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Resumen El sindrome del martillo hipotenar es una infrecuente lesion de la arteria cubital a su paso por el canal de Guyon relacionada con los traumatismos repetitivos. Su diagnostico requiere un elevado indice de sospecha y una adecuada historia clinica. Su tratamiento no esta bien definido en la literatura, y va desde tratamiento medico hasta cirugia reconstructiva. Presentamos el caso de un varon de 52 anos con parestesias de los dedos cuarto y quinto tras un traumatismo en la eminencia hipotenar. En el test de Allen destaco la ausencia de vascularizacion por parte de la arteria cubital, por lo que se sospecho una trombosis de la arteria que se confirmo mediante angiorresonancia. Se realizo reseccion del fragmento trombosado y bypass con una vena antebraquial para reconstruir el flujo distal. Presento una evolucion satisfactoria a los 6 meses de seguimiento.

Hypothenar hammer syndrome is an uncommon injury of the ulnar artery in its passage through Guyon's canal, and has been associated with repetitive trauma. Its diagnosis requires of a high level of suspicion and a careful clinical interview. The appropriate treatment is not well defined in the literature, ranging widely from medical treatment to reconstructive surgery. A clinical case is presented of a 52 year-old healthy male, who presented with numbness of his fourth and fifth fingers after a trauma at the hypothenar eminence. The Allen test highlighted an absence of vascularisation from the ulnar artery, thus suspecting an ulnar artery thrombosis, which was later confirmed by angio-MRI. The thrombosed segment was resected and a by-pass with a forearm vein was performed to reconstruct the distal arterial flow, presenting with a good functional outcome at 6months follow-up.

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 Ulnar carpometacarpal (CMC) joint dislocations and fracture–dislocations are uncommon injuries that are often overlooked. Most authors advocate surgical stabilization in order to prevent a secondary dislocation assuming that these injuries are inherently unstable. Case Description This is a series of eight ulnar CMC joint dislocations and fracture–dislocations treated by closed reduction and splint immobilization after assessing the joint stability. Mean follow-up was 30.2 months, and minimum follow-up was 12 months. Satisfactory results were obtained in range of motion, grip strength, pain, DASH (Disabilities of the Arm, Shoulder and Hand) questionnaire, and time to return to working activities. In the same period, the closed reduction and cast failed two (20%) cases that were referred for surgery. Literature Review There is little published literature on the nonoperative treatment of these injuries. Most of them are isolated case reports, whereas the largest series reports four cases. All of them have reported satisfactory results. Clinical Relevance Based on our results, we believe that if the diagnosis of an ulnar CMC joint dislocation or fracture–dislocation is early accomplished and a concentric and stable reduction is initially achieved, the nonoperative treatment may be a successful option to take into account but requiring a close follow-up for the first week.

Background: Management and indications for surgery in the tetraplegic patient are highly complex because of the substantial functional deficits that they present and their effect on their daily activity. Our purpose was to evaluate the functional outcome in tetraplegic patients who underwent biceps-to-triceps transfer surgery according to Zancolli’s modified technique. Methods: This is a retrospective study of 6 biceps-to-triceps transfers using Zancolli’s modified technique in 4 patients. Mean follow-up was 45 months. We evaluated each patient’s DASH (Disabilities of the Arm, Shoulder and Hand) score before surgery and 12 months later. Results: In the 6 arms that underwent surgery, 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 twelve months postoperatively. One complication occurred. One patient reported loss of elbow flexion preventing thigh lift for transfers. This was resolved with a program of rehabilitation and specific muscle strengthening Conclusions: Zancolli’s modified technique is simple and effective, with few complications, whereby we can provide more autonomy for the tetraplegic patient.

Objectives The aim of this study is to analyse the outcomes of the surgical treatment of metacarpophalangeal stiffness by dorsal teno-arthrolysis in our centre, and present a review the literature. Material and methods This is a retrospective study of 21 cases of metacarpophalangeal stiffness treated surgically. Dorsal teno-arthrolysis was carried out on all patients. A rehabilitation programme was started ten days after surgery. An evaluation was performed on the aetiology, variation in pre- and post-operative active mobility, complications, DASH questionnaire, and a subjective satisfaction questionnaire. Results The mean age of the patients was 36.5 years and the mean follow-up was 6.5 years. Of the 21 cases, the most common cause was a metacarpal fracture (52.4%), followed by complex trauma of the forearm (19%). Improvement in active mobility was 30.5°, despite obtaining an intra-operative mobility 0–90° in 80% of cases. Mean DASH questionnaire score was 36.9 points. The outcome was described as excellent in 10% of our patients, good in 30%, poor in 40%, and bad in the remaining 20%. There was a complex regional pain syndrome in 9.5% of cases, and intrinsic muscle injury in 14.3%. Conclusion Because of its difficult management and poor outcomes, surgical treatment of metacarpophalangeal stiffness in extension is highly complex, with dorsal teno-arthrolysis being a reproducible technique according to our results, and the results reported in the literature.

Resumen Objetivo Analizar los resultados obtenidos en el tratamiento quirurgico de la rigidez metacarpofalangica en extension mediante tenoartrolisis dorsal en nuestro centro y revisar la literatura al respecto. Material y metodo Estudio retrospectivo de 21 rigideces metacarpofalangicas intervenidas. En todos los pacientes se realizo tenoartrolisis dorsal de forma ambulatoria, comenzando la rehabilitacion a los diez dias postoperatorios. Se registro etiologia, variacion de la movilidad activa tras la cirugia, complicaciones, cuestionario DASH y una encuesta de satisfaccion con el resultado. Resultados El seguimiento medio fue de 6,5 anos y la edad media de 36,5 anos. La causa mas frecuente fue la fractura de un metacarpiano (52,4%) seguida de los traumatismos complejos de antebrazo (19%). A final del seguimiento la mejoria en la movilidad activa fue de 30,5° pese a obtener una movilidad intraoperatoria de 0-90° en mas del 80% de los casos. En el cuestionario DASH la puntuacion media fue de 36,9, calificando el resultado como excelente el 10% de nuestros pacientes, bueno el 30%, regular el 40% y malo el 20% restante. En el 9,5% de los casos se produjo un sindrome de dolor regional complejo y en el 14,3% lesion de la musculatura intrinseca. Conclusion Por su dificil abordaje y pobres resultados, el tratamiento quirurgico de la rigidez metacarpofalangica en extension es de gran dificultad mostrandose la tenoartrolisis dorsal como una tecnica reproducible en relacion con nuestros resultados y a los resultados publicados en la literatura.

Purpose To assess the clinical and functional outcomes of proximal interphalangeal (PIP) joint denervation using a volar approach in the treatment of PIP joint osteoarthritis. Methods We retrospectively reviewed 11 cases treated from June 2007 to June 2016. The patients were identified and outcomes collected through a single institution’s registry, collecting demographic data, comorbidities, preoperative and postoperative visual analog scale (VAS) for pain, and Disorders of the Arm, Shoulder, and Hand (DASH) questionnaire. Results The ring finger was the most commonly treated. The VAS for pain improved from 7.8 to 1.4, and the DASH questionnaire improved from 43.6 to 8.7. The PIP joint active range of motion also improved from 52° to 79°. Two patients reported postoperative digital paresthesia that resolved spontaneously. There were no major complications. Conclusions Proximal interphalangeal joint denervation is a safe technique. It achieves good clinical results and, in case of failure, a more traditional and aggressive operation remains possible. Type of study/level of evidence Therapeutic IV.

Resumen Introduccion y objetivo La epicondilitis es una lesion muy frecuente en la poblacion. La mayoria de los pacientes mejoran con el tratamiento conservador, pero en un pequeno porcentaje sera necesaria la cirugia. Nuestro objetivo es analizar los resultados clinicos obtenidos mediante una intervencion consistente en «4 gestos quirurgicos». Material y metodo Estudio retrospectivo de 35 codos intervenidos con un seguimiento medio de 5,3 anos. En todos los casos se realizo denervacion epicondilea, extirpacion del nucleo de degeneracion angiofibroblastica, epicondilectomia y liberacion del nervio interoseo posterior. Se recogieron los resultados mediante Broberg and Morrey Rating System (BMRS), Mayo Elbow Performance Score (MEPS), Escala Visual Analogica (EVA), cuestionario DASH y una encuesta de valoracion subjetiva por parte del paciente. Resultados La puntuacion media del BMRS fue de 97,2 puntos, MEPS de 95,71 puntos. La reduccion media en la EVA fue de 8,12 puntos y la puntuacion media en el DASH fue de 1,68 puntos. El 94,3% de los pacientes valoraron el resultado como excelente o muy bueno. Se produjo una recidiva que se solvento con una nueva cirugia y una neuroapraxia del nervio interoseo posterior en 2 casos, recuperados integramente en 10 semanas. Conclusiones Con esta intervencion basada en 4 gestos, se ha conseguido la resolucion clinica en el 97,1% de los casos en la primera cirugia, por ello, consideramos esta tecnica efectiva, reproducible y con una aceptable tasa de complicaciones en el tratamiento quirurgico de la epicondilitis resistente a tratamiento conservador.

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.

Background: Axial carpal dislocations and fracture-dislocations remain difficult to understand and to treat. The outcome is directly related to the injury pattern and long-term results are not good in most cases. Methods: 39-year-old male admitted to our emergency department after his left hand was caught between 2 rollers for 10 minutes. He was diagnosed of an open axial carpal dislocation type B (perihamate peripisiform) and type E (peritrapezium) of Garcia-Elias. An extensive debridement, reduction of the carpometacarpal dislocations and stabilization with Kirschner wires was performed requiring a full thickness skin graft 14 days after the trauma. Results: At 4-year follow-up, he had 70° of wrist extension, and 78° of wrist flexion, grip strength of 65% compared to the healthy side and x-ray showed mild signs of osteoarthritis. He was satisfied and returned to the same job. Conclusions: Axial carpal dislocations continue to be difficult injuries to address but also to classify. Since the prognosis depends on the injury pattern and other associated lesions, we believe that adding a type G which include the association of different patterns to the classification of Garcia-Elias could be useful not in changing the treatment but probably indicating a worse prognosis.

Pacinian corpuscles are rapidly adapting mechanoreceptors distributed in the dermis of the fingers and palm of the hand. A neuroma of the pacinian corpuscle is rare and extremely painful, with only a few cases reported in the literature. A 71-year-old man with pain and swelling on his left index finger, initially diagnosed as tenosynovitis resistant to nonsurgical treatment, was referred to our center. During surgery, a cluster of spherical, gray lesions close to the digital nerve was found and excised. The pathological diagnosis was neuroma of the pacinian corpuscles. Two years later, he reported the same clinical findings on his right index finger with no improvement after nonsurgical treatment. During surgery, the same lesions were found and also identified as pacinian corpuscle neuromas.

Introduction and objectives Lateral epicondylitis is a common injury in the population. Most patients improve with conservative treatment, but in a small percentage surgery is necessary. The aim of this study is to analyse the clinical results obtained by a “4 surgical tips” technique. Materials and method This is a retrospective study of 35 operated elbows, with a mean follow-up of 5.3 years. In all cases epicondylar denervation, removal of the angiofibroblastic degeneration core, epicondylectomy, and release of posterior interosseous nerve, was performed. Each patient was evaluated using the Broberg and Morrey Rating System (BMRS), Mayo Elbow Performance Score (MEPS), Visual Analogue Scale (VAS), DASH questionnaire, and a survey of subjective assessment. Results BMRS mean score was 97.2 points, with 95.71 points with the MEPS. The mean decrease in VAS was 8.12 points, and the mean score on the DASH was 1.68 points. The results were rated as excellent or very good by 94.3% of patients. There was one recurrence, which resolved with further surgery. Two neuropraxia of the posterior interosseous nerve occurred, which completely recovered in 10 weeks. Conclusions Using the “4 surgical tips” technique, clinical resolution of symptoms in 97.1% was achieved at the first operation. Therefore, it appears to be an effective, reproducible technique with few complications, in the surgical treatment of lateral epicondylitis resistant to conservative treatment.

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.