Search

Resumo Objetivo A clinodactilia é uma deformidade congênita da mão, caracterizada por desvio angular coronal, podendo ocorrer em polegares ou dedos. O tratamento cirúrgico é indicado para angulações severas. Dentre as técnicas descritas, uma das opções consiste no alinhamento ósseo, através de osteotomia em cunha de adição da falange anômala. Essa manobra de alinhamento gera uma dificuldade de cobertura cutânea, juntamente com a tensão das partes moles no lado côncavo da deformidade. Sendo assim, algum tipo de retalho cutâneo é necessário para o fechamento adequado da ferida cirúrgica. Objetivamos demonstrar a técnica citada e avaliar os resultados do retalho bilobado no tratamento das clinodactilias da mão. Métodos Estudo retrospectivo entre janeiro de 2008 e janeiro de 2015. Foram incluídos cinco pacientes no estudo, nove dedos foram submetidos à cirurgia. Tiveram indicação cirúrgica os pacientes com desvios angulares nos dedos acima de 30 graus. Não foram excluídos do estudo os pacientes com deformidades no polegar, nem aqueles com deformidades associadas a síndromes. Foram avaliados os resultados funcionais e estéticos com o uso desta técnica, assim como as complicações e o grau de satisfação dos familiares. Resultados Todos os pacientes apresentaram resultados funcionais e estéticos satisfatórios, com cicatrização cutânea média de 18,6 dias. Entre os nove dedos submetidos à cirurgia, apenas um dos pacientes apresentou comprometimento vascular na porção distal do primeiro lobo do retalho, porém sem necrose ou necessidade de qualquer procedimento adicional. Os pacientes foram acompanhados durante um intervalo mínimo de 12 meses. Nenhuma deformidade ocorreu durante o período de observação. Conclusão O uso do retalho bilobado no tratamento das clinodactilias da mão é uma boa opção para cobertura cutânea após a realização de osteotomia.

Introducción. El fibroma desmoplásico (FD) es un tumor óseo de características benignas, pero localmente agresivo, que se considera primario, raro, lítico y no metastásico; esta neoplasia representa el 0.1% de todos los tumores primarios de hueso. A continuación se presenta el caso de un paciente con FD en el cual el diagnóstico se estableció a través de los hallazgos radiológicos e histológicos y se describe la decisión de tratamiento.Presentación del caso. Paciente masculino de 64 años, quien acudió al Servicio de Ortopedia del Hospital General de México por pérdida de la fuerza progresiva del brazo y antebrazo izquierdo con disminución de los rangos de movilidad y dolor en la zona. El sujeto fue diagnosticado con FD, intervenido con radioterapia por el servicio de radiooncología y manejado con una ortesis por el servicio de ortopedia. Se planteó la posibilidad de realizar transposición de los nervios mediano, cubital y radial, pero el paciente no aceptó el procedimiento.

The purpose of the present study was to determine clinical and radiographic outcomes in patients treated with limited-open retrograde intramedullary headless screw fixation for metacarpal neck and shaft fractures (group I) versus percutaneous antegrade and retrograde intramedullary double pinning linked by a connector (group II). We designed a retrospective comparative study, with the inclusion of two groups (20 patients each) of metacarpal unstable fractures. Both groups showed similar outcomes at the final follow-up, except for extension lag (significantly better in group II) and return to sport (significantly better in group I). Intramedullary screw fixation did not accelerate bone union and range of motion recovery in the early follow-up. In conclusion, limited-open retrograde intramedullary headless screw fixation and percutaneous connected antegrade and retrograde intramedullary double pinning are both reliable techniques of fixation for metacarpal neck and shaft fractures. LEVEL OF EVIDENCE: III.

The scaphoid is the carpal bone that most often fractures, accounting for up to 70% of carpal fractures and 11% of hand fractures. It is the second most common arm fracture, only surpassed by fractures of the distal radius. Despite being so common, these fractures can be difficult to diagnose and treat due to the anatomic and physiological particularities of the bone, including its precarious vascularization, its complex three-dimensional structure, and its ligament connections, which greatly contribute to the risk of complications such as malunion, pseudoarthrosis and avascular necrosis. Although there are many published studies on the treatment of these injuries, there is still controversy over what is the most suitable one for certain fracture types. The present article is a comprehensive and updated review of the literature. Combining strategies for clinical and radiological diagnosis, we propose a complete algorithm for the diagnosis of scaphoid fractures based on the varying availability of resources, and we also describe the most appropriate therapeutic approach for the different types of acute fractures of this bone.

Despite being the second most common osteoarthritis of the wrist, little is known about scaphotrapeziotrapezoid osteoarthritis. Not all patients with this type of osteoarthritis have symptoms, and, even in those symptomatic patients, the intensity of the complaint is not proportional to the severity of the degeneration. In symptomatic patients, when the conservative treatment fails, grading classifications to help define the surgical treatment are solely based on the joint characteristics, and fail to assess the rest of the carpus.In general, most carpal degenerative processes show the same evolution pattern, which varies according to the initial injury, along with the type of deformity and the inherent instabilities. Thus, we hypothesize that the degenerative evolution due to primary osteoarthritis of the scaphotrapeziotrapezoid joint also follows a logical evolutionary sequence, similar to the one that occurs in cases of scapholunate advanced collapse (SLAC), scaphoid nonunion advanced collapse (SNAC), scaphoid malunion advanced collapse (SMAC), and scaphoid chondrocalcinosis advanced collapse (SCAC), thus resulting in scaphotrapeziotrapezoid osteoarthritis advanced collapse (SOAC). We have divided the SOAC into three groups, and considered that their treatment shall be guided by the evolutionary stage of the disease, and not by the surgeon's preferred technique.

Resumo Objetivo Descrever a técnica e os resultados da artroscopia no tratamento cirúrgico dos cistos sinoviais volares no punho. Materiais e Métodos Foram incluídos e analisados neste trabalho 21 pacientes submetidos a artroscopia para o tratamento de cisto sinovial volar no punho, no período entre janeiro de 2015 e maio de 2017, com avaliação completa e mínima de 6 meses. A técnica descrita foi indicada para os pacientes com dor e incapacidade funcional com duração de mais de quatro meses, sem melhora com o tratamento conservador, ou para aqueles com queixas estéticas e que apresentavam o cisto havia mais de três meses. Resultados A média de idade dos pacientes foi de 43,6 anos, sendo 16 (76%) do sexo feminino, e 5 (24%) do masculino. O tempo de seguimento médio entre a cirurgia e a avaliação final foi de 10,9 meses. Um total de 2 (9,6%) pacientes apresentaram dor leve e uma restrição da mobilidade no pós-operatório. Nos 18 (90,4%) pacientes restantes, houve melhora das queixas estéticas, recuperação funcional completa, e melhora completa da dor. Não houve recidivas ou infecções. Nenhum paciente necessitou ser submetido a nova cirurgia. Conclusões A ressecção artroscópica do cisto sinovial volar mostrou-se uma técnica útil e segura. É um procedimento minimamente invasivo, com baixa morbidade e poucas complicações, sendo uma boa alternativa à técnica aberta.

Background Posterior dislocation of the elbow associated to a radial shaft fracture is a rare lesion, its treatment is difficult and complicated, and the indications, surgical options, and timing of surgery may vary. In the present case, we performed immediately after the trauma (urgent care) an open reduction internal fixation (ORIF) surgery of the radial fracture by means of a 3.5 mm locking plate, associated to closed elbow reduction and stabilization with dynamic bracing. Case Report A 26-year-old woman was seen in our service with a traumatic deformity of her right, dominant forearm and elbow after a fall from a balance board and presented with a radial shaft fracture and posterior elbow dislocation. The palmar approach was used and the shaft fracture was fixated. During the radial fracture reduction maneuver, the dislocation of the elbow was spontaneously reduced. At 1 year postoperatively, the patient showed good wrist, forearm, and elbow range of motion (ROM). Disabilities of the arm, shoulder and hand (DASH) score of 5, visual analogue scale (VAS) of 0, and grip strength of 92%, as compared with the nonaffected side. Clinical Relevance Nowadays, case reports of concomitant, ipsilateral multiple injuries that uncommonly occur together in a single traumatic episode are very rare. The awareness of this association for early recognition is of paramount significance for ideal clinical results.

Background Madelung's deformity (MD) comprises increased volar and ulnar tilt of the distal radius joint facet, secondary to an idiopathic physeal dysplasia. Such change causes radial shortening and a consequent distal ulnar prominence, along with wrist pain and loss of motion. Classic surgical techniques are problematic for adults, as they are specific for children and adolescents whose distal radial physis is still open. Description of Technique It is suggested a new treatment method for MD in skeletally mature patients: a distal radius osteotomy and joint realignment are performed through a volar approach to increase the support area of the lunate bone. The rotation and lengthening of the distal epiphysis of the radius generate support and cover to the lunate bone, with improvement of both radiocarpal and distal radioulnar joints. Patients and Methods We describe the technique in details and report the treatment of a 25-year-old female patient. Results Early clinical and radiographic outcomes are encouraging for the treatment of symptomatic patients. Conclusion There is a plethora on the literature about conflicting opinions on the best treatment options and surgical techniques are quite variable, although usually with good results. Besides, the technique here described is indicated during a specific stage of disease presentation, consisting of young adults without any wrist-degenerative changes. Having said that, it is possible to claim that MD treatment with shelf osteotomy is a concept change. Our main goal is to reconstruct the diseased segment and improve wrist stability.

The indications of wrist arthroscopy are expanding with the advancement of technical and instrumental development. Most of the diseases in the joint can be managed by this minimally invasive technique with proper portal selection and establishment. This chapter describes in detail the various portals of radiocarpal and midcarpal joint and indications, contraindications, and arthroscopic techniques to manage various pathologies of the wrist joint, including acute and chronic scapholunate ligament injuries, acute lunotriquetral ligament injury, chronic lunotriquetral instability, arthrofibrosis of the wrist, extrinsic ligament injuries of the wrist, midcarpal instability, acute scaphoid fractures, scaphoid nonunion and scaphoid nonunion advanced collapse (SNAC) lesions, distal radius fractures, intra-articular malunions of the distal radius, perilunate injuries, Kienbock’s disease, inflammatory and degenerative arthritis of the wrist, osteochondral lesions, volar, and dorsal wrist ganglion.

The triangular fibrocartilage complex (TFCC) is the major stabilizer of the distal radioulnar joint. TFCC disorders may have traumatic or degenerative etiology. TFCC is most often lacerated at its ulnar periphery. According to the magnitude and direction of the traumatic force, the TFCC may rupture in a variable manner, and the ulnar styloid may also fracture, producing different subtypes of type 1B tears. Treatment options are variable, depending on the tear’s features. Atzei introduced in 2011 a novel treatment-oriented classification subdividing 1B-type lesions into five different classes according to the finding of special radiocarpal arthroscopic tests and distal radioulnar joint arthroscopy. In this chapter, the all-inside arthroscopic repair technique for Atzei class 2 and 3 TFCC foveal lesions is described.

Purpose Evaluate the Scratch Collapse Test in an objective way, by replacing the subjective evaluation made by the physician with an objective evaluation measure, made with a digital dynamometer. Methods Observational study carried out, in 90 patients divided into three groups of 30 patients, taking into account the electromyographic study of the median nerve in the carpal tunnel (no alteration, moderate, severe).The external rotation of the shoulder was measured in four different situations (no scratch, scratch over the carpal tunnel, scratch in the dorsum of the wrist and scratch in the shoulder). Results There were no statistical differences in the result of the strength in any of the four different situations in patients without carpal tunnel of with moderate carpal tunnel syndrome. However, there were statistical differences between the basal measurement (without scratching) and the measurement after tunnel scratching in patients with severe carpal tunnel syndrome. But this statistical difference was only 0.08 kg in the average measure, and this difference is clinically undetectable and far for producing a real collapse of the external rotation of the shoulder. Conclusion The Scratch Collapse Test is not a valid diagnostic exam for carpal tunnel syndrome if the strength is measured in an objective manner.

Our purpose was to review the clinical usefulness of the scratch collapse test (SCT) in the diagnosis of proximal entrapment of the median nerve in the forearm. Eighteen consecutive cases were reviewed. The diagnosis was based on the patient’s symptoms and signs. The SCT was positive in the affected forearm in all clinical assessments before surgery and it was negative in all after median nerve release. An anatomical reason for nerve compression was identified in all cases at operation. The SCT is a useful tool for the diagnosis of the proximal entrapment of the median nerve. Level of evidence: IV

Purpose To study the time to wound healing and recurrence rate achieved in the treatment of distal interphalangeal joint mucous cysts using the Zitelli modified bilobed flap. Methods We surgically treated 33 patients from January 2006 to June 2015. We assessed demographic data, comorbidities, location and size of the cyst, time to wound healing, and complications. Results The most affected finger was the right middle finger. All flaps survived and wounds healed in 14 days on average. The mucous cyst recurred in 1 of 33 cases. There were no major complications. Conclusions The Zitelli bilobed flap can provide good-quality skin coverage over the distal interphalangeal joint in a short period. Type of study/level of evidence Therapeutic IV.

Background: The trigger finger is characterized by the painful blocking of finger flexor tendons of the hand, while crossing the A1 pulley. It is a rare disease in children and, when present, is usually located in the thumb, and does not have any defined cause. Methods: We report 2 pediatric trigger finger cases affecting the long digits of the hand that were caused by an osteochondroma located at the proximal phalanx. Both children held the diagnosis of juvenile multiple osteochondromatosis. They had presented at the initial visit with a painful finger blocking. Surgical approach was decided with wide regional exposure, as compared with the trigger finger traditional surgical techniques, with the opening of the A1 pulley and the initial portion of the A2 pulley, along with bone tumor resection. Results: Patients evolved uneventfully, and recovered the affected finger motion. Conclusion: It is important to highlight that pediatric trigger finger is a distinct ailment from the adult trigger finger, and also in children is important to differentiate whenever the disease either affects the thumb or the long fingers. A secondary cause shall be sought whenever the long fingers are affected by a trigger finger.

Proximal radioulnar synostosis is a rare but highly disabling posttraumatic complication in periarticular elbow injuries. Surgical treatment is an option for functionally limiting proximal radioulnar synostosis; however, the approach can endanger local neurovascular structures, especially if the synostosis affects the level of the bicipital tuberosity. We report two cases of proximal radioulnar synostosis with a preoperative prono-supination range of motion of 0° and 15° treated by a reverse Sauve-Kapandji procedure resecting a 1-cm section of the radial shaft distal to the bicipital tuberosity and leaving the synostosis in place. An improvement in prono-supination arc of motion of 82.5° was achieved at 2 years of follow-up with no complications associated with the technique. The reverse Sauve-Kapandji procedure could be an option in the treatment of proximal radioulnar synostosis in selected cases.

La artrosis de la muneca es una de las patologias mas frecuentes y precisa un estudio detallado de la misma para realizar el tratamiento mas adecuado. La artrodesis de cuatro esquinas con reseccion del escafoides es un procedimiento aceptable para tratar los cambios degenerativos, especialmente en la muneca SLAC/SNAC. El objetivo es fusionar las articulaciones mediocarpianas dolorosas manteniendo la movilidad a traves de la articulacion radiolunar. Las tecnicas quirurgicas se han ido desarrollando a lo largo de las ultimas decadas y los resultados funcionales han mejorado, pero no sus complicaciones. En este articulo se presentan los metodos de fijacion y se revisa su evidencia cientifica en la literatura, asi como los nuevos conceptos y tecnicas, como la artroscopia. Osteoarthritis of the wrist is one of the most common conditions and requires careful analysis and specific indications and rationale for appropriate treatment. Four-corner arthrodesis with scaphoid excision has been shown to be an acceptable method for treating this degenerative changes, especially SLAC/SNAC wrist. The goal is to fuse the painful, diseased midcarpal joints and to preserve motion through the radiolunate joint. Surgical techniques have advanced over the last few decades, and the functional outcomes have improved but complications not decreased. In this article we discuss the fixation methods available and review the corresponding evidence in the literature. New implants and new concepts are also discussed, as arthroscopic-assisted technique.

A 40-year-old woman presented with Madelung deformity and severe arthritic changes at both the radiocarpal and the distal radioulnar joints. She was treated by using her lunate as an osteochondral graft into the radius allowing reconstruction of the lunate fossa. The scaphoid and triquetrum were removed concomitantly and a Sauve-Kapandji procedure was performed. Complete bone healing was achieved. Ten years later, an excellent functional result was maintained, with a pain-free wrist, an acceptable wrist joint range of motion, as well as a favorable aesthetic appearance. This procedure may be indicated for patients with severe Madelung deformity with painful radiocarpal and distal radioulnar joints associated with severe arthritis changes.

Background: The anterior interosseous nerve (AIN) is a motor nerve innervating the deep muscles of the forearm. Its compression is rare, its diagnosis is not easy, and the existence of 2 really differentiated injuries (anterior interosseous syndrome and Pronator Teres syndrome) seems to be, at least, questionable from a clinical point of view. Purpose: The purpose of this study was to study the results obtained after surgical treatment of patients clinically diagnosed of AIN compression by the Scratch Collapse Test (SCT). Materials and Methods: From June 2013 to January 2016, 20 patients underwent surgery for proximal compression of the median nerve. The diagnosis was made based on the patient’s symptoms and positivity of the SCT in three consecutive consultations. In all patients, electromyogram (EMG) and magnetic resonance imaging (MRI) were performed to exclude other space-occupying injuries that could justify the symptoms. They were 13 men and 7 women. Average age at surgery was 32 (13-53) years and follow-up was 14 (1-32) months. All surgeries were carried out by the same surgeon and all areas of possible nerve compression were released. In 4 cases, the diagnosis of “double crush syndrome” was made and the carpal tunnel was also released. Results: EMG was reported as abnormal only in patients diagnosed of “double crush syndrome.” MRI showed any abnormality in 4 patients. In all patients, the SCT was negative at the first postoperative consultation. All patients returned to their normal activities without sequelae but 4 of them developed a keloid scar. Conclusions: Based on our results, we believe that the SCT is a useful test in clinical diagnosis and postoperative monitoring of anterior interosseous nerve compression.

Background: The coronoid process has not received much attention in the treatment of traumatic injuries of the elbow until recent years. In addition, there are few studies in the literature that explore the arthroscopic treatment thereof. Purpose: To study the feasibility of arthroscopically assisted treatment of coronoid process types I and II fractures. Materials and Methods: From February 2009 to October 2015, 11 patients underwent surgery for a coronoid process fracture associated with other injuries. There were all males with a mean age of 43 (28-61) years and follow-up of 14.5 (4-28) months. In all patients, arthroscopic reduction and transosseous fixation of the fracture were carried out using a FiberWire (Arthrex, Naples, Florida) suture, and the associated bony and ligamentous injuries were also repaired. After surgery, a splint was used for 18 days, and physical therapy was started after its removal. Range of motion was measured, function was assessed with the Mayo Elbow Performance Scoring (MEPS) questionnaire, pain by Visual Analogue Scale (VAS), and disability using the Disabilities of Arm, Shoulder and Hand (DASH) questionnaire. Results: Ten fractures were type II and 1 fracture was type I. Nine patients had an associated injury of the radial collateral ligament, whereas 1 had an associated injury of the ulnar collateral ligament. Six had an associated fracture of the radial head (5 osteosynthesis and 1 fragment excision). Six patients were diagnosed as terrible triad of the elbow. Mean time to bone healing was 5 weeks. All patients had a stable elbow. The range of flexion and extension at the end of follow-up was 131.5° (120-140) to 9.5° (0-25), and pronosupination was 89° (80-90) to 86° (70-90). MEPS was 90.7 (70-100) points, VAS at rest 0 points, active VAS 0.6 (0-2), and force VAS 2.6 (0-5); finally, DASH questionnaire was 13.6 (4.5-20.5) points. No postoperative complications were reported. One patient developed mild residual pain. Conclusions: Although our series presents a limited number of cases, we believe this work shows the feasibility of an arthroscopically assisted treatment in fractures of the coronoid process using a high strength transosseous suture fixation and repairing the associated injuries when necessary.

BACKGROUND The corticoperiosteal flap from the medial femoral condyle has become the workhorse in the management of recalcitrant nonunions with vascularized periosteum. Inclusion of the outer condylar cortex has been advocated to avoid damaging the osteogenic capacity of the periosteum and is at present an ordinary technical step in the procedure. PATIENTS A clinical prospective study was undertaken to evaluate the effectiveness of periosteal-only microvascular transfers from the medial femoral condyle associated with bone grafts in the treatment of recalcitrant nonunions. A group of 8 patients with periosteal-only flaps (study group) is compared with a corticoperiosteal control group (13 patients). A statistical analysis is made of the results. RESULTS We had 100% union rate in both the study and control groups. Evaluation of early signs of bone healing by two independent evaluators did not found differences between the groups (4.5 months in the study and 4.9 months in the control group). CONCLUSIONS Although not statistically significant because of the small sample size, our study might support the idea that both periosteal and corticoperiosteal flaps from the medial femoral condyle are effective, when associated with a bone graft, in the treatment of recalcitrant nonunions with small gaps. A further analysis of the results suggests, albeit no statistical significant, that structural and nonstructural bone grafts are both effective when associated with a vascularized periosteal or corticoperiosteal transfer from the medial femoral condyle.

Non-surgical approaches have been developed to enhance nerve recovery, which are complementary to surgery, and are an adjunct to the reinnervation process. A search of PubMed, Medline, CINAHL, DH data and Embase databases was performed using the keywords ‘peripheral nerve injury’ and ‘treatment’. Most of the conservative therapies are focused to control neuropathic pain after nerve tissue damage. Only physical therapy modalities have been studied in humans and their effectiveness is not proved. Many modalities have been experimented with to promote nerve healing and restore function in animal models and in vitro studies. Despite this, none have been actually translated into clinical practice. The hypotheses proved in animals and in vitro should be translated to human clinical practice.

Objetivo: La fractura de la extremidad distal del radio (FEDR) es un traumatismo frecuente a cualquier edad y su tratamiento es aun tema de controversia. El objetivo del trabajo es determinar la tendencia actual de manejo en cirujanos especialistas en cirugia de la mano. Material y metodo: Se realiza una encuesta electronica remitida por correo electronico a miembros de la Sociedad Espanola de Cirugia de la Mano (SECMA). A los participantes se les pregunta por sus preferencias respecto a clasificacion, tratamiento conservador y quirurgico de estas fracturas. Se valoran sus resultados con la evidencia cientifica actual al respecto. Resultados: Se obtuvieron 49 respuestas (14,41% de los socios encuestados) La mayoria tenian mas de 21 anos de experiencia como cirujanos de mano. La clasificacion mas usada fue la de AO-ASIF. Las FEDR estables se realiza de forma conservadora con yeso sin incluir el codo. El tratamiento de eleccion quirurgico es la fijacion interna con placas volares y tornillos. No es habitual la utilizacion de la artroscopia como asistente de la reduccion y en casos de inestabilidad de la RCD se trata mediante fijacion con agujas transfixiantes o tornillos de fijacion de la estiloides cubital. No hay consenso de utilizacion de suplementos biologicos ni tratamiento coadyuvantes de la osteporosis. La toma de decisiones se realiza tomando en cuenta su experiencia personal y los conocimientos adquiridos durante su vida profesional. Conclusiones: El manejo de las FEDR varia en funcion de la experiencia de cada cirujano y no se correlaciona necesariamente con la evidencia cientifica publicada al respecto. Su manejo es heterogeneo y se necesitan estudios mayores y elaborar patrones de consenso para el manejo de estas lesiones. Purpose: Distal radius fracture (DRF) is a common injury at any age, and treatment is still controversial. The aim was to determine current trends of managing DRF among hand surgeons. Methods: A single electronic questionnaire was e-mailed to members of the Spanish Society of Hand Surgery (SECMA). Participants were asked for their preferences regarding classification, conservative and surgical treatment of these fractures. Their results are compared with current scientific evidence on this. Results: A total of 49 SECMA members completed the questionnaire (14.41%). Most of them had over 21 years of experience as hand surgeons. The AO-ASIF classification was the most used. Stable DRF was treated conservatively with plaster, excluding the elbow. The surgical treatment of choice was open reduction and internal fixation with volar plates and screws. The arthroscope was not used routinely as reduction assistant, and instability of the distal ulnar joint is treated by fixation with transfixing pins or screw fixation of the ulnar styloid. No consensus was found as regrards bone supplements and biological treatment of osteporosis. Decision making is by their personal experience and knowledge acquired during their working life. Conclusions: DRF management varies depending on the experience of individual surgeons, and does not necessarily correlate with the published scientific evidence. Management is heterogeneous and larger studies and standard protocols are needed for the management of these injuries.