulanda, José Vicari, Magally Ortiz

Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Instituto Autónomo Hospital Universitario de Caracas, Caracas, Venezuela

Background: To compare the postoperative evolution of small metacarpal fractures with percutaneous Kirschner wires, transverse and retrograde intramedullary. Material and Methods: A descriptive and prospective study with postoperative follow-up time of consolidation and complications, The contrast of the variables, depending on the type of surgical technique was analyzed with the chi-square test, with a significant confidence value if p <0.05. Results: From a total of 157 patients, 79 (50.3%) underwent retrograde intramedullary fixation and 78 (49.7%) cross-fixing, 138 (87.9%) men and 19 (12.1%) women. The frequent age group was 15-25 years (33.1%). Most were diaphyseal fractures, 45 (57.0%) in each group, followed by fracture of the neck, of these 34 (43.0%) received retrograde intramedullary fixation and 33 (41.8%) fixation cross ( p = 0.945). In the consolidation of the fracture to the 4th week advantage of the transverse fixation on retrograde intramedullary fixation (p = 0.002) at the 5th week the consolidation ratio was statistically similar (p = 0.416) was evident. After 6 weeks, all they consolidated in each group. When evaluating changes within each group regarding consolidation in the group of patients with retrograde intramedullary fixation was significant between week 4 and week 5 (p = 0.004) and between week 4 and week 6 (p = 0.005 ), also between week 5 and week 6 (p = 0.006). The proportion of deformity among group was statistically similar (p = 0.078). The pain was present in 10.3% of patients in the group with cross-clamping and in 6.3% of the group with retrograde intramedullary fixation (p = 0.546). Only 2 (2.6%) of patients in the group with transverse fixation with infection (p = 0.471). Extensor injury was present in 1 patient (1.3%) of the group with retrograde intramedullary fixation (p = 0.995). The migration of the wires was higher in the group with cross-fixation (7.7%) (p = 0.036). Conclusions: The evolution metacarpal fractures treated with retrograde wires and cross intramedullary percutaneous Kirschner is satisfactory, both methods are comparable, with good results, no statistically significant among themselves and with low complication rate differences.

Wei Tan, Xu Li, Wei-Ping Wu, Denghui Xie, Hua Yan, Qiang Shi, Xuemei Lin

Department of Pediatric Orthopedics, The Third Affiliated Hospital of Southern Medical University(Academy of Orthopedics•Guangdong Province), Guangzhou,China

Objective: To report and assess the usefulness of ultrasound (US) findings for occult fractures of growing bones.Methods: For two years, US scans were performed in children younger than 16 years who were referred with trauma-related local pain and swelling of the extremities. As a routine US examination, the soft tissue, bones, and adjacent joints were examined in the area of discomfort, in addition to the asymptomatic contralateral extremity for comparison. Twenty occult fractures in 20 children (age range, five months-11 years; average age, 5.5 years) were confirmed by initial and follow-up radiograms. Results: The most common type of occult fractures was supracondylar fracture of humerus (n = 9, 45%), followed by the olecranal fracture (n = 4, 20%), fracture of neck of radius (n = 3, 15%), The fracture of lateral condyle of humerus (n = 3, 15%), fracture of medial condyle of humerus (n = 1, 5%). On the retrograde review of the routine radiographs, 13 out of the 20 cases showed no bone abnormalities except for various soft tissue swelling. For the US findings, cortical discontinuity (direct sign of a fracture) was clearly visualized in 19 cases (95%) and was questionable in one(5%). Conclusion: Performing US for soft tissue and bone surfaces with pain and swelling, with or without trauma history in the extremities, is important for diagnosing occult or missed fractures of immature bones in pediatric-aged children。

Wei Tan, Xu Li, Wei-Ping Wu, Denghui Xie, Hua Yan, Qiang Shi, Xuemei Lin

Department of Pediatric Orthopedics, The Third Affiliated Hospital of Southern Medical University(Academy of Orthopedics•Guangdong Province), Guangzhou,China

Objective To discuss the clinical effect of ulnar osteotomy and unilateral external fixation
combined with flexion of elbow joint and combined external fixation in treatment of pediatric chronic Monteggia fracture.

Methods In this retrospective study,11 patients who suffered from chronic Monteggia fracture with Bado I were treated with reduction of the radiocapitellar joint was successfully achieved in all patients after Open reduction 、reconstruction of the radio-ulnar-capitellar joint 、ulnar osteotomy and acute correction using the unilateral external fixation combined with flexion of elbow joint and combined external fixation.Reconstruction of the anular ligament was not undertaken. The patients were between 4 and 11 years of age at the time of injury. The time from injury to treatment was between 3 and 32 months.

Results All these patients were followed up for 4 to 32 months with an average of 18 months. according to the Mackay curative effect evaluation standard,9 cases are excellent,2 cases good,and the curative results were 100%. There was no severe complication occurred in these cases.

Conclusion The treatment of pediatric chronic Monteggia fracture by ulnar osteotomy and unilateral external fixation combined with flexion of elbow joint and combined external fixation has the advantages of satisfactory effect and less complications.

Wei Tan, Xuemei Lin, Xu Li, Hua Yan, Denghui Xie

Department of Pediatric Orthopedics, The Third Affiliated Hospital of Southern Medical University(Academy of Orthopedics•Guangdong Province), Guangzhou,China

To assess the usefulness of rapid prototyping technology for surgeries of the pediatric chronic anterior monteggia lesions.
8 patients of chronic anterior monteggia lesions were examined by lamellar CT to gain two-dimensional data of bilateral forearms, Three-dimensional reconstructions of anatomical models were accomplished by computer aided technology. The radioulna models were manufactrured by rapid prototyping. Which operation project were formulated, preoperative sham operated were enforced and superise the operation of the chronic anterior monteggia lesions(in addition to the asymptomatic contralateral extremity for comparison , Simulating ulnar osteotomy, and fixing the osteotomy with the hinged external fixator, The position of the hinge).
Results indicated that RP models is useful for preoperative planning, reference during surgery, communication with patients, and for increasing the safety of the procedure. Preoperative sham operation shortened the time of operation.
RP models could provide significant benefits for complex surgeries of the chronic anterior monteggia lesions in the areas of preoperative planning, intrasurgical navigation, and communication with patients. A reduction in operating time may also be expected for cases of chronic anterior monteggia lesions.

José Marulanda, María Tortolero, Olimar Salones, José Vicari, Magally Ortiz

Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Instituto Autónomo Hospital Universitario de Caracas, Caracas, Venezuela

Background: Angiolipomas also known as lipoma telangiectaticum or Lipoma Cavernosum are defined as benign tumors containing adipose tissue and blood vessels, is a rare disease that leads to firm tumors under the skin, whose location is usually on the chest wall, forearm, arm and even neck, rare in hands. Material and Methods: For women of 54 years old, dextromana, secretary occupation, who had 1 year evolution painless mass in thenar region, progressive growth, accompanied "tingling and electrical shock" in thumb, index and middle is reported left hand. In imaging studies reveal the presence of a mass of adipose tissue characteristics. Results: It was planned for incisional biopsy and subsequent marginal resection of the lesion be Angiolipoma reporting. Conclusions: It is important to understand the specific characteristics of the treaty as well as practices and treatment guidelines updated, so consider indispensable a regular review of comparative clinical studies before treating patients with tumor lesions tumor.

Rafael Esis 1, Brenda Romero 1, Daniel Ferrer 1, Alex Quintero 1, José Vicari 2

1 Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Dr. Miguel Pérez Carreño, Caracas, Venezuela; 2 Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Instituto Autónomo Hospital Universitario de Caracas, Caracas, Venezuela

Background: During the last decades has increased the number of accidents, injuries projectile gun and knife in our country with fatal injuries and most disabling as brachial plexus injuries. To characterize patients with brachial plexus injury according to diagnosis and treatment in the Department of Surgery of the Hand of IVSS Hospital "Miguel Pérez Carreño". Method: A descriptive, cross-sectional field purposive sample not probabilistic from July 2013 to July 2014 Results: 42 patients, 100% male, 62% between 21-30 years of age were studied. 81% of cases were related to motorcycle accidents, 7% are accidents plexus injuries in automobile and Firearm 5% related to direct stab wounds. The motorcycle accident was preganglionic type in 100%. In stab injuries was 100% postganglionic. In Firearm injuries, 100% postganglionic and was distributed in 33% and 33% supraclavicular infraclavicular. A protocol for the diagnosis and treatment of patients with brachial plexus injury described. The goal of treatment was: sensitivity recover and restore basic functions of the upper limb by cervicotomy explorer, epineurorafia, external neurolysis, and neurizacion. Conclusions: The clinical improvement of patients operated with improved sensitivity of 100% and 50% of upper limb motor function.

Alfredo Cabello G 1; Javier Corredor 1, Alfredo Cabello B 2, Jesús Hernández 2, José Vicari 3

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Universitario Dr. Manuel Núñez Tovar, Maturín, Venezuela. 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Complejo Hospitalario Universitario Dr. Luis Razetti, Barcelona, Venezuela. 3 Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Instituto Autónomo Hospital Universitario de Caracas, Caracas, Venezuela.

Background: To describe the case of male patient preschool 4 years, with both hands deformity from birth. Material and Methods: Clinical evaluation of the right hand: Full webbed first commissure, thumb flexion contracture, abnormal nail plates without crease paroniquio and limited joint balance; Radiologically there latero-lateral distal phalangeal fusion, angular deformity middle and distal phalanx of the index and ring fingers. On the left hand: Incomplete interdigital membrane of the first corner is located, joint balance without limitation or skeletal deformity. Incomplete webbed third commissure. Results: The surgical plan is carried out in three stages, focusing on increasing the depth of mergers interdigital incomplete dorsal left by flaps associated with z palmar flap. Syndactyly complicated release the first right corner flap with intrinsic rotation and forward and zigzag interdigitated. Release of flexion contracture sectioning the adductor fascia and arthrolysis, lengthening of the intrinsic muscles and pin fixation. In the third corner, rectangular flap with dorsal and palmar interdigitated triangular flaps, more coverage of skin defects Hypothenar skin graft. Conclusions: Although the postoperative complications such as wound dehiscence, joint instability, angular deformity, hypertrophic scarring, distal advancement of the interdigital membrane and accentuation of interdigital commissure, were presented was achieved provide the patient with one hand functionally acceptable.

Pedro Quiñonez 1, Rafael Rojas 1, Jorge Valero 2, José Vicari 3, Ymaru Rodríguez 3

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Cnel. Elbano Paredes Vivas, Maracay, Venezuela; 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Sor Juana Inés de la Cruz, Mérida, Venezuela; 3 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Vicente Salías Sanoja, Caracas, Venezuela.

Background: Anxiety is a complex reaction of the person against potentially dangerous situations and stimuli. When a patient faces a situation where an external violence compromises the anatomical and functional integrity of his hands, a number of situations conscious or not, including anxiety, which undertake in a negative way the treatment and progress of their improvement are developed. Material and Methods: This study was conducted to estimate the level of distress of patients, by applying the questionnaire Idare Inventory Spielberger anxiety / state / trait. Results: We studied 62 patients with hand injuries. A 31 of them were administered the questionnaire for anxiety / state and 31 questionnaire anxiety / trait. Result indicate that 31 patients anxiety / trait 99.99% were between low-medium level and 31 cases studied with the questionnaire for anxiety / state, 62.28% were in a medium-high level. Conclusions: We recommend using Trait Anxiety Inventory-State, for its simplicity in application, sensitivity and the unlikelihood of manipulating the results. We believe that this study could be continued at different stages of post-operative rehabilitation or to compare results. Do not forget the individualization of patients and their environment.

Diego Fernando Rincón Cardozo , Juliana Andrea Rojas Neira, Alvaro Antonio Kafury Goeta, Jhon Fredy Castañeda Lopez, Carlos Andres Lores Restrepo

Centro Medico Imbanaco, Santiago de Cali, Colombia

Fibromyxoid sarcoma, first described by Evans in 1987, is a rare tumor of aggressive behavior. Hand involvement is uncommon and mostly affects young adults. Although classified as benign, this tumor behaves aggressively, with relapses being reported in 9% and metastases in 6% of cases.

Materials and methods - Case report
This case refers to a 12-year old boy presenting 7 months after onset of the disease. The physical exam revealed a tumor in the base of the middle finger in a radium sized 3 x 2 cm that was adhered to deep planes and showed signs of inflammation with no changes in mobility. An open biopsy confirmed the diagnosis of low-grade fibromyxoid sarcoma that required radical resection of the tumor with subsequent skin grafts. He had favorable progress at 14 months with no relapses.

The occurrence of fibromyxoid sarcoma in children is uncommon as well as its localization in the hand; its presentation in men and women is the same, and there are no known predisposing factors. Treatment of this condition should be aggressive, with resection of the tumor leaving free margins. If not possible, radical management with amputation may be considered to reduce local relapse. If resection is performed, defects can be managed with grafts, local flaps, or free flaps. Chemotherapy (including doxorubicin, ifosfamide, or trabectedin) is indicated for the management of metastases as well as palliative radiotherapy, although these have not improved the number of patient survival when performed as adjuvant measures for the initial management of the tumor.

Treatment of low-grade fibromyxoid sarcoma of the hand, a rare tumor, should be aggressive but leaving margins free of tumor to prevent relapses and metastases. In addition, periodic follow-up of the patient should be practiced for tumor behavior surveillance.

Cesar Useche 1, Eduardo Macrobio 1, Verónica Montilla 1, Aloha Isea 1, José Vicari 2

1 Departamento de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Carlos Arvelo, Caracas, Venezuela; 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Vicente Salías Sanoja, Caracas, Venezuela.

Objective: the technique of platelet rich plasma was evaluated to stimulate bone healing of fractures of the distal radius; Material and Methods: A field research study, descriptive, non-experimental design, with a sample of thirty (30) female patients aged 45 to 60 years, with fractures of the distal radius type was performed Frykman 2. Results: half of the sample (15) was treated with intralesional inoculation of platelet rich plasma and in the other half (15) not rich plasma used in platelets, in all patients braquiopalmar plaster was used for immobilization. Results: Bone consolidation for the group without platelet rich plasma, was evident between 7th and 8th week in 12 patients (80%); unlike the group to which was placed platelet rich plasma where bone healing demonstrated for 10 patients (66.66%), between 5th and 6th week. Conclusions: 2 weeks differential is evidence consolidation time, so that the use of platelet rich plasma to decrease bone healing time is recommended.

Diego Fernando Rincón Cardozo , Juliana Andrea Rojas Neira, Alvaro Antonio Kafury Goeta, Jhon Fredy Castañeda Lopez, Carlos Andres Lores Restrepo

Centro Medico Imbanaco, Santiago de Cali, Colombia

Giant cell tumor of the hand, most commonly located in the phalanges, followed by metacarpal and carpal bones, is an uncommon condition. When occurring in the hand, it is usually aggressive and causes large bone deformities with a tendency to be multifocal and with high rates of local relapse and higher potential for metastases than those giant cell tumors affecting other areas. The purpose of this report is to propose another treatment option compliant with the principles of functionality, esthetics and tumor control.

Materials and methods - Case report
The case refers to a 32-year old woman, whose clinical presentation included a tender mass (4 x 4 cm) and edema of the left hand lasting for 7 months. Radiographic findings included generalized lysis, and cortical thinning and expansion. Magnetic resonance imaging showed a solid lesion with expansion to the cortical area and compression of soft tissues.
The mass in the affected bone was resected using a posterior approach, with reconstruction of the bone defect using fibula graft and joint reconstruction with a silicone prosthesis. No complications were observed during follow-up.

Classical management involves curettage and filling of the defect with bone grafts, with a relapse rate of approximately 80%. Phenol, cryotherapy, and bone cement have also been used, with the added risk of lesion of parallel structures. However, the rate of relapse decreases to 0% with the use of either large or radical tumor resection by reconstructing bone defects with grafts obtained from the iliac crest or the fibula; allografts, and vascularized metatarsal bone or fibula grafts have also been described.
Autologous fibula allograft has been found to be more versatile and resembles the shape of metacarpal bones, in addition to allowing adaptation of a prosthesis for joint reconstruction, with greater mechanical strength as compared to iliac crest grafts, and also allows better fixation of osteosynthesis materials without risks of pathogen transmission by allografts. The use of autologous grafts, however, increases procedural morbidity and requires longer immobilization times to achieve graft integration, which may lead to subsequent rigidity. Outcomes reported in the literature have been successful in patients with the use of both reconstruction techniques, with no reports of relapses.

It is concluded that the use of fibula grafts should be taken into account as a therapeutic strategy for patients with extensive tumor involvement. Furthermore, concomitant management with silicone prosthesis allows preserving joint function.

Angel Sifontes 1, Jorge Carreño 1, Chessaysna Silva 1, Jesús Hernández 1, José Vicari 2

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Complejo Hospitalario Universitario Dr. Luis Razetti, Barcelona, Venezuela; Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Centro Médico Docente La Trinidad, Caracas, Venezuela.

Background: To determine the histopathological changes of the tendon sheath of the first dorsal carpal compartment and its correlation with clinical, sociodemographic and labor variables in patients with De Quervain disease. Material and Methods: A quasi-experimental study without a randomized control group of 21 female patients with unilateral pathology of which 21 samples for biopsy of tissue that were fixed in solution of neutral formalin 10% were obtained, once revised clinical data from each patient and identified the predominant histopathologic features, the Pearson correlation coefficient was used to determine what type of correlation existed between the variables studied. Results: No anatomical variations were found in the trans-operative. In histopathology, inflammatory component not found, an increase of fibrous component associated with myxoid fibroblastic proliferation and degeneration was evident. Conclusions: The pathology is not characterized by inflammation, but by degenerative processes that begin with myxoid degeneration and end with fibrosis, leading to biomechanical changes that influence the onset of clinical patient. There is evidence that gender, premorbid conditions and the type of functional demands at work are the triggers of this process.

Alex Quintero 1, Franci Blanco 1, Lisette Irausquin 1, Yaretzi Torrealba 1, José Vicari 2

1 Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Dr. Miguel Pérez Carreño, Caracas, Venezuela; Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Centro Médico Docente La Trinidad, Caracas, Venezuela.

Background: To treat retractable scar, there are several surgical techniques that allow us to make the skin coverage, among them are the radial forearm flap (Chinese flap), which allows to solve the problem in a single surgical time, as this case of a male patient age 4, who after electrical burn, have severe palmar region retractable scar on the right hand end of the interdigital spaces of the fingers. Material and Methods: prepositioning of proximal forearm skin expander to cover the defect of skin from the donor area, the flap embodiment according to the established technique and interdigital zetaplastias. Results: In the patient retractable scar cure was achieved giving complete coverage of the palm of the right hand with the restoration of anatomy and function of the dominant hand, without any complications. Conclusions: The benefits of using this type of flap, have far exceeded the difficulties of their use; not only by the plasticity of their tissues and adaptability to different receiving areas, which earned him the flap of choice for reconstruction of head, neck and upper limb, but also for safety with this procedure resolves definitively the lesions of patients affected.

Javier Corredor 1, Gonzalo Palomo 1, Alfredo Cabello G 1, José Vicari 2, Ymaru Rodríguez 2

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Universitario Dr. Manuel Nuñez Tovar, Maturín, Venezuela. 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Vicente Salias Sanoja, Caracas, Venezuela.

Background: Tumors in hand despite their kindness, lead to the limitation of osteoarticular physiology so the standardization of procedures aimed at achieving improvement is necessary. This study provides an overview of benign and malignant tumors that may compromise the hand and proposes an effective therapeutic approach. Material and Methods: Observational and transversal cohort of 30 patients with a mean age of 35 years. Diagnostic assumptions were confirmed by histopathology in an average of 3 weeks. Evolutionary monitoring based on assessments at 3, 6, 12 and 18 months recording clinical and radiological findings, evaluations and treatment complications until the final cure. Results: Female gender and the right side were more frequent. The most frequent symptoms were increasing volume. For analysis of the injured tissue excisional technique in 9 patients (30%) and incisional in 21 patients (70%) it was used. Pathologic findings, reported mostly benign tumors. The therapeutic approach recommended oncologic resections were: Marginal, intralesional, radical and wide. 3 patients required chemotherapy and complications presented were: Death, joint stiffness and relapse in 28 cases the results were satisfactory. Conclusions: The treatment of tumors of the hand requires surgical techniques focused on oncology resolution conception, plastic and reconstructive according to the objectives pursued in the case and are often contradictory. However, in the search for optimal results must conform strictly to cancer at the expense of difficulty consecutive subsequent reconstruction principles.

Chessaysna Silva 1, Yenny Medina 1, Angel Sifontes 1, Manuel Montana 1, José Vicari 2

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Complejo Hospitalario Universitario Dr. Luis Razetti, Barcelona, Venezuela. 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Vicente Salías Sanoja, Caracas, Venezuela.

Objective: The complex fractures of the proximal ulna are difficult to reduce and there is a pattern for all types. In this case a choice of mixed synthesis technique modifies useful for complex cases is demonstrated. Material and Methods: Male patient 22 years old, who after trauma to the left elbow, presents fracture coronoid and olecranon fracture with comminution of the lateral and medial edge thereof, classified according O'Driscoll in type III fracture, subtype 2 lateral posterior elbow approach is performed, showing traces of fractures that merited combined reduction and osteosynthesis mixed: absorbable Sutures, non-absorbable, more reconstruction plate and screws, which required modification of the surgical technique for reducing fracture of the coronoid process, anterolateral facet and subchondral fracture of the olecranon. Conclusions: Preoperative planning is important and imaging support, however the basic criteria applied knowledge, help make intraoperative decisions with good functional results.

Bertha Marquez 1, Carlos Golindano 1, José Viamonte, 1 Jorge Carreño 1, José Vicari 2

1 Unidad de Cirugìa de la Mano y Reconstructiva del Miembro Superior, Complejo Hospitalario Universitario Dr. Luis Razetti, Barcelona, Venezuela. 2 Unidad de Cirugìa de la Mano y Reconstructiva del Miembro Superior, Centro Médico Docente La Trinidad, Caracas, Venezuela

Background: To present the case in a male infant of 16 months, with no pathological or traumatic history, whose mother reports having pain, limitation for mobilization and presence of tumor in the left wrist. Material and Methods: Multiple clinical and laboratory studies are conducted; Then proceed to remove the tumor on the left wrist and sampling for biopsy, which reported chronic osteomyelitis, moderate and unspecific, the immuno-histochemical study concludes that presents chronic granulomatous inflammation and finally the study of biopsy with the Grocott stain describes yeast structures with the shape and size corresponding to Histoplasma Capsulatum, treated with Itraconazole for 10 months. Conclusions: Histoplasmosis is a systemic fungal infection granulomatous, which mainly affects the lung area and also affects bone and soft usually in the form of an arthritis self-limited sensitivity and occurs at any age, with the highest incidence parties between the 3rd and 4th decade of life, probably by occupational factors, particularly uncommon in this age group.

Josien Homburg

The Hand Clinic, Amsterdam

Abstract IFSSH 2016 e-Poster presentation
Purpose: to evaluate the long term AROM of the proximal interphalangeal (PIP) joint after a surface replacement arthroplasty for osteoarthritis using a neuflex implant, treated after chirurgery with a static splint with extension block for six weeks.
Background: at The Hand Clinic (Amsterdam), we treat patients after a PIP replacement arthroplasty with a static PIP splint with an extension block of 20-30 degrees. The allowed flexion is build up during 6 weeks, with improvement of 10 degrees every week. Three days after surgery the patient receives a splint with a relative flexion of maximum 30-40 degrees. The splint has to be worn 24/7.
Prior to the operation the active Rang of Motion is measured; flexion and extension from the MCP, PIP and DIP joint. After one year the measurement of the AROM is repeated.
Methods: a long term retrospective analysis of results in 20 patient with PIP joints replacement first reported in 2013. From the 56 PIP replacements arthroplasty’s 16% involved dig2, 42% dig3, 26% dig4, 10% dig5. Active Range of Motion was measured by a certified hand therapist.
Setting: The Hand Clinic in Amsterdam.
Participants: patients with PIP osteoarthritis, exclusion of the replacement arthroplasty for PIP joint dig 2.
Results: A year after surgery the average active flexion improvement of the MCP joint is 15 degrees, of the PIP joint it is 10 degrees and for the DIP joint 10 degrees.
Conclusion: 90% of the PIP joints gained in flexion, when the PIP joint did not gain in flexion (due to stiffness of scar tissue), the MCP and DIP joint compensate the lag of flexion. Although subjective the patients are very satisfied with the splint that allows use of their hand because of the small splint (which allows active use of all the joints).

María Ganem 1, Luciano Drigo 2, Luiz Sobania 3, Gerson Molina 4, José Vicari 5

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Central, San Cristóbal, Venezuela; 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital de los Trabajadores, Curitiba, Brasil; Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital XV de Fracturas, Curitiba, Brasil; 4 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Centro Clínico, San Cristóbal, Venezuela; 5 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Centro Médico Docente La Trinidad, Caracas, Venezuela.

Objectives: The nonunion of the scaphoid is a particularly difficult problem when there carpal degeneration, this paper resection of the distal pole of the scaphoid is evaluated as a treatment for their nonunion in the presence of osteoarthritis secondary wrist after a minimum postoperative 6 months. Material and Methods: Clinical and radiological evaluation of 14 patients undergoing this procedure, with no indication of restorative surgery and in the presence of some secondary osteoarthritis of the carpus, with a time of postoperative minimum of 6 months. Results: 5 patients had pain relief and 4 patients reported mild pain efforts. All activities could perform manual effort. The average global motion improved from 32 ° to 37 ° (68% to 79% of the contralateral side). Grip strength reached 82% (37 kg) of the healthy side. The results according to the Quick DASH scale: 10 excellent and 1 good. There was no progress or degeneration carpal collapse post treatment. The average follow-up time was 26 months. Conclusions: The results showed that this procedure led to a satisfactory clinical evolution so it should be considered as an option for the treatment of scaphoid nonunion associated with carpal secondary osteoarthritis radio. However, other methods should be considered in patients with compromised intercarpal joint.

José Torres 1, David Maciñeiras 1, Edgar Uzcategui 1, José Vicari 2, Jorge Valero 3

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Instituto Autónomo Hospital Universitario de los Andes, Mérida, Venezuela; 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Vicente Salías Sanoja, Caracas, Venezuela; 3 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Sor Juana Inés de la Cruz, Mérida, Venezuela.

Background: The scaphoid fractures are the most common injuries to the carpal bones, so the use of cortical screw Hidden for fractures type B of the scaphoid, presenting association with a pattern of instability or greater displacement was evaluated 2 mm. Material and Methods: A clinical series of 19 patients was performed by percutaneous technique dorsal anterograde and internal fixation with cortical screws Hidden fractures type B of Herbert and Fisher, evaluating the results with the Rating Scale wrist Mayo Clinic to 6 weeks postoperatively. Results: 94.74% were male and female 5.26%, the predominant age was between 20 and 40 years (52.63%), with an average age of 26.6 years. Most patients were students (52.63%). In a 42.11% fracture it was associated with sports, 42.11% of traffic accidents and 15.78% to falls. Regarding the epidemiology of fracture, it was 63.16% 36.84% right and the left. Most cases were classified according Herbert and Fisher type B2 fractures (57.89%), B3 (21.05%), B1 (5.26%) and (15.79%) were associated with dislocations trans-escafo-semilunar B4. The total score according to the Rating Scale wirst Mayo Clinic was an average of 89.74 points, or 42.11% of these showed excellent results, good results 31.58% and 26.32% satisfactory results. In the series presented no cases were reported with poor results. Discussion: The appearance of the dorsal approach has represented a great advantage for the management of scaphoid fractures, in view of protection of the vascular system and ligamentous, avoiding complications such as avascular necrosis and carpal instabilities. excellent and good results were obtained in most cases, rates of 100% consolidation.

Hawys Lloyd-Hughes, Jeremy Rodrigues, Michele Peters, David Beard, Abhilash Jain

University of Oxford

Different treatments are available for common hand conditions, many of which are provided with uncertainties of outcomes that are yet to be resolved. Optimising patient care requires appropriate outcome measures. The use of Patient Reported Outcome Measures (PROMs) has the potential to identify effective treatments in a patient-centred manner. However, existing options are mainly surgeon-centred and have not been subject to contemporary assessments of validity. The aim of this study was to assess which PROMs are available and used to measure outcomes in hand surgery and what is their quality.
Methods :

Literature search

To identify all relevant publications, a systematic search in the bibliographic databases Medline, Embase, PubMed and CINAHL from January 1992 to January 2016 was conducted. The reference list of included articles was hand searched for the relevant publications. For each PROM identified through these searches we conducted an additional search to ensure no validation study performed had been missed in the original search. A reference and related article search was also performed.

Selection criteria and definitions

Two authors independently reviewed the search findings for potential eligibility for systematic review using the databases mentioned. Any disagreements were resolved by a third reviewer The inclusion criteria were: (i) full text articles only, no abstracts or case reports were included; (ii) the study had to investigate health-related quality of life post hand treatment using questionnaires; (iii) all treatment modalities for acquired hand conditions were included. Only structured questionnaires measuring quality of life were included and evaluated. Interviews with no format or reproducibility were excluded. Validation studies were included if they studied the PROM and published as original and full text studies.

Assessing the quality of the PROMs

The consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist was used to assess the methodological quality of the included PROMs. All aspects of reliability, validity and responsiveness were therefore assessed. Although, not a measurement property in itself we also assessed interpretability as all authors felt this is an important characteristic of a measurement instrument. The COSMIN checklist contains multiple questions to critically appraise the methods for each reported measurement property and uses a 4-point scale ranging from ‘excellent’, ‘good’, ‘fair’ to ‘poor’. It is the lowest score given that counts as the overall score for that property. Two independent reviewers (JR /HLH) performed the quality assessment for each PROM. The senior author (AJ) resolved any disagreement between both reviewers.


Out of 6028 studies, 818 studies were included. These studies included 13 PROMs that can be divided into generic, symptom specific and disease specific questionnaires. Of these, most of the measurement properties of the PROMs were not, or not adequately assessed.


A new hand outcome measure developed fully in line with the consensus-based standards for the selection of health status measurement instruments (COSMIN) checklist would be valuable. In the meantime current PROMs when interpreted carefully do have the potential to add value to clinical practice and related research in evaluating outcomes that are important to patients.

José Durán 1, Carlos Fuentes 1, Lisette Irausquin 1, Yaretzi Torrealba 1, José Vicari 2

1 Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Dr. Miguel Pérez Carreño, Caracas, Venezuela; 2 Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Instituto Autónomo Hospital Universitario de Caracas, Caracas, Venezuela.

Background: Forearm fractures in children account for 40% of all pediatric fractures distal region being the most common site. Epiphyseal arrest in treatment is based on the remaining growth according to age and if less than 50% of the physis is affected. Material and Methods: We present a patient, male 15 years of age, which radiologically, presents closing early 70% of the physis and shortening of 20 mm from the left distal radius, as a result of epiphysiolysis the distal third of the radius left, Salter-Harris type IV treated orthopedic manner, which will pose a bone lengthening radio, by placing an external fixator monoplanar Orthofix® type. Results: At the 7th day of the intervention begins with the process of callotasis distraction, by making ½ turn nut transport head / extension and performing every 12 hours for the duration of the process of elongation distraction. The patient was evaluated every 7 days during the first month and every 20 days during the following 4 months with no evidence of infection at the site of insertion of the pins or the osteotomy site, achieving bone transport without misaligning transported fragment, with improved grades of articular amplitude (flexion 70 °, extension 80 °, 30 ° ulnar deviation, radial deviation 20 °). Conclusions: The management of patients with fisiarias injuries varies according to the characteristics thereof, the type I-II can be treated with manipulation and closed reduction and types III-IV-V treatment is surgical, meriting some open reduction and internal fixation, as in our case which presented satisfactory results in the correction of the deformity and functional limitation of the affected wrist.

Manuel Montana 1, Chessaysna Silva 1, Yenny Medina 1, Angel Sifontes 1, José Vicari 2

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Complejo Hospitalario Universitario Dr. Luis Razetti, Barcelona, Venezuela; 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Vicente Salías Sanoja, Caracas, Venezuela

Background: To report the case of a male patient of 11 years old, who after wounded by shotgun shell, presenting 50% loss of muscle mass and skin coverage right first interdigital space. Methods: I was performed exhaustive surgical cleaning and preparation of groin flap McGregor, to meet 21 days after surgery and given the favorable conditions of the flap, it proceeds to takeoff the same over reconstruction of the volar aspect of the first interdigital space to improve the aesthetic and functional aspect of the injured hand. Results: Biomechanical ranges were recovered, with a good opening of the first interdigital space and flexion of metacarpophalangeal joint of right index finger. Conclusions: The groin flap has been little used in children, due to the recovery time and the delay in the return to daily activities, most however historically has shown good results and their use represents an excellent alternative to cover large defects skin in hand in pediatric patients from 10 years according to our experience.

Sergio Daroda, Rodolfo Cosentino, Paul Pereira, Fernando Menvielle, Juan Cosentino

Clínica de la Mano GAMMA, La Plata, Argentina

We performed 29 macroreplantations in the last 30 years. Twenty-one were in the upper limbs but only 3 were bilateral.
Materials and method: we retrospectively evaluated 3 cases of bilateral hand replantations with a follow-up of 3, 4 and 21 years. We analyzed motion, grip strength and sensitivity, and a DASH questionnaire was made.
Results: the objective data were similar to those of unilateral amputations as well as the ones reported in the literature. Patient’s satisfaction was much better than the unilateral cases.
We had one case with superficial infection solved with debridement and antibiotics. There was another case with a deep infection and crash syndrome which had to be amputated so as to save patient’s life.
Conclusion: there were few cases of bilateral hand replantations reported in the international literature. We agree with O´Brien (Australia, 1974), Hegazi (Saudi Arabia, 2000); Hoang (Vietnam 2006) and Urpi (Argentina, 2008) on the objective results. However we don’t agree with Atzei (Italy, 2005) when he states that only strongly motivated patients deserve a bilateral hand replantation. We firmly believe that the bilateral hand replantations should always be made.
Bilateral amputations are a rare condition and the replantation is mandatory. We believe that the freedom of the patient is the main objective in the treatment of these cases.

W. M. Calonge 1, E. García-Guixé 2, J. Baxarias-Tibau (1, 2), A. Pla 2, N. Balagué 1

1 Permanence de Vermont Grand-Pré, Geneva, Switzerland;2 Anthropology Laboratory, Museu Arqueologia Catalunya, Barcelona, Spain.

The osseous remains of an adult male from the medieval cemetery from Sant Benet Monastery (10th -11th centuries CE) show unequivocal signs of an oblique fracture of the third left metacarpal and secondary sclerosing osteomyelitis. A complex high energy mechanism entailed compression and disruption of carpal bones and a probable perilunate luxation. Malunion of the third metacarpal combined shortening and bone bridges between second, third and fourth metacarpals in a peculiar pattern. Abscesses were probably associated and the carpometacarpal, mid carpal and radio carpal joints present signs of focal infection.
The natural evolution into ulnar-deviated ankylosis suggests a long-term survival in spite of infection as well as a tolerable, spontaneous outcome in the pre-antibiotic era. Nothing can be gathered about the nature of available treatments, even considering that monasteries were the most important deposit of science in this period.

Henri Asse, Wenceslao M. Calonge, Kadio Augustin Kouakou- Adonis, Constant Koffi Yao, Kouassi Marcelin Assie N'da, Patrick Meredith

Institut de Chirurgie Reconstructive, Abidjan, Ivory Coast

Infection by Mycobacterium ulcerans, also known as Buruli ulcer (or Bairnsdale ulcer in Australia), constitutes a neglected tropical disease. Its prevalence seems to have overrun those of cutaneous tuberculosis and leprosy, counting more than 7000 people each year. Some aquatic insects are hosts to the bacteria but their role as vectors remains unclear. The aggressivity of M. ulcerans depends on the production of mycolactone, an immunosuppressive and necrotizing toxin.

The lesions can involve skin, tendon and bone. They may show a large spectrum of manifestations, including non-ulcerative (papules, nodules, plaques), ulcerative and edematous presentations as well as osteomyelitis with muscular contraction and ankylosis.
Upper limbs account for more than two thirds of the infection sites. The dorsal aspect of the hand is particularly prone to them. Besides antibiotherapy, surgical treatment may involve different modalities as tendon transpositions, partial and total skin grafts. Amputation may be the only option in a minority of cases.

We present a series of more than 140 cases that underwent surgical management in our institution. Treatment options included partial skin grafts (anterior thigh), total skin grafts (inguinal region), ilioinguinal flaps, tendon transfers and ressections of the first carpal row.
Unfortunately, due to socioeconomic constraints many patients were lost to follow-up. It has been pointed that global warming may be a crucial factor in the spread of endemic areas like marshes in the forecoming years and this condition deserves further attention from media and teaching programs..

Ding-Sheng Lin, Weiyang Gao

Department of Hand and Plastic Surgery, the Second Affiliated Hospital of Wenzhou Medical university, Wenzhou,China;

Objective:To investigate the effect of moxibustion on the random skin flaps.Methods:48 SD rats were randomly divided into a control group and a experimental group. The “McFarlane flap(3×9cm)” rat models were established on the rat dorsum. Moxibustion was performed in the experiment group 30 min every day ,and last for 7 days.The flap survival area in the two groups was measured and tissue samples taken from proximal(I),middle(II)and distal(111)portions of flaps were hematoxylin and eosin. Vascular endothelial growth factor (VEGF) expression was determined using immunohistochemical methods. Superoxide dismutase (SOD) activity and malondialdehyde(MDA) content were examined with kits.Results: Moxibustion significantly reduced the necrotic area in the treatment groups after 7 days compared with the control group. In the middle portion, edema and infiltration of neutrophils observed in tissue sections in experimental group is slighter than that of control group,the VEGF expression and SOD activity markedly increased in the treatment groups compared with the control group, whereas MDA levels were lower in the treatment groups than in the control group. Conclusion: Moxibustion promotes random skin flap survival.

Tan En Si, Soumen Das De, Janice CY Liao, Tun-Lin Foo

Department of Hand & Reconstructive Microsurgery, National University Hospital, Singapore

Full thickness skin grafts (FTSGs) are often employed to resurface small defects of the hand to provide a durable and functional surface with minimal secondary contracture. The ideal FTSG donor site should provide good skin type match (particularly glaborous skin) from donor sites easily accessible within the surgical field, and with minimal donor functional and esthetic morbidity. We describe a technique of FTSG harvest from the palmar crease that meets these characteristics.

A transversely oriented skin graft centered upon the palmar crease over the ulnar side of the palm readily yields glabrous skin graft while hiding the scar within the crease. The donor width is usually limited to 15mm to allow primary closure without compromising metacarpophalangeal joint extension, and the donor site is closed primarily.

In our experience, all our patients experienced satisfactory outcomes, with primary closure of the donor site achieved within a relatively concealed region. No complications were encountered. While there is risk of skin contracture at the donor site, this is reduced by limiting the width of the graft harvested.

The palmar crease donor site is advantageous for scar camouflage and ease of access, affording greater levels of patient satisfaction.

Tianhe Chen, Ding-Sheng Lin

Department of Hand Surgery,The Second Affiliated Hospital of Wenzhou Medical University,Wenzhou,China

Cinepazide maleate is validated as a vasodilator and calcium blocker.We investigated the effects of Cinepazide maleate injection on random skin flap survival in rats.

McFarlane flaps were established in 60 rats divided into two groups. Postoperative celiac injections were given to both groups for 7 days.Cinepazide maleate was injected into the test group, and the same concentration of saline was injected in controls.On day 7, the survival area of the flaps was measured.Tissues were stained with hematoxylin and eosin, immunohistochemically evaluated,and the expression levels of xanthine oxidase determined.

The mean area of flap survival in the test group was significantly higher than in controls. Superoxide dismutase activity increased substantially in the test group compared with that in the control group.Expression of vascular endothelial growth factor was markedly increased alone with microvessel development in the test group,and the malondialdehyde level was reduced.

Cinepazide maleate promotes random skin flap survival.

Alex Quintero 1, Franci Blanco 1, Lisette Irausquin 1, Sgro Biaggio 1, José Vicari 2

1 Servicio de Cirugìa de la Mano y Reconstructiva del Miembro Superior, Hospital Dr. Miguel Pérez Carreño, Caracas, Venezuela; 2 Servicio de Cirugìa de la Mano y Reconstructiva del Miembro Superior, Instituto Autónomo Hospital Universitario de Caracas, Caracas, Venezuela.

Objectives: to a 16-year-old is described, with catastrophic consequences left elbow injury 3 years of evolution and whose case is relevant because it presents several unusual conditions for a replacement primary elbow joint. Material and Methods: First surgical time: Placement of skin expander 150 spherical cc smooth surface on the dorsal aspect of the distal third of the affected forearm, achieving tissue expansion at 10% of total weekly expander, for 10 weeks. Second surgical procedure: With posterior approach, the exeresis of the retractable scar elbow and fibrotic tissue in the distal third of the humerus was performed, then performed arthroplasty primary elbow, with semi-constrained non-conventional cemented prosthesis Coonrad type I, then Palmaris Longus ipsilateral graft of 20 cm was taken. long, to reconstruct the tendon Triceps, by anchoring the olecranon with the technique of Krackow, and closure of the fascial plane to cover the prosthesis, finally skin coverage of the elbow was performed with forearm flap radial (Chinese flap) more close the Chinese flap donor site, using the previously expanded tissue skin expander was neighbor to the donor area. Results: At 3 months postoperatively the patient presented, joint range of active flexion of 90 °, 60 ° active extension from 90 ° flexion, supination without limitation, without neurovascular sequelae that compromise the function of the limb. The 1st year after surgery, arthroplasty continue offering good elbow function without clinical signs of loosening or instability and with some restrictions like not exceed the limb more axial load of 5 kgr and not play sports that involve movements pitches. Conclusions: Reconstruction is not an easy road and requires many tools and extensive experience and skill on the part of the surgical team. Quality functional elbow after presenting complex fractures, merits the restoration of normal anatomic relationships. In patients with low demands, it is possible that the total elbow prosthesis get the fastest recovery of function. To function properly the implant soft tissue should be appropriate, otherwise, be considered performing flaps.

Lv Qingbo, Lin Dingsheng

The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China

Objective: To investigate the influence of Diammonium Glycyrrhizinate on random skin flap survival in rats.

Materials and Methods: McFarlane flaps were established in 60 male Sprague–Dawley rats randomly divided into three groups. Group I considered as the control group was injected with saline (10mg/kg) once per day. Group II and group III considerd as the test groups were injected with Diammonium Glycyrrhizinate (10mg/kg) once per day and twice per day, respectively. On day 7, the survival area of the flap was measured. Tissues were stained with H&E (hematoxylin-eosin) stain and immunohistochemically evaluated. Tissue edema, neutrophil density, superoxide dismutase (SOD) and malonyldialdehyde (MDA) contents were evaluated.

Results: The average survival areas of the flaps in group II (71.983 ± 7.084%) were significantly larger compared with that of the control group (50.618 ± 8.455%) (P<0.05), and group III which received Diammonium Glycyrrhizinate (10mg/kg) twice per day had the highest survival rate (75.373 ± 6.708%). Histologic and immunohistochemical evaluation showed that microvessel development (MVD) ((19.76 ± 3.61)/mm2, (24.39 ± 3.21)/mm2, (26.36± 2.89)/mm2 for group I, group II and group III, respectively) and expression of vascular endothelial growth factor (VEGF) ((2050.14 ± 494.97), (3056.21 ±627.91), (3337.16 ± 513.29)for group I, group II and group III, respectively) were higher in the two test groups than those in the control group. SOD activitieswere markedly increased in the two test groups ((28.740 ± 5.657)u•mg-1•protein-1, (57.605 ± 4.052)u•mg-1•protein-1 , (62.345 ± 6.329)u•mg-1•protein-1for group I, group II and group III, respectively), while neutrophil density ((37.91 ± 3.54), (30.59 ± 5.39) and (26.52 ±4.24) for group I, group II and group III, respectively) and MDA levels ((54.717 ± 7.644)nmol•mg-1•protein-1, (28.444 ± 9.479)nmol•mg-1•protein-1, (18.446 ±8.062)nmol•mg-1•protein-1 for group I, group II and group III, respectively) of test groups were reduced compared with control group.

Conclusion: In summary, Diammonium Glycyrrhizinate may have a dose-dependent effect on promoting the survival of random skin flaps.

Nickmarson Salazar 1, Aloha Isea 1, Edoardo Macrobio 1, Edgar Sánchez 1, José Vicari 2

1 Departamento de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Carlos Arvelo, Caracas, Venezuela; 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Vicente Salías Sanoja, Caracas, Venezuela

Background: To present a descriptive and retrospective to know the incidence of bone tumors and pseudotumoral lesions of the upper limb study evaluated in our clinic from February 2012 to 2013. Material and Methods: reviewing medical records of 69 patients was performed with pathological and grouped based on the classification of the World Health Organization diagnosis. Results: Of the patients studied, females predominated with 36 patients (52.17%) of this total, 34 (94.4%) had diagnosis of bone tumors, while in the male these pathologies presented them in 27 patients (81.81%). Between 31-50 years of age he increased incidence of bone tumors was presented while in the group of 19-30 years pseudotumoral cases of injuries occurred. Within pseudotumoral lesions not classified, the ganglion was the injury most evidenced with 36 patients (59.01%), where 20 (55.55%) were female and 16 (44.44%) male. Likewise, the gouty tophus 3 (37.5%) was found in a ratio of 2: 1 in males. a low incidence of malignant bone tumors, which accounted for 10% (1 Osteosarcoma, 1 Squamous Cell Carcinoma and 1 Liposarcoma) and which merited a radical treatment for final resolution was found. 2 (2.8%) patients with bone tumors, merited reoperation for correction due to the commitment of the soft tissues. Conclusions: pseudotumoral bone tumors and lesions are frequent complaint in our institution, giving us a high success rate at the time of surgical resection in accordance with the studies of other authors.

Aj Acuña, AE Michelini, I Abdon

Sanatorio Franchín, Buenos Aires, Argentina

Hypothesis: It is possible to allow ulnar nerve regeneration in a gap wider than 10 mm
Materials and Method: We present a healthy, non smoker, 30 years old woman who suffered a glass wound in the medial aspect of her left forearm, explored by another surgeon several months ago. She complained about anesthesia on the ulnar side of the wrist and hand, weakness and claw deformity. Once indicated re-exploration, she refused absolutely the possibility of performing an autologous nerve graft but accepted to give a chance to a nerve regeneration chamber. We found the ulnar nerve completely sectioned. Te gap obtained after both stumps resection couldn't be closed, even after extense neurolisis. A segment of a PVC nasogastric cannula was used as a bridge, pulling both ends into the tube with 6/0 perineural separated sutures. Gap was reduced down to 13 mm. Aditional tendon repairs were made. The limb was immobilized during 30 days in a long splint with 90° elbow flection. No special medication was given.
Results: eight months after surgery, sensitivity had almost revovered, claw deformity had almost disappeared and strength had been improved. Since we didn't have any data about leaving PVC tubes indefinitely, we asked the patient to consider the possibility of perform a final procedure to extract the device. She accepted to underwent the extraction. After almost eleven months from surgery, the hand was most likely healed. The tube was split in two halves. Inside of it had been formed a white bridge, almost the same diameter as the normal nerve. No other procedures were made in adition to direct observation.
Conclusions: Some kind of nerve regeneration can occur bypassing a 13 mm gap of an ulnar nerve with a PVC tube, in the forearm of a healthy30 years old woman, with no aditional medication.

José Marulanda, Olimar Salones, Maria Tortolero, Magally Ortiz, José Vicari

Servicio de Cirugía de la Mano y Reconstructiva del Miembro Superior, Instituto Autónomo Hospital Universitario de Caracas, Caracas, Venezuela

Background: To report the case of a male patient 54, who after falling motorcycle, present deformity, increased volume and difficulty extending the fingers of his right hand, radiologically incongruity was observed joint carpometacarpal the long fingers scrolling fly and radial, converging without fractures bases II, III, IV and V metacarpal and the thumb unscathed. Methods: Under infraclavicular regional blockade of the right upper limb and visualization with image intensifier length of each metacarpal skeletal traction was performed, starting with the index finger, once the reductions closed completed, we proceeded to perform percutaneous internal fixation with Kirschner wires 1.2 mm and 1.5 mm for the joints of the foundations of II-III and IV metacarpal is not necessary to fix the V metacarpal articular reduction and proven stability, drainage palmar and dorsal held download hand, due to edema present, I was immobilized with plaster splint for 3 weeks plus intrinsic. Results: A week of postoperative began his scheme rehabilitation and occupational therapy. Conclusions: Multiple carpometacarpal dislocations are very rare lesions high energy and whose bibliographic reports are scarce. There is no agreement on the optimal treatment options range from closed reduction with immobilization to open reduction and internal fixation. Some authors have reported successful results with closed reduction, others with open reduction and internal fixation, and all ensuring the integrity of the tendon insertions.

Yenny Medina 1, Bertha Marquez 1, José Viamonte 1, Igor Indriago 1, José Vicari 2

1 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Complejo Hospitalario Universitario Dr. Luis Razetti, Barcelona, Venezuela; 2 Unidad de Cirugía de la Mano y Reconstructiva del Miembro Superior, Hospital Militar Dr. Vicente Salías Sanoja, Caracas, Venezuela

Background: The case of a male patient aged 68, who after fall of his feet is presented, I present open metacarpophalangeal dislocation of the four long fingers of the right hand, with full bone exposure head V metacarpal and part of the fourth metacarpal, being right thumb. Methods: Under sedation and blocking regional anesthetic, exploration and surgical cleaning was performed, more release of the interposition of the volar plates of the 4 metacarpal, then reductions dislocations were performed using distal traction and bending progressively, achieving reductions anatomical. Flexion and extension active and passive at the level of the injury and did not present joint blockage was found, finally raffia primary skin was performed on the palmar wound dressing softer. Results: In the immediate postoperative period, beginning the movements of flexion and extension of the fingers, without load or support. Successive controls and the 4th week, beginning the rehabilitation plan and occupational therapy were performed at 3 months postoperatively, not present limitation of joint range or pain at the affected joints, which was incorporated into its daily activities. Conclusions: It is rare that this condition is present simultaneously, affecting all triphalangeal fingers, so when performing the literature review of this case, we find that is the second case reported worldwide and the first reported in our country.

Jorge G. Boretto, Gerardo L. Gallucci, Agustín Donndorff, Verónica Alfie, Pablo De Carli

Hospital Italiano de Buenos Aires, Argentina

In the treatment of bone defects and nonunion there are cases where either the type of trauma or previous surgeries produced a poor vascular bed. In these cases, the use of vascularized bone grafts has proved to be a safe choice with faster healing time. Vascularized fibula graft is an accepted method to treat defects of more than 6cm with structural bone graft requirement. However, in defects smaller than 6cm the use of vascularized bone graft is not widely accepted. The medial femoral condyle, supplied by the descending genicular artery, has proved to be a reliable source of periosteal, corticoperiosteal, osteochondral and corticocancellous flaps. Most of the reports about this flap showed it utility in scaphoid nonunion.

To evaluate the rate and healing time and complications with the use of vascularized corticocancellous bone graft of medial femoral condyle in situations other than scaphoid non-union.

Material & Methods
Five men and one woman with an average age of 33 years (range 17-65) were operated on. In 5 cases due to pseudoarthrosis and in 1 case acute traumatic bone defect. Non-union included: 1 Lisfranc joint, 1 diaphyseal ulna, 1 diaphyseal radius, 1 carpometacarpal joint and 1 clavicle. The traumatic bone defect included a partial first phalanx and first metacarpal. Five cases had been previously operated 2 times on average (1 to 4). The time between the initial injury and surgery averaged 21 months (range 0-48)
The size of osteo-periosteal flap averaged 4.25 cm (range 3,5 to 5cm). In five cases arterial suture was termino-lateral and in one case a termino-terminal suture to a branch of the toracoacromial arterial trunk. In all cases venous suture was termino-terminal. Antithrombotic prophylaxis was performed with low molecular weight heparin and aspirin.
Bone scintigraphy for postoperative evaluation of bone perfusion was performed during the first five days.
Consolidation was assessed using radiography and computed tomography. Complications of the procedure are described.

In all cases bone scintigraphy showed flap perfusion. Bone healing occurred in all cases at an average of 8 weeks (range 6-12). One patient had a postoperative hematoma that had to be drained.
No patient had complications in the donor area.

This versatile vascularized flap can be crafted to requisite shapes and is useful for defects up to 5cm not only in nonunion cases but also in acute traumatic bone defects. The consolidation was obtained in all cases, even in cases with previous surgery in an average time of 8 weeks. A refined surgical technique avoids complications in the donor site.

Juan Carlos Sanchez Hernandez, Sergio Fernandez Roldan, Fernando Aranda Romero, Sergio Ramon Bitrian, Maria Antonia Martinez Castillo

Ramón y Cajal Hospital; Madrid, Spain

We have observed a curvature deformity of the first metacarpal associated with advanced stages of thumb carpometacarpal osteoarthritis
The purpose of this study is to quantify and clarify the correlation between this deformity and osteoarthritis of the thumb carpometacarpal joint
We performed radiological measurements of the hands of 250 patients.
We studied 100 patients randomly selected, aged between 20 and 81 years who had undergone an X-ray PA of his hand in the emergency room and another group of 150 patients aged 45 to 83 years diagnosed with TM symptomatic osteoarthritis in X-ray examination before surgery.
Radiological measurements of both cohorts were compared.
Both populations were divided into groups of similar ages. And 3 groups were also established depending on the degree of involvement osteoarthritic TM: 1. Normal (Normal Thumbs) mild arthritis (Eaton stage 1 or 2) and severe arthritis (Eaton stage 3 or 4)
Measurements are made with the system calibration software for viewing digitized radiographs our Hospital (PACS) (Acronym for Picture Archive and Communication System, a computer network for digitized radiologic images and reports)
Specific measures of the degree of curvature of the 1st metacarpal were performed. With this objective, we draw a line connecting the point where the surface began the distal articular changes orientation and where the silhouette of the metacarpal base. By measuring the angle formed with the further from the external and internal diaphysis cortical with respect to both lines point.
In addition we also measured sizes of the metacarpal as well as the Trapezium and the degree of dorsal subluxation and tilt articular facet of the base of the first metacarpal
We proceeded to compare statistical analysis of the measurements of the different groups. The correlation by age groups and between different groups stratified by affectation of TM osteoarthritis is studied.
Both dorsal subluxation angle and the angle were Significantly greater facet in the arthritis group than in the standard group and Significantly greater in the severe arthritis than others groups. A significant positive correlation was moderately between dorsal subluxation also apparent and facet angle in patients with TM osteoarthritis.
Angles reflecting the degree of deformity of the first metacarpal medial curve also increased in the most severe degrees of TM osteoarthritis.
Articulate tilt, dorsal subluxation and progressive deformity of the first metacarpal curve based are closely related, and all are increased with advanced -stage TM osteoarthritis
1.- Trapezial-metacarpal joint arthritis. Radiographic correlation between first metacarpal articular tilt and dorsal subluxation. Kurosawa K, Tsuchiya I, Takagishi K. J Hand Surg Am, 2013 Feb; 38(2): 302-8.
2.- Trapezial tilt: a radiographic correlation with advanced trapezio metacarpal joint arthritis. Bettinger PC, Linscheid RL, Cooney WP 3rd, An KN. J Hand Surg Am. 2001 Jul; 26(4):692-7
3.- Degenerative changes of trapezia-metacarpal joint: radiologic assessment. Cooke KS, Singson RD , Glickel SZ Eaton RG. Skeletal Radol. 1995 Oct, 24 (7): 523-7
4.- The Classic: Radiography of Trapezialmetacarpal Joint. Degenerative Changes of This Joint. Robert m. Clin Orthop Relat Res 2014 472: 1095-96

frederic Lebailly 1, Lucas Lima 2, Ahmed Zemirline 3, Chihab Taleb 4

1 Clinique Saint Paul, Fort de France, Martinique; 2 Instituto Politécnico, Universidade do Estado do Rio de Janeiro, Nova Friburgo, Brazil; 3 Centre hospitalier Privé Saint Grégoire, Renne, France; 4 Centre hospitalier de Mulhouse, France

Objective / hypothesis: Distal radius fractures are among the most frequently encountered trauma in daily surgical practice. Volar locking plates have become one of the best surgical options of osteosynthesis. It provides a very strong fixation and allows early mobilization after surgery. In case of poor bone density, particularly in elderly women, secondary displacement remains possible. In our experience, we observe mostly loosening of the proximal screws. Several models of plates are available. Most commonly, plates have 3 proximal screws perpendicular to the plate. We assume that divergent or convergent proximal screws may improve the proximal fixation. The aim of this study is to evaluate the influence of the orientation and of the numbers of the screws on resistance to loosening of the proximal part of radial volar locking plate. A computational parametric model was used.
Materials and Methods: The external surface of the radius was obtained from an open source database. In order to adapt this surface to our application, the number of triangles was increased and a Taubin filter was applied to obtain a smother surface without loss of radius volume. Internal cortical layer was obtained by offsetting the external surface using a constant cortical thickness obtained from literature. A hexahedral mesh was constructed using in-house applications. Material properties of cortical and cancellous bone were obtained from the literature. Radius fracture was simulated as a simple trait of metaphyseal osteotomy, dividing the radius in two parts: proximal and distal. A plate with a deep surface that perfectly matched the volar external surface of the radius was constructed. A perfect mechanical bound between the distal part of the radius and the plate was considered. Proximal screws were simplified as 2.8mm diameter cylinders. Their length was adapted to their orientation in order to be 2 mm longer than the thickness of the proximal radius. A perfect mechanical bound between the plate and the screws was considered. Contact elements with Coulomb friction properties were used to simulate screws-bone interface. Once shear stresses were greater than bone resistance, sliding could occur. Different versions of the model were constructed with 2 or 3 proximal screws and with different orientation of the screws: perpendicular to the plate, 10° convergent or 10° divergent.To each configuration, a moment around the mediolateral to the front axis was applied to the distal part of the radius. A finite Element solver was used to obtain principal stresses around the screws. We consider that loosening might occur when clusters of elements surpassed bone strength limits. The different configurations were compared regarding this criterion.
Result: Preliminary results showed that models with divergent screws have better resistance to loosening. Three screws seemed to offer better resistance than 2.
Conclusions: By the authors knowledge it is the first study of its kind. Despite simplifications and approximations, tendencies must be valuable since they are based in comparative results. Nevertheless, it must be confirmed in an in vitro study. And if so, new designs of plate with divergent screws should be considered.

Jose J Monsivais 1, Diane B Monsivais 2

1 Hand and Microsurgery Center of El Paso, El Paso, Texas 2 The University of Texas at El Paso School of Nursing, El Paso, Texas

This presentation provides an overview of a collaboration to develop a teaching and research program in the upper extremity for the Palestinian population (predominantly children and women) between 2010-2015.

There are no hand surgeons for a population of over 10 million Palestinians leading to neglected care of treatable conditions. Some cases are now sent to other countries for care, causing increased expenses to the economy. The majority, however, are not provided any specialty care, which may serve as a breeding ground for anti-Western sentiment. This collaboration may serve as an opportunity to ameliorate this attitude.

The program is being accomplished through collaboration with local medical personnel, university medical facilities, and the Palestinian ministry of Health. Development of local capacity has been enhanced by assigning a local resident or fellow who are dedicated to the program and provides continuity and ongoing communication by electronic methods about the patients’ treatment.

To date, over 300 patients have been evaluated, and 127 procedures performed. Types of cases include revision of complex syndactyly releases, tendon transfers and nerve transfers for irreparable nerve injuries. Cases include brachial plexus injuries, Erb’s palsies, peripheral nerve injuries, congenital differences reconstruction, post-burn contracture release to include skin grafting and flaps, osteotomies for malunions, failed flexor tendon repairs, pollicization, and complex fractures.

This program aligns with the strategy to improve global health outlined by the US Department of Health and Human Services and US Department of State. Challenges and opportunities related to program sustainability and support needs will be discussed.

Jose J Monsivais 1, Diane B Monsivais 2

1 Hand and Microsurgery Center of El Paso, El Paso, Texas 2 The University of Texas at El Paso School of Nursing, El Paso, Texas

BACKGROUND: Neuropathic pain resulting from total avulsion of the brachial plexus root often poses a complex clinical problem that may interfere with rehabilitation. A complete reconstructive plan includes a contralateral C7 transfer that targets median nerve to improve hand function and sensation. Based on clinical experience, it may also be useful for the management of brachial plexus pain.

METHODS: This is a retrospective review of the outcomes of the surgical management of 11 patients with global plexopathy and avulsion from C8 to T1 roots. Ten of the patients had brachial plexus pain. A group of 6 patients with avulsion plexopathy who did not undergo contralateral C7 transfer are used as a control. Mean follow-up is 10 years, and the longest follow-up is 15 years.
The cases were managed with contralateral C7 transfer with the goal of restoring median nerve sensation and motor function and improving pain. Standard grafting and nerve transfers were performed for the remaining roots. Sensory recovery was measured using Semmes-Weinstein monofilament testing, and motor recovery was measured with voluntary motor testing grading system. Pain was assessed using pain scales and quality of life by the Brief Pain Inventory.

FINDINGS: Sensory recovery was consistent in returning to some degree in 10 out of 11 patients. Pain and quality of life were consistently improved in the majority as compared to a control group. Motor recovery was consistently poor. Only 1 patient achieved motor recovery, graded as M4. Two patients obtained grade M2 recovery, and the remaining obtained no motor recovery. Two patients who obtained no motor recovery when submitted to electrical stimulation had contraction of the median-innervated muscles in the forearm and the thenar eminence. This may represent a “neglect-type” condition. The patient who achieved the best overall recovery was also the most motivated and had a high degree of initiative for the rehabilitation program. Short- term complications consisted of transient hypoesthesia in the contralateral mid-palm and digits. There were no long-lasting complications or deficits noted on the contralateral side as reported from other institutions.

CONCLUSION: Contralateral C7 transfer may be useful for the management of brachial plexus pain and sensory improvement compared to the control group. The benefits may be limited to meaningful motor recovery in less than 10% of the cases. Careful selection of highly motivated patients may improve results.

Paula Simaro 2, Lucia Pastorino 2,1, Elena Santamarina 1, Geraldine Ewens 1, Ma. Agustina Davalos 1,2

1 Hospital Italiano de Buenos Aires 2 Hand therapy Clinc Davalos

The aim is to restore the body image of the shoulder-disarticulated patient, which is important because of esthetic reasons. The purpose is to improve the body symmetry while dressing with different daily clothing.
Improve the acceptance of the traumatic situation; favor the adaptation, the emotional impact and the preservation of bilaterally.
A static splint was made in the Occupational Therapy department, required 20 days post-surgery by a 65 years old patient, female entrepreneur and housekeeper who got an amputation of her left shoulder because of a tumor.
The materials used were: 20 centimeters width, 30 centimeters length and 1 centimeter thickness of high density foam rubber; 3 centimeters width and 50 centimeters length of 3,2 centimeters thickness thermoplastic; cement contact glue; 2,5 centimeters width and 60 centimeters length of Velcro to fasten the splint. Regarding the tools: heat-gun and scissors.
The foam rubber was used to shape the shoulder, and shoulder´s frame was made with the thermoplastic. After joining the pieces, the splint was fasten with the Velcro crossing it below the right underarm.
The splint allows support the emotional reactions that takes place after the amputation, fulfilling the esthetic and body symmetry goal, enabling the person beats progressively the traumatic situation caused by the amputation.
100% of patient satisfaction; regarding to comfort and visual esthetic after dressing, very satisfactory; the splint weight very light; very easy to put and take out. Before splinting, the patient didn´t wear and integrate to society comfortably. After splinting, the patient was able to integrate to society and wear their costume without discomfort.
The social integration and the improvement of the personal esthetic in the use of daily clothing were reached by the use of a passive splint.

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios

Hospital de Clinicas UBA

The carpal tunnel syndrome results from compression of the median nerve in the wrist, can be caused by multiple factors. Typical symptoms are pain (most often by night), paresthesia, hypoesthesia, and numbness in the territory of the median nerve. We prospectively studied patients clinically diagnosed with carpal tunnel syndrome and treated with the injection of corticosteroid. This study aims to evaluate the efficacy of corticosteroid injection at the carpal tunnel, such as treatment of mild and moderate cases of carpal tunnel syndrome.

METHODS: We enrolled patients who presented to our hospital from March 2013 through December 2014. The patients were clinically diagnosed with carpal tunnel syndrome, but only those who had mild and moderate electromyogram results were accepted for this study. Exclusion criteria were: previous treatment with surgical release or injection of corticosteroids, inflammatory disease or pathological etiology (such as rheumatoid arthritis), previous adverse reactions to corticosteroids or local anesthetics.

RESULTS: The procedure was performed on 71 hands: 45 women and 26 men. The ages were between 42-85 years. They were infiltrated those with mild or moderate electromyogram result. Steroid solution was used (each vial contains: Betamethasone, dipropionate and 10 mg, and betamethasone as disodium phosphate, 4 mg; Excipients of 2 ml.). And 1 ml of 1% lidocaine. No immediate or mediate adverse effects were observed after injection. Follow-up was four dates at 15, 45, 90 and 180 days after injection. A number of 20 from 71 patients had a poor outcome, recurrence or persistence of symptoms, this represents 28, 5% of the population studied (average age was 59,8 years; 80% were women).

CONCLUSION: We agree with the published literature that injections of corticosteroids are more effective in the short-term treatment of carpal tunnel syndrome, as we have registered more patients with recurrences at 90 days. Also, influence the success of this technique, the degree of compression using electromyogram and the patient's age at diagnosis. We did not get significant differences in the ratio of time of diagnosis of the disease.

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios

Hospital de Clinicas UBA

Polydactyly is the most common malformation of the hand, and can happen sporadically or inherited. In well-developed extra digits, a cosmetic and reconstructive orthopedic challenge comes. It can appear and radial sides (preaxial) ulnar (postaxial) member. Usually it inherited and transmitted in an autosomal dominant manner, but with a pattern of variable penetrance, and is more common in Africans. It is estimated that the prevalence of polydactyly postaxial is 1 of every 1339 live births. The polydactylies can also be classified into: Finger supernumerary well developed (type A); rudimentary finger and pedicle (type B).

Materials and methods
19-year-old woman present a left postaxial polydactyly. Physical examination showed a finger fully formed in the ulnar border of her hand. Unable to flex the metacarpophalangeal joint, otherwise normal examination. The main complaint of the patient was the aesthetic deformity that this was causing her. The patient under study, had a family history of this anomaly. She underwent surgery to amputate the sixth finger, which consisted of an incision on the ulnar border, opening of the capsule, amputation, and reconstruction of the ulnar collateral ligament, which was fixed with a harpoon, and insertion of the abductor of the little.

Currently, the patient reported being satisfied with the surgery. Reported having had a couple of episodes of numbness in the area early and phantom limb sensation the first few months. No repeat it at the time.

The complication of a well-developed postaxial polydactyly (type A), it requires surgical amputation followed by a transfer of all the important elements (ulnar collateral ligament and abductor of the little finger) adjacent finger

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios, Marcelo Melo

Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires Argentina

Among the complications that can have a closed or open reduction in forearm fractures, are compartment syndrome, re-fracture, nonunion, infection, and less frequently, bone ingrowth of nerves or tissues.

Methods:A 20-year-old man that showed a contraction of the middle finger, ring finger and little finger of the right hand with 8 years of evolution. He had a history of a forearm fracture by direct trauma at 12-year-old, which was treated with a immobilization with a cast for a month after a closed reduction. The patient evolved with progressive flexion contracture of middle, ring and little fingers of the right hand. It was decided to perform surgical exploration. Postoperatively he had an immobilization for 2 weeks and afterword, he begins with passive movements of finger flexion and kinesics exercises.

Results:The patient recovered the extent of the affected fingers, one month after surgery.

Conclusions:Bone ingrowth of the flexor tendons has been documented as a rare complication of forearm fractures. There have been very few cases described in the literature about this complication, who despite being rare, should be considered in follow-up of patients with this type of fracture; by comorbidities that may develop. Surgery is the treatment indication for release of tendon adhesions once the fracture healed. But we should also consider that this complication could be avoided if after proper anatomic reduction was obtained during patient follow-up is considered a careful physical examination.

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios

Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires Argentina

Introduction: Gout is a common metabolic disorder. Tophaceous gout in the hand and wrist are often presented as the first sign of the disease process in the elderly. The content of tophaceous gout may occur as a pasty liquid or granular state. Surgery is indicated when the patient has tumors of significant size in the tendon, subcutaneous tissue, joints and damage to the skin, and also, decompression of peripheral neuropathy.

Materials and methods: 60 year-old man, rural worker, diagnosed with gout 10 years ago, which he did not adhere to medical treatment. Physical exam: multiple tumors in both hands on the back most, and at the level of the proximal metacarpophalangeal joints of the index finger and ring finger, which decreased their range of motion and generating constant pain. In the back of both elbows also presented larger tumors (approx 4x5cm) that limit full extension. No neurological or articulate compromise. First, the excision of tophi hand and left elbow was performed, and two months later on the right.

Results: With a follow up of 18 months, he presented a good evolution, he could return to his usual activities. The only limitation he referred was pain (Visual Analog Scale 3/10), when he tries to lift heavy objects. The range of motion of the affected joints are not fully recovered. Currently the patient has pharmacological treatment, and he respects him.

Conclusion: The treatment to prevent gout complications, with medication that block uric acid production, such as xanthine oxidase inhibitors (including allopurinol) is especially suitable not only in patients with gouty arthritis, but those with tophi. Early diagnosis and proper medication will generally prevent crystal deposits in soft tissues and its aftermath. Because when the patient needs surgery to restore function, it is that it has been too long.

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios

Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires Argentina

Introduction: There are still some controversies in the treatment of proximal humerus fractures, there are gray areas on the classification such as the treatment of fractures with multiple fragments that are traditionally treated with shoulder prosthesis. Today, with the advent of precast osteosynthesis devices, it is possible to fix fractures, that many years ago it would have been impossible to solve.

Objective: to present fractures of the proximal humerus with formal indication of hemiarthroplasty, according to Neer classification, treated with osteosynthesis.

Materials and Methods: We evaluated 6 patients with proximal humerus fractures with multiple fragments (Neer Classification 3 and 4). They all suffered indirect trauma. They were treated by reduction and fixation with a Phyllos plate. They started with rehabilitation a week after surgery. Remote clinical results were evaluated by DASH questionnaire.

Results: There have been no necrosis of the humeral head, or other complications of relevance that have made us regret our decision to treat the fracture without prostheses. The DASH questionnaires, in most cases had good results. None have express limitations in daily living activities.

Conclusion: Overall fractures with multiple fragments have formal indication of hemiarthroplasty, because they are difficult to reduce. We argue based on our experience, that despite this indication, if it is a good reduction achieved, these fractures can be treated in this way, to maintain the viability of the humeral head.

In our experience we have obtained good results, and patients were satisfied with their surgery.

We conclude that it is appropriate to review the indications of the Neer classification, since, when it was described, surgeons did not have the quality of implants that we have today, and this technological advancement can change the quality of life of patients.

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios

Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires Argentina

Introduction: hypoplastic thumb refers to the thumb which has some degree of deficiency in their anatomy. Congenital anomalies between 1-2% of newborns, of which 10% are alterations in the upper extremities.

Materials and Methods: Female patient, 7 years with a diagnosis of bilateral congenital floating thumb. No family or genetic history. Surgical treatment is started by right. Dominant member. Physical examination showed bilateral floating thumbs In radiographs, absence of the first metacarpal hypoplasia of proximal phalanx. No hypoplasia radio. Hypoplastic thumb (Blauth 4) palmar approach. Neurovascular elements of the first ray and tenolysis flexor isolated. Opening pulleys, 2nd osteotomy proximal and distal metacarpal. Then placed it at the base of the thumb setting with harpoons and plug to the first ray as opponents. Forming flap.

Result. Wound closure without tension of both hands. Neurovascular been preserved. Antebraquipalmar plaster immobilization. Control the first and third month of surgery. Good wound healing. Apprehension capacity for medium sized items.

Conclusion The goals are to achieve an independent flexor and extensor function, an appropriate first space for the apprehension, length, and joint stability without altering the sensitivity. And always keep in mind the importance of the social context of a child, so these procedures should be performed as early as possible in life, to avoid difficulties in the social and educational integration of these children who tend to withdraw to do friends and have a normal life

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios

Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires Argentina

Introduction: While it is widely known the effect of disodium pamidronate on bone metabolism in our literature search, we have not found any to describe the intralesional treatment, alone or combined injection of this medication in lesions that affect bone structure. Our goal is to report the evolution of a patient with a diagnosis of aneurysmal bone cyst treated percutaneous with intralesional and pamidronate 90 mg and autologous bone marrow aspirate.

Materials and methods: 15 year-old woman that present a pseudotumoral injury in her right proximal humerus. In the same operating room it is placed in position beach chair under regional anesthesia. Using a fluoroscopic guidance, we performed two separate puncture of the lesion, proximal and distal. We crossed the lesion in all of its margins from both inputs to trocars and plugs 2 mm to break the septa. The cavity is filled with 8 cm3 of autologous bone marrow aspirated from the iliac crest in mixed with 10 ml solution of 90 mg of pamidronate.

Results: 48 months follow up. Clinically excellent. We observed bone remodeling, with remaining islands of the initial injury that attach to the percutaneous technique.

Conclusions: Excellent clinical and aesthetic results in the short and medium term, using percutaneous minimally invasive technique with the advantages inherent therein. Early return to normal duties (3months) and sport (5 months).

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios

Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires Argentina

INTRODUCTION: Trigger finger, also known as stenosing tenosynovitis, happens when a finger stuck in a position of flexion and then suddenly straightened. It is caused by a narrowing of the sheath that surrounds the tendon in the affected finger. People whose work or hobbies require repetitive gripping actions are more susceptible. We prospectively studied patients clinically diagnosed with trigger finger and treated with injection of corticosteroid. This study aims to evaluate the efficacy of corticosteroid injection such as treatment for trigger finger

METHODS: We enrolled patients who presented to our hospital from March 2013 through December 2014. The patients were clinically diagnosed with trigger finger. Inclusion criteria were patients presenting clinically trigger finger, characterized by pain at the A1 pulley with or without palpable nodule on this, demonstrable history of entrapment on physical examination by snapping to get caught in flexion. Exclusion criteria were: previous treatment with surgical release or injection of corticosteroids, inflammatory disease or pathological etiology (such as rheumatoid arthritis), previous adverse reactions to corticosteroids or local anesthetics.

RESULTS: The procedure was performed on 64 patients, 54 women and 10 men, aged between 24-81 years. Evolution time was between 1 month to 7 years, with an average of 8, 8 months. The fingers that were affected: 25% thumbs, index 15%, 31% greater, 28% ring and little fingers are not recorded with spring. 75% and 25% were left rights. Steroid solution was used (Each vial contains: Betamethasone, dipropionate and 10 mg, and betamethasone as disodium phosphate, 4 mg; Excipients of 2 ml.) And 1 ml of 1% lidocaine. Follow-up was four dates at 15, 45, 90 and 180 days after injection. The group was evaluated with special importance in the recurrence or persistence of symptoms. Only 6 of the 64 patients had a poor outcome and they were performed an open surgical release.

CONCLUSION: Steroid injection has proven to be an effective procedure for the treatment of trigger finger, as well as fast, safe and cheaper. We agree with the international literature on our results.

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios

Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires Argentina

INTRODUCTION: De Quervain's tenosynovitis is a stenosing tenosynovitis of the first dorsal compartment of the wrist, typically causes pain at the radial side of the wrist, this condition involves inflammation in the sheath of the long abductor of the thumb and the short extensor tendon of thumb at the level of the radial styloid. Patients usually complain of pain located in the radial side of the wrist that intensifies with the movement of the thumb. The diagnosis was justified by the discovery of swelling over the first compartment. Surgical treatment is considered by many as a final measure orthopedists for treating this disease. However, surgery does not guarantee complete relief of symptoms. The aim of this paper is to describe the experience with local infiltrations. We prospectively studied patients clinically diagnosed with De Quervain's tenosynovitis and treated with injection of corticosteroid. This study aims to evaluate the efficacy of corticosteroid injection such as treatment for De Quervain's tenosynovitis.

METHODS: We enrolled patients who presented to our hospital from March 2013 through December 2014. The patients were clinically diagnosed with De Quervain's tenosynovitis. Inclusion criteria were patients presenting positive Finkelstein test. Exclusion criteria were: previous treatment with surgical release or injection of corticosteroids, inflammatory disease or pathological etiology (such as rheumatoid arthritis), previous adverse reactions to corticosteroids or local anesthetics.

RESULTS: The follow-up included three events, the first at 15-45-90 days. Only one patient presented recurrence of symptoms within 90 days of the procedure. 60 The patient presented to a year tenosynovitis. The procedure was performed on 30 patients, 28 women and 2 men, aged between 34-69 years. Evolution time was between 1-12 months years, with an average of 8, 8 months. Steroid solution was used (Each vial contains: Betamethasone, dipropionate and 10 mg, and betamethasone as disodium phosphate, 4 mg; Excipients of 2 ml.) And 1 ml of 1% lidocaine. Follow-up was four dates at 15, 45, 90 and 180 days after injection. The group was evaluated with special importance in the recurrence or persistence of symptoms. Only 2 of the 30 patients had a poor outcome and they were performed an open surgical release.

CONCLUSION: We hold that is Steroid injection a simple and quick treatment for patients with De Quervain's tenosynovitis. We agree with the international literature on our results

Caloia Martín F 1,2, Piazza Diego 1, Caloia Hugo 2, Nogueira Federico 1,2

1 Fundacion Favaloro Hospital Universitario, Buenos Aires, Argentina 2 Hospital Universitario Austral, Buenos Aires, Argentina.

The key to a successful result in the treatment of PLDs and PLFDs, is to restore the normal alignment of carpal bones, followed by stable fixation of soft tissue and bones, main focus on the integrity of the scaphoid and scapho-lunate joint. The purpose of this retrospective study was to assess if arthroscopic technique, realized in two specialized centers, is a reliable surgical option for the treatment of these challenging injuries.
Material and Methods
Between 2004 and 2013, 9 PLDs -PLFDs cases were surgically treated at the acute stage. There were 8 males, 1 female, with the mean age of 40 years (range 17- 55). According to Herzberg’s classification, 8 cases were dorsal displacement type (stage: I: 3, stage II: 5). One case presented volar displacement type, stage I. Our series included 4 PLDs, 5 trans scaphoid PLFDs, 2 of them, associated with ligament avulsion of triquetral, and ulnar styloid fracture. The mean time from injury to operation was 7 days (range 2-10). The average follow up was 40.6 months (range 14–79); all patients were assessed by clinical examination, range of motion and grip strength and the Modified Mayo Wrist Score (MMWS), Quick-DASH score, as well as radiographic evaluations. Closed reduction under fluoroscopy, followed by arthroscopic reduction and percutaneous fixation was performed to reduce the scapholunate and lunotriquetral intervals using Kirschner wires as joysticks. Scaphoid ORIF by using cannulated headless screw for PLFD injuries. The arthroscopic view allows the surgeon to identify the grade of ligamentous and cartilage injury, soft tissue interposition and scaphoid fracture reduction assessment. In 1 PLDs with a wide joint gap, a temporary screw through the SL joint was used. The K-wires were removed at 8.2 weeks (range 8-11). The transindesmal screw was removed when radiological signs of loosening appear. In three patients with associated TFCC injury (ulnar avulsion), simultaneous repair was performed.
All scaphoid fractures consolidate, including three comminuted fractures. The average consolidation time was 19 weeks (range 12 -33). In comparison to the contralateral side, the range of motion of the injured wrist was 85% and the average grip strength was 78%. The mean Quick-DASH score was 6. Overall functional outcomes, according to the MMWS were rated as excellent in 3, good in 5, and fair in 1. Two patients had developed asintomathic arthritis in the midcarpal joint at last follow-up.
Since the year 2000, many surgeons have attempted to use mini-invasive techniques, including wrist arthroscopy, for the treatment of acute PLD-PLFDs, with the goal of improving wrist motion and reducing the incidence of osteoarthritis. In the management of the PLD and PLFD injuries and in line with recent publications, our midterm results have shown that the arthroscopic technique can provide: an adequate anatomy restoration, stable fixation and carpal alignment with satisfactory functional and radiological results, and low rate of degenerative changes.

Eliana Mariel del Coco, María Agustina Zambón, Romina Vanina Aguirre Santoro.

HIGA Gral, San Martín, La Plata, Buenos Aires, Argentina.

The objective of the study was to describe the characteristics of patients with burned hand and the treatment of Occupational Therapy (OT) in a general acute care hospital, between January 2012 and October 2015.

Materials and methods
The present work was an observational case series study, retrospective and descriptive. A total of 318 medical histories, were revised. Patient records of people with burned hand (107) were included. Medical records of deceased patients (31) and those who did not have sufficient data for analysis (7) were excluded.

Most of the patients were from male sex, between the age groups 20-34 and 35-49 years. In the 34% of the cases the cause of the injury was home accident. 42% of patients presented less than 15% of burned body surface. 64% of patients presented burn in both hands. According to Benaim’s classification (1971), 70% of patients presented burn in hands type A or AB. The most frequent localization was the back of the hand. 86% had no associated injuries. 65% did not receive skin graft. 61% presented edema in hands.
75% of patients started OT treatment during hospitalization between 24 and 48 hours after hospital admission.
During hospitalization, 25% of patients received from 1 to 5 sessions and 24% from 6 to 10 sessions.
58% took from 1 to 5 sessions of OT treatment through external consulting rooms.
The interventions that prevailedin OT during hospitalization were active and active assistive exercises, training in basic Activities of Daily Living (ADLs), prevention and treatment of edema, splinting and positional equipment.
In external consulting rooms, interventions related to scar management were: pressotherapy, scar massage, use indication of polymer gel, active mobility plan and skin care.
36% of patients evolved with normal healing and 35% with hypertrophic scars.
72% of patientshad limited range of movement in the initial evaluation of OT.
51% of patients presented no limitation in their range of movement in the last assessment of OT.
Regarding the level of patient functionality, it has prevailed the group of medical histories where data was insufficient for this analysis. 40% of patients were independent in the ADLsat the end of the treatment, because of medical discharge or abandonment. 72% of patients abandoned OT treatment.

The intervention of patients with burned hand has been an outstanding field in OT. Our hospital is an institution of reference in the treatment of these patients, and this has allowed us to obtain an important sample size. We highlight the importance of early treatment of OT: edema control, early mobility, anti-deformity positioning and training in ADLs.
On the other hand, the scarce and deficient records in medical histories, as well as the lack of specific assessments of ADLs in the area of burned patients, has hindered the processing of data.
Finally, we believe it is necessary to expand more lines of research in the field of burned hand and thus determine the effectiveness of our interventions.

Juan Manuel Castro, Sebastian Alberto Ruiz

Hospital Español de Mendoza

Introduction: Giant cell tumor (GCT) represents 5% of all bone tumors. The presentation in the tubular bones of the hand is rare, more often localized in the metaphyseal region metacarpals and phalanges. Compared to other locations, when presented in hand does so in a more advanced state, with diaphyseal extension and increased bone destruction, which complicates the prognosis and treatment. There are numerous treatments proposed for aggressive GCT according to Campanacci, in which are not indicated intralesional treatments and the tumor has violated the cortical or cartilaginous barrier. The proposed treatment is usually en bloc resection and reconstructive methods, such as bone grafts and eventually arthrodesis in functional position.
Materials and methods: The case of a female patient 32 years old who has a bulky and painful tumor in left P1 thumb 8 months of evolution is presented. Radiology and MRI studies are performed to evaluate extent and characteristics of the lesion. The diagnosis of high-grade GCT is confirmed after performing a biopsy and pathological study. Due to the characteristics of the tumor, its location and age of the patient, we chose to perform en bloc resection of first phalange (including the proximal and distal end of the first metacarpal and the last phalange) at first. Then was drawn and carved a bone allograft according to the defect present. Finally MTC- and IP arthrodesis was performed at 20º and 15 º flexion respectively, Using a straight plate DCP 2.0 mm in compression and adding iliac crest autograft bone chips to restore bone stock.
Results: Radiographic outcome was highly satisfactory, presented at 14 months postoperative definitive signs of consolidation. Functionality and aesthetic achieved were excellent. After 50 months of follow up no signs of recurrence were presented.
Conclusion: The fusion emerges as a valid alternative treatment in this complex and aggressive pathology of the hand, presenting low rates of complications and good functional results.

Federico Paganini, Christian Allende, Luciano Gentile, Lorena Zecchini, Maria Laura Rizzi

Instituto Allende Cirugía Reconstructiva de los Miembros, Sanatorio Allende, Cordoba, Argentina

Objective: to evaluate a new therapeutic strategy for the treatment of resecable giant cell tumor of bone (GCTB) with the use of Denosumab drug and reconstructive surgery. Denosumab is a human monoclonal antibody thats targets and binds with hight affinity and specificity to RANKL preventing binding to RANK on the surface of osteoclast precursors and osteoclast, thereby inhibiting bone resorption. Our hypothesis is that Denosumab induced tumor reduction and bone formation, improving the quality of bone preoperatively and therefore facilitating the surgical procedure and reducing the recurrence rate.

Materials and Methods: three patients with diagnosis of GCTB pathologically confirmed preoperatively by puncture biopsy were treated wiht the association of Denosumab and reconstructive surgery. Denosumab 120 mg via subcutaneous injection was administered every four weeks two months before surgery. We did not use a weekly loading doses on days 1,8 and 15 as it is reported. After two doses of Denosumab the surgery was performed. After surgery they had two more doses, except for the child that had only one.
Results: one patient was a 24 years old girl who presented a GCTB in the first phalanx of her rigth fifth finger that was treated with curetagge and phenolized, the resulting defect was filled with tricortical autogenous iliac crest bone graft, and external fixation was used. A second patient was a 14 years old boy with a GCTB localized in the capitate of his left wrist, treated with curetagge and phenolized, filled with cancellous iliac bone grafting. The third patient was a 19 years old girl wiht an GCTB in her right distal radius that was treated with wide resection (distal radius and first carpal row) and reconstructed with a non vascularized free fibular autogenous bone graft fixed with a 3,5 LC DCP plate. The tumors were Campanacci´s grade II (the first two patients) and III (the last patient). Radiographic quality of bone improved significantly after Denosumab administration (there was more bone formation and less bone resorption) facilitating curettage, bone grafting and osteosynthesis. Histologic evaluation showed that both the stromal cells and osteoclast-like giant cells have significantly decreased or disappeared. Finally, we didn´t have any recurrence until the last control but it should be necessary a longer follow up. The average follow up was eight months. In the child with the GCTB localized in the capitate, growth plate increased mineral density was evidenced after the first postoperative dose, and denosumab administration was discontinued.

Conclusions: based on the results of our comparative radiological and pathological analysis of the pre/post treatment tumour with the asociation of Denosumab administration followed by reconstructive surgery in patients with GBCT, we could afirm that this new therapeutic strategy should be taken into account when treating this type of tumour. However there is no current evidence on how long Denosumab treatment should be continued, therefore, further investigation of the long-term use of denosumab are mandatory. While hypocalvemia is a well known side effects denosumab discontinuation may produce severe hypercalcemia, especially in paediatrics patients.

Daishi Hamada, Yukichi Zenke, Kunitaka Menuki, Hideyuki Hirasawa, Yoshiaki Yamanaka, Takafumi Tajima, Kayoko Furukawa, Akinori Sakai

University of Occupational and Environmental Health, Japan

[Objective]Pyogenic flexor tenosynovitis is a serious infection that can result in considerable morbidity if not promptly diagnosed and properly treated.Many patients sequelae, including stiffness or soft-tissue necrosis. Early stage rehabilitation is important in recovering a range of motion in the damaged fingers, it is possible to undergo rehabilitation using Negative Pressure Wound Therapy(NPWT).We report 3 cases of performing NPWT for treatment to pyogenic flexor tenosynovitis.
[Subjects and methods]All 3 subjects were males, aged 54, 64, and 83. Only one patient had an underlying illness (type2 diabetes and hepatic cirrhosis), and one patient had inducement (burn injury). All the surgeries were performed on the date of onset. Skin incisions were made from the palmar by the zigzag approach in the first surgery, and complete debridement was performed. We used NPWT and surgical gloves for the purpose of reducing swelling and managing the wound exudate.
[Results] All the patients were operated on for a second look a few days after the first operation. We placed drain tubes and closed the wounds, with the exception of one patient who had a defect in the skin. The wound cultures revealed methicillin-resistant staphylococcus aureus (MRSA), methicillin-susceptible staphylococcus aureus (MSSA), and streptococcus agalactiae, respectively. All the patients received only one operation and did not need additional debridement, and there was no reactivation of infection. All the patients got a good range of motion. The addition of the surgical gloves allowed for early rehabilitation for sufficient range of motion, which could not have been achieved with the film dressing alone.
[Conclusions] The treatment of the pyogenic flexor tenosynovitis needs prompt diagnosis and treatment with appropriate antibiotics, surgical drainage, and irrigation.
When the debridment was performed widely, We achieved good resuls and hand function recovery after debridement and using NPWT and a surgical glove.

Manuel Mendez, Marcia Carrasco, Elias Concha, Catalina Parot, Karina Barriga

Instituto de Rehabilitación Teleton, Santiago

To evaluate the elbow flexion strength in patients with obstetric brachial plexus

Materials and methods
Prospective cohort study of 5 patients with upper obstetric brachial plexus palsy (one patient Narakas group I and 4 patients Narakas group II). One man, and 4 women, all with right brachial plexus palsy. Indication was no active elbow flexion after 6 months. Surgery was performed between 6 and 17 months of age. One extrinsic ulnar fascicle was transferred to one biceps motor branch. All patients underwent exploration and neurolisis of the brachial plexus, and all of them had also a spinal accessory to supraescapular nerve transfer (for active abduction and external rotation of the shoulder). After surgery patients were immobilized with soft Velpeau. Clinical motor strength evaluation was performed at 6, 12 and 24 month after surgery with the Active Motor Scale of Movement (AMSM). Sensory and motor deficit of the ulnar nerve territory was specifically assessed. Satisfaction of caregivers was also asked.

Clinical flexion motor strength of the elbow was M2 to M4 at 6 months of surgery, M4 to M5 at 12 months. At 24 months of surgery motor strength of the elbow was M7 in 1 patient, M6 in 3 patients and M5 in one patient according to the AMSM. No motor or sensory deficit was detected at ulnar territory. There was one superficial wound infection and no other complications. Caregivers were satisfied after two years of surgery mentioning a significant improvement in the limb motion.

Nerve transfer from ulnar motor fascicules to one biceps motor branch in patients with upper obstetric brachial plexus effectively restores functional elbow flexion. All patients achieved antigravity elbow flexion, which is concurrent with other series.
This technique is a reliable and safe procedure that offers good clinical results and technically simpler and faster than root grafting.

Gregory Hoy 1,2, Chris Stubbe 3, Hamish Anderson 1,6, Ben Cunningham 4, Eugene Ek 1,2, Jason Harvey5

1 Melbourne Orthopaedic Group; 2 Monash University Dept of Surgery; 3 University of Melbourne; 4 Action Hand Therapy; 5 Orthosports Victoria; 6 Anderson Hand Therapy

Australian Rules Football is a fast paced contact sport played extensively across Australia. The premier professional competition has 18 teams around the capital cities, and extensive documentation of injuries. The AFL Injury Report is based on reporting injuries that result in loss of a game or more at AFL level. The reported hand, wrist and forearm incidence is 1.6 per club per season, and has remained static since 2002 in the AFL annual injury report. By way of comparison, the incidence of shin, ankle and foot injury was 10.3 per club per season, and shoulder, arm and elbow was 2.7 per club per season. Based on the clinical experience of the authors, it seemed that hand and wrist injuries may have been underreported.

We present the results of a single club audit at AFL level for one season assessed by the hand therapy department at the club in conjunction with the team sports physician and the hand specialists managing those conditions. Demographic data as well as field position, time of injury, and management was recorded.

A dramatically different picture to that of the official Injury Report was revealed. There were 28 hand, wrist and / or forearm injuries to 26 players on a 42 man squad, with 18 of these injuries occurring during the course of competition games. Four players missed one game due to hand injury, one of these had surgery during the season. Three players were scheduled for end of season surgery. The commonest injuries were finger sprains and dislocations which were all managed conservatively initially despite severity.

Whilst AFL football is essentially a running game, the numbers and degree of injury suggest that hand injuries in AFL football are a more significant issue than the percentage of total injuries (4.4%) would indicate. It is also worth noting that similar levels of incidence have been reported in other collision type sports such as rugby union (7%), rugby league (5.6%), and American football (6%). How these injuries are reported and managed should be examined in more detail. Bearing in mind the responsibility the club has for long term outcomes, including life after football, there should be a greater requirement for thorough recognition, assessment and management of these injuries during respective players’ careers.

Gu Yudong Xulei

Department of Hand Surgery, Hua-shan Hospital, Fudan University, 12 Middle Wulumoqi Road, Shanghai 200040, China

Contralateral C7 nerve root transfer was first reported by Gu et al. in 1992. It has been used primarily in the repair of total brachial plexus avulsion. Advance in cC7 transfer in recent years including:
1.cC7 transfer has three different routes: prespinal route、sub-cleidomastoid route and subcutaneous route. In 2008, we reported the modification of the prespinal route severing the anterior scalene muscle of both sides and forming a transverse prevertebral tunnel by bilateral mobilization. Now we made further improvements, conclusions prove: prespinal route can obtain the earliest functional recovery. The earlier restoration of function, the better brain plasticity.
2.According to previous studies, contralateral C-7 root transfer to 2 different recipient nerves has been proved as a viable and effective approach.
3.We designed a new procedure by using both double blood supplied ulnar nerve and medial antebrachial cutaneous nerve to repair both the median nerve and the musculocutaneous nerve to improve the utilization of cC7 fiber and ensure the blood supply of bridging nerve.
4. Basic research achievements as fellows: By climbing movement in rats,we prove that C7 transfer is safe and feasible. The motor endplates and muscle fibers in the target muscle innervated by cC7 fiber achieve compensation through super terminal sprouting. Electrophysiological dominance analyze of cC7 prove triceps brachii muscle is the representative muscle.
Through the work of these years, we have come to the following conclusions: contralateral C7 nerve root transfer is safe and effective, and total contralateral C7 root transfer is preferable, In order to improve the therapeutic effect, we recommend using total root of C7 nerve fiber and assuring adequate blood supply. Earlier restoration of function, the better brain plasticity.

Ma.Laura Frutos, Pablo Valle

Hospital Privado Universitario de Córdoba, Córdoba, Argentina

Study Design: Case report
Introduction: Limb amputation on a person of working age can lead to high rates of disability.
Microsurgical techniques in recent years have achieved positive results both in limb preservation and ability to function.
Many variables such as replanted segments, techniques and patient characteristics are not available from case series publications describing the sequence of a rehabilitation program after a total replantation of hand.
Objective: The purpose of this report is to present the rehabilitation program carried out after a total hand replantation for a transcarpal amputation produced by a grinder.
Materials and Methods: Male 51 years-old, right hand dominant, who suffers a work accident (cutting grinder) on his left upper extremity, on the first row of the carpus. He is immediately taken to a hospital where emergency surgery by a specialist surgeon. Reimplantation surgery included: resection of the first row of carpal bones, stabilizing the wrist with external fixator type Penning, repair of all injured tendons, arteries and nerves.
Rehabilitation begins two days following the reimplantation, while being hospitalized. Antebraquidigital static splint is made to keep the wrist and fingers extended. Initial assessment: ROM: Wrist: Flex-Ext: 0º Long fingers (average): MCP: 0 - 20 ° PIP: 20º – 30º DIP: 20º - 20º
Thumb ROM: MCP: 0 ° IP: 0 ° Sensitivity: full anesthesia (S0) Strength: 0 - 1 / 5
DASH: 97.41. Pain (VAS): 10/10
The rehabilitation was carried out in 17 months’ exercises, including neuromuscular re-education, sensitivity training and training in activities of daily living.
First stage: Antebraquidigital static splint. Edema control, active-assisted ROM, stimulation of protective sensitivity and palmar-digit grips.
Second stage: At 8 months, tenolysis flexor wrist and fingers and wrist anterior capsulotomy was performed. Antebraquipalmar static splint. Active ROM, stimulation of protective sensitivity and palmar- digit grips. Training in unimanual activities of daily life with support products.
Third stage: At 11 months tenolysis of EPB, ECRB, ECU and grafting the EDC, EI and EDM with the plantaris was performed.
Antebraquipalmar dynamic splint. Active resistive ROM, stimulation of discriminative sensitivity, and grip strengthening. Training bimanual activities of daily life. Job skills training with support products.
Results: ROM: Wrist: Flex:20º Ext: 0º Long fingers (average): MCP: 0 - 45 ° PIP: 20º - 75º DIP: 20º - 30º
Thumb ROM: MCP: 0 ° - 30º IP: 0 ° Pulp-to-palm distance: 5 cm.
Protective Sensitivity (S3 +) Strength: 3 - 1/5 DASH: 17.24. Pain (VAS): 2/10
Conclusion: The rehabilitation program appropriate patient outcomes permitted a recovery of the global hand function with sensitivity and independence in activities of daily living.

Afrânio D. Freitas, Marco Antonio Yánez Sotomayor, Ângelo José Nascif de Faria, Pedro Pires, Antônio Barbosa

Complexo Hospitalar São Francisco, Belo Horizonte, Brasil

Purpose: There are two well stablished techniques for treat trigger finger surgically. The conventional open release and, most recently, percutaneous release of the A1 pulley has been used with success. In this retrospective study, the authors compare the outcomes, complications and costs of conventional open surgical release against percutaneous release in the treatment of trigger finger.
Material and methods: The study comprised 76 adults patients, 95 fingers, who were treated with either open pulley (n=54) or percutaneous (41) release between 2014 and 2015. All patients were reevaluated at 01 week, 02 weeks and 03 months after surgery. Outcomes measures were recurrence, pain on movement or over the A1 pulley, infection, digital nerve or tendon injury, range of motion, patient satisfaction and cost of each procedure. The groups were similar regarding age, sex, laterality, dominance and grade of the trigger on initial admission.
Results: At final follow-up we had 02 recurrence in the percutaneous group and both patients got success with a new open procedure, when was verified tendon injury in both cases. No other clinic difference was found, with the exception that, relative to costs, the study showed that the percutaneous release tends to be 19% cheaper to execute.
Conclusion: Based on the results the author advocate the best technique to be adopted is an option of the surgeon despite of lower cost in percutaneous release.
Key words trigger finger, open and percutaneous release

Ilaria Saroglia, Giulia Pompili,

Clinica Multiservizi Salus, Grosseto, Italy

Objective: The aim of this study is round up the main evidences concerning evaluation and treatment of pulleys injuries in freeclimbers patients.
Materials and Methods : We carried out a reviews concerning the flexor tendons stress and pulleys lesion in professional and amateur climbers. Search engines used: Pub Med, Cochrane. The articles selected, from 1998 to 2004, are in English and French.
Results: Tubiana has shown that the load of lesion of the A2 pulley in an arched grip of the hand is 241 N, and 250 N on the A4 .The digital pulleys A2 e A4 have a predominant role in maintaining the flexor tendon adjacent to the bone during the act of grasping. Moreover, as the two pulleys are more rigid and resistant, they allow the tendon to change direction during the flexion without causing volar dislocation . Therefore, the mechanical action is ensured by the strength of these two pulleys. On the other hand , as pulleys A3 e C1 are more elastic, they allow the tendon to reach a greater angle compared to the rotational axis of the PIP.
Discussion: The programme following surgical repair proposed by existing literature is a total release of the repaired pulley with a dorsal wrist splint and annular protection of the pulley for 45 days. Treatment continues with a rigid circular splint for protection of the pulley until the 6th week. A return to climbing is not advised before 3-4 months. In the case of partial lesions a rigid circular annular splint is applied for 45 days with rest from sports activity. The most common grips are: CRIMP GRIP with PIP at 90° and hyper-extension of the DIP; the tension applied by the flexor tendon is concentrated on the distal part of the A2 pulley . This grip causes the majority of lesions to the pulleys. The bio-mechanical result of a lesion to one or more pulleys is the loss or even the inability to bend the finger. The complete lesion of A2 e A3 causes the total loss of flexion of the finger. If the A1 is also severed the situation is even more serious. SLOPE GRIP OR OPEN GRIP : DIP 30° PIP 60° ; the tendon strength weighs on the A4 pulley which can lead to lesion. POCKET GRIP: with only one finger. Remember: at muscular level we can obtain a strengthening effect in one month but to train the resistance of a tendon 3 to 5 years are needed. Anular taping decreases the bowstrining by 22% and absorbs the strain on the pulley by 17% .Conclusions: in the light of all that has emerged from relevant literature as protection for the injured pulley we propose a rigid annular splint with an elastic variant in neoprene which allows it to adhere better and makes it easier to use.

Gilles Cohen 1,2, Didier Fontès 1

1 Hand, Shoulder and Sports Institut, Paris 2 Centre Main Paris Sud, Antony

Introduction :
Wrist arthroscopy development has allowed a better knowledge of functional anatomy.
The dorsal part of ScaphoLunate Interoseous Ligament (SLIL) is not the only stabilizer of scapholunate joint but there is a real “dorsal complex” including the Dorsal Capsular Scapholunate Septum (DCSS) and the Dorsal Intercarpal Ligament (DIC).
So, recovering of a normal SL stability requires a complete restitution of all these different anatomical structures.
For this procedure, we propose an “all arthroscopic” technique using a 2,5mm Bio-PuskLock anchor® (Arthrex) consisting in an evolution of our classical procedure for SLIL reattachment.

Materiel and Methods :
This new procedure uses a knotless absorbable anchor as it was previously described for foveal TFCC injuries. It consists in a SLIL reinsertion into the proximal part of the scaphoid associated with a dorsal capsulodesis
We report our procedure in 3 acute scapholunate injuries
The technique doesn’t require any complementary pinning.
The wrist was immobilized in a splint for 4-6 weeks.

Results :
Concerning the 4 patients, after a mean follow up of 6 months, preliminary results were good and the pain decreased in all the cases. Range of motion was around 80% of the controlateral side, and grip strength of the affected side was 70% of the opposite side.
The mean DASH score was better than before surgery.

Conclusion :
As what we can see in others joints, arthroscopic approach seems to provide a better quality of management for severe SLIL injuries with better results than in open surgery.
The preliminary results of our original technique predict beautiful perspectives, but they demand a long term follow-up and a larger cohort of patients to validate definitively the reliability.

Santiago Fossati, Natalia Sorrenti, Juan Manuel Fossati

Departamento de Cirugía Plástica y Microcirugía Hospital Pasteur, Motevideo, Uruguay

Introduction. Chondrosarcoma is a malignant tumor with differentiation of pure hyaline cartilage that can present myxoid changes, calcification and ossification. It accounts for 10% of bone tumors, and occurs between the 5th and 7th decades of life. The location in hands and feet is rare, accouting 1%. There are variants of chondrosarcoma that count as separate clinical-pathological entities, from a slow growth form, to an aggressive sarcomatous form with high probability of metastasis. Histologically they have variable cellularity and atypia, and it may present with infiltrative and destructive growth. There are 3 recognized grades regarding prognosis, that guide therapeutical approach. Low-grade chondrosarcomas with myxoid changes are classified as grade 2. Amputation of a finger or part of the hand, depending on the location and extent of the tumor, provides a good chance of cure. Treatment with curettage, incomplete ablation, or any procedure other than a complete resection have not been successful. Chemotherapy and radiation therapy are used only in high-grade lesions with very limited effectiveness.
Objectives: Given the rarity of this disease, according to the review published in the literature, the purpose of this paper is to present the case of a patient with an acral myxoid chondrosarcoma. Clinical presentation, imaging studies conducted, histopathology of the piece and the surgical procedure employed will be described.
Clinical case: 64 year-old female patient, HBP, consulted for a large exophytic lobed mass of 13 cm in diameter, it was localized in the back of hand on the 3rd and 4th rays, generating great deformity as a result of bone expansion and invasion of surroinding soft tissues. The changes were insidious, progressive, and over a very long period of time. There was no pain or fractures. Radiologically it presented as a mass of ill-defined borders, endosteal erosion, lobed edges, and calcified matrix. With a positive biopsy for low-grade myxoid chondrosarcoma an allegedly curative surgical treatment was performed, with amputation of the 3rd and 4th rays. No postoperative complications or recurrence elements to date, with a good functional outcome of that hand. It did not require adjuvant systemic therapy, or radiotherapy. The final histological results confirmed the diagnosis, resected with lesion-free margins.
Conclusions: Given the rarity of this disease, we present a case report of a patient with long-standing acral myxoid chondrosarcoma of his left hand, to show its clinical, radiological and histological aspects.

Natalia Sorrenti, Santiago Fossati, Juan Manuel Fossati

Departamento de Cirugía Plástica y Microcirugía Hospital Pasteur, Montevideo, Uruguay

Introduction: Practice using anatomical dissections is a very old respurce for medical education. Anatomical knowledge enriches medical teaching. In surgical specialties knowledge of normal anatomy is by far a fundamental tool for topographic compression. At the same time it gives more confidence when performing surgery. In our country the curriculum places the human anatomy class in the early years of the medical career, and cadaveric dissections does not exist in a curricular way or compulsory practice in Plastic Surgery Residency. It is then that the following question arises, “what do the residents say about the absence of this resource?”.
Objective: To demonstrate that there is real interest by post graduate students of the specialty, to use anatomical dissections as a tool in their training in specialized Hand Surgery.
Materials and Methods: A survey of closed multiple choice questions was developed to explore the opinion of post-graduate students about the importance of practice on cadaveric dissections. It was answered by the residents of the last 8 generations (years 2008 to 2015), who studied in the Department of Plastic Surgery and Microsurgery of our Hospital. In total it was applied to 13 residents and former residents.
Results: The results indicate that 100% of respondents stated it is important to integrate cadaveric dissections to the curricular activity their post-graduate training, and believe that knowledge of anatomy for surgical practice is fundamental. A high percentage (54%), believe that the practice of dissection helps to perform better surgeries, a smaller percentage (23%) consider that it helps to theoretical-practice integration, 15% believes it helps to identify anatomical surface and 8% for lear to work together. As for the frequency of performing an upper limb dissection workshop, 23% consider a frequency of once a week for a month (2 hours each session), 23% once a week (2 hours each) for two months, and 54% once a week for three months. There were no cases that consider the course unnecessary
Conclusions: The analysis of the results leads us to think that despite advances in teaching resources, dissection remains as recognized and appreciated tool by students. In this study we can conclude that theres is high interest to include cadaver dissection practice in the curriculum for residents of Plastic Surgery who specialize in Hand Surgery. This fundamental training resource training allows more familiarity with the reality of the human body, apply it to the clinical and anatomical projections and as coordinates for the performance of surgery.

Bruno Eiras Crepaldi, Fábio Duque Silveira, Raul Itocazo Taira, Celso Kiyoshi Hirakawa, Marcelo Hide Matsumoto

Hospital Santa Marcelina Itaquera São Paulo, Brazil

Superficial Acral Fibromyxoma (SAF) is a rare tumor of soft tissues. It is a relatively new entity described in 2001 by Fetsch et al.

Case Report:
We present a 57-year-old man, without any known allergies. He referred having had cutaneous changes not associated with any trauma in his 3rd finger that started in March 2015. The mass grew from 0.5 cm to 3 cm length in a 5-month period.

Upon examination in 27/08/2015, patient presented an important dorsal swelling and reported cutaneous rush in his 3rd right finger. He referred a painless dorsal mass with had approximately 3cm length in the dorsal aspect of PIP joint with occasional bleeding.

Antero-posterior, lateral and oblique X-rays were requested and showed tumor growth, with density similar to the adjacent soft tissues, without calcifications and without bone erosion, deformity or periosteal reaction. An Ultrasound demonstrated a dorsal nodular, hypoechoic and inhomogeneous mass. Color Doppler exam showed variable vascularity and necrotic zones.

The therapeutic approach included complete removal of the tumor, with resection margins in order to avoid recurrence. A 1st dorsal metacarpal flap was designed to cover the skin loss in the dorsal aspect of 3rd PIP joint.
The macroscopic examination showed that the specimen was a discoid tissue fragment of 4.5 X 3,0 X 2,0 cm in diameter and, with a face consisting of a yellow and soft tumor surface. Examination under a microscope associated with clinical and anatomopathological findings confirmed the diagnosis of Superficial Acral Fibromyxoma (SAF).
Patient at this moment have 2-month post operative with a good flap aspect, an increase of the finger range motion and free from disease.

Discussion and Conclusion:
In this case report we discuss and illustrate a rare acral tumor in unusual location, We also performed a short review of the literature regarding SAF.

Adriana Pemoff 1,2, Hernan Blanchetiere 1,2, Ivonne Gomez Avellaneda 1,2, Candelaria Torre 1,2, Julieta Carbonell 2

1 Hospital General de Agudos Juan A. Fernandez, Buenos Aires, Argentina; 2 Fundación Las Manos del Músico, Buenos Aires, Argentina

Objective: dystonias are a group of disorders with abnormal movement, with overflow activation of antagonist muscles and/or co-contraction of antagonist muscles that are not required for a specific movement. In musicians, it´s a task-specific disorder, with lack of voluntary control of the specific and detailed movements while playing their instruments. It is an exclusion diagnosis of other neurologic disorders as Parkinson disease, Esencial Tremor, among others.
In the literature, there are only USA and Europe reports about the epidemiology of this entity: 3.4 x 100.000 population in USA and 15.2 x 100.000 population in Europe.
The aim of this study is to present the incidence of focal dystonia in Argentinian musicians, the relationship with instrument, if they are classical or popular performers, and the treatment developed.

Materials and methods: This is a prospective study, between 2000 and 2015, conducted in Buenos Aires, Argentina. In 15 years, we evaluated 782 instrumentalist musicians, who were treated in our institution.
The inclusion criteria were: lack of voluntary control of the upper limb or embouchure in the instrument performance. The exclusion criteria was: other neurological comorbidities, muscular pathologies or lack of data in clinical report.
All the patients were evaluated by a protocolized clinical history.
We identified risk factors, disease patterns, duration of symptoms, task and instrument involved and the severity of the disease based on Tubiana Scale.
About instrument involved, we divided in 6 groups: bowed strings, plucked strings, winds, wind bellows, swinging strings, percussion and embouchure.
A multidisciplinary team compound by orthopedic surgeons, physioterapist, occupational terapist, musicians and psychologist, was involved in the diagnosis, follow up and treatment of the dystonic patients.

Results: A total of 51 patients, 44 men and 7 women were included.
The range of age was between 21 and 75 years old, with a median of 28,5 and an average age of 31,32 years old.
29 patients performed classical music and 22, popular music.
We identified risk factors, according to Rosset, in all except 1 patient: lack of prevention habits (warm up, breaks, stretching maneuvers), 50 had a previous stress episode.
The prevalence of dystonia according to the instrument performed is: 32 plucked strings, 9 swinging strings, 4 bowed strings, 2 wind bellows, 2 percusion, 1 woodwind and 1 embouchure in a brass instrument.
We proposed a multidisciplinary treatment based of 5 steps: introduction of prevention strategies, acquirement of corporal awareness (2 subgroups: Fedora technique and aerobical activity), occupational therapy treatment, musical adviser and psychology treatment.

Conclusion: The focal dystonia in musicians is a task-specific disorder, characterized by involuntary and abnormal movement of any part of the body. It affects preferably professional musicians.
The delay in the diagnosis is related to misknowledge of musician`s cramp and also because of the shame to recognize the pathology in front of their colleges.
It is very important to implement prevention habits in musical conservatories and early detection strategies to achieve a better treatment.

Olivier Mares 1, Benjamin Degeorges 1, Christophe Bosch2, Cyril Lazerges 3, Pascal Kouyoumdjian1

1 CHU Nimes, 2 SOS Mains Nimes, 3 CHU Montpellier, France

For treating painfull wrist wtih a pre dynamic scapholunate (SL) instability, wrist denervation have been advocated but many papers showed the functionnal importance of the proprioceptive function of the wrist. We evaluated retrospectively the results of an arthroscopic scapholunate tenodesis without pinning.

Twelve patients (mean age, 36.5 y) presenting with persistent posttraumatic pain and weakness to the wrist were diagnosed with pre SL instability (positive Watson scaphoid shift test result, SL gapping on grip-view radiographs, arthroscopic findings of a EWAS III B or C tear) and treated, after failure of medical treatment. Range of motion, grip strength, radiographic measurements, and the Mayo wrist score were used to evaluate the results.

The mean delay between trauma and surgery was 19 months( range,2-36). None patients had subsequent surgery before the procedure. The mean follow-up period was 17,7months (range, 3-41 mo). The mean MWS, PRWE and quick-DASH are : 80,4, 27,6 and 28,8. In these patients, the mean range of motion was 65 degrees of extension, 73.5 degrees of flexion. The mean EVA score for pain at rest and activities were signicantly improved at last follow up compare to pre operative data : respectively at rest from 6.3 to 0.91, in activities from 7.3 to 2.4.
No persistent radiographic SL gapping in grip views was noted in 11 patients but one progressed to dorsal intercalated segment instability.

The results of this technique are suboptimal; however, it may be an conservative option for patients with predynamic painful wrist.This procedure doesn’t cut the way to any further procedure in case of bad result.

Natasha van Zyl 1, Stephen Flood 1, Michael Weymouth 1, Jodie Hahn 2, Cathy Cooper 2

1 Austin Hospital, Heidelberg, Victoria, Australia 2 Royal Talbot Hospital, Kew, Victoria, Australia

Objective/ Hypothesis
Restoration of absent elbow extension, grasp, key pinch and release are the principal goals in low-level tetraplegia. In 2014 our unit published a case report describing the outcome of a bilateral triple nerve transfer for simultaneously reconstructing these functions in a C6 tetraplegic. Since then 14 triple nerve transfers have been performed in our unit. The authors have found the brachialis to anterior interosseous nerve (AIN) transfer to be the least reliable component of this combination and have sought an alternative nerve transfer option for grasp reconstruction. In this case report we present an alternate nerve transfer combination and the outcome one year post surgery.

Materials and Methods:
A right hand dominant 32-year-old woman sustained a motor complete C6 spinal cord injury following a motor vehicle accident. Shoulder function, elbow flexion, radial wrist extension and pronation were normal in the right upper limb. She had no triceps function, wrist flexion or hand function. Surgery was completed eleven months after injury with a combination of nerve transfers. Teres minor and motor posterior division of axillary to long and medial head of triceps nerves, extensor carpi radialis brevis (ECRB) to anterior interosseous nerve (AIN) and supinator to posterior interosseous nerve (PIN) transfers were successfully used to reconstruct elbow extension, key pinch, grasp and release simultaneously. A side-to-side synchronisation of ECRB to ECRL was performed at the wrist to aid immediate wrist centralisation.

Interim Results:
At 13 months post operation (18 month follow up results will be presented at IFSSH) our patient has achieved strong M4 elbow extension M3 thumb and finger flexion for the index and middle fingers and M4 thumb and finger extension. Her current lateral pinch strength is 0.7kg and grasp (dynamometer position 3) is 0.6 kg. There was no loss of function as a result of donor nerve harvest. At one year she is able to use a spoon and a fork, hold objects like her phone, operate an ATM card, put on makeup, brush her hair and put in her contact lenses.

In the lower level tetraplegic with functional pronation the ECRB to AIN nerve transfer is another option for pinch and grasp reconstruction. The advantages over the brachialis to AIN transfer include a coaptation closer to the target muscles with a shorter reinnervation time and a transfer directly onto the AIN, rather than the AIN fascicle within the median nerve. Transferring directly to the fully formed AIN nerve after it has branched from the median nerve avoids inadvertent loss of axons down non-AIN targets, which may downgrade outcomes, and avoids injury to adjacent sensory or motor fascicles within the median nerve. In our algorithms for management the brachialis to AIN transfer remains a reconstructive option for higher-level tetraplegics but ECRB to AIN is preferred when the ECRB donor nerve is available.

Prathap Ravindranath Venkatesh, Chaitanya. D

HOSMAT Hospital, Bangalore

BACK GROUND- Perilunate Injuries are uncommon, involving approximately only 7% of all injuries of the carpus. Often missed in the emergency room. They most often result from high-energy trauma. Early treatment is necessary to prevent the complications of chronic carpal instability and post traumatic arthritis. Even with optimal treatment outcomes are guarded.

8 patients( males) in the age group of 19-48 yrs, all were right hand dominant. 6 of them were involved in motor vehicle accident and 2 had fall from height. Mean hospital presantation was 2days (0-5 days). 7 of them had closed injuries and 1 presented with open injury. Transcaphoid perilunate type was seen in all with 7 of them had waist fracture and 1 proximal pole fracture. Combined volar and dorsal approach was used in 5 of them and dorsal approach in 3 of them. FIxation with Herbert screw, K- wires, external fixator were used to stabilise the fracture dislocation. Mean follow up was 13.8months. All patients were evaluated using Mayo wrist Scoring.

RESULTS: Clinical parameters were active ROM(wrist extension/flexion, radial/ulnar abduction, Grip strength (isometric measurement, Jamar dynamometer). Pinch strength.The radiological outcome was classified as described by Herzberg et al.
Using Mayo Wrist Score good result were seen in 2, and satisfactory results in 6 patients.. Mean VAS was 4.

CONCLUSION: Good to satisfactory results can be obtained in the intermediate term. Counselling to the patient about expected outcome and need for salvage procedures necessary.

Catherine Cooper, Bridget Hill, Jodie Hahn, Natasha van Zyl

Austin Health/Victorian Spinal Cord Service, Melbourne Australia

Tetraplegic Hand Surgery - the Therapy goes Live!


Occupational Therapists working with tetraplegic patients post upper limb surgery, are embracing internet communication platforms to enhance the “reach” of therapy.

Reconstructive hand surgery for tetraplegia is very specialized and only offered in a relatively small number of hospitals worldwide. By definition, patients are often travelling interstate or long distances to attend assessment, surgery, and follow up treatments.
Centre based therapy, whilst the gold standard treatment, is not always practical or indeed possible for this client group.

Social media and communication technology now allows people easy access to video calls or teleconferencing using computer, tablet or mobile phone devices.
Following reconstructive hand surgery in tetraplegia, it is critical to provide specific aftercare and education to all involved in the care post discharge from hospital. This need has lead therapists at this centre to trial a program of “telerehabilitation”.

The aim of the trial was to assess the reliability and efficacy of this alternative delivery of treatment sessions.

Material and Methods

28 participants were recruited to examine the feasibility of introducing telerehabilation for patients with tetraplegia following upper limb surgery. A convenience sample of 4 Centre based treatment sessions were independently observed along with a matched group of patients receiving Telerehabilitation. A minimum of three sessions via telehealth was provided in each case.
Telephone questionairres were used pre and post telehealth intervention to record the expectations, experiences and outcomes with those involved. Interviews captured recruited patient, family member, carer and therapist opinion.


Outcomes were analysed according to type and efficacy of treatments performed via telehealth as recorded by an independent observer. This was compared to independent observations of the matched client group at centre based outpatient therapy appointments.
Some technical difficulties arose in Telerehabilitation sessions with internet connection, but the number of these events was surprisingly small and usually managed well.
Overall differences in treatment themes between the two groups (telerehabilitation V centre based) were minimal with the same critical therapy issues routinely addressed.
The identified treatments that did not translate as effectively via the Telerehabilitation method were not surprising. These predictably revolved around wound management in the acute post-operative phase, and reliable manual muscle testing and palpation during nerve and muscle retraining.
Feedback from patients, family/carers and community therapists detailed in this study was overwhelmingly encouraging.


Telehealth is gradually becoming more popular as a service delivery method for therapists, and appears particularly useful for those with clients living remotely or with specialist care needs. Telerehabilitation is uniquely placed to support Spinal Cord Injury out-reach services given large geographic catchment areas, and the ongoing and extensive co-morbidities in this population. This study demonstrates one example of the value of telehealth to improve surgical outcomes and the quality of patient care after reconstructive hand surgery.
The style of telerehabilitation interventions in this study continue as standard practice for remote patients and have successfully extended to surgical consults in our clinic.

VMC Elui 1,2, DN Goia 2, F Saconi 3, CA Fortulan 3

1Department of Neuroscience and Behavior Sciences of Ribeirao Preto Medical School of University of Sao Paulorn2Postgraduate Inter Bioengineering Program (School of Engineering of Sao Carlos / Ribeirao Preto Medical School/ Chemistry Institute of Sao Carlos), University of Sao Paulorn3 Department of Mechanical Engineering at the Engineering School of Sao Carlos

Purpose: Describe the development process of a customized hinged (kinetics) orthosis to correct finger ulnar deviation (FUD) using direct manufacturing. Design/methodology/approach: Is the evolution of the orthosis design (Long Self-hinged for Ulnar deviation correction orthosis – OLADU) using project development methodology based on Pahl and Beitz (2004), focused on the detailed design and equipment validation phase. The project was approved by the Ethics Committee HCRP No. 15857/2014. Process included direct manufacturing and parameterization and validation. A hand without deformity was reference and the design was modified and tested by the researchers. Three patients were invited to try the OLADU, give their opinion about what needed to be modified. Researchers evaluated the biomechanical aspects and using theirs expertise, design was changed. Patients returned and tried again until they report comfort and the deviation was functionally corrected. Fingers deformity correction was verified using goniometry and photography. To get to this stage 23 version were made. This study is regarding the 22nd version. Four volunteers/patients both sexes, aged 45-76 years with FUD deformity (20º to 70º FUD and 0º to 80º lack of metacarpophalangeal extension) used two designs orthosis (3D orthosis-OLADU and a thermoplastic orthosis with elastic traction) for a month each and rated from 0 to 10 (0 bad and 10 good) regarding comfort, put on/off, pain, use of the hand. The answers were analyzed and compared the orthosis. Results: Using a specific and innovative methodology for orthotic devices design and its customization was successfully using the direct manufacturing orthosis. The orthosis has six manufactured parts and a metal rod with screw with end lock. The articulated parts are fixed with shaft and nuts. The 3D orthosis provides finger ulnar deviation correction, allowing wrist and finger flexion/extension and their use during daily activities. Patients rated the 3D orthosis better regarding facility to clean (OLADU 8/Elastic 4), put on/off (OLADU 7/Elastic 5), deformity correction (OLADU 7/Elastic 6), diminish pain (OLADU 7,5/Elastic 5), moving the hand and picking up objects (OLADU 4,6 /Elastic 3,7), Comfort has no difference (7) and appearance they rated it worse (OLADU 5,2/Elastic 4,7). Their opinion regarding the elastic traction orthosis is: hard to use because cause pain at the first space, palmar volume makes hard to grasp objects, it corrects the deformity, and is hard to clean and OLADU is that the fingers get straighter, is easy to put on/off, able to use during activities and 35% reports after a continuous use that feels some type of discomfort at the 5th finger and the rings fells like wants to displace distally. Conclusion: The orthosis fabrication using 3D technology is possible, the orthosis validation is being developed and in course. After each modification, the test with patients starts again, when they use it for a month period and answer the questionnaire. Design modifications (23rd version) were made to achieve better results with less discomfort and more functionality and test with more patients is being performed.

Jose Nelson Urciuoli

Instituto Nacional de Ortopedia y Traumatologia- Montevideo -Uruguay Hospital Policial- Montevideo- Uruguay Casa de Galicia- Montevideo - Uruguay Asociacion Española - Montevideo -Uruguay

Report an unusual lesion –less than dozen published cases– and show a diagnosis algorithm for radiolucent lesions in fractured scaphoids: with a brief bibliographic review; and some therapeutic considerations.
Material and methods
A 24 years old man, percussionist musician; with a low energy trauma of his right wrist, showing a fracture of his distal third of scaphoid through a lytic lesion. We made biopathogenic considerations, imagenology, and surgical treatment by curettage, bone grafting and osteosynthesis with double threaded headless screw.
The clinical and diagnosis-for-image evaluations were confirmed by the histopathology; and the treatment heal the lesion letting the patient to return to professional activity after nine months.
The diagnosis algorithm applied for lytics (or radiolucents) lesions showed be effective. In addition, the therapeutic protocol of curettage, bone grafting and osteosynthesis achieved a complete healing and recovery of hand and wrist funcitons.

Katsuro Furumachi, Kotaro Sato, Yoichi Kamei, Takaaki Saigo, Kenya Murakami

Iwate Medical University, Morioka, Japan

Clinical symptoms and pathomechanism of SNAC (scaphoid nonunion advanced collapse) change
is not yet fully understood. We investigated the fracture type and progression of arthrotic change after scaphoid nonunion .
Thirty wrists (duration 3 month to 35 years) sustaining scaphoid nonunion which underwent surgery
were included in the study. The operative procedure is comprised of osteosynthesis with iliac bone graft or radial styloidectomy, scaphoidectomy, partial arthrodesis, proximal row carpectomy in advanced cases. We investigated fracture types, carpal alignments, clinical profiles and stages of SNAC change.
Fracture type distributed as B1: 10 wrists, B2: 17 wrists, Prosser IIc: 1 wrists, and unclassified: 2wrists. All the 8 wrists with DISI showed SNAC change to some extent. There were tendency to have SNAC change in type BI fracture and DISI deformity.
-Discussion -
We suggest the following hypotheses for predominant SNAC change in B1 group. 1)Horizontal movement causes more arthrosis than vertical one. 2)B1 has the hypermobile proximal intraarticular fragment which promotes arthrotic change. 3)B1 fracture is a stable type due to the distal insertion of the dorsal radiocarpal ligament. Asymptomatic nature of B1 can contribute to the inciduous progression of SNAC. TypeB1 fracture may have a tendency to result in SNAC deformity.

Takao Omura1, Tomokazu Sawada2, Hiroaki Ogihara3, Yukihiro Matsuyama1

1 Hamamatsu University School of Medicine, Hamamatsu, Japan 2 Shizuoka City Hospital, Shizuoka, Japan 3 Hamamatsu Red Cross Hospital, hamamatsu, Japan

Iatrogenic nerve injuries can result from direct surgical trauma, compression due to mal positioning during anesthesia, and direct or indirect injuries due to injections. The purpose of this study was to review cases of peripheral nerve injuries caused by direct surgical trauma.

Patients and method
Fourteen patients who were referred to our department complaining of either sensory or motor deficit after surgical interventions were reviewed in this study. The patient consisted of 11 males, 3 females and the average age was 44.4 years old. We reviewed the initial type of surgeon causing the nerve injury, the affected nerve, treatment of the paralysis and the pathogenesis of the nerve injury.

Nine patients initially were operated by an orthopaedic surgeon, 2 by a vascular surgeon, and one each by a gynecologist, dermatologist and an otolaryngologist. The injured nerves were three for the radial and the common peroneal nerve, two for the sural and the accessory nerve and one for the femoral obturator nerve, sciatic nerve and the brachial plexus. Of the 14 patients, 8 required surgical interventions, consisting of nerve graft, tendon transfer (2 cases each), neurolysis, direct nerve suture and removal of the ligature that was placed on the nerve. We directly exposed and visualized six nerves and identified 4 cases of nerve transection. Out of the 14 cases, there was only one case where the nerve was visualized at the time of injury and the remaining 13 paralyses were created lacking exposure and any visualization of the injured nerve.

Iatrogenic nerve injuries account for around 20% of the traumatic nerve lesions. In our series, 64 percent of the injuries were created by orthopaedic surgeons. With an exception of one case, all the paralyses were created without the visualization and identification of the nerve. A thorough knowledge of the anatomy is vulnerable to avoid iatrogenic injuries and surgeons should not hesitate to make a larger incision to identify and retract the nerve.

Lisa Lattanza 1, Kelvin Lim 1, Jaclyn Bailey 1, Alyssa Ricker 2

1 University California San Francisco - San Francisco, CA, USA; 2 Materialise - Plymouth, MI, USA

Chronic missed Monteggia fracture dislocation represent a rare, but serious condition. Previous study(1) and recommendations for correction have focused on the deformity of the ulna without mention of a problem in the radius. In addition, the ulnar deformity has not been well characterized. The purpose of this study is twofold: to describe a new finding of deformity of the radius in chronic missed Monteggia fractures and to further characterize the ulnar deformity in three dimension.

Six cases of chronic Monteggia fractures were studied. Pre-operative CT scans were performed of the affected and contralateral forearm from hand to elbow. Commercially available software (Mimics, Materialise, Leuven, Belgium) was used to convert the CT data into 3-dimensional digital models. The contralateral radius and ulna models were then superimposed over the affected radius and ulna using a computerized registration technique to view the relative displacement of the affected radius and ulna. Axial, coronal and sagittal angular deformities were analyzed to describe this displacement.

For the radius, the average differences in the axial, coronal and sagittal plane are 16.3, 4.4 and 6.5 degrees, respectively. For the ulna, the average differences in the axial, coronal and sagittal plane are 10.8, 2.9 and 6.0 degrees, respectively.

Additionally there is a difference in the relationship between the ulna and the humerus with increased valgus (12.4 versus 6.5 degrees, affected and normal side, respectively) and axial rotation (31.1 versus 23.4 degrees, affected and normal side, respectively).

To our knowledge deformity of the radius in chronic missed Monteggia fractures has not been previously described. This has important implications for surgical correction of this injury as correction of both the radius and the ulna may be necessary in some patients in order to reduce the radial head. In addition, we have confirmed and expanded on findings of a previous study(1) regarding 3 dimensional deformity of the ulna.

1. Three-Dimensional analysis of acute plastic bowing deformity of ulna in radial head dislocation or radial shaft fracture using a computerized simulation system. Eugene Kim MD, PhD; Hisao Moritomo, MD, PhD; Tsuyshi murase, MD, PhD; Takashi Masatomi, MD, PhD; Junichi Miyake, MD, PhD; Kazuomi Sugamoto, MD, PhD; J Shoulder Elbow Surg (2012), 21, 1644-1650

Cui Jianli, Gong Xu, Liu Yuejiao, Jiang Ziping, Huang Dongxu, Lu Laijin

The First Hospital of Jilin University, Changchun,China.

Objection:To explore the indications for the method of, and the announcements on free anterolateral thigh flaps in reconstruction of large scalp defects with crinial bone exposure after ablative surgery for carcinoma and trauma. To decrease the postoperative complication, exairesis rate and cure rate.
Methods: Eight consecutive patients, aged 37 to 74 years, presenting with large scalp defects with crinial bone exposure. Three defect cases on the cupular part are for squamous cell carcinoma,neurofibromatosis and hemangioendothelioma resection operation respective, and the other five cases are for trauma in traffic or other accident including kick by horse, wich located on frontal and temple regions with infection for delayed coverage in inferior hospital. On operating, thorough debridement was performed on the infective wound, and the primary tumors including the periosteum of the underlying bone were resected with a 2-3cm margin of normal tissue. To cupular part carcinoma cases, we used the free anterolateral thigh flaps in reconstruction based on the superficial temporal artery and vein,while to cutaneous deficiency cases on the temporal region for trauma, local vein and transverse cervical artery served as recipient vessels. All the free anterolateral thigh flaps were accomplished with the usage of standard microsurgical techniques. The donor defects were covered with split-thickness skin grafts.
Results: All the flaps ranged from 18cm × 8cm to 30cm × 25cm in size, survived successfully without perioperative mortality, meningitis, stroke, and cerebrospinal fluid leak. No flaps demonstrated primary insufficiency, microvascular problems, or incurred significant donor morbidity, except for the one local infection continued postoperative increased length of hospital stay. Follow-up ranged from 6 to 42 months, with a mean of 19 months. The tumor recurrence rate was 0% with excellent function and satisfactory cosmesis.
Conclusion: The free anterolateral thigh flap is an optimal alternative to reconstruct the large scalp defects for its advantages such as large size available, long vascular stalk, thick artery diameter, and minor donor site complication. The transverse cervical artery is an ideal recipient substitute available vessel for its long and matched diameter.

Juan Martin Perrone, Hugo Sarmiento, Angel Ferrando, Roberto Andreozzi, Martin Balmaceda, Guillermo Belluschi

Hospital Churruca

Introducción: The MIPO approach has already been used on other long
bones with good results. The benefits include avoiding muscular or soft
tissue injury and damage to the skin nerves which in turn results in less
disestesias and a better cosmetic outcome.
Objective: The purpose of this work is to describe the mini invasive
technique with locking plate for midshaft clavicular fractures and to
show our clinical and radiological results.
Materials and Methods: Fifteen patients with midshaft clavicular
fractures were evaluated retrospectively from July 2012 to May 2014.
Using the Allman classification eleven type 1, three type 2 and one type
3 were found. Clinical exams were administered and x­rays were taken
for all patients at four week intervals until the fractures were healed. The
patients were evaluated with Constant and DASH score.
Results: All of the patients’ fractures were healed. On average the
fractures took 13 weeks to heal. The average DASH score was 4.8 +/­
2.9 (range 0­10) and the average Constant score was 99 +/­ 1.9 (range
95­100). The patients were satisfied with the esthetic results and the
functional outcome.
This study demonstrated that this MIPO procedure for midshaft
clavicular fractures, which uses superior anatomic locking plates, can be
a reproducible procedure and an alternative to conventional operative
methods. In addition, satisfactory clinical and radiologic outcomes were
obtained without serious complications. Therefore, we believe it’s
important to keep this technique in mind for those patients concerned
about their appearance.

Jesús Manzani 1,2,3, Natalia Cortabarría 1,2, Noel Fraga1,3

1 Banco de Seguros del Estado. Montevideo. Uruguay 2 Cátedra de Cirugía Plástica y Quemados. Hospital de Clínicas. Montevideo Uruguay 3 Centro de Asistencia del Sindicato Médico del Uruguay . Montevideo. Uruguay

To introduce a new technique of open surgical treatment of Carpal tunnel syndrome with a minimal incision.

Materials and methods
45 patients were operated in a period of one year in different assistance centers. These patients had clinical and electrophysiological diagnosis. All of them were operated with the same surgical technique of minimal open incision.
The technique consists of a vertical minimum palmar incision in the Kaplan line, at the intersection of a horizontal line tangent to the edge of the thumb in abduction and an oblique line tangent to the curvature of the thenar from the radial end of the distal palmar crease. This incision is approximately 1,5 centimeters in length.
After sectioning the skin, subcutaneous and palmar aponeurosis superficial medium, we transect the anterior edge of the anterior Carpal annular ligament, it is the thickest portion of the ligament, creating a small window through which a grooved probe is placed to protect the median nerve. Before cutting the ligament completely with a fifteen scalped blade with the blade up, we explore the content of the tunnel, the median nerve or elements of synovitis, discarding pathological elements and checking indemnity of the median nerve. We proceed to perform forced dorsiflexion of the wrist , which takes us away from the median nerve palmar area, and so again introduce the grooved probe proximal to complete the section of the annular anterior Carpal ligament.

Absence of paresthesia in all cases. Pillar pain less than 5%. Median nerve injury 0%. Alteration in power tools prehension 0%. Excellent scar quality.

Open surgical technique of minimal incision for treatment of carpal tunnel syndrome has excellent results.
Advantages: scar away from the heel of the hand, which is a support area were work instruments are supported. Excellent quality scar. Greatly reduces pillar pain. Minimum risk of injury of median nerve.
Disadvantages: this technique needs experience. It is not recommended if it associate Guyon desease. It does not allow synovectomy of flexor tendons or direct nerve surgery.

Luis F. Náquira-Escobar 1, Mauricio Toro-Restrepo 2, Daniel Restrepo-Mejía 2, Daniela Villa-Moreno2, Alejandro Medina-Vásquez 2

1 Universidad CES, Medellín, Colombia; 2 Industrias Médicas Sampedro, La Estrella, Colombia


Distal Radius fractures are the most frequent fractures of upper limb, and sometimes can present malunion, a complication that produces pain, osteoarthritis, reduced range of motion and decreased grip strength. In order to recover the anatomical position of the radius, corrective osteotomies are the treatment of choice. Nevertheless, in osteotomies where the traditional technique is used, is difficult to obtain accurate results due to the surgeon's human error and the lack of precision of the instruments used in surgery. 3D virtual planning is now being used for obtaining more precise osteotomies designing patient-specific surgical guides. The aim of this study is to compare the results obtained using the traditional technique with the results obtained using patient-specific surgical guides for the osteotomies.

Materials and Methods

CT images of both upper limbs of a female patient, with a malunion in her left radius, were obtained and 3D reconstructed. The 3D model was used for planning the correction osteotomy. A physical model of the malunited distal radius and ulna was obtained using 3D printing and was then used as a mold to manufacture 24 polyurethane bones. Patient-specific surgical guides were created using virtual surgical planning and 3D printing. The planned correction was compared with the correction made using the patient-specific guides and using the traditional technique.


For a significant comparison three anatomic values were measured on each sample and compared to the planned correction, those were: radial angle, radial shortening and radial displacement. For each anatomic value and each technique, the average, standard deviation, deviation from planned and percentage of planned were obtained. The most representative values were the “Percentage of planned”, the most similar values to the planned correction were the radial angle with the guided method. Although this value presented the highest variability across all dimensions studied, the guided method had a lower variability compared to the traditional technique. Similar values were observed for the other dimensions, where the most similar measurements were obtained with the guided technique.


The higher standard deviations found using the traditional procedure suggests that the use of the patient-specific guides allows for more repeatable results. The higher “Percentage of Planned” values found using the guided technique suggest a more precise procedure compared to the planned correction.
A good anatomic correction is critical in obtaining good patient outcomes for distal radius malunions. Corrective osteotomies for distal radius using patient-specific surgical guides are a good technique to obtain corrections as planned, which allows to a reduction of surgical times decreasing the risk of patient infection and blood loss, and reducing the exposure to radiation produced by the fluoroscopy.
Using the guided technique involves a big responsibility when planning the correction, in order to obtain the expected results.

Esther Fernandez Tormos, Limousin Aranzabal, Blanca Del Campo Cereceda, Covadonga Arraiz Díaz, Fernando Corella Montoya

Hospital Universitario Infanta Leonor, Madrid, Spain


Detailed knowledge of the hand’s dorsal anatomy is very powerful information for hand surgery. There is a great variability in the dorsal innervation patterns.


The purpose of this research is to study the hand’s dorsal innervation distribution by analyzing the variability of itself.


11 cadavers’ distal upper-extremities were dissected. Sex 7 male; 4 female. Mean age 71,25 years (53-92), mean height 159,72 (157,48-180,34), mean weight (79,22 (54,43- 124,74).

A skin, subcutaneous and superficial fascia careful dissection was run, dissecting nervous structures from proximal to distal.

In order to simplify dorsal nerves’ nomenclature, they are named in an alphanumeric form (the thumb’s radial digital nerve is denominated D1R; the index’s ulnar nerve D2U, etc.)


It was found that radial nerve’s superficial branch distribution had the same pattern in 73% of the cadavers (8/11). One main branch for DR1 and common branches are further divided into dorsal digital branches from DU1 to DR3.
In one case (9%) there is a common thumb’s dorsal nerve divided into DR1 and DU1. One branch provides innervation of DR2. A common branch is divided into DR2 and DR3.
In the 18% of cases (2/11) the total dorsal innervation depended on the superficial branch of the radial nerve.
The ulnar innervation in all cases came from the dorsal branch, which gave a branch for DU5 and two trunks from DR5 to DU3.


The hands dorsal innervation patterns knowledge is critical in hand surgery, as a large number of hand interventions are approached by the dorsal side.
As these patterns are not constant in every patient, it is essential to be careful when making incisions on the dorsal side in order to avoid damaging the innervation in uncommon distribution patients.

Borja Limousin Aranzabal, Blanca Del Campo Cereceda, Esther Fernandez Tormos, Covadonga Arraiz Díaz, Fernando Corella Montoya

Hospital Universitario Infanta Leonor, Madrid, Spain

Arthroscopy of the metacarpophalangeal (MCP) despite their usefulness in many diseases, is not commonly used. There are few anatomical and clinical studies about their safety.


The aim of this study is to quantify the risk of injury in the dorsal innervation when performing direct MCP portals in the 2nd - 5th radius.


11 cadavers’ distal upper-extremities were dissected. Sex 7 male; 4 female.
The limbs were placed in traction tower (5-10 pounds), simulating the real scenario of arthroscopy.
Two portals were developed in the depression on both sides of the central extensor tendon (2mm lateral tendon) of each finger. Two intramuscular needles were placed with a 45 ° direction towards the midline.
Extensor tendons and nearby sensory branches to the portals of the 2nd-5th radius were dissected, and distances of both portals (marked by the intramuscular needles) to their nearest nerve were measured by digital caliper.
Relative size of hand was estimated by measuring the total length of 2nd MCP and the width between the head of the 2nd-5th MCP.
In order to simplify dorsal nerves’ nomenclature, they are named in an alphanumeric form (the thumb’s radial digital nerve is denominated D1R; the index’s ulnar nerve D2U, etc.)
Distances > 4,5mm are considered as safe for arthroscopy. And distances <2.5 mm are considered of high risk of injury.


In 2 cases one of the nerves were directly injured. Distances with high risk of injury were found in 3 portals.
Measurements are safe in 90% of the DR2 portal (>4.5mm); and in 72% of the DR3, 82% of the DU3, and 54% of the DU4 y DR5,
No relationship was found between demographic data and hand’s relative size with high risk of injury.
The 3rd radius is the safest to performed MCP portal arthroscopy, meanwhile DR2 y DU4 are the most dangerous.


The nerve injury risk when performing direct MCP portals is high.
The MCP of the 3rd radius is the safest to performed portal arthroscopy, meanwhile in DR2 y DU4 the nerve injury risk is increased.

Karin van Pelt-Dieleman

Ziekenhuisgroep Noord-West, Alkmaar, The Netherlands

The Burton-Pellegrini procedure is a frequently practised surgery for Trapeziometacarpal arthritis. Although this surgical technique has been extensive investigated, very little attention has been directed to the rehabilitation after this surgical procedure with standarised Hand Therapy.

Published studies investigating rehabilitation after a Burton-Pellegrini procedure have a large variation in immobilisation period (between 3 and 8 weeks) and exercise program (homework, hand therapy, none). Most studies lack detail and justification of choices that were made considering postoperative rehablitation.
The purpose of this study was 1) to present a detailed investigate functional outcomes of a theory based standarised Hand Therapy protocol after Carpometacarpal (CMC-I) arthroplasty (Burton-Pellegrini procedure) and 2) to investigate functional outcomes pre- and postoperative.

Materials and Methods:
Retrospective review of a series of ten patients treated by a hand therapist after CMC-I arthroplasty. All patients were diagnosed with Trapeziometacarpal arthritis Eaton and Littler stage 3 and 4. Surgery was performed by an orthopedic surgeon. After surgery hand therapy was performed at various hand therapy centers according to a standarised protocol. All hand therapists were trained prior to the study. The protocol is based on available evidence supplemented by theory of phases of wound healing, joint stability and dexterity of the thumb. The hand therapy protocol consisted of an early active approach. As isometric exercises were commenced after 10 days of immobilisation, splint withdrawal and progressive ADL use started at 3 weeks post surgery. When the patient can perform an isometric ‘OK-sign’ dynamic exercises are started. Forceful gripping and adduction needs to be avoided in first 5-6 weeks.

Data were collected pre-operative and at 4, 6, and 24 weeks after surgery. Primary outcomes measures were: active and passive range of motion (goniometer) of palmar/radial abduction CMC-I, flexion/extension MCP-I, flexion/extension IP, Kapandji (0-10), grip strength (Jamar), pinch strength (gauge meter), pain (VAS 0-10), functional use of the hand (DASH-DLV/VAS 0-10) and patients level of independence (VAS 0-10).

Descriptive data will be collected until June 2016. Study results will be available at the time of the congress.

This study provides functional outcomes for with patients who have undergone a theory based early active therapy protocol after CMC-I arthroplasty. Conclusions will be available at the time of the congress.

Blanca Del Campo Cereceda, Borja Limousin Aranzabal, Esther Fernandez Tormos, Covadonga Arraiz Díaz, Fernando Corella Montoya

Hospital Universitario Infanta Leonor, Madrid, Spain


Recurrence of carpal tunnel symptoms after surgery regarding neuritis by traccion are rare complications, still have great impact on patients.
Coverage lumbrical muscle nerve is a technique with good results, but there are few references in the literature.


Analyze the first lumbrical vascularization, evaluating the gain in flap length depending on lumbrical area rotation is performed above or below the superficial palmar arch.


11 cadavers’ distal upper-extremities were dissected. Sex 7 male; 4 female. Mean age 71,25 years (53-92), mean height 159,72 (157,48-180,34), mean weight (79,22 (54,43- 124,74).
The artery responsible for the 1st lumbrical vascularitation is analyzed assessing the points of entry of vessels in the muscle and the length of themselves.
The scope of the flap is analyze in lumbrical area, taking as a reference de proximal artery, and as points of reference the proximal tunnel origin and the lumbrical myotendinous union. The flap’s scope was studied depending on it was performed above or belowed the superficial palmar arch.
All measurements were performed by two surgeons using a digital gauge (0.002 mm accuracy , resolution 0.01mm).


81% of the cases (9/11) had a superficial palmar arch. Vascularization of 5 of them came from the arch itself, meanwhile 3 cases had a communicant artery. In 1 cadaver we found the existence of a radiopalmar artery.
19% of the cases(2/11) there is not a superficial palmar arch, being the median artery the responsible for the lumbrical vascularitation.
We found a mean gain of 5.35 mm in length of the lumbrical area flap by making rotation in the depth of the arch.


The lumbrical flap is useful in the treatment of carpal tunnel recurrence .
It is extremely important to know the vascularization and innervation of muscle lumbrical in order to use the lumbrical flap.
Guiding the flap in the lumbical area at right depth into the superficial palmar arch is a practical surgical procedure, which increases the scope of itself.

Patricia Curbelo, Rodrigo Olivera, Martín Sosa, Nicolás Casales

Clínica de Ortopedia y Traumatología, Montevideo, Uruguay

Carpometacarpal join dislocations, are really infrequent injuries, with an incidence that goes from 0,5 to 1% of all bone hand dislocations. Being extremely rare the simultaneous luxation of all five fingers. This are injuries caused in most cases by contuse high energy trauma that can be accompanied by carpus and metacarpus base fracture.

Our work objective is to report a very infrequent injury found on a patient treated at our medical center. As well as getting up to date with diagnosis and treatment of such injury.

Clinical case
A 63 year old male case is presented, right-handed, wood and iron artisan, who was involved in a high-impact car crush against a motorbike, suffering a trauma on his right hand, without any other injuries. At the emergency room, the physical examination showed a painful right hand deformed on the back, with good perfusion, without skin injuries, with conserved movement and sensibility of all five fingers. X-rays and computer tomography (TC) were performed on the right hand showing: dorsal carpometacarpal luxation of all 5 metacarpus, with a distal fracture of the trapezium, trapezoid, capitate and hamate bones. A closed reduction at the surgical room was performed, with general anesthesia, being the reduction unstable therefore Kirschner needles were used for stabilization. A plaster cast was used for its protection. A control TC was performed showing good reduction of all 5 carpometacarpal joints. Kirschner needles were taken out 6 weeks later, at which point the rehabilitation program was started with the physiatrist team. Three months after the injury, the hand was painless, with a good range of movement, a diminished maximum catching strength compared with the other hand. The patient restarted his usual chores, fully reincorporating to his job 6 months later.

Luxation of all 5 metacarpus is an extremely rare injury. It has been reported less than 20 cases worldwide. In spite of clinical suggestive elements, the diagnosis of this injury is quite difficult, being of great importance to count with x-rays with a straight profile incidence of the hand. The results of this injury are uncertain; the functionality of the hand and wrist is frequently sustained associated with a reduction of the catching strength. This type of trauma will end up developing in greater or lesser degree, long term carpometacarpal arthrosis.

Julio Hernandez E, Mario Humeres R, Pedro Diaz A, Francisco Neumann C, Joel Hernandez D.

Hospital de Rengo VI Región CHILE

Purpose: want to evaluate the effective of dynamical digital traction on the treatment of intra-articular fracture and dislocation /fracture on fingers.
Methods: A Cohort – prospective investigation was conducted between 1998 and 2005. Thirty four patients with joint injuries of the fingers, with dislocation or sub dislocation were selected. We included Industrial accidents, direct trauma and open fracture. Patient with neurovascular injurie were excluded. All with the dynamic traction application.
Results: Thirty four patients, 91% of these got an expected results compared to literature. 2.9% with wrong result, because a sociocultural characteristics and postoperative care of the patient. It was found that, the most common injury was the intraarticular comminuted fracture. More injured join: distal interphalangeal. The most affected finger was the second finger. 100% of those who joined to the study were reintegrated to their normal activity.
Conclusions: We found that 25 of 34 patients who joined to the project, obtained excellent results. The principal cause of the fracture and fracture / dislocation was a level fall. It was noted that the most affected join, was the right index proximal interphalangeal, on the second finger and in the right hand. It was demonstrated that using the dynamic traction method, reduce the treatment less than 8 weeks.
The intraarticular comminuted fracture was the most frequent injury. Another important fact was that the distal interphalangeal joint reaches the best range of motion.
Keywords: Dynamic traction, articular fractures, dislocation

González Diego, Vaamonde Federico, Mondino Nicolas P., Rodriguez Borgonovo Andres.

1 Hospital Duhau; 2 Hospital Magdalena V. Martinez. Pacheco. Tigre. Bs.As. Argentina

Malunion fractures with great displacement can lead to a shortening of limb, resulting in a change in attitude of shoulder to antepulsion, lowering it, producing glenohumeral dysfunction and patient’s dissatisfaction with the aesthetics of the shoulder.
The aim of this work is to show a case of a young female patient with a malunion of left clavicle , with 4 cm shortening, underwent an osteotomy to restore the anatomy autologous graft.

Materials and Methods
It’s a case of a female patient, 25 years old, right handed, student with a history of defective consolidation of her left clavicle, from middle unión to distal third level.
The patient presented as background polytraumaof 4 years evolution from an accident on the street, which also suffered burns on 70 % of her body , staying 30 days in therapy, reason why the broken clavicle did not receive any treatment.
She comes to consultation with her left shoulder in antepulsion, down with girdle pain intensified at lifting weight, difficulty at maximum lift and aesthetic discomfort because of the discrepancy mentioned.
The surgery was performed under general anesthesia in “beach chair position”, assisted with image intensifier . With a lenght of 2 hrs 20 minutes.
It was performed an anterior approach, transverse longuitudinal 10cm, 2 cm below the clavicular edge above. After splitting the deltopectoral fascia, it was performed the osteotomy with Mini Saw as planned taking great care of the underlying noble structures. Both proximal and distal fragments were released and opened operculums. It was taken ipsilateral crestal graft, performed according to technique. It was also taken a structural graft 4cm lenght with Mini Saw and chisel as preoperative calculations. This structural graft was placed in the defect, fixed with titanium blocked plate (newClip, BIOLAP S.A.), filling with cancellous graft. It was closed the deltopectoral-fascia, achieving good plate coverage and skin closure with separated stitches. It was placed a banded sling. The patient was controlled 48 hours later, with good performance of both wounds. Removing stitches at 2 weeks. Keeping the intermittent sling for 6 weeks. Indicating active movements for the hand and elbow. There were radiographic controls at 3, 6 and 8 weeks after, and then monthly checks. There were indicated 30 sessions of physiokinesis, excercises at home with a frequency of 10 minutes every 2 hours: first pasive-pendulous, then active.
DASH points obtained at the evaluation: 13 (2 years), with a preview of 32. The patient was satisfied with the result due to functional improvement, decreased pain, and cosmetic enhancement.
Osteotomy clavicle in young, selected patients, with malunion shortening, and glenohumeral dysfunction can give a great functional improvement and patient satisfaction for the cosmetic improvement.

Ana Carreño, Ernesto Muñoz-Mahamud, Andrés Combalia, Marian Vives, Jose María Arandes

Hospital Clínic de Barcelona, Spain

Hand metastases have been estimated to represent 0.1% of all metastases in the skeleton. These lesions often mimic septic or inflammatory processes, although occasionally may be the first manifestation of an occult malignancy. They are usually preterminal lesions, indicating diffuse metastatic spread. The bones that are mainly affected are the distal phalanges and the primary tumors that most commonly metastasize to the hands are lung, followed by breast and kidney, being extremely rare secondary to gynecological cancer. We report herein a series of 4 cases that illustrate the rapid progression of the disease when diagnosed by a metastasis in hand.
Material and Methods
Since 2010 to 2014 we managed 4 cases of bone acrometastasis: two cases from lung, one from cervix, one from a malignant melanoma and one from hypernephroma. In one case, the acrometastasis appeared as a debut of a lung carcinoma, and other of them had been diagnosed as a felon, through debridement and antibiotics. In all cases the study by plain radiographs showed a destructive lytic lesion of the affected bone (two distal phalanxes, one middle phalanx and one metacarpal).
In two cases (distal and middle phalanx involvement) ray amputation was performed, improving pain and function in both, whereas in the other cases abstention was performed owing to the advanced stage of the disease. In all cases the patients died within the next months after the diagnostic.
Bone metastases in the bones of the hands are a rare form of presentation of a neoplasm. Its apparition as a debut of a carcinoma is even more rare and is associated with poor prognosis. High index of suspiction in patients with persistent bony symptoms and known malignancy or risk factors is needed to prompt identification of these lesions. Confirmation by image studies and biopsy will avoid delayed diagnosis and inadequate treatment. Whereas amputation is recommended in those cases of solitary metastases in patients with at least a few months of surveillance, radiotherapy may be useful as a symptomatic treatment of pain and to partially restore functionality.

Bafiq Nizar, Mohammad Nassimizadeh, Duncan Avis, Dominic Power

The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK


Axillary nerve injury is a common association with glenohumeral dislocation and most are low-grade nerve injuries with conduction block (neurapraxia) and resolve spontaneously. Intermediate-grade injuries result in Wallerian degeneration and the outcome depends on successful reinnervation. Severe injuries result in either avulsion of the axillary nerve from the posterior cord, axillary nerve rupture in the quadrilateral space or formation of neuroma in continuity and there is no recovery potential without surgery.


A systematic neurological examination should be undertaken prior to and immediately after shoulder reduction. Evidence of infraclavicular brachial plexus dysfunction or deteriorating lesions should be referred to a specialist peripheral nerve injury service without delay. Isolated axillary nerve lesions are defined as altered or absent sensation over the axillary nerve territory in the upper lateral arm with motor weakness or paralysis of the deltoid and teres minor.


An expectant policy may be pursued with anticipation of full functional recovery of the deltoid within 12 weeks in cases of prolonged demyelinating conduction block or intermediate grade degenerative nerve lesions (Sunderland 2). The absence of motor recovery by 3 months requires further evaluation. Deep muscle pain on squeezing the deltoid is a sign of reinnervation and clinical evidence of muscle contraction will follow in a few weeks. The absence of this sign at 3 months suggests a proximal lesion or higher grade lesion (Sunderland 3-5). Tinel’s sign may be elicited in the posterior quadrilateral space in regenerating grade 3 lesions but a non-progressive anterior Tinel is found at this stage in grade 4 and 5 lesions. Electomyography should be performed at this stage. Reinnervation with polyphasic responses should be observed. Active denervation without reinnervation signs should be referred at this stage for exploration.


The decision to nerve graft can be undertaken at 3-4 months in severe cases using this algorithm. Salvage nerve transfer using radial to axillary techniques offer reliable functional restoration and can be used up to 9 months post injury in cases where there is no recovery after grafting, late presentations, poor recovery after grade 3 injuries or where there is a contraindication to nerve grafting.

Bafiq Nizar, Caroline Miller, Cooke Catherine, Nicola Birch, Dominic Power

The Peripheral Nerve Injury Service, Queen Elizabeth Hospital, Birmingham, UK

Nerve transfer surgery has extended the reconstructive options following peripheral nerve injury. Distal motor nerve transfer directs axons to a denervated muscle with short re-innervation times and improved functional results. Axillary nerve damage is commonly seen with shoulder dislocations. Nerve transfer surgery provides a treatment option for patients presenting late after nerve injury when standard nerve grafting techniques will not achieve re-innervation before irreversible motor end plate degeneration.
The evidence supporting rehabilitation strategies following motor nerve transfer surgery is limited. Targeted therapy to facilitate cortical re-organisation, strength, muscle balance and control is believed to achieve optimal functional outcomes.
The Birmingham rehabilitation guidance for motor nerve transfers was developed during the treatment of 65 patients who underwent motor nerve transfer surgery over a 2-year period. Seventeen of these patients had a nerve transfer for dysfunction of the axillary nerve and 10 for the suprascapular nerve. A literature review (Medline, Ovid, Embase, CINAHL and Amed) in December 2014 and an audit of these patients’ outcomes were carried out to inform the development of the guidance.
The audit results showed that re-innervation occurs at approximately 4 months (Radial nerve to Deltoid) and 5 months (Spinal Accessory nerve to supraspinatus) following motor nerve transfer surgery. 170 abstracts were screened during the literature review process and twelve papers with level of evidence IV (9) and V (4) were included in the review.
The Birmingham guidance was developed and includes 6 stages of targeted therapy interventions: Pre-operative, Protection, Prevention, Power, Plasticity and Purpose. The progression between stages is individualised depending on the timing of muscle re-innervation. In addition there are common therapeutic aims throughout the whole recovery period.
The therapist has a key role with motor nerve transfer surgery that starts in the pre-operative period. The key stages will be presented with video case illustrations.

Mohammad Nassimizadeh, Bafiq Nizar, Deepak Samson, Shakeel Dustagheer, Dominic Power

Centre for Nerve Injury and Paralysis, Birmingham Hand Centre UK

The introduction of locking plate technology has led to widespread uptake of volar distal radius fixation due to the lower rates of extensor tendon complications. Injury to the palmar cutaneous branch of the median nerve (PCBrMN) may be associated with this surgical approach.
The peripheral nerve injury database at our institute was interrogated to identify, all injuries to the palmar cutaneous branch of the median nerve related to distal radius fracture internal fixation treated during a 5-year period. The case records, neurophysiology records, operative records, therapy records were reviewed. The time to referral, source of referral, presenting symptoms, management and outcome were recorded. The data was analysed with regard to the grade of surgeon performing the procedure, the site of injury, complexity of the fracture, delay to surgery, implant choice and outcome of the treatment. Variations in nerve anatomy were documented during revision surgery.
1280 patients were assessed at the regional nerve injury service during the study period. There were 140 (11%) patients identified as having sustained iatrogenous injury of whom 7 (5%) were injuries to the palmar branch of the median nerve associated with volar plate fixation of the distal radius The male: female ratio was 1: 6 and the mean age of patients was 47.8 years (33-74 years). In 85 % of the patients the predominant presenting symptom was pain on extension of the wrist. 71 % of the patients had paresthesia, hyperaesthesia or dysaesthesia in the distribution of the palmar branch of the median nerve. Anaesthesia or hypoaesthesia was present in 57 % of the patients. Three patients (29 %) presented with symptoms of severe nerve pain, allodynia, hyperpathia, hyperalgesia, trophism and autonomic function sufficiently severe to warrant a diagnosis of complex regional pain syndrome (CRPS) Type 2 under the International Association for the Study of Pain (IASP) Budapest criteria. Five patients (71%) required revision surgery and two (29%) resolved with targeted therapy to address nerve tether within the surgical scar. All seven patients had complete resolution of symptoms related to the palmar branch of the median nerve. In three (60%) of the patients who underwent revision surgery for a non-progressive Tinel sign and intractable neuropathic pain an iatrogenic injury to the palmar branch of the median nerve was identified with an end neuroma tethered in scar. Two patients had aberrant anatomy of the median nerve identified on exploration.

Injury to the PCBrMN is a rare complication of volar plate fixation of the distal radius. The proximity of the nerve to the surgical approach renders it susceptible to injury. Injury may be associated with aberrant nerve anatomy.

Mohammad Nassimizadeh, Bafiq Nizar, Caroline Miller, Dominic Power

The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK


Degenerative spinal conditions may result in motor radiculopathy and paralysis. Motor nerve transfers are a reliable option for restoration of motor function after brachial plexus nerve root avulsion and could offer a novel reconstructive option for reconstruction or degenerative spinal paralysis.


All patients undergoing motor nerve transfer surgery at our institution are recorded in a bespoke database which was interrogated for patients with a primary degenerative spinal cause of upper limb paralysis.


Since 2011, 8 patients have been treated with motor nerve transfer surgery for upper limb paralysis as a consequence of spinal disease. Two patients had sustained iatrogenous injury to the cervical roots during decompressive surgery, one had tumour erosion of C5 and C6, one spinal fracture dislocation with C5 paralysis and the remainder had degenerative root compression. Five nerve transfers were undertaken for elbow flexion and five for shoulder abduction (deltoid 4 and supraspinatus 1) and one had a transfer to infraspinatus. All patients had functional motor function at final review.


Motor nerve transfer may salvage paralysis for spinal degenerative conditions. The patient group is older than typical brachial plexus injuries and the pre-operative paralysis typically of longer duration. Adaptive end plate changes and progressive denervation may extend the reconstructive window over traditional complete nerve root injury transfer patients.

Flores Gabriela, Gutierrez Natalia, Jabif Javier, Paganini Federico, Allende Christian

Instituto Allende de Cirugía Reconstructiva. Sanatorio Allende. Córdoba, ARGENTINA

Introduction: The objective of this study was to evaluate the results achieved after open reduction and bone grafting without internal fixation in scaphoid nonunions.
Methods: We retrospectively evaluated 30 patients with scaphoid nonunions, treated with iliac crest bone graft (20 cases) or vascularized distal radius bone graft (10 cases), without osteosynthesis; between 2008 and 2015. Exclusion criteria were: patients in which any kind of osteosynthesis was used (k-wires or screws), and patients in which salvage procedures were performed. Twenty-six patients were male and four female; patients age averaged 26 years (range, 18 to 43); the dominant wrist was affected in 11 cases. Initial fracture was secondary to sport trauma in 19 cases. Four patients smoked. Initial fracture treatment was with a cast in 14 patients, a screw and a cast in 4 patients, and 12 cases had had no previous treatment. Time between initial trauma and surgical intervention for scaphoid nonunion averaged 21 months (range, 6 to 120). All patients were evaluated using AP and lateral x-rays; when AVN was suspected an MRI was performed. Nonunions were located at the proximal pole of the scaphoid in 12 cases, at the waist in 12 cases, and at the distal third in six cases.
A volar approach was used in waist and distal third nonunions, while a dorsal or dorso-radial approach was used for proximal pole nonunions. Iliac crest bone graft was obtained using 7mm or 12mm trephines according to the size of the resulting defect at the nonunion site (after curettage of the nonunion), the bone graft was molded to fit the defect, and was placed at the defect with the scaphoid under maximum distraction (achieved using k-wires used as joysticks). The vascularized bone graft used was that described by Zaidemberg. All patients were placed in a long-arm cast for six weeks, followed by a short arm cast for six more weeks.
Results: Follow-up averaged 29 months (range, 10 to 69). Bone union was obtained in twenty eight nonunions; time to radiographic union averaged 14 weeks (range, 11 to 24). Scapho-lunate angle preoperatively averaged 56,1 degrees (range, 30 to 76), and at last follow-up averaged 50,2 (range 30 to 75), their difference was statistically significant p<0,0036. Preoperative carpal height averaged 33,4 (range, 26,56 to 38,72), and postoperatively carpal height averaged 35,7 (range, 29,18 to 41,67), this difference was statistically significant p<0,03. One patient in each group of bone grafts did not unite; both patients had had previous surgical treatment and had been stabilized with a screw; in one case with a failed scaphoid waist nonunion a proximal row carpectomy was performed, and in the second case with a proximal pole nonunion the patient preferred no further treatment.
Conclusions: In our series of patients, in which press fit bone grafting was used (whether vascularized or not), without internal fixation, good results were achieved, and reduction was maintained. This classic technique allows achieving good predictable results and avoids the possible complications of screw fixation: protrusion, loosening and migration.

Lei Xia, Yuben Xu, Junzhang Zhao, Peng Li, Liangku Huang

Department of Hand Surgery, Honghui Hospital, Xi'an Jiaotong University of Medicine, Xi'an, China

Objective: to investigate the clinical efficacy of joint fusion therapy for treatment of osteoarthritis of carpometacarpal joint.
Methods: A retrospective study was performed from August 2010 to January 2015, and 5 male and 24 female patients with osteoarthritis of carpometacarpal joint who underwent joint fusion therapy were enrolled. Age of enrolled patients ranged from 45 to 71, and the mean value was 58. 9 lesions located in left thumb while 20 lesions located in the right thumb. All cases were classified according to Eaton-Glickel staging system, and 4 cases were in stage 2 while 25cases were in stage 3. Fixation in all cases was performed by using AO mini-piates, and autologous distal radiusbone graft was performed in 6 patients. Evaluation of bone fusion and arthritis around trapezium-trapezoid by regularly re-examination of X-ray. Grip strength, tip pinch strength, motion extent and visual analogue scale (VAS) were also analyzed.
Results: Joint fusion was achieved in all patients who underwent surgery. Both grip strength and tip pinch strength were significantly increased after surgery, and VAS was significantly reduced after joint fusion therapy.Satisfaction was met in all patients though arthritis around trapezium-trapezoid occurred in 4 patients.
Conclusion: Our results showed joint fusion therapy is effective in osteoarthritis of carpometacarpal joint treatment. Joint fusion therapy could also benefit old patients with osteoarthritis of carpometacarpal joint by improve hand function and alleviating sufferings, although this surgery has potential risk of arthritis around trapezium-trapezoid.
Key Words: Joint Fusion TherapyOsteoarthritisCarpometacarpal Joint

Peter P Abolfathi 1, Raymond A Jongs 2, Robert Segal 1

1 Healthcare Innovations Australia, Australiarn2 The Royal North Shore Hospital, Australia

For individuals recovering from damage, pathology or surgery to the hand, vigilant, timely, appropriate and effective therapy can significantly improve the outcome of the healing process and the restoration of hand function. Prior to the prescription of appropriate therapy, comprehensive assessment of the hand condition is necessary. Ongoing assessment during the course of the therapy can ensure the treatment will continue to be appropriate and provide optimal benefits to the patient.

Of the variety of clinical examinations and assessment procedures employed in current practice, evaluation of the range of motion (ROM) is considered the most informative and useful. Active ROM (AROM) and passive ROM (PROM) measurements are typically taken by therapists using goniometers. It is generally understood that improvements in these ranges are indicative of general and functional recoveries of the hand.

Despite the accepted value of ROM measurement, there are shortcomings with the methods used in the field. These measurements are cumbersome and time consuming and not always applied. Furthermore, reliability and accuracy are difficult to achieve with traditional PROM or AROM measurements. In prior studies, the error margin of ROM has been shown to be between 6 and 10 degrees.

In order to increase reliability, repeatability, ease of application and, therefore, increase the diagnostic value of ROM measurements, the process may be automated and, hence, standardised. A new technology, Exoflex, has been trialled. This device aims to complement and enhance therapy and assessment of the hand. Exoflex therapy mimics some of the manual interventions normally performed by a therapist but also creates opportunities for new forms of therapy. The assessment features are provided to map the joint stiffness and range of motion in each finger segment of the affected hand. This automated measurement system creates trend data that can be further analysed over time, and is complementary to current physiological and functional assessment methods. Importantly, the trend data may help steer more effective interventions and processes that improve patient outcomes.

In a first study of the assessment potential of the Exoflex technology, participants with eligible hand conditions underwent standard treatments as Hand Therapy clinic patients. Subsequently, the participants underwent assessment procedures using the Exoflex after each therapy session. The device measured passive and active range of every joint under study. The AROM and PROM measurements as well as joint stiffness scores derived from force sensors in the device were timestamped and kept as trend data for every joint and then accessed in relation to therapeutic activity, and patient adherence to take home exercises.

Data has indicated that measurements taken by the Exoflex are equivalent to ROM measurements normally made by therapists. Exoflex has been shown to quantitatively record the trajectory of health for a patient's hand during the course of recovery. This form of assessment should lead to more effective and standardized measurement of conditions for the improvement of hand therapy.

Li Xueyuan

Department of Hand surgery, Ningbo sixth Hospital, Ningbo, China

The lateral arm perforator flap is a work horse for covering soft tissue defect over the upper extremity, however the major limitations of this flap is the width, when larger than 5-6 cm, direct closure of the donar site can not be achieved. With the concept of kiss design, in which we separate the defect area into two pieces, the width of each area is less than 5 cm, we now can cover large defect over upper extremity which extends the applications and minimize donor-site morbidity.
7 cases of KISS flap based on LAP/ELAP reconstruction were performed. Defect locations included, proximal thumb, dorsum of the hand 5 cases, palm 1, wrist 1 cases. Defect area range from 10cm X 8cm to .11cm X 14cm.
Seven patients were successfully treated with the kiss designed LAP/ELAP with no major complications. In 6 cases, the second flap extended the lateral epicondyle, all the donor site was closed directly. All patients were satisfied with their outcomes.
Kiss flap design based on lateral arm perforator flap is an excellent method of covering large defects of the upper extremity. The new design conception had further extended indications of LAP/ELAP flap,while the outcome was quite acceptable both for the donar and reciepient area.

Hong Chen

Department of Hand surgery, Ningbo sixth Hospital, Ningbo, China

Objective To investigate the clinical efficacy about treatment of scaphoid nonunion advanced collapse (SNAC) using wrist arthroscopy. Methods Seven cases confirmed SNAC got arthroscopic examination to evaluate arthritis severity from Oct.2011 to Aug.2014. All cases accepted most part of scaphoid resection and capitate-lunate fusion. The average follow-up time was 13 months, including regular X-ray films and functional assessment. Results All cases were observed scaphocapitate fused in 10.5 weeks on average. Modified Mayo Wrist Scores were excellent in, good in 4, fair in 2. Conclusion Authors suggest patients suspected SNAC should take wrist arthroscopic assessment for accurate staging. Arthroscopic treatments include most-scaphoid removal and capitate-lunate fusion for patients with surgical indications.

Xiaofeng Teng

Department of Hand surgery, Ningbo sixth Hospital, Ningbo, China

Objective To investigate the clinical efficacy about treatment of tear of the triangular fibrocartilage complex (TFCC) using wrist arthroscopy. Methods 43 cases confirmed TFCC after MRI scans accepted different treatments by wrist arthroscopy according to injury areas, from Mar. 2011 to Jun.2015 in the same center. Treatments included synovectomy, resection of the distal part of the ulna (Darrach's procedure) and TFCC repair. Results All cases were observed wound healed and 38 cases finished follow-up in 4-12 months with an average of 7.2 months. Modified Mayo Wrist Scores were excellent in 12, good in 25, fair in 6. Conclusion Authors suggest patients with TFCC injuries accept wrist arthroscopic assessment and treatment. It's considered that synovectomy, Darrach's procedure and TFCC repair are effective treatments. The same should be take attention to rehabilitation after surgery.

Haoliang Hu

Department of Hand surgery, Ningbo sixth Hospital, Ningbo, China

0bjective To discuss the technique and clinic outcome of the perforator pedicled micro propeller flaps for soft tissue coverage of the finger defects. Methods Eighteen patients with soft tissue defects in the finger were repaired using perforator pedicled micro propeller flaps from January 2014 to December 2014. The defects including 8 cases of thumb,5cases of the index finger,3 cases of the middle finger and 2 cases of the ring finger.The defect area ranged from 1.5cm × 0.9 cm to 3.5cm ×2.0 cm with tendon or bone exposion.The flap size ranged from 1.8 cm × 1.1 cm to 4.0 cm × 2.5cm. The donor sites were closed directly for 8 cases and skin grafting for 10 cases. Results 15 cases survived successfully , 3 cases suffered from venous crisis ,which was solved by removing some of the stitches. 16 patients were followed-up 3 to 9 months, all flaps survived well with satisfactory appearance and pliable texture , with smooth pedicle.According to the TAM, finger function showed excellent in 8 cases, good in 6 cases, fair in 2 cases, the excellent and good rate was 87.5%. Conclusion Perforator pedicled micro propeller flaps for soft tissue coverage of the finger defects is relatively simple with less damage of the donor site, the appearance of the flaps and function of the fingers are satisfactory, therefore it is an ideal technique.

AJ Acuña1,2, AE Michelini1,2, I Abdon1,2, A Ramos Vertiz 1, A Rullan Corna1

1 Hospital Militar, Buenos Aires, Argentina 2 Sanatorio Franchin, Buenos Aires, Argentina

Objectives: Analize the experience obtained through the treatment of circular saw injuries in the volar aspect of the wrist and forearm.
Materials and methods: Between March 2008 and September 2015, 46 patients injuried by high speed circular saws were attended, all of them were men; in 16 of them (35%) the injury involved the volar aspect of the wrist (6 cases, 37,5% of the sample) or the forearm (4 (25%) in distal forearm and 6 (37,5%) in the musculotendinous region). Average Age: 46. Only 3 were repared among the first week after injury; the average delay was 26 weeks. The same protocol was always followed: Apropriate wound extension to proximal and distal; Removal of all ragged , blunt or free tissue fragments; Bone stabilization; Visual identification of both ends of each one of the damaged structures; FDP and FPL suture, continueing with FDS and FCU; Nerve suture, graft or tubulización; Arteries Bypass; FCR suture; Clossure (two levels); Immobilization with dorsal plaster valve, in 60° flexion of wrist and MPJs. Immediate active Flexion and extension fingers exercizes.
Results: Tendons: most of them were able to be repared by any of the known techniques. Some difficults were found when injury occurred at musculotendinous site. Nerves: After resection of proximal and distal stumps, the remaining gap averaged 42 mm (17 to 80). Arteries: in all the cases it was present the detachment of the intimae layer, in an extension of at least 1 cm in both segments. Bone: 3 patients were fractured; 3 radius and 1 ulna.
After Treatment: 7 patients (44%) achieved a complete range of flexion and extension of the fingers; predictive fact was easy moovements prior to 15 days from surgery. Worst prognosis for patients who could not close the fist after 6 weeks, and injuries proximal to musculotendinous area. 6 patients (37,5%) regained protective sensibility up to the tips of all compromised fingers, after an average of 23 weeks. 6 patients had to be reoperated: 1 because of the injury infection; 5 to the revision of the PVC Spacer. 2 to the change of the tube for graft; 2 for termino-terminal neurorraphy; 1 for tube remotion due to nerve regeneration).
The injuries made by circular saws are characterized by the ragging of the tissues and the detachment of the intimae of arteries.
Most of the tendons can be repared in termino-terminal union.
Nerves and arteries must be repaired through the interposition of bridges.
Tubes can be used as spacers, facilitating regeneration or delayed reconstruction.
The final results depend more on the quick mobility than on the method used to repair the affected nerves.

Liber Fraga, Daniel Wolff, Lucia D`Oliveira, Santiago Wolff, Juan Fossati

Plastic and Microsurgery Department. Hospital Pasteur, Montevideo, Uruguay

Introduction: Brachial plexus injuries is one of the most severe injuries of the upper limb and in most cases they have incomplete recovery. There are few international publications reporting bilateral traumatic brachial plexus injuries. The aim of this study was to review the literature to asses most frequent treatment method and present our case report
Materials and Methods: Electronic databases were searched (MEDLINE, Embase, Cochrane, SCielo) in Spanish and English. We analyzed Clinical and electrical findings and treatment method of bilateral brachial plexus injuries in adults.
Results and conclusions: Five articles were identified according to the inclusion criteria. Our case report was a male 34 years old who had had a motorcycle accident and came to the clinic seven months after with a bilateral plexus injury plus cranial nerve injuries. Surgery was performed with 2 simultaneous teams, elbow flexion and shoulder stabilization was prioritized. We are currently discussing surgical methods for improving to improve hand function.

Cristobal Greene 1,2,3, Arturo Verdugo 1, Guillermo Droppelmann 1, Nicolas Oliver 1, Julio Rosales 1

1 Clinica MEDS 2 Hospital DIPRECA 3 Universidad Diego Portales

Platelet Rich Plasma (PRP) has been used for treatment in Epicondylitis with fair results. No studies adress treatment of a selected group of patient with tendon rupture with PRP. Objective: evalaute patients with epicondylitis with tendon rupture greater than 2 mm2 in ultrasound imaging treated with a PRP protocol. Methods: 28 patients meet the inclusion criteria (ultrasound tendon rupture, compatible clinical findings and following our clinical protocol). Ultrasound follow up was done at 6 weeks and 12 weeks. Clinical follow up was done using the Patient Rated Tennis Elbow Evaluation. Stadistical analysis was made with Wilcoxon test. Results: mean age of patients was 50 years (26 to 74) with a mean surface of rupture of 8,16 mm2. At 6 weeks ultrasound findings show a a mean surface of rupture of 1,36 mm2 and of 0,1 mm2 at 12 weeks (p < 0.05). Dully recovery was achieve in 26 patiients returning to their pre injury sports activities. In 2 cases pain persists due to other elbow pathology. Conclusion: epicondylitis with tendon rupture has excelent results and almost complete resolution when treated with our PRP protocol.

WPK Hemalatha1,   RBBS Ramachandra 2

1 Occupational Therapist, Plastic and Reconstructive Unit, National Hospital Sri Lanka 2 Public Health Lecturers, Department of Research, National Institute of Health Sciences

Brachial plexus birth injuries (NBPI) are occurs during difficult labor mostly in large babies. Many children with brachial plexus birth injury develop shoulder problems with subsequent joint deformities of upper limb without treatment. Occupational Therapist assess, plan and intervene the therapeutic management to prevent contractures and deformities and improve the active range of motion to promote the clients activities of daily living and instrumental activities of daily living.

To assess the effectiveness of occupational therapy for shoulder joint after neonatal brachial plexus injury

This study is a pre and post assessment of function of shoulder joint. Study was carried out in Occupational Therapy Unit, Plastic and Reconstructive Unit, National Hospital of Sri Lanka. 36 patients regularly attend to the unit over 2 years were assessed using “Mallet Scale”. A self administrative questionnaire also was administrated to mothers of above children to identify selected factors contribute for continuation of treatment.

Children were coming from all over the country and over 95% parents are satisfied with the improvements gained. Parents spend average of Rs.2000/= (14US$) for one visit and many children are brought to the hospital once a week for exercises. Over 75% mothers are educated over grade 10 and capable of continuing exercises at home. Mean birth weight of affected children was 3617.5 g only 03% of caesarian deliveries are affected. Shoulder abduction. External rotation, hand to nape, hand to back, hand to pocket and hand to mouth all had highly significant improvements when analyzed using paired t –test.(p<0.000 in each).

Conclusion and Recommendation
Occupational therapy is an effective mode of treatment mode. In Sri Lanka each District has at least one tertiary care hospital with an occupational therapist. Therefore improving facilities in those hospitals can easily expand the services. Further hand therapy can be recommended to be developed as a sub specialty. Incidence of NBPI and incidence of normal deliveries among large babies in Sri Lanka need further research.

Bafiq Nizar, Mark Foster, Simon Tan, Dominic Power

The Centre for Nerve Injury and Paralysis, Birmingham, UK


Peripheral nerve surgery is a complex speciality with exciting developments for the treatment of complex nerve injuries including axonal fusion, nerve autografts, processed nerve allografts and nerve conduits. Meaningful outcome data is difficult to collect without multicentre collaboration. Registries enable large volumes of data to be collated and intelligent systems enable patient interaction.


A designated nerve registry has been developed using Structured Query Language (SQL) database with a customisable responsive and user friendly interface. This enables clinician registration, tailoring and access with minimum training. The clinician enters key demographic and procedure data and the system can provide an intelligent evidenced based outcome plan or bespoke rehabilitation assessment tools for completion by therapists. Patient interaction enables patient related outcome measure (PROM) collection and monitoring over time.


The use of a registry allows clinicians to benchmark their practice and outcomes against their peers. Data can be collected for infrequent procedures and performance of commercial devices can be tracked. The outcomes data may be used to establish multicentre co-operation for trials.


Healthcare providers must provide meaningful and robust outcomes at a time when financial constraints limit long term clinical follow-up. The International Registry enables robust performance data to be collated and shared to inform users.

Acuña AJ 1,2, Michelini AE 1,2, Abdon I 1,2, Romero CM 2

1 Sanatorio Franchín, Buenos Aires, Argentina 2 Hospital Militar, Buenos Aires, Argentina

Objectives: To validate the use of draintubes as spacers for severe nerve injuries, in order to facilitate the reconstruction process.
Materials and methods: Between March 2008 and September 2015, 46 patients injuried by high speed circular saws were attended, all of them were men; in 16 of them (35%) the injury involved the volar aspect of the wrist or the forearm. Average Age: 46. 3 were repared in acute stage, even when it was not possible to perform a nerve graft to solve the existing gap in the median nerve. A PVC nasogastric or thoracic draintube was used as a nerve spacer after bone and tendons reconstruction, in order to allow early motion and afford the nerve graft in more appropriate circumstances.
Since each patient had done well moveing their fingers, nerve reconstruction was delayed until movility and aedema were completely solved. Facing the results, the tubes were used in three other selected patients. The average nerve gap was 34 mm (17 - 70).
Results: All the five patients achieved a complete range of flexion and extension of the fingers, but had to be reoperated on to remove the tubes. The access to the affected nerve was much easier. The tubes were surrounded by a vascularized tissue described by Maskelet. Each tube was splited in halves longitudinally. The gaps were filled in with autologous multifascicular external saphene nerve graft. some kind of regeneration was observed in 2 cases (27 and 22 mm gaps) The hypotrophic central portion was removed and a secondary termino-terminal non microsurgical suture was possible. Protective Sensitivity was recovered up to the tip of the affected fingers in about 16 weeks. Complete nerve regeneration was possible in a Cubital Nerve with a 13 mm gap.
PVC nasogastric and small thoracic draintubes were well tolerated as spacers for the median nerve.
Tubes can be used as spacers, facilitating a secondary approach.
Some kind of regeneration allowed direct non microsurgical suture in gaps up to 27 mm.
Complete regeneration was possible in an ulnar nerve with a 13 mm gap.

Bafiq Nizar1, Suzanne Beale1, Andreas Gohritz3, Jan Friden2,3, Dominic Power1

1The Centre for Nerve Injury and Paralysis, Birmingham, UK 2Swiss Paraplegic Centre, Nottwil, Switzerland 3Centre for Advanced Reconstruction of Extremities (C.A.R.E.) and Department of Hand Surgery, Sahlgrenska University Hospital, Göteborg, Sweden


The optimum timing of rehabilitative surgery for restoration of upper limb function following traumatic cervical spinal cord injury is not established. Useful motor progressive recovery is not inevitable and salvage tendon transfers and tenodesis may be offered to patients with persistent severe deficits. Nerve transfer surgery offers exciting possibilities in patients where there is no tendon transfer option or may be used in conjunction with tendon transfers to achieve greater functional gains. Registries provide an opportunity to collect meaningful longitudinal data to inform the debate on timing of intervention for this complex and rare patient group.


A SQL database has been employed as the backbone of our registry with a mobile responsive web interface. This enables us to collect anonymous multicentre patient data following cervical spinal cord injury. A steering group of international experts was established to define the diagnostic and demographic data sets, follow up protocol and outcome assessment tools.


Patient related outcome measures (PROM) consensus enables patient interaction with the registry to track outcomes in both non-operatively and operatively treated sub-groups. Future database interrogation will establish comparable outcomes in a multicentre setting. Capabilities of the upper extremity, Canadian Occupational Performance Measures and the Spinal Cord Independence Measure may be monitored remotely following initial specialist assessment using patient and care provider interaction with the Registry.


Healthcare providers must provide meaningful and robust outcomes at a time when financial constraints limit long term clinical follow-up. The International Tetraplegia Registry enables robust performance data to be collated and shared to inform users, establish normative data, evaluate outcomes following intervention.

Marta Jokiel, Piotr Czarnecki, Leszek Romanowski

Department of Traumatology, Orthopaedics and Hand Surgery, Poznan University of Medical Sciences, Poznań, Poland

Objective: Tennis elbow is the most common upper limb entezopathy. It is associated with microtrauma accumulation due to wrist and fingers extensors muscles overload. Basic diagnosis is composed of the interview and clinical tests which allows to exclude other diseases which can imitate tennis elbow. Biomechanical testing is more and more emphasized due to patients muscle objective testing. Results verification and main reason of the disease are remarkably important according to treatment choice and further prognosis. The aim of the study was to assess tennis elbow patients forearm muscles parameters by isotonic testing and grip strength examination. Biomechanical parameters were compared also due to probable reason of the disease.
Materials and methods: 73 patients with unilateral tennis elbow [32W, 41M] and 70 healthy volunteers [33W, 37M] were examined with isotonic protocol on Biodex System 4 Pro ® dynamometer. Protocol consists of 3 trials with constant tension 0,5/1/0,5 Nm combined with repetitive wrist flexion and extension movements. Global grip strength was conducted with
3 maximal global grip testing with Biometric Hand Kit electronic dynamometer. To assess patients condition VAS and QuickDash Questionnaire was taken. According to interview and questionnaire results patients were classified to one of the groups connected with probable reason of the disease: physical workers, amateur sportsman, manual workers.
Results: Muscles were assessed with average peak torque, medium power, total work and functional range of motion. Wrist and fingers extensors biomechanical parameters were significantly lower than wrist and fingers flexors biomechanical parameters (p<0,01). Results of the dominant tennis elbow limb were significantly lower than the results of the control group but greater than healthy nondominant results. Results of the nondominant tennis elbow limb were significantly lower than control group and dominant healthy limb. There were no significant differences between average grip strength comparatively to healthy limb and control group. There were significant difference (p<0,001)between examined biomechanical parameters in manual workers group due to physical workers and sportsman group. Grip strength in manual workers group were significantly lower (p<0,0001) than grip strength in other groups.
Conclusion: Tennis elbow leads to significant decrease of wrist and fingers extensors biomechanical parameters in comparison with wrist and fingers flexors. Limb dominance significantly affects the decrease of the forearm muscles biomechanical parameters inhibition. Limb dominance do not influence the global grip strength of patients with tennis elbow. The probable reason of the tennis elbow and work type significantly influence the process of decreasing the forearm muscles biomechanical parameters of tennis elbow patients.

Ewa Breborowicz, Marta Jokiel, Izabela Olczak, Tomasz Balcerek, Leszek Romanowski

Department of Traumatology, Orthopaedics and Hand Surgery, Poznan University of Medical Sciences, Poznań, Poland

Objective/Hypothesis: Carpal tunnel syndrome (CTS) is the most common peripheral neuropathy. CTS diagnosis is usually based on physical examination. Tinel’s and Phalen’s tests are proved as high sensitive and specific. Two-point examination test is one of standards in diagnostic process. Subjective scales such as DASH (Disabilities of the Arm, Shoulder and Hand) or PRWE ( Patient Rated Wrist Evaluation) Questionnaires can be helpful in diagnosing patients condition and problems during every day living activities. Grip strength evaluation is useful for confirmation of functional weakness of involved hand. In the literature it is unclear if mentioned tests and symptoms are equal-occurs in acute and chronic cases of carpal tunnel syndrome. The aim of the study was to assess patients clinical condition with chronic, long lasting carpal tunnel syndrome.
Materials and methods: We examined 93 patients [75W, 18M] average age 59 y.o. with long lasting carpal tunnel syndrome (mean: 8 years). Grip strength was examined with electronic Biometric dynamometer. Sensory deficits was assessed with two-point discrimination test. Patients underwent clinical examination with basic tests confirming clinical condition (Tinel’s and Phalen’s tests). In problematic cases the ENG examination were provided. We used DASH and PRWE Questionnaire to assess patients condition.
Results: Carpal tunnel syndrome in 51 cases were observed in dominant limb. Orthopedic examination confirmed carpal tunnel syndrome with Tinel’s test in 73 cases, Phalen’s test in 65 cases. 27 patients observed additional development of carpal tunnel symptoms. ENG examination were provided in 23 patients with confirmation of 17 cases of median nerve damage. Grip strength in involved limb was 14,3 kg and 16,5 kg in uninvolved limb with significant difference (p=0,03) between limbs. Two-point discrimination test reveled significant difference (p<0,05) between sensory function with mean 6,6 mm in involved limb and 5,5 mm in healthy limb. The mean DASH Questionnaire result were 44,5 and PRWE result were assessed at 43,9. One of the most difficult activities in patients opinion were opening a tight or new jar (3,8) and carrying heavy objects (3,4). In 45% the atrophy of thenar eminence were observed.
Conclusions: Long lasting carpal tunnel syndrome influence patients everyday living activities and diminish hand function. Prolonged time of disease leads to slight decrease of fingers two-point discrimination and significant decrease of grip strength.

Fuminori Kanaya, Masaki Kinjo, Chojo Futenma

Department of Orthopedic Surgery, Graduate School of Medicine, University of the Ryukyus,Okinawa, Japan

Objective; We devised a mobilization procedure consisted of a free vascularized fascio-fat graft to prevent re-ankylosis and a radius osteotomy to reduce the dislocated radius head. Results of our mobilization procedure and proposed classification according to surgical outcomes were reported.
Materials and Methods; This mobilization procedure was performed on 26 forearms of 25 patients. There were 21 boys and 4 girls. The mean age at the surgery was 8 years (range, 5.3 to 13.4 years). Preoperative forearm ankylosis was between neutral and 100 degrees of pronation (mean 32.0 degrees pronation). Radius head dislocation was seen in 23 forearms (posterior in 14, anterior in 9). The mean follow-up duration was 51 months (range, 24 to 111 months). Patients were divided into 3 groups according to the preoperative location of the radius head (posterior dislocation, anterior dislocation and no dislocation). Surgical results were compared between groups.
Results; Neither re-ankylosis nor neurological complications occurred except a transient radial nerve palsy in one patient. Posterior dislocation of the radius head was observed in 9 patients. The mean range of active forearm rotation after surgery was 81.6 ±15.8 degrees. All patients reported some improvements in performing some activities, such as catching a ball, accepting objects such as coins, holding a bowl of soup and performing gymnastics. The radio-ulnar synostosis with posterior dislocation of the radius head showed more pronation ankylosis than those with anterior dislocation and without dislocation. The mean post-operative range of forearm rotation was 98 degrees in the group without dislocation, 96 degrees with anterior dislocation and 78 degrees with posterior dislocation. The group with anterior dislocation showed better forearm rotation than those with posterior dislocation (p<0.05). The group with posterior dislocation was further divided according to the preoperative pronation ankylosis. Those with 50 degrees or less pronation (n=5) gained 85 degrees range of forearm rotation and those with more than 50 degrees pronation gained 73 degrees (n=9). The former (less than 50 degrees pronation ankylosis) gained significantly better forearm rotation than the latter (50 degrees and more pronation ankylosis) (p<0.05). Pre-op pronation ankylosis showed significant negative correlation with post-op ROM (p<0.01).
Conclusions; This mobilization procedure prevented re-ankylosis after separation of the synostosis and provided the ability to rotate the forearm that improved a child's daily activities. New classification according to the dislocation of the radius head and pronation ankylosis will predict postoperative range of forearm rotation. Therefore we would like to propose the new classification of the synostosis according to the preoperative location of the radius head and pronation ankylosis as following 3 types; those with anterior dislocation of the radius head, posterior dislocation of the radius head with 50 degrees or less pronation and posterior dislocation of the radius head with 50 degrees and more pronation. Those without dislocation of the radius head showed similar outcomes with those with anterior dislocation but statistical analysis could not be performed because of small number of cases.

Manuel de Elias, Martín. F. Caloia, Walter M. Parizzia, Diego Gonzalez Scotti, Marcos Galli Serra

Hospital Universitario Austral


Several techniques have been described for the surgical reconstruction of bone defects that result from the resection of the distal radius when treating a giant cell tumor (GCT) of the wrist. The options for these procedures are arthrodesis, arthroplasty, reconstruction with vascularized fibular allograft and frozen allograft reconstruction.

When the GCT does not affect the entire distal radius the most commonly treatment used is curettage and filling with cancellous bone. The risk with this technique is tearing the basal membrane of the articular surface with the resulting necrosis and collapse of the articular surface.

The objective of this article is to report an unusual surgical technique for joint reconstruction using a distal radius structural hemi allograft and to show the clinical and radiological evolution of this particular patient in the mid term.


A 32 year old woman presented with a 2 month history of a painful right wrist. Examination revealed what seemed like a distal radius hard mass, painful to the touch, adhered to deep planes. Plain X-rays showed an osteolytic image in the distal third of the radius. A CT-guided biopsy puncture determined the diagnosis of giant cell tumor, stage III of Campanacci´s staging. The initial treatment consisted of an intralesional resection, with curettage, cauterization with argon, and filling of the defect with 100 cm3 of cancellous frozen bone allograft. During the postoperative period the patient was immobilized with long cast (above the elbow) with good performance in the first months. Four months after the surgical procedure a control x-ray showed an articular collapse of the medial column involving the radio-lunate and distal radio-ulnar joints.
Taking into account this localized involvement of the medial column we decided to make a biological reconstruction of the affected segment using a distal radius structural hemi allograft in order to supply de defect previously mentioned. Restitution of the double joint congruence was accomplished by stabilizing the graft with interfragmentary screws and a locked volar plate. The dorsal portion of the triangular fibrocartilage complex (TFCC), dorsal capsule and carpal ligament radio were arthroscopically reinserted.


Complete radiographic union of the allograft was observed during the 10th month p.o. Physical examination showed full radio-carpal and radio-ulnar stability, with a range of motion of 60º of flexion of the wrist, 80º of extension, 80º of supination and 90º of pronation, without pain.


A new technique for reconstruction of bone defects in the distal radius is described with functional, radiological and tomographic results at 30 months of postop, showing a complete integration of hemi-allograft with articular congruity of radio-ulnar distal and radio-carpal joints, and a functional range of motion for a patient with high functional demand on her dominant hand.

Mariane Campopiano Abrahão Silva 1,2, Alessandra Assis Miura 1, Rafaella Arboleda 1,2, Laryssa Lopes 1, Maria Ligia Kalamakian 1

1 Beneficencia Portuguesa Hospital, São Paulo, Brazil 2 Projeto Rede, São Paulo, Brazil

Objectives: To describe the rehabilitation process of a patient with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) during hospitalization focusing on functional recovery of the upper limb; improvement of the functional ability and independence in activities of daily living (ADLs) through the use of adaptive equipment; and splinting.

Methods: This paper presents a case study that demonstrates the Occupational Therapy (OT) rehabilitation treatment of a 53 years old patient with CIDP during the hospitalization period (January 6th, 2016 to January 23rd, 2016). She recieved a total of 9 sessions of OT before being discharged from the hospital. The Functional Independence Measure (FIM) was used as a standardized tool to evaluate the intervention and to define the aims of the treatment. The patient scored 1 for all of the scale items in the first session. The main complaints of the patient were: impossibility of bringing food to mouth and to perform oral hygiene; and impossibility of using mobile applications and to type messages to her family. The assessment of muscle strength of the upper extremity was made through the manual muscle testing according to the Medical Research Council Scale. In the first session, the patient got a grade 0 for shoulder extention and grade 1 for shoulder flexion and abduction; grade 2 elbow flexion and extension; grade 1 for wrist extension; and grade 0 for fingers flexion and extension. During the treatment, exercises and functional activities were used combined with adaptive equipment to increase the functional independence level during ADLs performance, and resting splints during the night to prevent hand deformities. The FIM instrument was reapplied weekly and in the patient’s discharge.

Results: During the programme of occupational therapy, the patient increased her function to feed herself and to perform oral hygiene by the use of adaptive equipment; resulting in better upper extremity function, strength and movement efficiency. At the discharge moment, the team noted an importante progress in the patient’s ability to perform self-care items, with a score 4 in the FIM scale. We also noted an increase of the upper limb muscle strength, with grade 2 for shoulder flexion and abduction; grade 3 for elbow flexion and extension; grade 2 for wrist extension; and grade 2 for fingers flexion and extension.

Conclusions: The rehabilitation intervention helped to improve the quality of life of a patient with CIDP and to recover the function of the upper extremity. The use of assistive technology devices - such as adaptive equipment and splinting; the improvement of the ability in executing ADLs; and functional activities and exercises increased the independence of the patient during hospitalization.

Yong Park, Yoon-Min Lee, Seok-Whan Song

Department of Orthopedic Surgery, The Catholic University of Korea, Yoido St. Mary’s Hospital, Seoul, Korea

The object of this study is to evaluate and compare the clinical and radiographic outcomes of two different surgical techniques of external fixator and plate fixation for AO type C distal radius fractures.
Forty patients with only plate fixation (group I, dorsal or volar) and forty-patients with external fixator with additional K-wires or plate fixation (group II) of AO C type distal radius fracture were reviewed from March 2003 from October 2014. Range of motion and Green and O’Brien score were evaluated as clinical results, and radial inclination, radial length, volar tilt at postoperative and last follow up were evaluated as radiographic results.
According to AO classification system, there were 28 cases of C1, 33 cases of C2 and 19 cases of C3 distal radius. The mean Green and O’Brien score was 94.4 in group I and 92.2 in group II, and 71 patients had satisfactory result. There was no statistical significant difference in clinical results between the groups. There were no statistical significant changes within radiographic parameters. No extensor tendon rupture was reported. Range of wrist motion at 6 months after surgery showed no significant differences with both groups.
Although external fixator have been known to cause stiffness of wrist joint, but the main factor which affecting the actual limitation of joint motion was severity of distal radius fractures regardless of fixation methods. Although external fixation has been known as the obsolete method, it may obtain good reduction of intra-articular fracture by ligamentotaxis with less complication.

Najarro FJ, Jimenez A, Navarro S, Gomez Infantes JG, Sicre M, Santos FJ.

Fremap Hospital, Seville, Spain

INTRODUCTION AND OBJECTIVES: distal radius fracture represents 10-25% of all fractures. The normal anatomy determines that 80% of the loads pass through the radio and 20% through the ulna, hence proper joint reconstruction is essential to a fracture of the distal radius. Our goal is to review fractures treated in our hospital by open reduction and osteosynthesis with volar plate fixed angle, assess the most common types of fractures and the role of arthroscopy in the treatment of associated injuries .
RESULTS: Statistical analysis using SPSS 15.0, of the results obtained. mean age of 40.85 ± 8.7 years prior to surgery 16.2 ± 18 days, ranking Fernández time: Type I (11.1%), II (23.8%), III (52.4%), IV (7.9%) and type V (4.8%). in the radiologic findings are a final step of 0.5 ± 0.8 mm, distal radio-ulnar variance of 2.4 ± 3.8 mm, 7.3 ± fly tilt 4.7º and radial rake angle of 16.4 ± 7.3 °. dominant hand in 48.1% and 4.5% associated cases injuries. Mayo Clinic Scale 78.7 ± 16.7 points, with excellent and good results in 69.7%, 17.1% in regular and bad in 13.2%. Need for removal of osteosynthesis material in 29.2%. arthroscopy associated wrist in 32 cases, can not establish differences in improvement of results was performed.
DISCUSSION AND CONCLUSIONS: osteosynthesis plates fixed angle has been a great improvement in the treatment of these fractures. There are many jobs in the biblografía and this presentation you just collect a piece of treated at our center fractures within the entire collection that is preparing for future publication, but which represents a significant number of cases in relation to other publications the subject. As a precursor via palmar for reduction and fixation of these fractures, Orbay, collects the osteosynthesis with plate fixed angle (DVR) reaches a tilt flying 6th, radial 20 °, radial shortening of <1 mm, average dorsiflexion 58º flexion average of 55 flying with strength of 77% compared to the opposite side. The volar approach would fracture causes a faster healing, less need for bone grafting and minor tendon damage. Also for authors such as Musgrave, who reviewed 32 fractures treated with volar plates, the average loss reduction was flying 0 ° tilt, radial inclination 1, 0 mm radial length. This osteosynthesis allows the start of movements between 8 and 14 post-intervention, days with flexion and extension end to an arc of 112 ° and pronosupination end to an arc of 151º. Our results are similar to those of other series, with ratings in the excellent and good scale in May despite the complexity of fractures. As for the role of arthroscopy, we will complete the series by increasing the number of arthroscopy, to assess whether or not this procedure is able to improve the results obtained with the reduction and osteosynthesis of the fracture, before the same group of lesions (classification Fernandez), which will be the subject of further work ..

Yong Park, Yoon-Min Lee, Seok-Whan Song

Department of Orthopedic Surgery, The Catholic University of Korea, Yoido St. Mary’s Hospital, Seoul, Korea

Volar locking plate fixation is now widely used surgical technique due to development of design and functions of instruments and relatively easy surgical techniques compared to dorsal plate fixation. However, distal radius fractures are often associated with other injuries such as injuries of carpal ligaments or carpal bones, and due to severe intra-articular fractures, it is difficult to obtain satisfactory results with only volar plate fixation in such cases. The purpose of this study is to report advantages of dorsal plate fixation with good clinical results and show easy procedures of dorsal approach.

From March 2008 to October 2014, 30 patients treated by dorsal plate fixation and 30 patients by volar plate fixation for distal radius fractures were reviewed retrospectively. Three months and six months after surgery, radiologic findings and clinical results including wrist motion (flexion, extension, supination and pronation), grip power and Quick DASH score were evaluated.
Three months after surgery, group of dorsal plate fixation showed limitation of wrist flexion compared to the group of volar plate fixation. But, after 6 months, there was no difference of wrist motion and final Quick DASH. The group of volar plate fixation group had two cases of EPL rupture and attritional injury of flexor tendons, and there were no injuries of extensor tendon or complication of extensor retinaculum in the group of dorsal plate fixation.

Xu Lina, Lin Dingsheng

The second affilated hospital of Wenzhou medical university ,Wenzhou,Zhejiang. China

• Introduction: Dilong Injection is a traditional Chinese medicine for activating blood circulation and removing blood stasis. The aim of our study is to investigate the potential effects of Dilong Injection on random skin flaps survival.
• Materials & Methods: McFarlane flaps were established in 60 rats divided into two groups. Dilong (1ml/mg) was injected into the test group, and the same concentration of saline(1ml/mg) was injected into the control group. The flaps surviving area was measured after 7 days, and the tissue samples were taken for histological analysis. Vascular endothelial growth factor (VEGF) was determined using immunohistochemical methods. Superoxide dismutase (SOD) activity and malondialdehyde (MDA) content were examined.
• Results: Compared with the control group, the mean survival area of the flaps in the test group was significantly larger (p <0.01). Expression of vascular endothelial growth factor (VEGF) and superoxide dismutase (SOD) activity increased obviously in the test group(p <0.01), while malondialdehyde (MAD) level in the test group was significantly reduced(p <0.01).
•Conclusions:Dilong promotes skin flaps survival by accelerating angiogenesis, having anti-inflammatory effects, reducing oxidative stress.

Burcu Semin Akel, Sedef Karayazgan Şahin, Meral Huri

Hacettepe University, Faculty of Health Sciences, Depatrment of Occupational Therapy, Ankara,Turkey

Objective/hypothesis; Lymphoma is frequently seen among pediatric cancers after lykemia. The treatment of lymphoma (chemotherapy) has many systemic side effects, and one important negative effect of this treatment is on gross and fine motor functioning. Altough fine motor skills are very important on academic skills of children and in daily living, there is lack of research on hand skills of children with cancer. This study aimed to investigate upper extremity oriented occupational therapy on fine motor skills of chidren with Non Hodgkin Lymphoma (NHL). Materials and Methods; Seven girls with Non- Hodgkin lymphoma with mean age of 12.20 ± 3.11 (min:9 years- max:16years) participated to the study. They were diagnosed as NHL and staying at hospital for chemotherapy. Fine motor skills were evaluated with response speed, upper extremity speed and dexterity subtests of the Bruininks - Oseretsky Motor Proficiency Test (BOMPT). Occupational therapy program involving academic skills, handwriting, strengthening and other fine motor skills like manipulation were tailored in a client centered manner. The effect of occupational therapy were analyzed with Wilcoxon signed-rank test for statistical analysis. Results: Average scores of fine motor skills according to BOMPT was 36.40± 4.56 (min:30 - max:42 points) before intervention. After treatment, the score incread to 46.80 ± 3.83(min:41- max:50 points). The difference between these measurements were statistically significant (p<0.05).Conclusions: As the main concern of cancer treatment is survival, and rehabilitation focus on general mobility, hand functioning can escape the attention. However the overall aim of rehabilitation is functioning and quality of life. Therefore, as hand skills diminish during treatment, focus should be given to increase fine motor skills. By this way, academic and playing skills can increase and will have a positive effect on well-being.

Hayato Kuno1,2, Masahiro Tobe1, Hiroshi Kuroda2, Keizo Fukumoto3

1Hand Surgery Center, East Hokkaido Hospital, Hokkaido, Japan; 2 Kameda Medical Center, Chiba, Japan; 3 Saitama Hand Surgery Institute, Saitama, Japan

To report short-term result of the capitate reconstruction with free vascularized 2nd metatarsal head transfer for type3 avascular necrosis of the capitate (capitate-AVN).

The patient was 40 years old female who had already received vascularized pedicled bone graft from 2nd metacarpal with diagnosis of left capitate-AVN at another hospital a year ago. But collapse of the proximal pole had progressively worsened and her symptoms did not improve.
On physical examination, she had severe dorsal wrist pain and limited wrist ROM. Radiographs showed DISI deformity, severe carpal collapse and MRI showed entire avascular necrosis of the capitate (type3). To reconstruct the carpal alignment and preserve the motion of wrist joint, necrotic capitate was replaced with free vascularized 2nd metatarsal head from right foot. The follow up time was 1.5-year.
Wrist range of motion, grip strength, and radiographic parameters-radiolunate angle (RLA), scapholunate angle (SLA), and carpal height ratio (CHR) were assessed before surgery and at 1.5-year post-operatively. The visual analogue scale for pain (VAS) and Quick-disability of arm, shoulder and hand questionnaire (Q-DASH) were recorded before surgery and at 1.5-year post-operatively.

There was severe collapse of proximal pole and sclerotic change of entire body, but osteoarthritic changes of the capitate facet of scaphoid and lunate was not seen on intra-operative findings. After the capitate was resected entirely, it was replaced with 2nd metatarsal head in combination with the metaphysis, vascular pedicle and skin island from right foot. The first palmar metatarsal artery (FPMA) was anastomosed with dorsal branch of radial artery, and the vein was with concomitant vein of radial artery. Transferred metatarsal head was fixed to 3rd metacarpal bone by small titanium plate.
At 1.5-year follow-up, the wrist flexion-extension was 140°( vs 90°before surgery), and grip strength was 83% (vs 38.7% before surgery) of contralateral hand. VAS and Q-DASH score before surgery showed a significant improvement following the course. DISI deformity and carpal collapse on preoperative X-ray has been corrected and maintained at 1.5-year. She resumed the working without limitation of activity, and there was no donor site morbidity.

Capitate reconstruction with 2nd metatarsal head is worthwhile procedure in the setting of the capitate AVN with severe collapse. It can be considered as alternative to other salvage procedures like partial carpal fusion, because this procedure can provide adequate pain relief and preserve the joint motion.

Yan-Qun Qiu, Xu-Yun Hua, Wen-Dong Xu

1 Department of Hand and Upper Extremity Surgery, Huashan Hospital, Jing’an Branch, Shanghai, China 2 Department of Hand Surgery, Huashan Hospital, Fudan University, Shanghai, China

Objective: Brachial plexus avulsion injury (BPAI) is one of the most serious peripheral nerve injuries. The treatment remains a major and challenging reconstructive problem. It was realized that central nervous mechanisms may play an important part in the functional restoration of the palsy hand. However, the neurological mechanism of BPI remains unclear, which provides a basis for further investigation.
Materials and Methods: Two patients suffering left total brachial plexus roots avulsion were followed up for 5 years consecutively. Both patients received the same surgical procedure of peripheral nerve rewiring, which included a complete contralateral C7 transfer to the median nerve to save limb function. The paralyzed hand’s motor recovery was assessed by scores of target muscle power and the peripheral regeneration examined via electromyography at every 6 months’ follow-up. Positron emission tomography (PET) results of cerebral glucose metabolism were recorded every year.
Results: One patient regained an M4 muscle power of the wrist and finger flexion while the other only showed a poor M2- muscle power. In the longitudinal PET study, a correlation analysis with motor recovery was done and the results indicated that metabolism in corpus callosum, BA6 and precuneus showed a significant (P<0.01) positive correlation with motor recovery of the injured arm.
Conclusions: The cortical remodeling may last for a long period after peripheral nerve rewiring. The differences within the PET results indicate that the precuneus and the premotor cortex may play an important role in the upper-limb motor function recovery.

Miranda Bűhler 1, Cathy Chapple 1, David Baxter 1, Simon Stebbings 2

1 University of Otago School of Physiotherapy, Centre for Health and Rehabilitation Research (CHARR), Dunedin, New Zealand; 2 University of Otago Dunedin School of Medicine, Dunedin, New Zealand

Objective/Hypothesis: To determine the effectiveness of splinting for reducing pain and increasing functional status and health-related quality of life in individuals with thumb base osteoarthritis (OA).
Materials & Methods: The Cochrane Central Register of Controlled Trials (CENTRAL), Medline (OVID), EMBase (OVID), CINAHL, ISI Web of Science, Google Scholar and SCOPUS databases were searched. The WHO International Clinical Trials Registry Platform along with relevant conference proceedings were screened to identify unpublished and ongoing or recently completed trials. Electronic searches were supplemented with manual searching of reference lists of systematic reviews and included studies.
A comprehensive search strategy was developed combining medical subject headings and text terms describing thumb (trapeziometacarpal joint) osteoarthritis with terms describing the splint interventions. No restrictions with regard to study type, date or language were applied.
Study selection was based on inclusion of adults with a diagnosis of thumb base osteoarthritis, intervention(s) of thumb orthotic device (orthosis, splint, brace) with or without standardised co-interventions, and control/comparator interventions of other intervention, no intervention, or sham (placebo) intervention. Randomised controlled trial (RCT), before and after, interrupted time series, quasi-experimental/non-randomised controlled trial and prospective cohort study designs were included.
The primary efficacy outcome was pain, and the primary safety outcome was withdrawal or dropouts due to adverse events. Secondary outcomes were measures of physical function or disability and measures of quality of life.
Two reviewers independently searched the databases and screened the titles, abstracts and descriptors of identified studies for possible inclusion. Studies considered potentially eligible by either author were obtained in full text and independently assessed for inclusion. Data was extracted independently by two reviewers using a piloted data extraction form.
Results: Study quality as assessed using the van Tulder scale for RCTs and the MINORS instrument for quasi-experimental designs, will be presented. Risk of bias for each study will be reported according to the Cochrane Risk of bias tool.
Descriptive statistics will be displayed for study design, population characteristics, splint parameters, control group/standardised treatment, case definitions, and outcome measures. Where studies are sufficiently homogenous, data will be pooled in a meta-analysis using a random-effects model. The quality of the overall body of evidence will be judged as ‘High’, ‘Moderate’, ‘Low’ or ‘Very Low’ following the Grades of Recommendation Assessment, Development and Evaluation (GRADE) approach.
Conclusions: The overall strength and quality of the evidence for effectiveness of splinting for reducing pain and increasing functional status and health-related quality of life in individuals with thumb OA will be presented.

Natalia Cortabarria, Lucia Torroba, Noel Fraga, Raquel Di Stefano

Hospital de Clinicas, Montevideo, Uruguay.

To evaluate open surgery outcomes in patients with CTS. To describe the epidemiological profile of this population. To describe postoperative complications. To know neurotoxic risk factors. To recognize predictive factors of poorer outcomes.

Materials and Methods:
Prospective, double-blinded study. Male and Female patients over 18 years old, with clinical and electrophysiological diagnosis of CTS, at least 1 month of evolution, were studied. Patients with previous surgery of CTS or pregnant patients were excluded. AANEM Diagnostic criteria were implemented. Electrophysiological protocol was according to Joel-Delissa propositions, with electromiografic equipment NICOLET – VIASYS, Viking Quest System. Open surgery criteria included clinical and electrophysiological diagnosis, and academic discussion resolution. The surgical technique was standardized for all the patients of this trial. All patients were clinically examined pre and postoperative, evaluating the aspects of function, sensibility and strength. Materials included a patient data sheet, DN4 scale to evaluate neuropathic pain, EVA pain intensity scale, Likert scale for paresthesia severity, ARAT fine motor skills test, and DASH QUICK patient perception scale.
Clinical suggestive patients with CTS were recruited in ambulatory consult, and were submitted to an electrodiagnostic test. Compliance sheet was completed, as well as other evaluation scales for preoperative data collect. Patients with positive diagnostic criteria were derived to plastic surgery service, where surgery was coordinated in indicated cases.
Postoperative data collect was performed by plastic surgery service, implementing outcome measuring scales by week 1, 2 and 3, and the 3rd and 6th months. Both physiotherapy and plastic surgery services performed the activities in a blinded assessment manner.

CTS presents more frecuently in women, between 40 and 60 years old. Recovering in patients with associated pathologies is slower, with poorer functional results. Regarding symptoms, paresthesia disappeared almost immediately in patients who received surgical treatment, and pain remained with slower resolution.

This is the first prospective, double blind study executed interdisciplinary, that demonstrates efficacy of surgical treatment, with a rigorous analysis, in our center. It allowed us to an approach of an epidemiological profile, and to identify poorer outcomes factors. Open surgery is the best treatment for this pathology.

Level of evidence: III

Natalia Gutierrez 1, Victoria Rosemberg 2, Marcelo Ruggeri2, Natacha Boyallian2, Christian Allende1

1- Instituto Allende de Cirugía Reconstructiva. Sanatorio Allende. Córdoba, ARGENTINA 2- Servicio de Cabeza y Cuello. Sanatorio Allende, Córdoba, ARGENTINA

Introduction: Microvascular free flaps have become the preferred method of reconstruction for most major head and neck oncologic defects. Treating advanced head and neck cancers requires a team of multidisciplinary specialists, including the need for microvascular surgeons. Historically plastic surgeons, otolaryngologists and head and neck microsurgeons performed these procedures. Over the past sixty years orthopaedic microsurgeons have developed skills in the management of soft tissue and bone defect for limb salvage. The aim of this work is to prospectively analyse the role of orthopaedic microsurgeons in head and neck oncologic reconstructive surgery at our institution.
Methods: Since 2014 a prospective case series review is being conducted. Ten consecutive microvascular free flaps were performed by a single orthopaedic microsurgeon for 10 head and neck oncologic defect reconstruction. Patient characteristics, surgical characteristics, and outcomes were recorded.
Results: Seven soft tissue flaps and three osteocutaneous fibular flaps were used to reconstruct 10 consecutive ablative defects between March 2014 and January 2016. All procedures were performed by a single orthopaedic microsurgeon. Patient’s age averaged 55 years. Reconstruction was performed by two teams, the flaps were performed simultaneously with the oncologic ablation; head and neck surgeons performed the ablative portion of the procedure. Three scalp defects and 7 oral cavity defects were reconstructed. Seven fasciocutaneous radial forearm flaps were performed; including one sensory innervated radial forearm flap for tongue reconstruction. Three fibula flaps with skin paddle were used to reconstruct mandibular defects. One of them was divided to create two cutaneous paddles to reconstruct intraoral and cutaneous epithelial surfaces. Fibular osteotomies were performed in two cases; mini plates were used. Skin graft was used to close donor sites. Microvascular arterial and vein end to end anastomoses were performed. The facial vessels where used in all cases. Total operative time averaged 9,4 hours. Median hospitalization time averaged 8,2 days. Three patients developed postoperative neck hematoma, 2 required evacuation. No other complications were observed at the flap, recipient or donor sites. Postoperative radiotherapy and chemotherapy were performed in one patient, 6 patients received radiotherapy alone and one patient chemotherapy alone. Patients with oral cavity defects (n:7) were assessed for deglutition and speech. All had a regular diet and none developed speech problems. There was one local tumour recurrence. Mean follow-up is 11 months (range, 1 to 22).
Conclusions. These preliminary results suggest that orthopaedic microsurgeons could play an important role in reconstruction of head and neck oncologic defects. Orthopaedic surgeons are familiarized with design, elevation and transfer of free flaps from the extremities; as well as in bone and soft tissue management, to decrease donor site morbidity. Results are comparable to previously published studies performed by plastic surgeons, otolaryngologists and head and neck surgeons. A bigger series is need for statistical comparisons.

Kenichi Takashima1 Hiroshi Arino1 Masatoshi Amako1 Koichi Nemoto1  Kazuhiro Chiba 1 Shinichiro Takayama2

1 Department of Orthopaedic Surgery, National Defense Medical College, Saitama, Japan 2 National Center for Child Health and Development, Tokyo, Japan

Background: Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy in adults, but is rare in children. Most of CTS in children were secondary entrapment neuropathies, and the primary disorder has been reported as mucopolysaccharidosis (MPS), mucolipidosis, diabetes mellitus, or obesity, MPS are a group of metabolic disorders caused by the absence of lysosomal enzymes and accumulate glycosaminoglycans in the connective tissue. Few children with secondary CTS caused by MPS type I have been reported, however, rarely seen in the sublings. We experienced two young siblings with CTS, caused by MPS typeⅠ.
Case1: A 19-year-old man complained tingling sensation and pain in the right hand at the age of 9, and conservative treatment was given. At the age of 18, aortic valve regurgitation and thalassemia were identified, and he was diagnosed with MPS I (Scheie syndrome). Thenar muscle atrophy was observed and he was referred to our clinic. Perfect O sign and Phalen’s test were both positive, and the delay of terminal latency was detected by nerve conduction study. Decompression of the carpal tunnel was performed through an open palm approach. The median nerve was severely compressed by the thickened flexor retinaculum. The histopathology revealed that mucin deposition was present in the flexor retinaculum. His numbness improved after one month and thenar muscle atrophy recovered after six months.
Case2: A 12-year-old boy (the younger brother of the first patient) complained numbness and night pain in the right hand. He was also diagnosed with MPS I simultaneously with his brother. Because of severe thenar muscle atrophy, he underwent surgery 6 months following his old brother’s surgery. The flexor retinaculum was resected to relieve nerve entrapment, and mucin deposition was found in the flexor retinaculum by histology.
Conclusions:We reported very rare young siblings with secondary CTS caused by MPS I.

Santiago Wolff 1, Daniel Wolff 2

1 Plastic Surgery and Microsurgery Service 2 Pasteur´s Hospital

Background: The Spinal accessory nerve is conventionally transferred to the Supraescapular nerve through an incision in the supraclavicular region (the anterior approach) to improve shoulder function in brachial plexus injuries.

The aim of the presentation is to exhibit the detailed surgical technique of this transfer considering in this case through a posterior approach, analysing its advantages and disadvantages in comparison to the previous classical approach, together with its results regarding morbidity and recovery of nerve function.

Methods: It has been conducted an extensive review of published literature on this matter. The review was carried out in books and magazines indexed in the following search portals: the Scielo, Pubmed, Cochrane and Science Direct. Details of surgical techniques together with the results of both approaches were obtained from the sources mentioned. In addition, clinical cases of surgeries in our service were included.

Results: The case-control studies show a lower morbidity of the donor nerve and better and earlier functional recovery of shoulder abduction and external rotation of the arm, together with more degrees of the shoulder abduction.

Conclusions: The transfer of the spinal nerve accessory to the Suprascapular nerve is the most frequently neurotization used in traumatic brachial plexus injuries. The anterior classical approach has been for years the only way for its accomplishment. Since the description of the posterior approach, scientific evidence confirming considerable benefits of this approach has been growing. Hence, the brachial plexus surgeon should learn and be trained on this technique, either for using it separately or in conjunction with the anterior approach.

Vinícius Neves Atti, Marcela Fernandes, Gustavo Santiago de Lima Figueiredo, Sandra Gomes Valente, Luis Renato Nakashima, Flávio Faloppa, João Baptista Gomes dos Santos, Carlos Henrique Fernandes, Walter Manna Albertoni

Division of Hand Surgery, Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil

Introduction: The treatment of peripheral nerve injuries has quite varied results. The search for new treatment methods allowed the knowledge of Platelet Rich Fibrin (PRF) and vein tubes, which release growth factors with potential for tissue regeneration. This study aims to determine if the addition of an adjuvant (vein tube with or without PRF) improve nerve regeneration rate, measured by functional score and histomorphometric analysis.

Methods: We used SHR inbred rats divided into 4 groups: nerve graft covered with vein (NGCV) (n = 10); nerve graft covered with vein filled with PRF (NGCVP) (n = 10); nerve graft (NG) (n = 10) and the SHAM control group (n = 10). The repair results of sciatic nerve damage through nerve grafts, nerve grafts enriched vein tubes with or without PFR obtained from centrifugation of blood were evaluated by sciatic functional index (SFI) at 0, 30 60 and 90 days, morphological and morphometric analysis of nerve distal to the lesion, and quantitative histological analysis of neurons labeled by the dye-Fluoro Gold® the anterior horn of the spinal cord.

Results: The graft groups covered with vein (NGCV) and graft covered with vein filled with PRF (NGCVP) had lower SFI values ​​than the control group (SHAM) throughout the study period. The NGCV group showed improvement in the sciatic functional index at day 90, a statistically significant when compared to the nerve graft group (NG). The diameter of the fiber and the axon of NGCV and NGCVP groups were similar to each other, and were lower statistically significant, the SHAM and NG groups.
Conclusion: All experimental groups obtained parameters decreased in relation to statistically significant SHAM. Functional improvement of the sciatic functional index at day 90, in NGCV group compared to NG, can be explained due to factors released by vein or vein itself as a conduit to reorient axonal. Further studies are needed to evaluate the role of adjuncts to nerve graft in repair of peripheral nerve injuries.

Olga Agranovich, Alexey Baindurashvili

The Turner Scientific and Research Institute for Children's Orthopedics Saint Petersburg, Russia

Objective. Elbow flexion contractures in children with arthrogryposis is rare pathology which very difficult for treatment. This elbow represents a severe disability, especially in the patients with bilateral flexion contractures. We reviewed literature and didn’t find out articles according this pathology in patients with arthrogryposis. The goal of our presentation is demonstration our approach to treatment elbow flexion contractures.
Materials and Methods;
From 2010 to 2016 we examined and treated 46 children (82 upper extremities) with elbow flexion contractures. The age of patients was from 2 months to 12 years. It was carried out clinical, radiology, electrophysiology, neurology examination.
Results. All deformities were divided into 2 groups: congenital and iatrogenic (after elbow release in children with elbow extension contractures). The choice of method of treatment depends on severity of contracture, amplitude of passive motion in elbow, skin pterygium (yes or no), triceps strength and age of patient. We used several variants of treatment elbow flexion contractures:
1. Conservative therapy - passive correction by cast with external device.
2. Elbow release with skin plastic and afterwards passive correction by cast with external device.
3. Passive correction by cast with external device and afterwards muscles transfer for restoration of triceps (thoracodorsal flap transfer).
4. Extension osteotomy of humerus.
Conclusions. Passive correction by cast with external device helps to eliminate or decrease the severity of elbow flexion contracture. This method has to use as isolated in children early age or as a step before operation. Surgery is recommended during the age of 1 to three years when conservative therapy fails. Early gentle manipulation soon after birth, adequate choice of conservative therapy or operative procedures and post operation rehabilitation improve function and cosmetic results of treatment.

Fernando Araujo Pires, Carlos Henrique Fernandes, Lia Myiamoto Meirelles, Marcela Fernandes, Luis Renato Nakashima, Flávio Faloppa, João Baptista Gomes dos Santos, Walter Manna Albertoni

Division of Hand Surgery, Department of Orthopedics and Traumatology, Escola Paulista de Medicina, Universidade Federal de São Paulo, São Paulo, Brazil

Introduction: Carpal tunnel syndrome association and trigger finger is very common in clinical practice and concomitant surgeries are performed routinely. The aim of this study was to evaluate whether carpal tunnel syndrome surgery and trigger finger surgery delays the functional recovery of the patient.
Material: The patients were divided into two groups. The group of patients with CTS without trigger finger (control) consisted of 45 patients, 41 female and 4 male, mean age 55 years. The hand operated to 24 right and 21 left, 44 with dominant right side and 1 with left dominant side. The group with CTS and trigger finger, consisted of 35 patients, 33 females and 2 males, mean age 54 years. As for the hand operated: 17 right and 18 left, all 35 with dominant right side.
Method: Patients were evaluated preoperatively and in the second week, first month, third month and six months after surgery. Patients underwent assessment of palmar and digital grip strength and applying the Boston questionnaire. The mean result The mean results were calculated and compared.
Results: No differences were found for the results obtained in any action studied in any of the five times.
Conclusion: Finger surgery concomitantly trigger carpal tunnel syndrome surgery did not alter the functional recovery of the patient.

Ruchelli Luis 1, Capomassi Miguel 2, Gardenal Martín 2, Allende Christian 1

1 Instituto Allende de Cirugía Reconstructiva. Sanatorio Allende, Córdoba, Argentina, 2 Instituto Doctor Jaime Slullitel, Sanatorio de la Mujer, Rosario, Argentina

Introduction: The aim of this study is to retrospectively assess functional and radiological outcomes, and complications in a series of patients with humeral fractures, stabilized with plates through lateral approaches, using minimally invasive technique.

Material and Methods: Retrospective Multicentric study of 14 patients with humeral fractures treated with minimally invasive plate osteosynthesis through lateral approaches between 2007 and 2013. Seven were females and 7 males, age averaged 48.7 years (range 21 -73). Fractures were classified according to the AO classification A1 12 n: 1; 12 B1 n: 1; 12B2 n: 3; C1 n 12: 6; 12C2 n: 1; 12C3 n: 2. Two lateral incisions were used proximal and distal. The plates were slid submuscular, and the radial nerve was protected.

Results: Follow - up averaged 30 months. Union was achieved in 13 cases (92.85%), time to union averaged three months (range, 2 to 6). Flexion averaged 174.8 °, external rotation 67.2°, abduction 173.8º and internal rotation 72.1°. Elbow flexion and extension ROM averaged 140.5 °. Constant´s score averaged 82.66 points; DASH score averaged 15.27 points. Four patients had radial nerve neurapraxia (23.5%).

Conclusion: Percutaneous osteosynthesis with plates using a lateral minimally invasive approach has proven effective for the treatment of humeral shaft fractures, applying the principle of bridge plate. It is a biological procedure, technically demanding, and not exempt of complications.

Ana Carreño Delgado 1, Francisca Pacheco Donoso 2, Marco Antonio Ardilla Ramirez 3

1 Hospital Clínic Universitari. Universidad de Barcelona, Spain; Institut Kaplan Barcelona, Spainrn2 Hospital Base San Jose de Osorno, Chilern3 Clinica Orthohand, Bogota, Colombia

Fractures of the Volar pole of the lunate in the face of a perilunate injury are rare injures result of high-energy trauma often go unrecognised in the emergency department. Aim of this study was to evaluate the clinical and radiological outcome of three patients treated of this recently described translunate arc injury and to compare the results to other cases published in the literature.
Two 25 yo and one 27 years old manual workers were visited at our emergency departments after a motorcycle accident in two cases and mountain accident in the last case. They presented severe wrist swelling and pain. Plain X-Ray demonstrate a trans-scaphoid perilunate (Mayfield III) dislocation in two patients and CT scan confirmed a displaced fracture of the volar lip of the lunate more than 90 degrees rotated in two cases and conminute fracture of the volar lip in the other patient. Slight anterior subluxation of the capitate was present in the patient withouth x-ray evidence of complete dislocation. Conminuted fracture of the proximal pole of the scaphoid and Distal radius fracture were associated in two cases.
A combined approach was used in two cases: Scaphoid fractures were fixed with headless screws . Volar lunate fractures with its radiolunate ligamentous attachments were exposed by an extended carpal tunel approach. Fixation of the volar lunate fracture was done through 2 transosseus tunnels from an 2,8 mm anchor suture. The third case wich was diagnosed as distal radius fracture had percutaneous K wire fixation of the distal radius fracture 2 weeks after trauma and a proximal row carpectomy performed 6 weeks after that.
After 18 and 24 months, 2 of the patients were pain free and fractures healed with good carpal alignment when fixation had been performed. They returned to previous work and sport activities despite of mild midcarpal degenerative changes. Range of dorsovolar motion was 45º/50º and 50º/50º respectively, pronosupination was complete and Grip was 65% and 75%. The third case who had a proximal row carpectomy was also pain free with a dorsovolar motion of 35°/40°, limited pronosupination and grip strenght of 50% 18 months after the procedure. Average PRWE for the patients was 22/29/40.
Less than 40 cases had been reported since 1976. In several cases diagnostic was delayed and a salvage procedure was performed. Internal fixation of the lunate is recommended first, followed by the other fractures and ligaments treatment. Lunate necrosis and chronic volar subluxation of the capitate and midcarpal arthritis had been reported.
-Displaced lunate fractures in the face of perilunate injuries (translunate arc injuries) require reduction and stable lunate fixation.
Simple x-ray frequently fail to visualize, or underestimate the size or displacement of fracture fragments, CT is recommended.
-Volar lip of the lunate can be dificult to fix. We used suture Anchors to reattach the bony fragment with its radiolunate ligaments to the remaining lunate achieving good results.

Mi Jing-Yi, Rui Yong-Jun

Department of Hand Surgery, Wuxi 9th People's Hospital, Soochow University, Wuxi, Jiangsu 214062 China

Objective To discuss the indication, surgical technique and rehabilitation of upper arm replantation by a retrospective study. Methods Twenty-two cases ( 2004-2012 ) of upper arm replantation were studied. The average age was 33.3 years old. In all patients, 81.8% were of rotation-twist-avulsion injury, and others were of crush-cut, wheel rolling or heavy crush injuries. The average MESS score was 7.5 points: 13 cases were 7, 7 cases were 8, 1 case was 9 and 1 case was 10. Ischemia time was 5-10 hours ( average: 8.1 hours ). Warm ischemia time was 4-7 hours ( average: 6.2 hours ). Different rehabilitation was performed at early, middle and late stage. Results Two patients were amputated at 5th and 10th day postoperatively due to muscle necrosis, severe infection or vessel ruptures. Twenty upper limbs survived. Seventeen patients were followed up from 3-10 years ( average: 4.2 years ). The average DASH scores was 58.35±19.42 in 17 patients. According to Chen Zhong-wei’s criteria for limb replantation: 70.6% good, 29.4% fair, neither excellent nor poor. 64.7% patients satisfied with results or accepted the appearance of limb and 47.1% satisfied or accepted the function recovery. Conclusions Except for general surgical indications, revascularized time should be limited within 9 hours. The median nerve and radial nerve should be functionally repaired. Soft tissue defect should be early covered with cutaneous flap or muscle flap to protect nerve and vessel bundles, providing a basis for further function recovery. Long-term encouragement and guidance guarantee functional, psychological and social recovery of patients.

Kleber Elias Tavares, Andre Martinez Amorim Prosdocimi, Marcos Vinicius Mourao Mafra, Deleon Jose Vilaca, Patricia Semino Tavares

Hospital Semper, Belo Horizonte, Brazil

Purpose: Minimize the atrophy and function loss of the intrinsic muscles innervated by the ulnar as much as possible and minimize sensibility loss and cutaneous atrophy of “V” finger.

Material: 28 years old patient, undertaker, motorcycle accident with total loss of all muscular mass in the forearm and extrinsic tendons of the wrist, fingers and thumb and 20 cm of the ulnar, from the elbow up until the wrist.

Actually he presents 3 years and 7 months of evolution.

1) Curative and partial skin graft from the thigh after granulation of the exposed tissue in all medial border of the forearm (photos).
2) Identified the recurrent branch of the median tissue and sutured on the motor branch (deep) of the ulnar in the palmar region (photos).
3) Transference of the own proprius extensor index finger to opponensplasty (video).
4) Transference of the vascularized digital nerve on the ulnar side of the “III” finger to the ulnar side of the “V” finger.
5) Tenodesis of the deep flexors of the fingers and thumb on the 1/3 radius distal.

1) Interosseal muscle recovery of the ulnar nerve with M4/M5 strength capability of adduction and abduction of the fingers, except from the moderate paw of the “V” finger, but preserving the muscle trophy of the intrinsic muscle (video).
2) Recovery of antepulsion and opposition of thumb with excellent extent and lateral and palmar contact with the tip of all fingers (video) and also complete antepulsion (video).
3) Moderate recovery of touchable sensibility of the “V” finger, although with moderate atrophy of the digital pulp and double sensibility of “III” and “V” fingers (video).
4) Capacity of grasp of up to 4kg and driving and writing capacity with very good hability (video).

Conclusion: In the absence of the possibility of using the anterior interosseal nerve because of trauma´s consequence, the recurrent branch of median to deep ulnar nerve transfer can achieve very good functional results. The tenar motor median nerve is thicker and carries more nervous fibers than the anterior interosseal nerve and the deep ulnar nerve and this can be an reason for the results achieved.

Michael Chu-Kay Mak, Pak-Cheong Ho

Department of Orthopaedics and Traumatology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong

The open four-corner fusion is a conventional motion preserving salvage procedure to provide pain relief for post-traumatic arthritic wrist conditions such as SLAC or SNAC. The nonunion rate varied in the range of 0-26%. Capitolunate fusion is an alternative that theoretically may preserve more motion. However a higher nonunion rate (of up to 33%) has been a concern. An all-arthroscopic method to achieve limited carpal fusion involves less soft tissue dissection and may improve union rate and result in better preservation of motion.

A review of the arthroscopic four-corner and capitolunate fusions in our centre in 15 years (2000 to 2014) was performed. A totally arthroscopic technique is described. Autologous cancellous bone graft was used in 6 cases. Headless compression screws were used in 11 cases and K-wires in 1 case. Range of motion, functional assessment based on 10 common standardized tasks of daily living, pain assessment based on a 3-point pain scale when performing those tasks, and grip power were assessed by an occupational therapist before and after the surgery.

Follow up duration was from 8 months to 6 years and 2 months. Fusion was achieved in 11 out of 12 wrists (92%). The non-union occurred in the only case with K-wire fixation. Nonetheless, a stable and painless fibrous nonunion was achieved and no revision was required. There was an improvement in the wrist function scoring system in 11 out of 12 wrists with a static score in one, with an overall significant improvement (p=0.005). In the pain assessment there was improvement in 11 out of 12 wrists on the final follow up with an overall significant improvement (p=0.01). One patient had deterioration in pain due to ulnar impaction syndrome causing ulnar wrist pain. One patient required total wrist fusion due to incomplete pain relief. The mean residual flexion/ extension arc was 88% of the pre-operative range. There was no significant difference between the four-corner fusion and capitolunate fusion groups in terms of range of motion, function or pain scores. All patients could return to their prior occupations within a mean duration of 9 months.

With an all-arthroscopic technique and the use of headless compression screws, a high fusion rate could be achieved, even without the need for bone grafting. A functional range of motion, adequate pain relief and restoration of functional performance could be obtained with this minimally invasive approach.

Filipa Santos Silva, Carolina Baptista, Ana Marta Coelho, Luís Barbosa

Hospital Beatriz Ângelo, Loures, Portugal

The arthroscopic approach for scaphoid non-union osteossynthesis with a percutaneous screw and trabecular bone graft interposition is a technique with increasing use in selected patients. The advantage of the percutaneous technique lies with the preservation of the non-injured ligaments and scaphoid vascularization. The purpose of this paper is to review 18 cases of schaphoid non-union treated arthroscopically with percutaneous interposition of trabecular bone graft and osteossynthesis with a compressive cannulated retrograde screw, presenting the surgical technique we used.

Materials and Methods
Between March 2013 and November 2015, we surgically treated 18 patients with scaphoid non-union, 17 men and 1 woman, with an average age of 25 years old. We performed osteossynthesis with arthroscopic interpostition of trabecular bone graft. The dominant hand was involved in 9 patients. The mechanism of lesion was fall in an outstretched hand in every patient. Fourteen patients presented a fracture of the middle third and 4 of the proximal third of the scaphoid. In the post-operative period, we evaluated frequency of wrist pain (using the visual analogue pain scale), radio-carpal joint mobility, grip strenght, and functional results with the Quick Disabilities of the Arm, Shoulder and Hand (Quick DASH) score. Scaphoid X-rays were evaluated for bone healing or graft resorption. Return to work and personal satisfaction were also evaluated.

The average follow-up was 16,37 months. The mobility arch of the radio-carpal join was 130º. Comparing with the contralateral hand, the mean force for grip strenght measured with the dynamometer was 88,95% (between 62 and 100%). We had one case of screw misplacement with insufficient repositioning of the scaphoid, which led to persistent pain. We surgically corrected the defect with tricortical bone graft and re-osteosynthesis. The subjective evaluation of pain based on the analogue visual scale had a mean value of 0.6 for pain in the radio-carpal joint. Patients were satisfied with the result. They were all employed at the time of injury and returned to work in an average of 60 days. We found dorsal intercalated segmental instability (DISI) in 1 patient.

Wrist arthroscopy appears to be a powerful and versatile tool in the treatment of wrist pathology and has shown promising results in the treatment of scaphoid complex fractures and non-unions. We can confirm its security and facilitated recovery in the post-operative period, as well as patient satisfaction, which corroborate the results published in many large series. The minimally invasive techniques avoid the complications related to open surgery as soft tissue lesion, and allowed for an early wrist and hand function recovery in our sample. However, larger series would be necessary for evaluation of results regarding fracture healing in arthroscopic treatment versus open surgery.

Fouzia Choukairi, Obi Onyekwelu, Anuj Mishra

Wythenshawe Hospital, Manchester, UK


Nerve repair and complex nerve injuries (e.g. brachial plexus) is now a specialist field, but all surgeons involved in trauma surgery must be able to diagnose nerve injuries and identify those that need referral to a specialist. The British Orthopaedic Association published the standards for trauma in September 2012. Despite the guidelines, we still find cases when these guidelines are not followed through. We conducted surveys among plastic and orthopedic trainees to evaluate the awareness and also to disseminate these audit standards.
We present a series of cases to highlight how these guidelines can be easily not adhered to. These cases are good learning examples on how to manage these nerve cases more effectively.

Over the course of 18 months, from August 2014 2012 to Jan 2016, 15 patients were referred to hand and peripheral nerve clinic in University Hospital of South Manchester. Data was collected and analysed retrospectively from operation notes and anaesthesia records. It included 5 paediatric cases and 10 adult nerve injury cases.


The age range of the patients varied from 7 months to 65 years. There were 11 male and 4 female patients. The time to referral varied from 2 days to 6 months. In paediatric cases, this was mainly following supracondylar fractures and exploration in infected wounds. There were 3 cases of radial nerve injury, 4 cases of posterior interosseous nerve, 2 of median nerve and 3 of ulnar nerve and two cases of musculocutaneous nerve and one of the medial cord and posterior cord injuries.


When faced with a patient with persistent peripheral neurological deficits, it is wise to suspect and eliminate the possibility of an axonal injury. On assessment of an acute presentation, axonotmesis can be detected with the following signs:
1. Pain in the distribution of the nerve that is severe and constant
2. Positive Tinel’s sign
3. Autonomic changes in the soft tissue, including sudomotor and vasomotor function loss. This refers to vasodilation, loss of sweating in the distribution of the nerve
This knowledge allows for a more prompt referral to be made to the hand clinic for earlier intervention and better prognosis. In our two surveys of trainees, none of the trainees were aware of the BOA standards. 60% were aware of the local referral pathways for these injuries. Clinical assessment skills were poor, but there was a trend towards higher standards with senior trainees. Trainee performance improved significantly with directed teaching on peripheral nerve injuries. We subsequently disseminated these standards to the trainees.

Improving standards in peripheral nerve surgery requires an enhanced uptake of national best practice guidance and targeted training in the management of peripheral nerve injuries.


Understanding the pathophysiology, signs and symptoms of peripheral nerve injuries is essential for increasing the rate of identification of such injuries. Shortening the delay between peripheral nerve injury, diagnosis and intervention will greatly improve the prognosis and outcome of these injuries.

Fouzia Choukairi, Wee Sim, Anuj Mishra

Wythenshawe Hospital, Manchester, UK

Carpal tunnel syndrome is the most common
peripheral compression neuropathy. Anatomic variations may be
encountered during carpal tunnel surgery. Variations have included aberrations of the median nerve itself and its branches, anomalies of muscles and tendons, and persistance of the median artery. Anatomic variations are of interest to both anatomists and surgeons alike. Some of the anatomic variations may be the cause of dynamic carpal tunnel syndrome. We present an unusual case of triggering in the carpal tunnel accompanied with pins and needles in the median nerve distribution whenever the patient made a fist.
Case report-
A 31-year old right hand dominant male presented to our hand surgery service with a clicking sensation in his dominant wrist upon making a full fist. This was accompanied by paraesthesia along the median nerve distribution in the hand. He sustained a fall two months prior to the initial onset of symptoms with no bony or soft tissue injury. He is otherwise fit and well.
Nerve conduction studies were normal. An ultrasound of the wrist revealed a hypoechoic mass measuring 10 mm x 8 mm which enters the carpal tunnel and impinges upon a bifid median nerve on full finger flexion. The mass appeared to increase in prominence on full flexion. Dynamic magnetic resonance imaging was normal on T1, T2 and STIR sequence.
Intraoperative finding showed increased amount tenosynovitis in the carpal tunnel which presented as a boggy swelling just proximal to the carpal tunnel. After debriding the tenosynovitis, the underlying cause was found to a very proximal lumbrical which was compressing the median nerve and leading to tenosynovitis. The proximal origin of the lumbrical was released and the patient made full recovery with no residual clicking or nerve symptoms post operatively.
We conducted a review of historical and recent literature on muscle anomalies as the cause of carpal tunnel syndrome. We present our intraoperative findings and histopathological results of this interesting case of dynamic carpal tunnel syndrome.

Andreas Gohritz 1 2, Dirk J. Schaefer 1, A. Lee Dellon 3

1 Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, Basel University, Switzerland, 2 Hand Surgery, Swiss Paraplegia Center, Nottwil, Switzerland, 3 Dellon Institutes, Towson and Johns Hopkins University, Baltimore, USA

Objective: Nerve transfers have been rediscovered since the 1990s and improved outcomes in complex peripheral nerve injuries, e.g. of the brachial plexus, yet little is known about pioneering work in the early 20th century.
This paper is dedicated to widely unknown German anatomist and orthopaedic surgeon Adolf Stoffel (1880-1937) who pioneered selective nerve fascicle transfers since 1910.

Methods: His work is reviewed based on historical articles, book chapters and parts of his estate.

Results: Stoffel lived all his life in the region around Heidelberg, Germany. Based on his cross-sectional studies, Stoffel recognized that nerve are not “cordlike struktures as tendons”, but consist of functionally diverse motor and sensory fascicles. Consequently, he inaugurated selective neurotomy operation used in spastic extremities (Stoffel operation) and devised multiple selective nerve transfer in the upper and lower extremities, e.g. transfer of radial nerve fascicles to the long or medial triceps head in axillary nerve palsy. Notably, Stoffel utilized intraoperative electrical nerve stimulation to identify dispensible donor fascicles at the level of the recipient nerve damage or below. He co-authored a book on “Orthopaedic Operations” with Vulpius (3 editions 1913, 1920 and 1924) which presented a variety of tendon transfers used until today, e.g. brachioradialis-to-wrist extensors and many innovative nerve transfers. He also transferred redundant radial nerve fascicles to restore the paralyzed musculocutaneous nerve or median nerve or used transfers of the subscapularis nerve (branch to teres major) to the axillary nerve and transfer of median nerve fascicles to restore intrinsic ulnar nerve function.

Conclusion: In summary, Adolf Stoffel appears as eminent protagonist of peripheral nerve anatomy, selective neurotomy and above all nerve transfers whose work and ideas deserve a thorough reconsideration.

Kleber Elias Tavares, Andre Martinez Amorim Prosdocimi, Deleon Jose Vilaca, Luciano Ramalho Alves Correa, Patricia Semino Tavares

Hospital Semper, Belo Horizonte, Brazil

Purpose: Demonstrate a new clinical diagnosis test of intrinsic motor paralysis on the ulnar nerve, by compression of the ulnar nerve at any level.

Material: Nine patients with complete ulnar nerve lesion isolated at the wrist level, with 4 years and 6 months of follow up, with average age of 24.2 years.

Material: Fifteen patients with static or dynamic compression of the ulnar nerve in the cervical thoracic outlet (3 cases) and in the elbow (12 cases).


GROUP “I”: Motor strength evaluation from M0 to M5 of each intrinsic ulnar muscle (interosseous, dorsals, palmars and hipotênar musculature), except lumbricals “IV” and “V”.
GROUP “II”: Adduction strength evaluation of the “III” palmar interosseous at dynamic compression (5 cases) in stress and relaxed positions of the nerve (video) and in the cases that the compression was not dynamic, that is, static (7 cases), before the immediate pre-operation procedures and in the first day after (video).


GROUP “I” Final results Surgical treatment
Abductor “V” finger M5 60%
M4 20%
M3 20%
“III” Palmar interosseous M5 15,38% M2 0%
M4 7,68% M1 7,68%
M3 15,38% M0 53,8%
The other dorsal and palmar interosseous muscles had a much higher strength recovery than the “III” palmar interosseous.

The patients with dynamic compression (video) presented inability to adduce the “V” finger completely, with a maximum strength M3 and in the relaxed condition of the ulnar nerve recovered strenght M5 and the patients operated of ulnar nerve compression on the elbow, presented strength M3 or M4 before the surgery and M5 immediately after it (video).

In group “I” it was characterized an inferior recovery of motor strength of “III” palmar interosseous compared to the muscles with distal innervation at its specific ramification. This fact can be attributed to the fact that its muscular mass is the smallest among intrinsic muscles the reason oh the of adduction of “V” finger.
Regarding group “II”, the fact that the dynamic compression causes inability to adduce the “V” finger completely and immediately after the removal of the stress the “III” palmar interosseous recovers strength M5, supports the validation of the test to precociously early transitory motor funcional loss of the ulnar nerve.
In the cirurgical cases, the decompression recovers the adduction strength of “V” finger immediately after the surgery, just the same.

Kleber Elias Tavares, Andre Martinez Amorim Prosdocimi, Deleon Jose Vilaca, Luciano Ramalho Alves Correa, Patricia Semino Tavares

Hospital Semper, Belo Horizonte, Brazil

Purpose: Proceed a resection with free margin, preserving digital pulp, appropriate osseous support and extensor function of the interphalangeal articulation of the thumb.

Material: Patient C.R.V., 82 years old, professionally active, real estate agent, normal cognition, showed up at about one year with a subungual lesion simulating a mycosis, treated with one year of evolution and progression of the lesion according to patient´s report. Biopsy and anatomopathological diagnosis revealed a subungual squamous cells carcinoma. X-rays and tomographies of distal phalanx demonstrated no osseous invasion by the lesion.

Procedures: Considering that there is no safe cleavage plan with free margin between the nail bed and the osseous dorsal cortical of the distal phalanx and that the nail bed is 1 to 3 mm distant from the extensor tendon insertion.
1) Desinsertion of the extensor tendon at 3mm from its insertion and resection of the dorsal cortical from the distal phalanx in shaped of bayonet, including an insertion of the extensor tendon, osteotomy of the distal phalanx between its two corticals (anterior and posterior) in longitudinal direction, observing therefore a complete resection of ungual matrix and nail bed with free margin.
2) Reinsertion of extensor tendon with coverage of the bloody area with a flag flap of “II” finger back, grafted with skin from the flexor crease of the elbow. In 15 days the flap was released.

Results: Skin consolidation of the flap with very good esthetic look, preserving total function of the digital pulp and complete interphalangeal flex extension.
The anatomopathological examination showed free margins.
Patient is actually with 3 years and 2 months of evolution with no intercurrence.

Conclusion: This method offers the possibility of substitution of the known intervention technics described exclusively on the ungual bed without free margins guarantee, avoids amputation if the tumor is limited to the nail bed or matrix and provides the opportunity of functional preservation of the distal tip of the thumb.

Slavica Bajuk, Jaka Borišek, Mira Barič, Barbara Osolnik, Helena Jamnik

Institute for Rehabilitation, Ljubljana, Slovenia

The incidence of partial hand amputation is 3 to 6 times higher in men than in women. The purpose of this paper is to show the rehabilitation of a 26 year old male patient after injury of the left upper extremity.

A 26 year old male suffered partial hand amputation after an explosion in June 2015. There was minor damage to the thumb, exarticulation of the first finger, fracture of the proximal phalanx of the second finger, third finger amputated due to fracture of the proximal phalanx, and fourth finger amputated due to fracture of phalanx. He suffered multifaceted damage to the medianus, ulnaris and radialis nerves. He also suffered a blow to the chest, right thigh, and left shoulder. There was neuropathic pain after nerve injury and phantom pain which was the worst in the region of the third and fourth fingers. Muscle testing, range of motion, pain assessment using the VAS scale, limb circumference, and sensitivity were evaluated to assess the functional status. The therapy program included individual therapy, joint mobilization to increase mobility, mirror therapy, transcutaneous electrical nerve stimulation, massage to reduce scar tissue, desensitization, and occupational therapy. An elastic splint was made to improve opposition.

The patient cooperated well, was motivated and was precise. Muscle test results for left upper extremity before/after treatment: Shoulder girdle muscles 5/5; Elbow flexors 4/5, extensors 5/5, supinator 4/5, pronators 5/5; Wrist flexors 4/5, extensors -4/5; Thumb flexors 3/4, extensors -4/5, adductor 0/-3, abductor 0/4, opponens pollicis 0/0. Finger flexors lumbricals 1/-3; Second finger digitorum sublimis -3/-4, digitorum profundus -3/-4; Second, third, and fourth fingers extensors 0/-4, interossei dorsal and volares 0/0; Range of motion for left upper extremity before/after treatment: Shoulder anteflexion 150°/165°, retroflection 60°/60°, abduction 110°/135°, external rotation 60°/80°, internal rotation 60°/80°; Elbow flexion 10°-135°/5°-135°, pronation 65°/80°, supination 50°/75°; Wrist dorsiflexion 40°/60°, volar flexion 45°/60°, radial deviation 10°/15°, ulnar deviation 35°/35°; Thumb flexion in the CMC joint 35°/45°, IP joint 60°/75°; Fingers MCP II 5°/40°, MCP III 10°/35°, MCP IV 10°/60°, PIP II 20°-30°/30°-75°, DIP II 50°-55°/20°-50°. During treatment pain decreased from 7 to 4 according to the VAS scale. At the beginning of treatment he could not touch thumb to middle finger, and the end he could. Sensitivity did not change in three weeks.

The patient was extremely motivated and after three weeks acquired joint mobility, muscle strength, improved hand functionality, softened and more elastic scar tissue, reduced pain, and improved over all physical condition.

KEYWORDS: partial amputation of fingers , rehabilitation , evaluation.

Max Gehrman, Jon Tueting, Jake Levin, Ken Noonan, Joseph Towles

University of Wisconsin, Madison, United States of America

Correction of the adducted thumb in children with cerebral palsy can include rerouting the extensor pollicis longus (EPL) tendon radially from the third compartment such that it would abduct the thumb. Different methods exist for rerouting EPL, yet it is unclear which technique provides maximal thumb abduction. The goal of this study was to investigate in-situ, with three popular techniques to determine the effectiveness of each for thumb abduction.
METHODS:Fresh-frozen cadaveric specimens were thawed and dissected to expose the tendon of EPL. Each specimen was mounted using a fixation device. A motion-tracking system was used to quantify thumb abduction. Maximal tendon excursion and the force resulting in maximal thumb extension was measured and named in situ excursion and in situ force, respectively. The EPL tendon was then removed from its normal anatomic position and rerouted such that: (1) stabilized by a retinaculum flap; (2) directed into the 1st compartment; (3) and rerouted around the APL insertion into the 1st dorsal compartment. For each technique, the EPL tendon was pulled such that its excursion matched that of the in-situ and then to match the in situ force. Average radial, palmar and combined abduction of the thumb were determined. The analysis of variance and post-hoc t-tests were performed to compare thumb abduction of the three methods to the in situ case.
RESULTS: Rerouting the EPL around the APL resulted in the largest, significant (p<0.05) change in thumb abduction with an increase in radial abduction from 8° to 16° relative to the in-situ case. Palmar and combined abduction were significantly (p<0.05) increased with 2° and 6°, respectively. Routing the EPL through the first compartment resulted in a significant increase from in situ in both palmer and combined abduction of 2° and 6°, respectively. Rerouting the EPL through the retinaculum resulted in a significant increase in combined abduction of 4°. When loaded to the in situ force, all three reroutes resulted in an increase of abduction distance. The EPL reroute around the APL resulted in the largest, significant increase in thumb abduction for radial, palmer, and combined of 8° to 17° (p<0.05), 34° to 36° (p<0.01), and 20° to 33° (p<0.01), respectively.
Rerouting the EPL through the 1st compartment resulted in a significant increase from in situ for both palmer and combined abduction, 34° to 35° (p<0.05) and 21° to 27° (p<0.01) respectively. The retinaculum stabilized EPL had a significant (p<0.05) increase in palmer (34° to 36°) and combined (21° to 28°) abduction.
CONCLUSIONS: All tested techniques for rerouting EPL improved thumb abduction in situ. The APL reroute resulted in the largest increases in the 3 measured angles of abduction. There is also a significant difference between the in situ excursion and force suggesting that shortening the EPL intra-op would be of benefit and reduce the redundancy occasionally seen after reroute. Retinaculum flaps do not require EPL transection and repair. A potential advantage with this technique is a shorter operative time and potential disadvantage is no long-term follow-up measuring stability of created retinaculum.

Mario Rodriguez Sammartino, Diana Alvarez, Ana Valle, Paula Frrontini, Juan Martin Rodriguez Sammartino

Clínica de Fracturas y ortopedia, Mar del Plata, Argentina

Objectives: Accidents caused by power take-off shaft to produce different types of injuries. Injuries can range from simple skin abrasion to amputation or sometimes fatal or serious damage to physical integrity. We present a series of injuries treated in our institution since 1997 in order to analyze the circumstances of these accidents and their pathophysiological mechanisms as well as the most appropriate treatment and prevention from the area of Occupational Therapy. The mechanism of the PTO shaft with a few key aspects to better understand the potential health hazard was also analyzed.
Material and Methods: Ten victims of power- take- off accidents have been received at our institution since 1997. All were men aged 26-66 years. In all cases except one, a cord caught on the turning shaft was the cause of the accident. Eight of the patients had upper extremity injuries of varying severity.
Results: The results after treatment depend on several factors: the severity of the injury, the circumstances of the accident and proximity to a health care center. In general, the consequences were worse for serious injuries which produced permanent disability. A significant decrease of these lesions in response to the implementation of preventive actions based on the analysis of the job from Occupational Therapy is expected.
Conclusion: The power take-off of the tractor which transmits power to agricultural machines through an axis of rotation can cause serious injury, disability or death as a result of inadequate protection measures or insufficient knowledge about its proper use. Promotion of various security measures and constant communication between company and worker and specialized health care services are required. Occupational Therapy should be included in this course of action.

Flavio Telis, Nelson Ponzo, Luis Francescoli

Clinic of Orthopedics and Traumatology . Institute of Orthopedics and Traumatology . School of Medicine. Montevideo. Uruguay.

Introduction: Treatment for comminuted fractures of the radial head and neck is still discussed, there are different treatment options such as: resection, osteosynthesis or radial head prosthesis.

Objective: To evaluate the functional results by the score: Broberg and Morrey, DASH and MEPI, for treatment by osteosynthesis "on table" for type III and IV Mason fractures. This surgical technique is intended to maintain the radial head, in which the reconstruction of the fracture is performed on the operating table and then proceeds to the positioning and fixing of the radial neck.

Material and Methods: 8 patients were operated between the period March 2011 to June 2012 6 patients female and 2 male, with an average age of 36.6 (range 24-54) and mean follow-up 23,25 months (range 19- 36 months).

Results: We obtained the consolidation of the fracture in 7 cases, while in the remaining patient evolved with nonunion of the radial head. Functional results according to MEPI were excellent in five cases and good in three; with an average score of 94.5 (80-100). The average score Broberg and Morrey according to functional rating index was 88.6 (65-100) with four excellent, three good and one regularly. The average DASH score was 7.5 (0 to 13.8) (0 = no disability scale 100 = severe disability)

Conclusions : In complex fractures of the radial head and neck, which would be indicated resection, reconstruction 'on table' is a good alternative in the treatment .

Ignacio J. Guillen1,2, Lionel Perez Menvielle 1,2, Agustin N Arrieta1,2, Roberto M Berro Elizalde 1,2, Diego M Paleo 1

1 HIGA San Martin La Plata, Buenos Aires, Argentina; 2 Instituto Medico Platense, La Plata, Buenos Aires, Argentina

Objective / Hypothesis
Case report. Description of treatment and its evolution.
Isolated fractures of the greater tuberosity are rare and mostly (75%), respond favorably to orthopedic treatment.
Correspond to a type 11-A1.2 classification of the AO.
In young patients the surgical indication is reserved to fractures with more than 2 mm of displacement.
One of the complications of bloodless treatment is nonunion, with the consequent functional limitation.

Methods and materials
Male 28 years old patient who consults for pain and functional limitation of his right shoulder. He refers humeral greater tuberosity fracture of 3 months of evolution treated with immobilization, without improvement after 20 sessions of rehabilitation. No Rx signs of consolidation. It was decided to perform open reduction and osteosynthesis with tension band harpoons.
Surgical technique: Patient on beach chair, anterolateral approach. The fracture is identified, fibrosis is excised, and cruent of the surfaces is performed. The fracture is reduced. 2 harpoons are placed in the fracture and the proximal fragment is tunneled. Both sutures are knotted on the rotator cuff. A 3.5 mm cortical screw is used as post. A loop is performed in "8” thereabout the screw, conforming the tension band.

Early mobilization by passive and active mobility from the third week results as complete joint mobility without pain. The patient had returned to work after the sixth postoperative week.

Fractures with displaced humeral great tuberosity have a high risk of pseudoarthrosis and functional limitation, so it is suggested the surgical treatment. Harpoons osteosynthesis in tension band is a method that provides satisfactory results, allowing early mobility and rapid reemployment.

Sergio Pino, Joan Enric Borras, Joan Vila, Gisele Cano, Joan Carles Bonilla

Hospital de Terrassa, Barcelona, Spain

Fractures of the distal radius are the most common bony injuries in the upper extremity, and many treatment methods have been described in the literature. External fixation remains a highly versatile method to treat many fracture types involving the distal radius. The primary indications for external fixation include reduction of unstable extra-articular fractures and most intra-articular fractures. The use of adjuvant pinning or mini open procedures can be used when external fixation inadequately reduces the joint line alone, especially with central depressions and highly comminuted injuries. The ease of use of the implants and successful track record make it an extremely versatile tool for treating complex fractures of the distal radius.
Materials and Methods:
We compare a retrospective study about AO type C intra-articular distal radius fractures. The fist group (40 patients) is treated with open reduction and internal fixation with DVR plate and the second group (65 pacients) is treated with external fixation and K-wires and mini-open reduction.
Objective, subjective, and radiographic outcomes were assessed at 2 weeks, 4 to 6 weeks, 10 to 12 weeks, 6 months, and 1- and 2-year intervals. The minimum follow-up period was 6 months; the average follow-up period was 18 months. The principal outcome analyzed was Jakim store that included pain, grip strength, range of motion, complications, and radiographic parameters. The groups were equal with respect to age, gender and fracture subtype.
No significant difference was found in the Jakim store outcome. The volar plate group, howevwe, showed a similar complication rate when compared with the external fixator group. The plate group also had similar levels of pain at 1 year when compared with the external fixator group. The external fixator group showed an average grip strength of 92% compared with the normal side and 86% in the volar plate group.
At midterm analysis the volar plate group showed a significantly higher complication rate compared with the external fixator group; therefore enrollment in the study was terminated. The volar plate group also showed statistically significant higher levels of pain, and weaker grip strength. Based on these results we can recommend the use of volar plates in treating complex intraarticular fractures of the distal radius.

Vicenç Punsola-Izard, Elena Ozaes-Lara, Claudia Peris-Fonte, Laia Pallejà-DeMingo, Carmen Valero.

Hand Therapy Barcelona, Escola Universitaria de Infermeria i fisioterapia Gimbernat , Universitat autónoma de Barcelona

Objective / Hypothesis
A distal radius fracture is an extremely common injury. Rehabilitation treatment used depends on many factors including the type of conservative or surgical treatment and the type of surgical technique applied. This type of procedure will outline the temporal organization of treatment, but in no case will it indicate the techniques to be used, the rehabilitation treatment or the structures to which it is oriented. The aim of this work is to determine which structures are affected by distal radius injuries through a therapy examination. The purpose of this work is to guide treatment in a simpler way by choosing the most appropriate techniques and focused on the structures whose normal mechanics needs to be restored.
Materials and methods
68 patients with distal radius fracture have been evaluated and treated at our centre between 2007 and 2014. All of them have been examined by our team and limitations detected have been recorded and photographed when they were very evident; this has allowed us to obtain the list structures and more evident alterations in each one.

More than 50 different limitations and alterations have been detected in these patients. The most frequently detected alterations were joint stiffness due to localized shrinkage in the wrist, and secondly, tendon adhesions affecting the various tendon groups crossing the wrist and finally, remote structures affected as a result of dystrophic responses and compatible with different degrees of complex regional pain syndromes
Knowing more precisely what elements are affected in each injury allows us to more easily choose the appropriate techniques to be used on structures with altered pathomechanics. This may facilitate treatment of this type of pathology.

Vicenç Punsola-Izard, Elena Ozaes-Lara, Claudia Peris-Fonte, Laia Pallejà-DeMingo, Carmen Valero

Hand Therapy Barcelona. Hand Therapy Barcelona, Escola Universitaria de Infermeria i fisioterapia Gimbernat , Universitat autónoma de Barcelona

Objective / Hypothesis
Proximal interphalangeal (PIP) joint stiffness is a frequent complication and is difficult to solve. The only approach proven to be effective is the TERT approach (Total End Range Time) which was first described in 1994. The clinical practice of this approach has not changed since then, and in practice it has been impossible to improve on 12 TERT hours a day because of patient pain and discomfort. Our goal in this study is to achieve a method whereby the TERT may be extended to 24 hours a day. Our hypothesis is that an extended TERT will reduce the required duration of the treatment.
Materials and Methods
Dynamic digital neoprene orthosis has been used to evaluate its effectiveness in the treatment of 10 PIP of 8 patients that suffered from flexion contracture. Only the intervention group was analysed. All the patients used a DDNO fitted according to their needs and changed once per week if the flexion contracture was modified. All patients were asked to use the splints for the whole day.
In our group of patients a mean of 21 TERT hours a day was reached and a mean improvement of 22.9º was achieved over a period of 3 weeks.
These data improve the results found until now in the literature and confirm that by extending TERT hours per day, PIP flexion contracture can be improved.

Vicenç Punsola-Izard, Elena Ozaes-Lara, Claudia Peris-Fonte, Laia Pallejà-DeMingo, Carmen Valero

Hand Therapy Barcelona. Hand Therapy Barcelona, Escola Universitaria de Infermeria i fisioterapia Gimbernat , Universitat autónoma de Barcelona

Objective / Hypothesis
Hand injuries require specialized rehabilitation and high exercise frequency to achieve the goals of recovery. The difficulty in obtaining access to specialized rehabilitation treatment and combining it with daily living activities and working life are obstacles to treatment follow-up. In turn, this type of injury also involves a lot of indirect costs that hinder its economic management.
The use of new technologies has improved contact between the therapist and the patient through videoconferencing and smartphone applications that bring patient and treatment together. Some aspects such as physically assisting patients with their exercises have not yet been resolved with new technologies and this is the aim of our work.
Materials and methods
We have created an exercise table that allows high-precision customized exercises enabling regulation of the direction and intensity of the techniques with great reliability. Thanks to a system of webcams that give an image from a zenith plane plus an integrated code system in the exercise table, the monitoring and recording of the session is possible. This system has been implemented live for hundreds of patients and has been applied in more than 20 patients for remote treatment.
The system presented has generated various benefits: first, it has facilitated control of the sessions that have been recorded automatically generating a PDF document with the complete record of the session. Secondly, it has generated savings in overhead as the patient is able to work from home and does not need to travel to each session. Third, it has generated savings in the number of sessions because sessions are recorded, allowing the patient to repeat the treatment session without the presence of the therapist, except in control sessions for the purpose of modifying treatment. Fourth, patient loyalty is enhanced with treatment as they are able to carry it out more often and at a more convenient time thanks to pre-recorded sessions.
The combination of new technologies and the exercise tables described allows a breakthrough in the therapeutic approach for patients with hand injury as it brings hand therapy closer to the patient. The distance as an obstacle to access a specialist is removed and there are great savings in the care process without this implying a reduction in the quality of care

Mohammad Nassimizadeh, Bafiq Nizar, Deepak Samson, Ahmed Abbas, Colin Shirley, Dominic Power

The Centre for Nerve Injury and Paralysis, Birmingham Hand Centre, UK

ObjectivesrnrnFollowing tetraplegic spinal cord injury upper limb function may be improved by selective use of peripheral nerve transfers in isolation or in combination with tendon transfers. Early surgery is essential for nerves originating in the injured spinal cord segments due to Wallerian degeneration. Motor nerves arising from the infra-lesional segment of the injured spinal cord will have an intact peripheral neural pathway and nerve transfer may be undertaken beyond 12 months. This study evaluates the role of electromyography in planning and timing reconstruction.
A consecutive series of 8 patients referred for consideration of nerve transfer surgery for restoration of upper limb function following tetraplegic spinal cord injury were evaluated with electromyography to establish volitional control, denervation or evidence of reinnervation. For those patients undergoing surgery, further evaluation of intra-operative stimulation thresholds and motor response was recorded using a 4-point scale.

The Birmingham Hand Centre established a service for rehabilitation surgery of the upper limb after cervical spinal cord injury in 2013. Electromyography predicts lower motor unit lesions without reinnnervation and early nerve transfer intervention may be offered to key target muscles in this group. For the C5/6 level tetraplegic with ICHT function at level 0-2 we recommend electromyography of EDC and triceps to establish timing of reconstructive nerve transfers.

Electromyography is an essential component of the pre-operative assessment of patients for nerve transfer reconstruction of the upper limb after spinal cord injury. For the C5/6 level tetraplegic with ICHT function at level 0-2 we recommend early electromyography of EDC and triceps between 3 and 6 months from injury to establish timing of reconstructive nerve transfers.

Elena Ozaes-Lara, Vicenç Punsola-Izard, Claudia Peris-Fonte, Laia Pallejà-DeMingo, Carmen Valero

Hand Therapy Bcn, Barcelona, Spain

Distal radius fractures (DRF) are a common pathological process that represent a 15% out of the total traumatic injuries. Watson-Jones pointed out that a fracture is also a soft tissue injury that happens to involve the bone, so we must keep that in mind because it can influence the final functional result of the hand.
The proposed physiotherapy interventions until today, cover a wide variety of techniques, from passive and active global mobilisations of the wrist and fingers, to reduction oedema techniques and electrotherapy. In fact, there are lots of published studies that are referred to the DRF rehabilitation, but none of the interventions have sufficient evidence to determine the most effective treatment. This could be because the researchers haven´t searched the specific cause of the movement limitation in none of their studies, thus, the treatments can lose efficacy.
The purpose of this study is to plan a physiotherapy protocol to treat the limitation of the wrist flexo-extension movements in the DRF, based on the examination and on the restrictions, so that we can influence in an analytical way the affected structures that provoked the lack of movement.
Methods and Measures
We designed a physiotherapy treatment for the flexo-extension movement according to the found restriction, whether it is for a restriction of the tendon excursion or for a limitation of an articular component.
The results obtained after 3 weeks of the treatment showed a significant increase in the range of motion, a function improvement and finally a slight pain relief.
Analitic treatment of the distal radius fracture can be a good method to improve individual limitations of specific structures and can be helpfull to improve the treatment outcomes.

Jordi Canosa, Ch. Gordo, Carolina López, J. J. Morales

Orthopedic Service, Hospital del Vendrell, Tarragona, Spain Orthopedic Service, Hospital de Reus, Tarragona, Spain

• As is known the complicated osteoporosis fractures it is an important public health problem because of its increasing frequency and associated morbidity involved.
• In general both distal radius fractures (FRD) and the proximal humerus (FHP) usually appear as the first manifestation of a silent osteoporosis.
• Reviewing the history various medical comorbidities (COM), old fractures, ... are recorded.
• We prospectively studied 25 patients diagnosed with FRD and 25 with the diagnosis of FHP treated in our department in the last 24 months.
• The diagnosis was made based on anamnesis, plain radiography in two projections and in the FHP, CT.
• recorded history of old fractures of type OP, medical comorbidities and concomitant chronic medication.
• We excluded patients over 80 years old.
• In approx. 30% of patients in both groups not previously diagnosed or assessed vertebral fractures are detected.
• In 15% of patients in both groups have a history of non-vertebral fractures previous (usually FRD).
• The following comorbidities were recorded in 70% of cases: 1. Diabetes mellitus Hypertension 2. 3. Hypothyroidism. 4. Kidney failure.
• All patients (35) had at least 2 COM 10 had 3 (HTA, DBT, IR) and 5 plaguing 4.
• In 10 patients a history of chronic corticosteroid therapy were recorded.
• We found no significant differences in the mean age of both groups.

• osteoporotic fractures context are included in a profile of patients with multiple comorbidities known and treated.
• Particularly striking is the absence of diagnosis of OP complicated sick with said pathological "constellation".
• It is convenient to "change the paradigm" care and trauma care to move from understanding and comprehensive approach to the problem of the patient.
• This "paradigm shift" should include parallel explanation to the patient in order to get their involvement.
• More studies are needed to define and stratify severity groups covering both the complicated OP as associated medical comorbidities.

Pedro Henrique T. Q. Almeida1, Joy C. MacDermid2, Tatiana Barcelos Pontes1, Clarissa C. dos Santos-Couto-Paz1, João Paulo C. Matheus1

1 University of Brasilia, Brazil; 2 McMaster University, Canada

The thumb is a unique part of the human anatomy, essential for daily living activities. Osteoarthritis of the first carpometacarpal (CMC-OA) joint is one of the most common conditions affecting the mobility and biomechanical stability of the thumb, characterized by pain, movement restriction, reduced grip strength and limited hand function. Among conservative interventions for CMC-OA, orthoses are the first line of non-surgical treatment, with increasing evidence to support its use to reduce pain and improve function among patients. However, although studies have shown its efficacy, few studies compared differences in orthotic models and its impact on upper limb kinematics.
Objectives: To investigate the influence of six different orthoses designed to stabilize the CMC joint on (1) upper-extremity motor performance and (2) hand dexterity.
Methods: Ten healthy, right-handed female university students were recruited as a sample of convenience for an observational, cross-sectional study. We selected six orthotic designs, with different lengths (forearm-based, hand-based and thumb-based), fabrication (custom-made, prefabricated) and materials (thermoplastics, neoprene, cloth). Participants underwent two different tasks: (I) the placing subtest of the Minnesota Manual Dexterity Test (MMDT) and (II) the kinematic analysis of a standardized reaching task involving a single piece of the MMDT. Both tasks were conducted seven times: one without orthotic devices and one with each of the six orthoses selected for this study. The order of the tasks and the order of use of the orthotics were randomly defined by a draw before the beginning of the procedure. Kinematic data was obtained through the Qualisys ProReflex MCU Capture System, with a set of four cameras. Kinematic variables selected were movement velocity, smoothness (measured by acceleration peaks), the range of motion of the shoulder, elbow, wrist and thumb joints and the time necessary to perform the reaching task. Dexterity was measured by the MMDT score. Data were analyzed through a multivariate analysis of variance (MANOVA), with posthoc analysis through a one-way analysis of variance (ANOVA).
Results: All the selected orthotics restricted CMC range of motion during the reaching task, when compared to the control situation, with no differences regarding the design or fabrication material – F(84, 285)= 3.22, p<0.001; Partial Eta Square = 0.46. Forearm-based orthotics presented further restriction of wrist motion, with an increased number of acceleration peaks when compared to other situations. When compared to the control situation, the MMDT scores were significant different (p<0.001) for all but a hand-based, neoprene orthotics, suggesting a negative impact of rigid orthoses on hand dexterity. No differences were observed in the time needed to complete the reaching task and in the maximum hand velocity among the participants.
Conclusion: Results suggest the influence of different orthotic on upper extremity kinematics, with impacts of movement smoothness, range of motion and hand dexterity. Although all orthotics stabilized the CMC joint, the design, fabrication method and material should be considered by professionals enrolled in the rehabilitation of patients with CMC-OA, due to the impact of different orthotics on task performance and hand function.

Claudia Peris-Fonte, Vicenç Punsola-Izard, Elena Ozaes-Lara, Laia Pallejà-DeMingo, Carmen Valero

Hand Therapy Bcn, Barcelona, Spain

Neuromas are axon endings developed because of different kinds of traumatic injuries. Some studies since 1915 (Tinell J) are focused on this treatment. But till 80s there were no more studies talking about conservative management of its treatment. Now we know that vibration can induce symptomatic neuromas relieve. This way, patient doesn’t depend on surgery procedures or medication
The aim of this study was to demonstrate the improvement of neuromas with positive Tingling Sign through vibration treatment. Even with previous surgery.
In 3 clinical cases, vibration was applied to reduce its symptoms. 3 times a week, 10 minutes per neuroma have been the indications to follow. Vibradol® have been used.
Tingling Sign have decreased after weeks of treatment. Positive signs are reduced to negative in the same session. Even though, improvement is maintained till the next session.
Conservative treatment is a good option for treating symptomatic neuromas, not complicated and cheaper than no conservative options. Having Tingling Signs is not always an intrinsic characteristic of neuromas.

Claudia Peris-Fonte, Vicenç Punsola-Izard, Elena Ozaes-Lara, Laia Pallejà-DeMingo, Carmen Valero

Hand Therapy Bcn, Barcelona, Spain

While treating hand disorders, sensory deficits can be found, even painful conditions. When hands are injured, new cognition mechanisms are active. This new learning procedure can establish painful conditions or sensory alterations which difficult patients to develop exercises as usual.
The aim of this study was to correlate upper extremity sensory disorders to concrete cognitive deficits in traumatic patients with painful conditions. These findings will be needed to design an exercise sequence that patient might complete and improve while recovering cognition disorders. This way, sessions will be develop depending cortex organization of learning information.
In 4 traumatic upper extremity patients without nerve lesions diagnosed, cognitive disorders were assessed. The study followed assessment founds to develop individualized hand therapy exercises.
Concrete cognition disorders have been found in these clinical cases, some of them were coinciding in all cases: selective and divided attentions, sequential memory, pondering, information processing, organization, vigilance between others. After a neuropsychological assessment has been possible to develop appropriate exercises taking care of cognitive possibilities of every patient.
All cases present some concrete cognition disorders which do not allow the therapist to develop a standardized treatment, but a standardized assessment, according to the neuropsychology tools. To identify and to understand cognition deficits of the patient, make the therapist able to design a sequence of individualized therapy exercises. More studies relating neuropsychology to hand therapy are needed.

Andreas Gohritz 1 2, Alice Thürlimann 1, Dirk J. Schaefer 1

1 Plastic, Reconstructive and Aesthetic Surgery, Hand Surgery, University Hospital, Basel, Switzerland 2 Swiss Paraplegia Center, Nottwil, Switzerland

Objective: Percutaneous A1 pulley release has become a popular procedure in fingers, yet concerns have been raised over using the technique in trigger thumbs and especially children, e.g. due to the risk of nerve injury.
This meta-analysis investigates evidence of success and complications in percutaneous release of the A1 pulley in trigger thumb in adults and children.

Methods: In a systematic study search, 30 studies including 976 procedures fulfilled the eligibility criteria: 1. target population of adult or paediatric patients treated with percutaneous release of the A1 pulley of the thumb, 2. studies reporting the exact ratio of successes and complications of the procedure, 3. studies about percutaneous release including other digits than the thumb if they specified complication and success rates for thumbs. Cadaveric studies and review articles were excluded.
Statistical analysis included inverse variance method to pool the estimates of studies, the proportions were transformed using logit transformation. Ƭ², a measure of the extent of variation, or heterogeneity, among the intervention effects observed in different studies, was estimated using the DerSimonian-Laird estimator. Confidence intervals for individual studies were estimated using the Clopper-Pearson confidence interval. The two surgical techniques were compared using a χ²–test.

Results: A total number of 909 successes out of 976 percutaneous procedures in adults and children were reported. Success rates reported for single studies ranged between 70% and 100%, whereas no study on paediatric trigger thumb reported a success rate of 100%. The median success rate was 94.9%. The total success rate, pooled using the random-effects model, was 91% (95% confidence interval, 89% to 93%).
Overall only three permanent complications were reported; two digital nerve injuries and one permanent flexion deformity out of 802 performed percutaneous releases in adults and children in studies that reported complication rates. For major complications, rates of 0% up to 2/35 were reported for 2 studies (mean 0.5%). If unsuccessful procedures with persistent triggering were counted as complication, there was a mean complication rate of 7.2% for 21 included studies (median 5.3%). None of the five studies reporting about percutaneous release in paediatric trigger thumb release reported about minor or major complications.

Conclusions: Despite absent direct visual control during percutaneous trigger thumb release, success rates were not decreased or complications increased compared to figures given in the literature about open procedures. Major complications were exceptional. Instrument type did not affect outcomes. In summary, percutaneous A1 pulley release in trigger thumb seems to be a safe procedure in adults and children.

Valeria Borghino, Natalia Gutierrez, Daniel Aramayo, Jorge Pedro, Christian Allende

Instituto Allende de Cirugía Reconstructiva. Sanatorio Allende. Hospital de Niños de la Santísima Trinidad. Córdoba, ARGENTINA

Introduction: An understanding of the epidemiology of congenital anomalies is necessary for health system, to monitor changes over time, to prevent when possible, and to facilitate development of treatment guidelines. Incidence of thumb duplication in upper limb anomalies and epidemiological reports are absent in our country. Aim of this work was to characterize the prevalence of thumb duplication and to assess sex, age and malformation type associations using a hospital- population-based study in our city.
Methods: From 2007 to 2015, a retrospective observational study was performed including patients with thumb duplication diagnosis treated in the Department of Upper Limb Pathology of a referral Children’s Hospital. Patients younger than 15 years old, not previously treated and without associated congenital hand anomalies were included. Wassel classification was used to grade the duplication and to determine the optimal reconstruction technique. Sex, age at surgery time and duplication grade (following Wassel classification) was recorded. Complications after surgery were also included. Thumb duplication prevalence rate in our institution was calculated for epidemiological purposes.
Results: The study included 45 patients with duplicated thumb (17 females, 28 males), being 1 bilateral case (46 hands were surgically treated). No significant differences between sexes were found (p=0,154). Age at the time of surgery was 2,9 years old (range, 4 months to 14 years), no significant differences between ages were found (p=0.660). The average of the follow up was 3,65 years (1-8 years). The most common type was Wassel IV (54.34%), being none Wassel type VI and VII cases reported. For both 2014 and 2015, biannual prevalence rate, calculated using all patients attended in the Orthopaedic Department, was 0, 06%. During the same period, 193 patients were attended in the Upper Limb Congenital Pathology Department, 4% were treated for preaxial polydactyly. 43% of patients were treated after 2 years of age. A second surgery was necessary in 5 patient with late axial deformity.
Conclusion: Considering the importance of thumb in grasping, pinch, and dextrous movements, polydactyly of the thumb is a particularly important congenital anomaly of the hand. Our study showed no differences between sexes and type IV as the most common type following Wassel classification. Regarding the time of the reconstructive process, it should ideally start before the development of prehension (our results show that 43% of the patients surgically treated were older than 2 years); it is necessary to develop an effective epidemiological surveillance program in our country, in order to allow early treatment access to all population, starting early treatment and allowing children to develop thumbs with the best possible function and aesthetic appearance.

Mineo Oyama 1, Masahiro Odagiri 1, Shota Matsuzawa 1, Yuichi Nakamura 2, Takae Yoshidu 2

1 Graduate School of Niigata University of Health and Welfare, Niigata, Japan; 2 Niigata Hand Surgery Foundation, Niigata, Japan

Main function of a muscle is to produce joint motion. In addition, muscles which are adjacent to a ligament having a function of joint stability may play a role as the dynamic stabilizer by muscular contraction. The wrist extensors locates on the lateral side of the elbow joint and is adjacent to the collateral ligament, so that we hypothesized that these muscles have specific activities for stability of the lateral side of the elbow joint. However, it is not obvious how the wrist extensors relate to the stability of the elbow joint. The purposes of this study were to examine activities of the extensor carpi ulnalis (ECU) and the extensor carpi radialis longus (ECRL) before and after grounding with hand in the falling down and to examine the electromechanical delay (EMD) that was described as a time delay between the onset of electrical activity and the force output.

Materials and Methods
The experiments were carried out on 6 normal human subjects (36 ±9 years). They all gave their informed consent for the experimental procedure. The experimental tasks were the grounding with hand in the imitation falling down positioning in forearm pronation and mid position. The electromyography (EMG) activities were detected through bipolar Teflon-coated tungsten steel wire electrodes from the ECU of the right side. The analysis section was 500 ms before and after grounding. The integrated EMG (IEMG) value was calculated every 100ms and normalized with the IEMG value during maximum voluntary contraction. In the examination of the EMD, the ECU was stimulated by the wire electrodes which were used in EMG study and twitches were induced with maximum stimulation intensity. The time delay between the trigger signal of stimulation and the point of the maximum ulnar deviation force of the wrist was measured.

In the forearm pronation, the IEMG values of the ECU increased with steep and reached to 45 % at 100 msec before grounding and sustained the values to 500 msec after grounding, which were significantly greater than the ECRL (P<0.05). In the forearm mid position, the IEMG values of the ECU and ECRL increased slightly before and after grounding. The EMD of the ECU was 144±0.02 msec.

We observed significant increase in the ECU activities before and after grounding comparing with the ECRL in forearm pronation and the time when the ECU activities began to increase was almost equal to the EMD. These findings suggested that the ECU contributed to the stability of the elbow joint and the ECU activities just before grounding might be a rational control to stabilize the elbow joint effectively from a predicted agitation.

Fabio Alfonso Suarez, Aida Garcia Gomez, Alberto Rojas Vargas

Hospital Militar Central, Bogota, Colombia

Purpose: To compare the clinical outcome between trapeziectomy arthroplasty with suture suspension versus arthroscopic arthroplasty without interposition for thumb basal joint arthritis.
Methods: Between July 2013 and August 2015, thirty patients with thumb basal joint arthritis who failed conservative treatment and had considerable disability were intervened. They were divided into two groups, fifteen patients were treated with trapeziectomy arthroplasty with suture suspension and fifteen patients were treated with arthroscopic arthroplasty without interposition. The patients were evaluated after a mean follow up of 12 months. The outcomes were assessed with the quick DASH, Kapandji score, mobility (radial and palmar abduction, opposition) and grip strength. There were no failures reported with both procedures.
Results: We found no significant differences between groups for mean pain at rest, pain at effort, and Disabilities of the
Arm, Shoulder, and Hand score. Both procedures showed no significant differences in strength or mobility.
Conclusions: This study showed similar outcomes between these two procedures. Since the arthroscopic arthroplasty without interposition is a more conservative, less invasive procedure and in case of failure, it could be revised in an easy manner, we prefer using this intervention as the primary surgical treatment option.

Luis F. Náquira 1, Jairo F. Gómez 2, Mauricio Toro 3, Natalí Uribe 3, Laura Campuzano 3

1 Universidad Ces, Medellín, Colombia; 2 Hospital El Tunal, Bogotá, Colombia; 3 Industrias Médicas Sampedro, La Estrella, Colombia


Elbow fractures treatment represents a challenge due to the fact that this articulation acts as a mechanical bond between the shoulder and wrist, and the lesions are common in all ages. The success of the treatment is related to the adequate reduction and fixation of the fracture. Depending on the type of fracture, distal humerus plates, cubital plates or radial plates need to be used. A variable-angle fixation system for distal humerus fractures was designed. The purpose of this study is to evaluate the biomechanical performance and resistance of the fixation system under static and dynamic loads and compare the results with other studies made with commercial brands in the market.

Materials and Methods

A complete articular distal humerus fracture was simulated in humerus polyurethanes bones (AO Classification: 13 -C1) and the fracture was fixed using medial and dorsolateral plates and using screws from the distal humerus osteosynthesis system. The specimens were prepared for testing potting the distal humerus shaft in polymethylmethacrylate inside an aluminium cylinder to ensure standardized axial load transfer. The capitellum and trochlea notch of the distal humerus rested on two small supports, which were positioned in order to realize a force distribution of 60% at the capitellum and 40% at the trochlea. Three specimens were tested under static loads and nine specimens were tested under dynamic loads. Static testing was performed until the failure of the specimen and the plastic deformation, stiffness and the displacement curve was obtained. Dynamic testing was performed using a universal testing machine with a 1 kN load cell. The specimens were loaded with loads from 500N to 666N, at a cyclic compressive load and a rate of approximately 5Hz for a total of 1.000.000 cycles. The Wohler’s curve, fracture displacement, load deformation curves and ultimate yield strengths were calculated.


In the statics tests the average failure load was 730N. Under dynamic conditions with a load of 500N no failures were presented after 1.000.000 cycles. With a load of 666N the first fracture was obtained after 16.781 cycles, and in some cases screws pull-out was observed.


The tests results showed that the fixation system for distal humerus fractures have an adequate mechanical behavior comparing to the loads that commercial brands resist under similar conditions and according to the loads that the plates have to resist during fracture consolidation, which occurs usually after 90 days of surgery.

Bafiq Nizar, Ryan Kirsten, Fadi Issa, Khurram Khan, Sarah Tucker

John Radcliffe Hospital, Oxford, UK

Hospital at night has become a common practice in NHS hospitals to ensure there is suitable cover for patients at night in light of the European Working Time Directive. Many of the junior doctors on this pan-specialty cross cover have never worked in one of more of the specialties that they are first on call for. This can make the trainee apprehensive for their night ahead and can lead to inappropriate admissions and emergency clinic referrals. This has had significant impact on quality of care for patients at the same time patients waits have been long and sometimes they are held in in environments designed for rapid assessment and onward movement.

Materials and methods
We designed and implemented an intuitive mobile friendly solution available to all referring units as well as junior staff. This mobile app and website guides users through the initial management of the majority of common hand trauma out of hour’s referrals.

Results :
Adherence to guidelines on first aid measures performed in the emergency department improved to 75 % from 49 % and inefficient use of trauma clinic slots decreased from 25 % to 5 % since the implementation of this system.
Our junior trainee survey was responded by 15 candidates. Out of this 7 trainees had never worked in a Plastic Surgery department, and a further 3 had only 6 months experience. Ten trainees used the app at least a few times a week, with 4 using it daily. Twelve found it easy to use and 8 found it improved their workload.

Conclusion :
Requiring doctors to cover specialities outside of their experience can lead to poor service delivery, inappropriate management and low morale. This low cost system improved the working environment for our out of hour’s first line doctors, and informed their decision making to be in line with departments standards. Use of this system has shown to improve service delivery and use of resources more efficiently.

Jorge López Gonzalez, Nelson Gerez, Nicolas Guzman, Jorge Pacios, Pablo Rotella

Sanatorio del Norte, Tucuman, Argentina

INTRODUCTION: the distal biceps tendon ruptures is a low frequency injury produced by the application of an excentric force on the inflected elbow. Without treatment it results in a decreased strength and flexion up to 25% and in supination up to 25 to 40%.
OBJECTIVE: to evaluate the results of reinsertion of the distal tendon of the biceps with a two ways incisions; its return to activity and postoperative satisfaction in high performance athletes.
MATERIALS AND METHODS: seven athletes patients with distal rupture of bíceps were evaluated (three rugby players, two bodybuilders, one judoka, one gymnast); all males with an average age of thirty-one years of age (range between twenty-five and thirty-eight years of age). The follow up was four years, surgically tretated up to seven days after the injury was produced. The elective surgical method used was Boyd Anderson technique with two ways fixation on the bicipital tuberosity of the radio. In 4 cases it was a tendon rupture and in 3, bone desinsertion was observed. The patients were evaluated with the DASH questionary, elbow(flexoextensora)movility and (pronosupinadora) of the forearm with goniometer and (supinadora)force with dynamometer. A self satisfaction and pain questionary, and elbow´s radiography were taken.
RESULTS: nor inmediately or long term postoperative complications were seen; the DASH questionary results were excellent in 86% of the cases and good in 14%; all patients returned to practice sports at their previous level of function at an average of fifty-two days; the satisfaction score was excellent in five patients and good in two patients.
CONCLUSION: with the two ways approach, two ways fixation, an early intervention and rehabilitation protocol it was possible an earlier return to sports activities. It is an effective surgical technique with trustworthy satisfactory results.

Diego Alejandro Davalos 1, Luis Alejandro Satizabal 2, Jose Armando Amador 3

1 Orthopaedic Department, National University of Colombia, Bogotá, Colombia; 2 Fundación Hospital De La Misericordia, Bogotá, Colombia

Triplane fractures are defined as fractures that occur in three planes (coronal, sagittal and transverse) through the epiphyseal plate of a long bone. Radiographically, these types of fractures look like a Salter–Harris type III injury on the anteroposterior view and a Salter–Harris type II on the lateral view. Triplane fractures typically occur in late childhood, and are often associated with beginning normal symmetric fusion of the physis. By their nature, they are intraarticular fractures, and the goal of treatment is to achieve an anatomic reduction of the physis and the articular surface.
Only 5 cases of triplane fracture of the distal radius have been reported so far in literature, we report the second case managed with open reduction and internal fixation and the only one who has had a successful outcome.
Patient 12 years old with traumatic history in distal third of posterior forearm traffic accident with secondary deformity and functional limitation of right wrist and diagnostic images that confirm a fracture metaphyseal the of distal end of the right radius with radial displacement and a fracture line that goes through the epiphysis, physis and metaphysis. This was confirmed through a CT Scan. It was performed an open reduction and internal fixation. Two years after the injury, the patient was asymptomatic, with preserved joint mobility arcs and diagnostic images with appropriate evidence of fracture healing, no alteration of normal growth physis and consequently normal growth of the radius.
In all triplane fractures the goal is anatomic reduction of both the physis and the articular surface. As most triplane fractures occur in older children with beginning physeal closure, physeal closure secondary to the fracture rarely leads to angular deformity or length discrepancy. Thus, the goal of achieving anatomic reduction of the articular surface becomes more important. Surgery achieved an anatomical reduction of the articular surface, a good clinical and radiographic result, and therefore we could add to the previous statements about the management of these fractures that open reduction and internal fixation might be good options for treatment.

Aldo G. Beltran P.

Hospital Central Policía Nacional, Bogotá, Colombia Clínica Partenón, Bogotá, Colombia Fundación Universitaria del Área Andina, Bogotá, Colombia

Patients with irreversible distal injuries of median nerve could have lack of thumb opposition, condition that impair seriously hand function. Usually nerve transfers in this type of lesions aren´t available, and tendon transfers called opponensplasties are described a lot of years ago. However, almost all the techniques publisehd until today try to bring donor tendon to first metacarpal in the same palmar plane; then, this motor unit act more like a metacarpal flexor than a real thumb opponent, because this force vector only pull first metacarpal in the palmar plane, but don´t add any pronation movement to thumb metacarpal.
We propose a change in this action vector; in a real opposition movement, tip of the thumb point to fourth web space at fourth finger proximal interphalangeal joint. Then we try to get this action vector, transfering ring finger Flexor Digitorum Superficialis with a palmaris longus graft that pass from palm to dorsum making a pulley in fourth metacarpal diaphysis, and return from dorsum to palm, been fixed to thumb metacarpophalangeal joint. We made a pulley with fourth metacarpal periostium for pass the tendon graft and no allow displacements in distal to proximal axis.
Between 2010 and 2015 we report 5 patients with cronic distal medina nerve injuries, with any evidence of motor reinnervation in at least ten months before surgery and made our proposed technique. 4 of 5 made early rehabiltation with dinamic splint specially designed for describe teh same vector of movement. This 4 patients show early recovery of both components of opposition, Metacarpa flexion and pronation with Kapandji oppositions measured 8 to 10 /10 at two months postoperative. The elderly patient don´t made rehabilitation with the special splint and only get 4/10 Kapandji; however indicate the subjective improve in thumb function and is satisfy with the result at one year of follow up. Although the tendon graft made a cord from dosum of the hand to the thumb and we was concerned about some difficult to rest palm with thumb abduction at the same plane of the palm, at almost three months all patients recover thumb retropulsión and can put thumb metacarpal on the palmar plane without any difficult.
Then, we propose this modification in opponensplasty vector for improve simoultaneously thumb metacarpal flexion and pronation for made a more phisiological movement in thumb of patients with irreversible distal median nerve injuries.

Aldo G. Beltran P.1,2, Héctor León3, Luis Meléndez1

1 Hospital Central Policía Nacional, Bogotá, Colombia 2 Clínica Partenón, Fundación Universitaria del Área Andina, Bogotá, Colombia 3 Plastic Surgery Resident, Fundación Universitaria San Martín, Bogotá, Colombia

Bennet fractures are described very long time ago, and through the time was received multiplicity of managements that was comprended between close reduction and open reduction and fixation. The most popular techniques are closed reduction and percutaneous pinning, and is a constant in literature that a stepoff of 2 mm or less is considered a good result, minimizing risks of postraumatic arthrosis. However, in diary clinical practice we encountered difficults trying to reduce subluxation of major fragment and get simultaneously articular congruence with an unique manouver looking for reduction of subluxation and fracture. Then, we think that Bennet fracture is composed of two different entities: the intraarticular fracture like itself, and a dorsal subluxation with some degrees of supination of the major fragment while the small fragment still fixed in its original position by intermetacarpal ligament.
We look for a method that allow us to first reduce and fix the metacarpal subluxation, but don´t lock subsquent manouvers for getting anatomic fracture reduction. Then, we pass an axial pin in the first metacarpal, flexing proximal phalanx for visualize a “recess” in the dorsal aspect of the metacarpal head, radial to EPB tendon or ulnar to EPL tendon, choice is taken accord to surgeon and patient position in operating table that made easy pin positioning and advance. Fluoroscopic guide advance until tip of the nail is located just in the articular surface of thumb metacarpal. Then, surgical assistant reduce metacarpal subluxation with axial traction of thumb and simultaneously pushing metacarpal base in its original position. Once we have X ray verification of anatomical subluxation reduction, we advance the Kirschner pin through the trapezium bone. In this moment we have completely corrected subluxation, have the metacarpal at the same height of the small fragment, and the axial pin permit us free pronation to reduce exactly the intraarticular fragment. Once multiplanar X ray images show satisfying reduction, we pass a second Kirschner nail form the metacarpal base to take the small fragment, or if it is very small, take base of second metacarpal. With subluxation and fracture reduced and fixed, we put a third nail between diaphysis of first and second metacarpal to mantain stability and an open first web space. Patients was inmobilized for eight weeks and at this time we retire both, pins and thumb spica, and beggin rehabilitation.
Between 2013 and 2016 we treat 8 patients with this technique with excelent results. All postoperative x rays, taken between 8 and 10 weeks show anatomical reduction without step offs in articular surface, 3 of them have postoperative axil tomographys confirmed x rays findings. At the end of rehabilitation process, taking an average of 16 to 20 weeks, all patients recovered trapeziometacarpal circunduction without instability or crepitus.
We consider that this new approach spliting the patology in its two components make easy the approach and management of this common entity, shorting surgical times and minimizing sequelaes.

Ma. Francisca Vazquez Alonso, Mario Alonso Cienega Valerio

Hospital de traumatologia y ortopedia lomas verdes del IMSS. nacucalpan edo de mexico. Mexico


La enfermedad de Kienböck es una forma común e incapacitante de necrosis avascular, que afecta el hueso semilunar del carpo, típicamente en pacientes jóvenes. Puede progresar desde cambios aislados en el semilunar, colapso del semilunar con cambios en la alineación carpal hasta la artrosis.
El objetivo del estudios fue el de correlacionar los resultados funcionales de la enfermedad de Kienböck, en pacientes sometidos a osteotomía de acortamiento radial y descompresión metafisaria distal radio cubital.
El estudio se realizo en el Servicio de Cirugía de Mano de la Unidad Médica de Alta especialidad Hospital de Traumatología y Ortopedia “Lomas Verdes“, en el periodo comprendido de Enero de 2009 a Enero de 2014.
Es un estudio transversal, descriptivo y ambiespectivo.
Los resultados funcionales en las escalas Mayo Wrist Score y Quick Dash, se califican como buenos en ambos grupos, aunque en el grupo de pacientes con osteotomía de acortamiento radial, el numero de pacientes con resultado excelente fue mayor.
El curetaje metafisaria distal radiocubital es una técnica que no altera la anatomía radiocarpal, es menos invasiva, estéticamente aceptable, y con la posibilidad de reincorporar precozmente al paciente a sus actividades laborales y de la vida diaria.
La osteotomía de acortamiento radial, presenta buenos resultados, un índice de satisfacción del paciente mayor así como igualdad en la funcionalidad, contraponiendo que es un procedimiento mas invasivo, con mas probabilidades de presentar complicaciones, estéticamente no tan agradable, costo y beneficios elevado al realizarle una osteosíntesis, y retraso en la reincorporación del paciente a sus actividades laborales y de la vida diaria.

Kienböck's disease is a common and disabling form of avascular necrosis, which affects the lunate carpal bone, typically in young patients. Can progress from isolated changes in the lunate until collapse of the lunate with changes in carpal alignment or even osteoarthritis.
The purpose of this study was to correlate the functional results of Kienböck's disease, in patients whom was undergoing radial shortening osteotomy and distal core radio
ulnar decompression
The study was conducted at the Department of Hand Surgery at the Medical Unit of High Specialty Hospital of Traumatology and Orthopedics "Lomas Verdes" in the period of January 2009 to January 2014.
It is a cross-sectional descriptive study ambispective.
Functional results in May Wrist Score scales and Quick Dash, are rated as good in both groups, even in the group of patients with radial shortening osteotomy, the number of patients was higher with excellent result.
The metaphyseal distal radioulnar curettage is a technique that does not alter the radiocarpal anatomy, it is less invasive, aesthetically acceptable, and the possibility of early reinstate the patient to their work activities and daily life.
Radial shortening osteotomy presents good results, an index of greater patient satisfaction and equal in functionality, contrasting it is a more invasive procedure, with more likely to develop complications, not as aesthetically pleasing, cost and high profit performed to this osteosynthesis, and delayed return of the patient to their work activities and daily life.

Ignacio J. Guillen1,2, Lionel Perez Menvielle 1,2, Agustin N Arrieta1,2, Roberto M Berro Elizalde 1,2, Andres Ryan 1

1 HIGA San Martin La Plata, Buenos Aires, Argentina; 2 Instituto Medico Platense, La Plata, Buenos Aires, Argentina

Steindler flexoplasty
Case Report

Objective / Hypothesis
Case report. Description of treatment and its evolution.
The Steindler flexoplasty technique transposes the flexor epitroclear muscular mass of the forearm to the humerus. It is indicated in cases with brachial plexus´s upper roots lesion, polio sequels and neuromuscular alterations, that may affect active flexion of the elbow.

Methods and Material
Male 36 years old patient, who consults presenting brachial plexus lesion, incapable of elbow flexion (M0), sensitive hand. He refers politrauma (motorbike), 1 ½ year before, presenting left femur, patella, forearm and clavicle fracture associated to brachial plexus of c5 and c6, being his dominant side . It was decided to perform a Steindler flexoplasty to conserve triceps function intact.

Surgical technique: Patient in prone position with accessory hand table. Curved medial incision over cubital tunnel. Ulnar nerve is identified and protected. Medial septum is identified and released from humeral insertion. Anteromedial shaft cortex is scratch 5 cm proximal to medial epicondyle. Medial epincodylar muscles are incised along with a small bone pill, leaving insertion of the flexor carpis ulnaris at the humerus. Then the epitroclear bone pill in reinserted with a cortical screw at the cruentous zone at the humerus with an elbow flexion of 110°. Ulnar nerve stability is checked at cubital channel. It would be transpose or left in situ. The arm is immobilized in a splint with the elbow at 110° of flexion. For 6 weeks

Results. Early mobilization by passive and active mobility from the sixth week results in a 128º of flexion and -18º of extension active arch of motion in 6 month.

Discussion. Many techniques are used to restore elbow flexion. Lattisimus dorsi transfer results in acceptable flexion strength but it requires a muscular function above 4 in Lovett scale. Triceps transfer has good results but could alter elbow extension strength leading to daily activities difficulties as getting up from a chair for example. Steindler flexoplasty is a simple, soft tissue friendly, that retour elbow flexion, useful when it´s decided not to alter triceps muscle or when the lattisimus dorsi is inadequate, reaching a 110 degrees elbow flexion average at the expense of a 25 degrees limited extension average. It has a lesser flexion strength in comparison with other techniques but with a better cosmetic results.

Diego Alejandro Davalos, German Hernandez, Rodrigo Vargas

University Hospital Mederi, Bogotá, Colombia

Distal triceps tendon rupture is a very rare entity, representing less than 1% of all upper extremity tendon injuries. Disruption of the extensor mechanism of the elbow most commonly follows either a traumatic rupture of the triceps or failed surgical reattachment. There is a considerable functional deficit and early reconstruction is the treatment of choice. When they occur, primary surgical repair of the tendon to the proximal ulna is recommended. However, some patients require reconstruction using tendon grafting due to shortening or insufficiency of the native triceps tendon. A chronic rupture is difficult to be reattached because of the retracted muscle belly. The literature provides limited methods for correction of large triceps insufficiencies. It includes a turn down flap of triceps, anconeus rotation flap, allograft of tendo Achillis and autograft of hamstring tendon.
We report a patient 18 years old with a traumatic history of 1 year in elbow due to traffic accident with secondary insuffienciency and unable to extension and pain.
Patient previously open reduction and internal fixation of olecranon were made but subsequently with great limitation of basic activities of daily living
Patient is found with a range of motion of 10 degrees, so it was decided to take to an Achilles allograft reconstruction
6 months follow-up and the surgical procedure is performed with a remarkable improvement in mobility, strength and pain
Mayo Elbow preoperative score: 35 and Mayo Elbow postoperative Score 100
Preoperative DASH: 61,7 Postoperative DASH: 15.8
The reconstruction of chronic injuries triceps procedures are very difficult and require a very good fitness for repair prior planning. It is a great result in the patient and believe that Achilles allograft provides great strength and optimal results

Luis Carlos Díaz, Enrique Vergara-Amador, Lina Fuentes Losada

1 Universidad Nacional de Colombia. Bogotá, Colombia; 2 Clínica de Ortopedia y cirugía plástica ASOTRAUMA Ibagué, Colombia

Introduction: The volar V-Y flap is used in transverse or dorsal oblique amputations in fingertip injuries; however, its use is contraindicated in patients with volar oblique amputations and cannot move much to cover the defect. The aim of this report is to describe a technique of double V-Y flap to cover the fingertips defects in which a simple V-Y flap is not enough.
Methods: Description of a technique than a second flap V-Y over the simple V-Y flap, minimum 30% and maximum 50% of the original flap. Report of cases a series of fingertip amputation covered with this technique.
Results: This technique was performed in 7 patients between 25 and 64 years old, with transverse, volar and dorsal oblique defects in the fingertip. The advancing of the flap was between 3 mm and 5 mm. There were no infections or necrosis of the flaps. In all patients acceptable aesthetic results with two-point discrimination between 4 and 6 mm in the proximal flap and up to 10 mm of the distal flap with a minimum follow up of 6 months.
Discussion: With this double V-Y flap, we have seen a good coverage even in volar oblique amputation. It is additionally possible to advance up to 5 mm more with this second V-Y flap without compromising the vitality of the flap.
It is a simple and reproducible technique that can be used on any finger, with good results without flap necrosis.

Enrique Vergara- Amador, Sergio Andrés Castillo Pérez,- Wilson Ferney Tovar Cuellar

Universidad Nacional de Colombia, Bogotá, Colombia

Background: Injuries to the fingertips are the most common hand lesions in children. There are many classifications but none includes all the structures involved, they are difficult to apply or poorly reproducible. This report describes cases of pediatric patients with fingertip injuries and proposes a practical classification.
Materials and methods: we reviewed the cases of 90 children with fingertip injuries and described the anatomical lesions and allowing ideas to suggest a new classification. This classification is divides in dorsal (D), volar (V) and fracture of the distal phalanx (F) with or without bone exposure (e); additionally was subdivided according to the level of injury.
Results: The fingertip was common in boys (59 %) and the main mechanism of trauma was crushing (85%); there was a dorsal injury in 93 % of cases. The most frequent surgery was autologous nail replacement (72%) and nail bed suture (60%). The most common injury was D1-V0-F0 (lesion of the sterile matrix without injury pulp or fracture) in 20% of cases.
Discussion: The fingertip injury is most common in children under five years old and the major mechanism of trauma is crushing. The Tamai and Allen classification are the most used, they are easy to apply but only include fingertip amputations. The Pulp Nail Bone (PNB) or the Jin Bo Tang (JBT) classifications are more complete, they describe the injuries but they have low accuracy and reproducibility. This new DVF classification includes all fingertip injuries, allowing a more accurate description and may be more reproducible.

Diego Gutierrez, Denisse Hartwig, Virginia Giachero, Oscar Jacobo, Juan Gambini

Hospital de Clinicas, Montevideo, Uruguay

Indocyanine green (ICG) is a hydrophilic dye, that binds with albumin and has fluorescent properties. Its use is of great value for the intraoperative evaluation of skin-flap perfusion.
The aim of our work is to report the value of using 99mTc nanocolloid indocyanine to assess the vascularization of the posterior interosseous flap during surgery, in a complex case.
Patient: male 47 years old, with a full thickness burn in the dorsal aspect of the left hand and wrist secondary to chemotherapy.
Procedure: During the surgery, the patient received 3 injections of ICG 99mTc nanocolloid via periphereal intravenous access, one 5 minutes before and 5 minutes after clamping the posterior interosseous artery, and the other after place the flap covering the back of the hand. Optical near infrared (NIR) images were performed to assess the vascularization of the flap.
During surgery, it was possible to prove the vascularization of the flap trough NIR images in the 3 times, and did not show filling defects. In the evolution, the flap doesn´t present any site of necrosis.
The 99mTc nanocolloid ICG is a feasible and helpful tool for assessing nutritive blood flow of the reverse flow flaps, such as the posterior interosseous flap, capitally in those patients with possible injury of the nutritive vessels of the flap.

Bruno Eiras Crepaldi, Marco Aurélio Matos de Castro Lima, Raul Itocazo Taira, Celso Kiyoshi Hirakawa, Marcelo Hide Matsumoto

Hospital Santa Marcelina Itaquera São Paulo, Brazil


Essex-Lopresti injuries are rare and present a clinical challenge. Incomplete diagnosis and treatment can lead to long-term instability, pain and functional impairment. We report on a clinical case of proximal radius fracture and no acute radioulnar joint (DRUJ) dislocation with unusual displacement after fracture fixation.

Case Report:

A 47-year-old, right hand-dominant man, mason, fell from 5 meters high onto his forearm and elbow in 26/01/2015. He was unable to recall the exact position of his limb on impact. He reported immediate swelling and pain to his elbow. He was otherwise fit and healthy with no other medical history.
The physical examination demonstrated a full range of motion in the shoulder, but there was considerable swelling and tenderness of the elbow and forearm and no skin or neurovascular compromise.
Antero-posterior and lateral radiographs showed a fracture of the radial head (MASON 2) and no sign of distal radio ulnar joint (DRUJ) dislocation.
At that time, the patient had undergone surgical treatment of the elbow, and reconstruction of the radial head with internal fixation with two compressive headless screws.
After 4 months of post-operative treatment, the patient had noticed a gradual decrease in range of motion and increasing discomfort in the elbow and wrist. The pain was greater in the wrist than in the elbow and worsened during forceful grip.
Plain radiographs of the right elbow showed a proximal radius migration and The DRUJ dislocation with the ulnar head displaced dorsally.
A MR scan was subsequently undertaken which showed a consolidated fracture of the radial head and the DRUJ was dislocated distally and dorsally and a suggestive complete disruption of the interosseous membrane and radioulnar ligaments.
These findings supported the diagnosis of an Essex-Lopresti injury.
A new therapeutic approach was performed in 13/10/2015. A Sauvé-Kapandji procedure associated with an opened forearm interosseous ligament (IOL) (the central band of the interosseous membrane) reconstruction using a palmar longus graft were made in order to improve the DRUJ instability.
The patient was followed up clinically, with further images. At 2 months, after the second procedure, wrist and elbow range of motion improved from: supination 30º, pronation 15º, flexion 60º, extension 60º in 12/05/2015 to supination 45º, pronation 30º, flexion 70º, extension 60º in 06/01/2016.

Discussion and Conclusion:

The critical step to successful treatment of an Essex-Lopresti lesion involves correct diagnosis of the injury. Missed diagnosis can lead to persistent wrist pain and instability. A thorough examination should raise clinical suspicion and CT scan and/or MRI should follow Inconclusive radiographs.
The injury should ideally be treated acutely to avoid painful ulnar-sided wrist degeneration and chronic elbow pain. A chronic injury that was improperly diagnosed or treated may require radial head prosthetic replacement, reconstruction of forearm interosseous ligament (IOL) and salvage procedures as Sauvé-Kapandji.

Lia Myiamoto Meirelles, Carlos Henrique Fernandes, João Baptista Gomes dos Santos, Luis recanto Nakachima, Marcela Fernandes, Flavio Faloppa, Walter Manna Albertoni

Hand Surgery Unit, Universidade Federal de São Paulo, Brazil

Introduction: Most randomized trials have shown similar results with different techniques of carpal tunnel release. We have performed studies suggesting less postoperative pain, faster improvement
in grip and pinch strength, and earlier return to work with technique of Paine's Retinaculotome. The goal of this study was to prospectively examine subjective and
functional outcomes, satisfaction, and complications after both Paine's Retinaculotome (PR) and open carpal tunel release (OCTR) in the opposite hands of the same patient, serving as their own control.
Material and Methods: This was a prospective, randomized study in which patients underwent surgery for bilateral carpal tunnel syndrome. The first carpal tunnel release was performed on the most symptomatic hand determined by the patient. Operative approach was randomly assigned and, later, the alternative technique was performed on the contralateral side. Eighteen patients (36 hands) were evaluated preoperatively and the second week, first month, third month, and sixth month after surgery. We used the Boston questionnaire, visual analogue pain scale (VAS) and grip strength. It is the comparative study made of the results obtained between the OCTR and PR for each of the five follow-up times, and the progress of each operation over a specific period divided in 2 weeks and 1 month.

Results: In assessing the strength, pain and symptoms, we observed better results with PR technique in all measured periods. This major difference in the 2nd week and 1 month with a trend of equality between the technical close to 6 months.

Discussion: Although many articles comparing the different techniques, have few results from the comparison between patients operated bilaterally.
We believe that the analysis parameters and measurements obtained from patients operated on bilaterally by two surgical techniques, forming one group for both techniques, allows greater accuracy in comparing the results.

Conclusion: Both OCTR and PR are well tolerated by the patients with better functional outcomes, symptom severity and functional status questionnaires with PR technique.

Chihiro Fujime 1, Kohei Takebayashi 2

1 Niigata university of health and welfare, Japan; 2 Katsuragi Hospital, Osaka, Japan.

We have created a “carpal continuous traction device: CCTD” for the purpose of continued stretching for the wrist joint contracture.
The structure of CCTD is hand parts, tower with pulley and weight. The hand parts is using an elastic stocking. The hand parts covers the hand. and using a pulley and weight, and traction a hand to the distal by the frictional force. The CCTD had the immediate effect was used for the distal radius fracture patients. In this study, we investigated the effects of CCTD had on the long-term results.

Materials and methods
In this prospective trial, 12 patients (3 man, 9 female , age mean 60.7±14,4 ) with surgery a volar locking plate after distal radius fracture: excluded case is severe pain, neurological symptoms, multiple injuries case) were randomly assigned into CCTD (6 cases) and control (6 cases). All patients received manipulative therapy for 20 minutes. CCTD group, were further added to the 20 minutes CCTD from after 4 weeks of surgery. Using the 2kg weight. Decided to discontinue immediately if they complained of pain and impaired circulation and numbness. It was measured wrist and forearm range at 4weeks and 10 weeks after surgery. The measured values were converted to the healthy side ratio. ROM and days after surgery for CCTD group and control groups at 4weeks and 10 weeks were compared using repeated measures ANOVA. Comparison between the groups at each measurement time using t-test.

The ROM (flexion, extension, radial deviation, pronation, and supination) had improved between 4 weeks and 10 weeks. Flexion and radial deviation of the CCTD groups was significantly improve compared to controls. In 4 weeks had significantly different at the radial deviation. In 10 weeks, flexion, extension, radial deviation, and supination of CCTD group was significantly improve compared to control group.

Better progress with CCTD may be expected in joints stiffness. Further research in needed to survey the more cases of multiple center.

Ignacio J. Guillen1,2, Lionel Perez Menvielle 1,2, Agustin N Arrieta1,2, Roberto M Berro Elizalde 1,2, Juan Francisco Gonzalez 1

1 HIGA San Martin La Plata, Buenos Aires, Argentina; 2 Instituto Medico Platense, La Plata, Buenos Aires, Argentina

Medial clavicle non-union and sternoclavicular dislocation

Case report

Objective / Hypothesis
Case report. Description of treatment and its evolution.
Fractures of the medial third of the clavicle are not frequent, being less than 5% of all clavicle fractures. Generally they can be managed by non-surgical treatment. Surgical treatment is left for orthopedic treatment failure. One of the most frequent complication in orthopedic treatment is the non-union, with it´s pain and bad functional outcome.
The most frequent sternocalvicular dislocation y the anterior. Mostly treated non-operatively but when the anterior joint capsule interpose causing to be irreducible.

Methods and materials.
Male 24 years old, handy worker, consults with pain, deformity and functional limitation in his left shoulder, associated with sternoclavicular impingement in overhead movements. He referred a medial third clavicle fracture with sternoclavicular dislocation 24 moth ago, treated orthopedically. In Rx non-union associated with sternoclavicular degenerative signs, and irreducible anterior sternoclavicular dislocation
Surgical technique: Patient in beach chair. Transverse anterior incision over medial clavicle, gentle dissection of clavipectoral fascia, and posterior protection of neurovascular elements. Resection of medial clavicle fragment about 1,5 cm, leaving sternocostoclavicular ligaments, and cautious closure. Immobilization with ling for 2 weeks.

Early mobilization by passive and active mobility from the third week results as complete shoulder mobility without pain. The patient had returned to heavy duty work after the fourth postoperative week.

Medial third clavicular fractures is an infrequent pathology with a probability of 50% of developing a non-union. Mostly treated non-operatively but posterior displacement whit esophagus or neurovascular mediastinal structures affectation.
Anterior sternoclavicular dislocation usually can be treated by non-operative methods, or in cases with high level of shoulder function demand, ligament reconstruction can be done.
There is not many information about the combination of this two pathologies, and the best treatment for simultaneously solve this pathology
Partial resection of clavicle is an easy and safe technique, with excellent pain and function outcomes in short and long term.

Nicolás Urroz, Denisse Hartwig, Victoria Rios, Oscar Jacobo

Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay.


Arteriovenous malformations are high-flow vascular anomalies happening as a consequence of an error in angiogenesis during embryological development. However, they may not be detectable until adulthood and their location in hand is not common.

Their treatment is complex due to several complications and the need to maintain proper function of the limb. As therapeutic methods we find: conservatory treatment, selective embolization and partial or full resection. All of the previous treatments may be carried out individually or together. Relapsing, having to reapply the previous methods and even amputation are frequent complications which make this pathology a challenge for ourselves.
While the aims of a surgical procedure are based on the removal of as much tumoral mass as possible, maintaining functions, avoiding complications such as damaging adjacent nerves, preventing bleeding and ischemia are also important.
This article describes the interdisciplinary treatment of a painful ulcerated AVM located in the forearm and hand of a 34 year-old patient treated at the Plastic Surgery Department - Hospital de Clínicas, Montevideo - Uruguay.


A previously diagnosed forearm and hand AVM case was presented. The implementation of a possible treatment, possible clinical recurrence and complications were taken into account. Research was carried out and the possible long and short term results were evaluated.


The patient was monitored for 94 months. The type of wound the patient had suffered was classified as infiltrating. As a first procedure, a partial resection of the AVM and a 5th ray plastic amputation were done due to the presence of ischemia. After 46 months, relapsing, ulceration, bleeding and pain were present. A selective embolization with Onyx and partial resection after 72 hours took place, the amputation of the 4th finger and local flap covering were needed.
After the above, the patient improved presenting a loss in the tumor burden, less pain, no evident recurrence or complications in the last 48 months.


The characteristics of a wound and it symptoms are important factors in the elaboration of a treatment plan for AVM's. Partial resections and embolization allow fair control over of the pathology, a better conservation of noble structures within infiltrating AVM's. All of the previous treatments, with few short or long term complications. Choosing what type of treatment the patient will receive must be done carefully by an interdisciplinary team, given that severe complications are possible. After each treatment, wounds must be reevaluated periodically and new methods of treatment must be considered by the professionals in the team.

Aldo G. Beltrán P. 1,2,3, Omar Gallo 1, Miguel Rivera 1

1 Hospital Central Policía Nacional, Bogotá, Colombia 2 Clínica Partenón, Bogotá, Colombia 3 Fundación Universitaria del Área Andina, Bogotá, Colombia

Fingertip injuries are one fo the most common urgences in hand surgery. For years hand surgeons in all the world have the V – Y Atasoy flap as workhorse in management of fingertip sof tissue defects. This is an smart techinque, safe and reliable, however although it save a lot of fingertips for amputations, have some details that not satisfying us completely. The oblique scars at the center of fingertip could cause tenderness and even contour deformities, more frequent in childrens that can show different growth in flap and segments lateral to the oblique scars. If you measur flap size the total area of a V – Y flap is only aporximate one third of total pulp surface. Then we progressively redesign our homodigital flaps to the point to considering it as a new design: the U flap.
As its name indicate, in anteroposterior view we trace an U that include almost all the pulp surface, with the proximal flap edge over the distal interphalangeal joint palmar crease. The “U” arms in lateral view are oblique, crossing the lateral aspect of distal phalanx from palmar to dorsal until reach the limits of soft tissue defect. Surgeon free the septal unions of pulp skin in angulated design from the incisions in proximal and dorsal direction, expanding the amount of subcutaneous tissue in the flap; this type of release sumated to supraperiostial disection in distal phalanx allow up to 1 cm of easy advance, preserving all the pulp surface without any scar. The oblique arms permit easy advance and location of scars only in lateral aspects of distal phalanx. The resultant defect distal to interphalangeal crease is left to ephitelize spontaneously.
Between 2013 and 2015 we made 22 flaps in 20 patients, 17 for acute trauma and 5 for management of fingertip sequelaes like tenderness, contour deformities or hook nails. All flaps survive without any problem and the expose subcutaneous tissue in proximal edge epithelize in all patients between 9 to 15 days. Patients was very satisfied with contour and aesthetic of fingertip.
We believe that this kind of new design of a workhose classic flap could reach popularity for it easy dissection and mentioned advantages.

Samuel Ribak, Alexandre Tietzmann, Sérgio Augusto da Gama, Helton Hiroshi Hirata,Mogar Dreon GomesPontifical

Catholic University of Campinas, Brazil

Objective: All forearm shaft fractures should be considered and treated as articular fractures, in a precise manner by the forearm pronosupination commitment risk and limited range of motion of the wrist and elbow. The choice of means to be used to access the radio should allow conditions that, after treatment, there is the restoration of axial alignment, the length and guarantee the forearm rotational movements. Considering that forearm shaft fractures are very common in the upper limb trauma, we find relevant to define the objective of this study the anatomical description of a lateral access on the forearm for the surgical treatment of diaphyseal fractures of the radio and evaluation of its versatility and effectiveness on the bone exposure achieved, morbidity and safety of the procedure.
Methods: Ten upper limbs of 05 fresh cadavers without fixation in patients aged above 18 years were used. Upper limbs who had scars, deformities or previous pathologies were excluded. In the surgical technique, the incision was lateral for access to the forearm. The antebrachial fascia in the long axis of the incision is sectioned and the plan between the brachioradialis muscles and extensor carpi radialis longus is dissected. In this plan, we have access to radio shaft throughout its entire length. Next, the radial sensory nerve, which is located below the brachioradialis muscle, is dissected and protected.

Results: With pronation and supination maneuvers, all radio faces can be easily exposed (lateral, anterior and posterior), obtained by this access. You could choose in which radio face any plate for fixation of the fractured radio could be inserted. With regard to morbidity, it was considered small in the case of placing the plate in the lateral and posterior surfaces of radio (without the need for detachment of any muscle or tendon) and medium morbidity in fracture fixation volar plate cases (by possible detachment muscle pronator teres). As for the safety of the procedure, it was considered safe by not having risk of injury to large vessels and medium security by the risk of the radial sensory nerve commitment.
Conclusion: The lateral approach of the forearm to surgical treatment of radius shaft fractures is feasible and allows good bone exposure. It is versatile to allow, in a unique way, access to the anterior, posterior and lateral radio. It presents low morbidity and is safe as for the vascular and nerve damage risk.

Mariane Campopiano Abrahão Silva 1,2, Alessandra de Assis Miura 1, Laryssa Lopes 1, Maria Ligia Kalamakian 1, Rafaella Arboleda 1,2

1 Beneficência Portuguesa Hospital, São Paulo, Brazil 2 Projeto Rede, São Paulo, Brazil

Objectives: To describe the use of customized adaptive equipments made from low-temperature thermoplastic that improve the hand function and the Independence of patients with neurological disorders during hospitalization.

Methods: Five adults, both genders, with neurological disorders (stroke sequelae, CIDP and spinal cord injury) received occupational therapy interventions during hospitalization. The main goals of the occupational therapist were recover hand function and improve the independence of the patients during the performance of activities of daily living (ADLs) through, if necessary, the use of customized adaptive equipments. The Functional Independence Measure (FIM) was used as a standardized tool to assess physical and cognitive disability. The mini–mental state examination (MMSE) was used to measure cognitive impairment: patients with any score greater than or equal to 19 points got the occupational therapy intervention focusing recovery of hand function and increase of independence in ADLs. During the assessment, it was observed that most patients had difficulty to bring the food to the mouth (holding the cutlery); to do personal hygiene (brushing teeth and hair doing), to write; and to use electronic devices such as computer, tablet and cellphone (typing and turning the devices on and off). After the assessment, the occupational therapist made a individualized treatment plan for the patients according to their needs and complaints; and started the rehabilitation program through ADLs training using adaptive equipments made from low-temperature thermoplastic. The thermoplastic was chosen as a adaptive equipment material owing to some advantages: its ability to conform (regardless of its molding properties), its stiffness, its weigh and the possibility of water exposure for the equipment cleaning. The patients were treated from two to three times per week depending on the complexity of the case. The FIM instrument was reapplied weekly and in the patient’s discharge.

Results: Adaptive equipments made from low-temperature thermoplastic for cutlery, pen, pencil, toothbrush, hairbrush, cellphone and computer keyboard were fabricated and customized according the needs of the patients. The use of the equipment was monitored by the occupational therapist and the families received a training about the use of devices (how to put on, remove and hygiene). It was observed a improvement of the FIM score, the increasing of quality of life, and greater social interaction; enhancing the sense of autonomy and independence of the patients during the hospitalization process. Furthermore, there was improvement in functional capacity and hand function to perform ADLs.

Conclusions: Customized adaptive equipments made from low-temperature thermoplastic for hospitalized and neurological injured patients showed to be effective; especially for its easy hygiene and the possibility of remodeling if necessary. The increase of the performance in ADLs was observed during the rehabilitation intervention; as well the improvement of hand function and a greater independence level of the patients.

Fernando Vicente de Pontes, Jeniffer Martins Souza Cazelato, Maria Cândida de Miranda Luzo, Edgard de Novaes França Bisneto

Orthopedic Institute of the Clinics Hospital of the University of Sao Paulo

Over the past few years we have achieved great progress in the surgical treatment of various hand diseases such as congenital. It is necessary to check the actual need and quantify the benefits of these procedures by conducting functional assessments. From this perspective, it was created the Congenital Upper Limb Clinic, a space where outpatient are assisted by surgeons, residents and occupational therapists for clinical and functional assessment of children with congenital diseases. Between July and November 2015, 19 children aged between 6 months and 13 years old were assessed, 10 boys and 9 girls, diagnosed with hypoplasia of forearm bones, syndactyly, camptodactyly, brachydactyly, hypoplastic thumb and unspecific anomalies of the hand. Children undergo functional assessment of Occupational Therapy, in order to define their skills and functional needs. Observational evaluation is performed, encompassing aspects of the development, the use of hands to play, movement patterns and general difficulties. In addition, parents or guardians answer the Children Health Assessment Questionnaire (CHAQ). When possible, according to age and cooperation, standardized assessment with measurement of range of motion, grip and grasping strength measurement and application assessment tool of motor function (Jebsen Taylor Hand or Sollerman Functional Test). With the start of the clinic an improvement in medical / therapist / family communications was noticed, which facilitated decision-making regarding the treatment plan. It was also possible to determine on the follow up assessments, if the surgical procedure improved the ability to perform functional tasks. Factors such as lack of cooperation and understanding of the child or even their adaptation and functional use of the hand were also considered avoiding unnecessary surgical procedures based on the data collected and this can collaborate with new evidence in the area.

Maria Solange Ferraguti, Gustavo Nizzo, Alberto Rios, Daniel Pereyra

Hospital de Clinicas, Universidad de Buenos Aires, Buenos Aires Argentina

Introduction. Compartment syndrome is an orthopedic emergency that requires immediate diagnosis and surgical resolution. The forearm and hand are the second and third in frequency; and they could be associated with vascular catheterization.The diagnosis is based on clinical exam: pain to passive limb movement, edema, pallor or cyanosis, paresthesia, hypoesthesia, and belatedly paralysis. Measurement greater myofascial compartment 30 mmHg. or a difference between diastolic blood pressure and intracompartmental pressure, confirms the diagnosis.

Materials and methods. 64 years old female diagnosed with kidney cancer, for which she underwent nephrectomy. At the moment she developed a metastasis in her left scapula, which was under study. Later a CT scan with intravenous contrast was made; she began with disproportionate pain on passive motion, progressive edema in hand and forearm. She was diagnosed with compartment syndrome of upper limb. We decided to perform a complete emergency fasciotomy in her right arm by the Henry approach for upper limb extended from the front shoulder to the hand.
Delayed closure is carried out in three stages, debride those devitalized tissue, performing cures every 72 hours with dermal patches, leaving a small skin defect, which was then covered with "pinch graft", ipsilateral thigh donor site.

Result. Fasciotomy by limb amputation was avoided. Conservation sensitivity and motility. The pinch autologous graft retain the vitality of the tissues, showing a good addition to the integument.

Conclusions. The main cause of upper limb compartment syndrome are vascular procedures such as contrast administration, catheterization, measurement of intra arterial injection and medication extravase the vascular system

Gustavo Nora Calcagnotto, Carolina Panizzon Santini, Vinicius Magni Bachinski

Hospital Pompéia - Caxias do Sul/ RS Brazil

Objective: The elbow’s fractures represent 8-9% of all fractures in the upper extremity in Children, most occur in patients between 5 to 10 years old, most commonly in boys. The objective of this report is correlate with the literature the case of two children that present plastic deformity of radio head with ulna fracture and were treated with cast splint in our service
Materials and Methods: Information were obtained by review of medical records,interview with the patients, photographic record of diagnostics methods to which a patient was submitted and literature review.

Results: Patients were submitted to closed reduction in surgical center and had the upper member immobilized for 3-4 weeks in a cast splint. At the end of our treatment, patients presented with a little decreased of the amplitude of the movement that was recovered in the return to activities of daily life. Bone consolidation progressed satisfactorily.

Conclusion: We found few reports talking about the combination of this fractures in the literature, there is correlation with the variants of Bado classification for Monteggia’s Fractures, but is not exactly the same. Publication of these cases help us in the choice of the better treatment for this patients.

Leonardo Osses, Raul Ulloa, Nazira Bernal Bader, Juan Jose Valderrama

Mutual Hospital, santiago, Chile

Introduction: The Intrarticular Distal Radius Fracture with Dorsal Displacement (IDRFDD) management has changed during last year’s. Nowadays there are clear trend to treat by volar due to new anatomic and locked implants.

Objective: To evaluate the clinical and radiological outcome of the IDRFDD treated with Volar Locked Plate (VLP) in Mutual Clinical Hospital.

Specific Objective: Measures radiological index (Frontal Index (IF) Radio height (RH) Ulnar Variance (UV), Sagital Index (SI)) Post quirurgical and 5 month control. Mobility ranks (flexion, extension, supination, pronation). Fist Force Percentage in relation to health side. Describes complications and reinterventions.

Materials and Methods: patients between 25 to 65 years old with IDRFDD types C1,C2 and C3 AO Clasification and dorsal displacement. VLP treatment by Microsurgery and Hand Surgeons from Mutual Clinical Hospital from 2008 to 2010.

Study type: Retrospective evidence type IV. Outcomes: 69 patients, 42 males and 27 females. Average age 46,6 years (26 to 65 years). AO Clasification; C1: 9, C2 22, C3 38. Implants type: SYNTHES LCP Plate 2.4/2.7: 49, SYNTHES Locked Plate 3,5 : 13, TRIMED Poliaxial Locked Plate : 4, SYNTHES Doble spine plate:S 3.
Post Surgery Radiological Index IF 21,2°, AR 10,8MM, VU -0,5MM, IS 2,0°. Five months control IF 21,2°, AR 10,8MM, VU 0,05MM, IS -0,7°.
No significant differences (DS) P<0,005. Mobility ranks: 48,7°, extension 50,9°, supinacion 81,6°, pronacion 82,6°. fist force 47,1% to comparison healthy side. 19 patients with complications (27,5) the most frequent ulna plus 9 patient (13%), extensor tendonitis 6 patients (8,7%), flexors tendonitis 6 patients (5,8%). reoperation 13 patients (18,8%) 10 patients removed plate (14,5%), 2 patients ulnar shirtening osteotomy (2,9%) and 1 patient total wrist arthrodesis (1,4%).
Conclusion: Good radiological results, at the five control month is observed a spine collapse 2.7 ° although no significant to statistical analysis. Good results in mobility ranks to be flexion the most limited. VLP use is not exempt from complications to be more frequents ulna plus and tendonitis.
All Patients with extensors and flexors tendonitis required implant remove. Of the total of 9 patients with ulna plus only 2 required ulnar shortening osteotomy and only one patient ended up with arthrodesis.
The authors claimed no conflict of interest in this investigation.
This investigation is authorizated by the ethical committee of the Hospital.

Fernando Vicente de Pontes, Maria Cândida de Miranda Luzo

Orthopedic Institute of the Clinics Hospital of the University of Sao Paulo

Individuals with spinal cord injury use wheelchairs as an aid to mobility. However, the biomechanical necessary to use a wheelchair can generate overload to entire body, causing injuries to joints, bones, muscles and/or ligaments. Thus, this study aims to determine the prevalence of musculoskeletal symptoms in the upper limbs of wheelchair users with spinal cord injury. This is a descriptive cross-sectional prevalence study, still in progress, realized at the Occupational Therapy service of a public tertiary care hospital. The study will be fulfilled in 2014. The current sample is composed of 6 individuals with spinal cord injury treated at the Occupational Therapy service. Sociodemographic variables (gender and age) and information about the time and manner of wheelchair´s use were collected with a questionnaire developed by the authors. Musculoskeletal symptoms, considered in this study as outcome were measured using the Nordic Musculoskeletal questionnaire composed of the following questions: "In the last 12 months, did you have problems (pain, tingling/numbness) in specific regions of the body (shoulders, elbows, wrists and hands)?; in the last 12 months, did you have difficulty at performance normal activities (work, housework and leisure)?; in the last 12 months did you consult a healthcare professional because of this condition?". The questionnaires were administered by 4 Occupational Therapists from the service. The data analysis is presented with descriptive approach through media, absolute and relative frequencies (percentage). The mean age of participants was 41.6 years, and 66.6% (n=4) were male and 33.3% (n=2) were female. As for the daily use of the wheelchair, 50% (3) employ participants 4 to 8 hours, 33.3% (2) employ less than 4 hours and 16.6% (1) employ more than 8 hours. Thus, 66.6% (4) of the practitioners said traverse a distance of 500 meters and 33.3% (2) of them runs about 500-1000 meters per day. It was seen that only 50% (3) of the participants had some form of postural adaptation in his wheelchair, and only 33.3% (2) use some protection for the hands. Of the participants, 100% (6) reported experiencing symptoms in the last 12 months. The areas most affected by these symptoms were: shoulder 66.66% (4) and wrist and hands 33.3% (2). Symptoms prevented 66.6% (4) of participants to conduct their normal activities, and yet only 50% (3) of them consulted a healthcare professional for this condition. We conclude that the prevalence of musculoskeletal symptoms in users of wheelchairs with spinal cord injury and high even in a small sample of participants, which can be related to daily use time, distance traveled and the lack of appropriate positioning in wheelchair . Other factors such as the time of injury, rehabilitation and the type of structure of the chair should be better exploited for other correlations were performed. It was hoped this study to identify the prevalence of musculoskeletal symptoms in spinal cord injured users of wheelchairs, and accordingly, when completed, the study will be useful for the development of educational and therapeutic measures, and subsequently performed studies with the highest level of evidence.

Julio Hernandez E, Mario Humeres R, Pedro Diaz E, Francisco Neumann C, Joel Hernandez D.

Hospital de Rengo VI Región CHILE

Purpose: Want to show the experience on the performing the Pollicization of the index as a replacement to a traumatic amputation of thumb, on a Public Hospital in Chile. A case report.
Methods: Surgery was performed on male, 67 year old, without morbid history. He suffers a traumatic amputation of the thumb on his left hand with an ax. It undergoes to a surgical scrub and further evaluation with trauma team on Hospital Rengo (Chile). The option of the Index pollicization, as a replacement for the thumb and restore utility hand was possible. It´s accepted for the patient.
Results: We follow-up the patient for 6 months. Patient return to the normal life, with independence, with a functional hand and performs all kinds of activities of daily living.
Conclusions: Secondary to the results obtained with the patient, the technique Pollicization of the index finger, as a replacement of a traumatic amputation of the thumb, is a suitable option to restore the functionality of the hand, which is why, reaffirmed the idea of using the technique in such pathology.
Keywords: Pollicization, amputation, traumatic amputation.

Charles A. Goldfarb, Lindley B. Wall

Washington University School of Medicine 1) St Louis Childrens Hospital 2) Shriners Hospital for Children, St Louis

Syndactyly and contracture release may be reconstructed using full thickness skin grafts. A single, recent study of hyaluronic acid skin substitute for syndactyly reconstruction reported good outcomes. We hypothesized that hyaluronic acid skin substitute for syndactyly reconstruction and scar contracture will result in good subjective and objective results.

A review of the medical records identified 7 patients treated at a single hospital with hyaluronic acid skin substitute for syndactyly or scar contracture. The diagnosis, post-operative treatment, healing time, and complications were documented. PODCI scores were obtained before and after surgery. Minimum follow- up for inclusion was one year.

Five hands were treated for syndactyly and 2 hands underwent contracture release. All wounds were healed completely by 12 weeks. There was one delay in healing secondary to poor compliance. The aesthetic outcome was excellent, scarring was minimal and PODCI scores improved. There were no infections or other complications.

Summary Points:
• Hyaluronic acid skin substitute can be used reliably in place of full thickness skin grafting in syndactyly reconstruction and scar contracture treatment.
• Post-operative healing is reliable and aesthetic outcome excellent.

Mala Satku, Sreedharan Sechachalam, Puay-Ling Tan

Department of Orthopaedic Surgery, Tan Tock Seng Hospital ,Singapore

Introduction: Two microsurgery skills workshops for nurses were held in our hospital in 2013. These workshops were directed at operating theatre nurses, who in their daily course of work, would be required to assist in microsurgical cases. To our knowledge, no such course has been evaluated in medical literature.

Materials and Methods: Each 4-hour course consisted of two lectures and two practical sessions, including microsurgical suture practice on a glove and end-to-end anastomosis of a vessel. The courses were evaluated using a 20-question survey, using a 5-point Likert scale for responses. The questions were designed to determine the changes in knowledge, attitudes and practices of the nurses as a result of attending the course.

Results: A total of 20 nurses attended the workshops. We achieved a response rate of 95%. All respondents reported an increase in knowledge of microsurgical skills, instruments, sutures and the use of the microscope. 95% of respondents reported that the course made it easier for them to assist microsurgery cases. 79% reported better tolerance of long microsurgical cases. All respondents reported that they would recommend the course to their colleagues.

Conclusion: Overall, the nurses had a positive view of the course. We will use the evaluation to improve future editions of the course. Other institutions may consider conducting similar courses for their nurses, in view of the positive response from our participants. The next steps would be to validate a questionnaire, which can be used to evaluate similar courses in the future.

Luciano Torres, Edgard França Bisneto, Evaristo Melo, Hsiang Teng, Rames Mattar Jr,

Hand and Microsurgery Division of University of Sao Paulo, Brazil

Intro:We report the treatment of a patient with ulnar clubhand and ipsilateral lower limb phocomely classified as femur-fibula-ulna complex (FFU) over 9 years of postoperative follow-up. We’ve applied microsurgical and conventional procedures and shows the functional and aesthetic result. Methods:A male child, born by cesarean childbirth, with not relative parents, old brother healthy and a history of tricyclics antidepressant use by his mother. The diagnosis was established by ultrasound previous during prenatal period. He comes with 1year & 10 months old. He presented no other problems associated to other systems. He had normal psychomotor development. Gait was possible over well-formed left phocomely foot with flexed right knee prosthesis or by pelvic socket prostheses (Canadian) with fenestration to exit the foot and ankle (very lateralized) and doing a strap belt embracing the iliac crest of the contralateral hip (R).The left upper limb had normal shoulder and arm with stiff elbow without skin folds. There was a shortened forearm, no wrist joint and absence of two digits on the hand that was functional gripper. One was a well formed not entirely clear thumb. The left foot was well formed with five toes and ankle motion. In November 2005 to three years, the patient underwent transplantation of two toes of the foot to left hand, neurotization of plantar digital nerves with the nerve of the forearm with end-to-side neurorrhaphy. The other toes were amputated at the base of the metatarsal (1). Thereafter, the forearm was centered relative to the numbers (2). Graft slender plantar flexor transplanted (3) fingers was performed. The hip was reduced, it was made a neo-acetabular roof with a muscle pedicled iliac crest fixed with a screw. The ankle bones were fixed to the “femur” that contains the epiphyseal head. There was provisional hip pinning with fK (4). Twice anomalous ossification that abducted and blocked the neo femur (5.6) were removed. Varus osteotomy was performed in the second surgery associated with a scar Z-plasty scar (6).Results:After reduction of the hip and the alignment of the "femur" the patient could change the Canadian socket and proceeds to a CAT-CAM one improving the quality of his gait and energy expenditure. rnThe digits attached to the hand are sensitive, however, little added to the upper limb function, since they are not aligned with the original pinch. However, the achieved aesthetics place a major role in the socialization of the child. Conclusion Sequential surgical treatments have achieved great results in this particular patient. Discussion:Because they are rare, distinct, it becomes difficult to obtain evidence for congenital deformities. This case report with long-term follow-up of brings an interesting algorithm for treating these specific deformities in isolated way or as syndrome. Surgery start along 3 years old, close follow-up and the choice for well established techniques seems to have been the key for good results.

Luciano Torres, Rosana Suzuki, Emygdio de Paula, Candida Luzo, Marina Sambuy, Rames Mattar Junior

Hand and Microsurgery Division of University of Sao Paulo, Brazil

Introduction:Unstable fractures of the proximal interphalangeal (PIP) joint often leads to joint stiffness and loss of hand function. This study aims to report our experience in treating these fractures with the use of a dynamic traction splint proposed by SCHENCK1986 associated with early passive mobilization. The traction is applied by a rubber band attached at one end to a movable component in the arch and at the other end to a wire placed through the neck of the affected middle phalanx.Patients and Methods:The traction apparatus was installed in 3 patients between june and october 2013. Patients are 2 males and 1 female, aged 16, 19 and 33. They had unstable fractures of the PIP joint. The involved fingers were middle, ring and small ones. In two cases, assembly application occurred in the acute phase. In one case the installation occurred 6 weeks after the trauma due to unsatisfactory functional results (stiffness, swelling and pain) after GAUL1991 traction-fixation device. Patients were treated with continuous use of the arcuate splint and performed passive exercise positioning the PIP joint at maximum flexion and extension tolerated, changing position after each four-hour period in the first week, two hours in the second week and one hour from the third week of treatment. Patients wore the splint during 2-6 weeks and continued performing exercises after interrupting the use of the splint.Results:One patient abandoned treatment immediately after removal of the traction apparatus, with a ROM of about 75° of the injured PIP. The other two were evaluated 3 months after the installation of the traction splint. On patient 1, volleyball player, who underwent delayed installation of the splint, the active flexion/extension of PIP was 75°/0°; DIP: 80°/10°; and hand grip strength: 21kgf. On patient 2, student, the active motion of PIP was 95°/0°; DIP: 90°/0°; hand grip strength: 10kgf. They returned to their previous professional activities with no complaints with regard to hand function. Conclusion:Based on the results of these 3 cases, the authors believe dynamic traction splint is a reliable method for severe fracture dislocations of PIP joint.Discussion:Open reduction and Internal fixation (ORIF) is effective when it allows early rehabilitation. But for certain types of comminuted burst fracture, dislocation quite skewed or even pilon fractures. When trying to anatomic reduction and stable fixation one can trigger aggression to thin soft tissues of the finger so that it is poor reconstructive and perhaps unnecessary. rnSystems of traction with pins and elastic, or plastic deformation of the wire Kirschnner and even custom fasteners for industry require good radiographic control and early active mobilization. In our country and the profile of our patients, in practical terms it seems unreal. The pins are troublesome, they often infect superficially, patients do not feel safe to mobilize and stiffness becomes paradoxically not unusual. Size of the arched bracing Schenck sometimes called "Pan Pizza" is the major drawback of the method.

Patrícia Grangeiro, Luciano Torres, Alessandro Félix, Aline Guimarães, Laura Lorimier Fernandes, Marina Pisani, Rames Mattar Jr

Hand and Microsurgery Division of University of Sao Paulo, Brazil

Introduction:Since its first application by UEBA in 1973, free vascularized fibula graft (fvfg) has proved the most versatile of vascularized bone grafts. Its application in the hip is most related to the treatment of osteonecrosis as systematized by URBANIAK. In the present study, vascularized graft was applied to consolidate nonunion of femoral neck in a child.
Materials and Methods(Case Report):11 year old boy was the victim of trauma bicycle against light pole in April 2009 . He presented with right femoral neck fracture, epiphyseal detachment of right greater trochanter and right pubic ramus fracture. He was operated on the 6th day post-trauma through open reduction by Watson-Jones approach and femoral neck fixation with two cannulated screws 7mm and trochanter fixation with a cannulated screw. (washers associated). After 4 months, patient developed nonunion femoral neck and signs of osteonecrosis of the femur epiphysis. Surgical hardware removal (screws and washers) was followed by examination by MRI scans. Exam showed viability of the femoral epiphysis. Valgus wedge resection osteotomy with lateral base. It was accompanied by blade plate fixation and iliac crest bone grafting. There was consolidation of the osteotomy, however, the patient developed synthesis failure and maintenance of nonunion. The fractured blade and the plate were removed. On July, 15 2011 patient was operated with fvfg. The anastomoses were performed on the the lateral circumflex system. The postoperative first week scintigraphy captured fibula viability. Buoy flap survived.
Fibula was fixed with a screw along the lateral femoral shaft that was thinned. With pistoning, the contact with femoral epiphysis was loosed and the femoral shaft ascended. Patient was re-operated with the installation of a monolateral orthofix external fixator which promoted artrodiastase associated with K wire osteosynthesis drilled through fibula channel and again another transverse screw.
Results:X-ray and CT scans showed bone healing. Patient resumed full load with good range of motion (ROM) in both hip flexion-extension, adduction-abduction. There was lack in the ROM on internal rotation and lower limb length discrepancy.
On x-ray there was coxa brevis, coxa magna and elevation of the greater trochanter. On physical examination there was no detected Trendelenburg gait. Bone lengthening corticotomy with monoplanar EF under intramedullary nailing was performed on distal femur metaphysis.
Conclusion: Fvfg with microsurgery in the presented case achieved bone healing and lasting function after the failure of conventional technique attempt. The evolution for hip degeneration in the very long follow-up seems unavoidable.
Comparative to scaphoid’s proximal pole fracture, fractures of the femoral neck in a child with dislocation may deserve primary treatment with use of vascularized bone graft to increase their biology. The use of pedicled iliac crest vascularized bone graft seems more reasonable that fvfg in emergency surgery.

Renata Paulos, Luciano Torres, Luiz Sorrenti, Marcos Leonhardt, Hsiang Teng, Marina Pisani, Rames Mattar Jr

Hand and Microsurgery Division of University of Sao Paulo, Brazil

Introduction Pedicled medial plantar artery flap (MPA) is a classic choice for plantar soft tissue coverage. Despite his reach allows the repair of lower third of the leg, ankle and Achiles tendon it is rarely applied as first choice. The series with current surgical solutions includes reverse sural and propeller flaps that show failures higher than free flaps. The authors studied pioneer series of MPA flap for non-weight bearing areas Methods The authors reviewed 11 consecutive cases of non-weight bearing application of MPA. Results There were no partial or total flap necrosis, no skin graft lost. Conclusion MPA flap in the series presents as a reliable option for lower third of the leg and ankle soft-tissue coverage. Discussion The authors agree with Oberlin classification about difficult on raising flaps. Reverse sural flap is grade 2, lateral supramaleolar is grade 3 and instep of foot 4. Despite our great results, we strongly advice microvascular experience and help of experienced surgeon on debuting this particular flap.