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BACKGROUND A snapping wrist is a rare symptom that results from the sudden impingement of one anatomic structure against another, subsequently causing a sudden movement only during wrist movement. CASE SUMMARY A 30-year-old woman with a history of right wrist contusion reported right wrist snapping after overuse. The snapping became symptomatic after moving heavy objects. The pain persisted even when she received 1 mo of conservative treatment. Physical examination showed painful wrist snapping during wrist radioulnar motion and thumb abduction-adduction. Radiography demonstrated bone overgrowth over the radial styloid process. Sonography disclosed a tendon jumping over a bony prominence in the first compartment during wrist motion. Magnetic resonance imaging revealed no anomalous tendon nor tumorlike lesion. Under the wide-awake local anesthesia no tourniquet (WALANT) technique, the lesion was identified in the first extensor compartment. The patient received stepwise extensor retinaculum release, synovectomy, and bone spur removal. By 6th week, the patient was completely free of pain and unable to snap her wrist. She started working 7 wk after the surgery. One year after the surgery, the wrist snap was not recurrent. CONCLUSION Careful physical examination and dynamic sonography may confirm the diagnosis of a snapping wrist. With the WALANT technique, the lesion could be identified under direct vision, and we could take stepwise interventions according to intraoperative presentations.

Tuberculosis (TB) is one of the major health problems in developing countries. India has the highest TB burden with approximately 27% of global TB [6]. (India TB Report 2018 Revised National TB Control Programme (2018)). The most common form of tuberculosis constitutes pulmonary tuberculosis. Among extra pulmonary tuberculosis, the musculoskeletal tuberculosis accounts for about 10–15% cases (Mohd Altaf Mir, Imran Ahmad, Mihd Yaseen (2016) World J Plast Surg 5(3):313–318). Hand involvement is seen in 10% of patients with musculoskeletal disease. There has been recent interest in tuberculosis of the hand because of a rising incidence owing to increasing numbers of immigration, an aging population, and immunosuppressed people including affected patients with human immunodeficiency virus [3,7] (Centre for Disease Control (1995) MMWR 14:1–16), Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Omawi M (2011) J Hand Surg 36:1413–1422). Tuberculous tenosynovial disease (TBTS) is the most common presentation of hand tuberculosis. In the hand, the flexor tendon sheath and radio-ulnar bursae are the most common sites of tenosynovitis. Tuberculosis of hand is more commonly seen in the dominant hand of the male population (Al-Qattan MM, Al-Namla A, Al-Thunayan A, Al-Omawi M (2011) J Hand Surg 36:1413–1422). Here, we present a case of TBTS affecting extensor compartment of dominant hand in a post renal transplant immunosuppressed individual.

Candida parapsilosis has been considered an emerging pathogen with increasing incidence reported in the literature. As a normal commensal of human skin, it is likely that Candida species could gain access to soft tissues of the hand and wrist by direct inoculation, resulting in an infectious tenosynovitis. With the increased prevalence of intravenous drug use (IVDU), users are at increasing risk for musculoskeletal infections including soft tissue abscesses, cellulitis, tenosynovitis, and septic arthritis. Chronic tenosynovitis, with rice body formation in particular, is a comparatively rare musculoskeletal infection. Knowledge of this entity, the related pathogens, imaging findings, and the treatment plan is important not only to the treating clinician, but also to radiologists as the physiological and anatomic consequences can be detrimental to patient recovery. Keywords: Candida Parapsilosis, Extensor tendon, Wrist, Intravenous drug use

The structures on the radial side of the wrist and thumb base can be approached by a longitudinal incision on the radial side of the wrist. However, longer longitudinal scars can be cosmetically unacceptable and can result in a scar contracture. It is preferable to curve longer incisions along the Langer’s skin lines to achieve better scar characteristics. Curving the incision also enables an extensile approach and provides easy access to the thumb base, radial carpus, and radial wrist joint. We describe our approach as a “Link” between the most common approaches that surgeons are familiar with; the dorsoulnar approach to the thumb metacarpophalangeal joint for ulnar collateral ligament repair and the flexor carpi radialis approach for distal radial fracture fixation. The zone between these two incisions is not as frequently approached. Our incision connects these two well established incisions and we have described a step by step approach to this unfamiliar area. This “Link zone” overlies the thumb trapeziometacarpal joint, scaphotrapeziotrapezoid joint, and the radial styloid. It contains superficial branches of the radial nerve, first extensor compartment tendons, and the deep branch of radial artery in the anatomic snuff box. The “Link incision” is an extensile approach in both the proximal and distal directions.

Resistance of de Quervain’s disease to conservative treatment has been associated with an intertendinous septum in the first compartment; little is known about the histological features of such a septum. This study aimed to examine the intertendinous septum histologically and note its variations. After dissecting the first extensor compartment of 24 hands from 12 fresh frozen cadavers, the presence of any intertendinous septa was determined. The length of the extensor retinaculum and intertendinous septum was measured; histological findings of the first compartment with or without septa were studied and compared with those of the third/fourth compartment. Intertendinous septa were observed in 12 of 24 wrists. Histological assessment of the intertendinous septum revealed tissue similar in composition to the retinaculum observed between the third and fourth compartments.

Case We report on the rare occurrence of first extensor compartment tendon injury at the myotendinous junction after fractures of the radial styloid and both-bone forearm in a healthy 59-year-old man. Here, a novel technique for repair of this unique injury and an additional proposed mechanism of tendon rupture are discussed. Conclusion We advocate for the suspicion of tendon rupture in the first dorsal compartment with fractures of the radial styloid and both-bone forearm. Tubularization and transfer of the abductor pollicis longus and extensor pollicis brevis tendons to the brachioradialis muscle may be of benefit in these patients.

A 53-year-old woman presented with a 2-month history of radial side pain in her right wrist. Physical examination revealed that the pain was worsened by right thumb flexion and on Finkelstein’s test. On wrist ultrasonography, the first extensor compartment revealed extensor pollicis brevis (EPB)

To evaluate the risk of iatrogenic injury when using a dual-incision minimally invasive technique to decompress the anterior and peroneal compartments of the lower leg. Forty lower extremities from 20 adult cadavers, embalmed with Thiel’s method, were subject to fasciotomy of the anterior and peroneal compartment using a dual-incision minimally invasive fasciotomy. The first incision was made 12 cm proximal to the lateral malleolus to identify and protect the superficial peroneal nerve (SPN). The second incision was made at the mid-point of the Fibula (half-way between the fibular head and the lateral malleolus). Release of the anterior and peroneal compartments was successful in all specimens. Two nerve injuries of the superficial peroneal nerve were reported. More precisely, in these cases the medial dorsal cutaneous nerve got injured during the fascial opening of the extensor compartment. Two incision minimally invasive fasciotomy to decompress the anterior and peroneal compartments of the lower leg appears to be safe with regard to the results of this study.

Background The bone graft vascularized by the 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) placed on the scaphoid by a dorsal approach is a technique used to treat scaphoid nonunions with avascular necrosis of the proximal pole and without significant bone loss or carpus collapse. We present the results of patients treated with a volar rerouting of the 1,2 ICSRA graft under the tendons of the first extensor compartment to treat more distal scaphoid nonunions than the proximal pole. The aim of this study was to assess the clinical and radiological outcomes of patients operated with this technique with the hypothesis that it would allow to treat more distal nonunions than those of the proximal pole. Patients and methods This retrospective study involved patients treated by a volar rerouting of the 1,2 ICSRA graft for nonunions of the middle and distal thirds of the scaphoid. Assessments included clinical outcomes and radiological bone consolidation. QuickDASH and Mayo Wrist scores were computed. Range of motion and grip strength were evaluated for both the operated and the contralateral sides. Results Nineteen patients were followed-up for 33 months (range: 6-75). Mean postoperative QuickDASH score was 10 (range: 0-45), and mean Mayo wrist score was 85 (range: 50-100). Flexion and extension, ulnar and radial deviations were statistically different between the affected and healthy sides (p Discussion This technical modification allowed good functional outcomes and scaphoid consolidation. It expands the classic indications of the vascularized 1,2 ICSRA bone graft to more distal nonunions than the proximal pole. Level of evidence IV.

Background Anatomical variations in the first extensor compartment are associated with the pathogenesis of de Quervain's disease. Here, we report two novel anatomical variations of the first extensor compartment. Methods The wrists of two adult cadavers were dissected to reveal the anatomical variations in the first extensor compartment. Results In one of the cadavers, no septum was present in the first extensor compartment. However, the extensor pollicis brevis tendon and its proximal muscle belly were absent. The abductor pollicis longus (APL) tendon had multiple slips, and one of them inserted on the dorsal base of the proximal thumb phalanx. In another cadaver, a septum was present in the first extensor compartment. One of the multiple APL tendon slips ran into the septum alongside the extensor pollicis brevis tendon for 4 mm, which then exited the septum and inserted into the base of the first phalanx together with the APL tendon. Conclusion Our findings may help to improve the awareness of the anatomical variations in the first extensor compartment.

Introduction Anatomical variations of the first dorsal extensor compartment (1st EC) are commonly noted. Materials and methods Forty cadaver hands were dissected to define the 1st EC. Through the gross findings, we classified the contents according to the presence of septation, subcompartment, and variation of tendons. Bony cross-section of the wrist was performed to reveal any bony pattern within the 1st EC. We also measured the anatomical structures of the 1st EC. Results A septum that results in subcompartments was present in 24, complete in 2 and incomplete in 22 hands distally. The mean size of the 1st EC was 20.69 ± 12 mm in length, and 8.65 ± 0.67 mm in width. The mean length of the septum was 11.18 ± 5.18 mm, while the mean width of the subcompartment was 3.18 ± 0.40 mm. All the subcompartments enclosed only extensor pollicis brevis (EPB) tendons. The mean number of abductor pollicis longus and EPB tendon slips was 2.6 ± 0.5 and 1.1 ± 0.2, respectively. The bony floor of the 1st EC was classified into five types. Two distinctive grooves separating two tendons with protruding osseous ridge (type I, n = 9), two distinctive grooves separating two tendons without protruding osseous ridge (type II, n = 10), a single distinct groove with osteophytes (type III, n = 16), indistinct groove with fibrous septum separating two tendons (type IV, n = 4), and indistinct groove without fibrous septum (type V, n = 1). Conclusion Knowledge about the 1st EC abnormality is mandatory for the successful treatment of de Quervain’s disease.

Background and aims: Extensor digitorwn brevis manus is an accessory muscle on the dorsum of the hand. It lies in the fourth extensor compartment of the wrist. Its occurrence is relatively rare. Incidence of this muscle is 4% in the general population. Presence of this muscle is usually asymptomatic but rarely it may produce painful swelling which can be misdiagnosed as lipoma or ganglion or synovial cyst. Aim of the present study was to find out the incidence of extensor digitorwn brevis manus muscle in Indian cadavers. Material and Methods : Study was conducted on 64 human hands of adult Indian cadavers of unknown age and sex in the department of anatomy. A longitudinal incision was placed on the dorsum of hand along the axis of middle finger, skin flaps were raised both on radial and ulnar side. A transverse incision was taken at metacarpo-phalangeal joints from second to fifth fingers. Dorsum of each hand was dissected carefully to see the presence of extensor digitorwn brevis manus. Results: We found extensor digitorum brevis manus muscle in 3 hands [rt.-1; It. - 2] out of 64, i.e. 4.68%. Conclusion: Anatomical knowledge of this muscle present in the extensor compartment may be helpful in planning tendon transfer or graft surgeries Therefore, the knowledge of these variant muscles may be important.

Our aim was to evaluate the feasibility of using shear wave elastography (SWE) to assess first extensor compartment tendons rigidity and its alterations with tenosynovitis.We performed B-mode ultrasound and SWE to total number of 80 participants. All participants were evaluated clinically to call the diagnosis of de Quervain tenosynovitis or to rule out the diagnosis. We composed 2 groups. Group 1 included 40 healthy volunteers (33 females and 7 male participants with ages ranging from 24 to 60 years, median age was 37.5 years) and group 2 had 40 de Quervain patients (32 females and 8 male patients with ages ranging from 25 to 51 years, median age was 34 years). SWE measurements were repeated 3 times and arithmetic average was used for the final SWE value.The median SWE value of healthy group (group 1) was 72kPa and the de Quervain patient group (group 2) was 29kPa. Two groups demonstrated statistically significant difference (p0.001). The ROC curve analysis was performed and the SWE value of 40.5kPA was calculated as a cut-off value for the diagnosis of de Quervain tenosynovitis with 95% specificity and 85% sensitivity.SWE modality can provide useful data regarding de Quervain tenosynovitis.

Abductor pollicis longus is a muscle of deep group of extensor compartment of the forearm. It is an abductor of the thumb. The aim of the study is to observe the variations in the number of tendons and the point of distal attachment of this muscle tendon. This study included 32 upper limbs of cadavers, both male and female which were dissected in the Department of Anatomy, Kasturba Medical College, Manipal. A significant variations were observed in the abductor pollicis longus. Majority of muscle having more than one tendon. Tendons vary from 1–4. Their point of insertion also varies. Some are inserted to 1st metacarpal, some to trapezium and some are to the both. Also found one which is attached to base of proximal phalynx of the thumb. This muscle helps in movement and stabilization of thumb. Accessory tendons have been found to be a feasible option for tendon transplants in reconstructive surgeries of the hand. Injuries in one tendon can be compensated by the remaining tendons. Thus, awareness in the variations of this muscle is important for surgeons.

This study was designed to evaluate the accuracy of ultrasound-guided injection targeting EPB tendon sheath and influenceable anatomical variances to the accuracy in the first extensor compartment of fresh cadaver wrists.Thirty wrists of 15 cadavers were used. The wrists were divided into right-sided wrists (control group) and left-sided wrists (group A) to compare the accuracy of the manual injection technique (control group) and ultrasound-guided injection technique (group A) targeting EPB tendon sheath. To estimate the influence of anatomical variances within first extensor compartment to the accuracy of each injection techniques, control group (manual injection group) was divided into Control group I (right-sided wrists without septum) and II (right-sided wrists with septum) and group A (ultrasound-guided injection group) was also divided into group AI (left-sided wrists without septum) and group AII (left-sided wrists with septum), respectively. After the methylene blue dye injection, the location of methylene blue dye and anatomical variances in the first extensor compartment was identified by dissection.The accuracy was higher in the group A (93.3%) than in control group (40.0%, p 0.05). The accuracy in control group I (55.6%) was higher than in control group II (16.7%, p 0.05). The accuracy between group AI (100%) and group AII (85.7%) was not significantly different (p 0.05). Wrists with more EPB or APL tendon slips showed a tendency not to have septum and all intratendinous injections was occurred in the wrist with 1 EPB tendon slip or 1 or 2 APL tendon slip.Ultrasound-guided injection targeting EPB tendon ensures correct needle placement through the visualization of compartmental anatomy and improves accuracy of injection though the septum in first extensor compartment encourage inaccurate injections.

A 60 year old female presented with painless nodule over right hand index finger. On the basis of clinical and histopathological finding she is diagnosed with giant cell tumour of tendon sheath.

Disseminated gonococcal infection (DGI) commonly presents with arthritis, flexor compartment tenosynovitis, and dermatitis. Osteomyelitis and extensor compartment tenosynovitis caused by DGI is rarely reported in medical literature. We describe one such case of extensor tenosynovitis and osteomyelitis of the wrist joint which symptomatically improved after arthrotomy and intravenous antibiotics.

Purpose Our hypothesis in this study is that the radial and ulnar collateral ligaments of the wrist exist and are true ligaments which can be visualized by high-resolution ultrasonography (US). Methods High-resolution US examination of the radial and ulnar collateral ligaments of the wrist was performed on 56 fresh cadaveric wrists. The visibility of these ligaments was assessed by four observers who classified the ligaments in consensus as well seen, adequately seen, or not seen. Surgical dissections of 12 radial collateral ligaments and 12 ulnar collateral ligaments were then performed and the ligaments were classified as present or absent. The US and dissection results were then compared. To confirm that the dissected structures represent true ligaments a histologic examination of the ligaments was performed. Results All examined radial and ulnar collateral ligaments were seen on the US examination. The radial collateral ligament was seen between the radial styloid and radial aspect of the scaphoid. The ulnar collateral ligament was seen between ulnar styloid process and the triquetrum. On all surgical dissections, the radial collateral ligament was present at the floor of the first extensor compartment and the ulnar collateral ligament was at the floor of the sixth extensor compartment. Both ligaments were proven to be true capsular ligaments on both dissection and histologic examinations. Conclusion The radial and ulnar collateral ligaments of the wrist are true ligaments and can be seen at the floor of the first and the sixth extensor compartments, respectively, using high-resolution US. Based on their anatomic location, they most likely provide static stability to the wrist joint.

Background First extensor compartment release is a common surgical procedure that represents a financial burden to the health care system. Questions/Purposes Study questions included (1) whether surgical encounter costs differ based upon surgical setting (operating room [OR] vs. procedure room [PR]) or (2) based upon anesthesia choice (local only, Bier's block [BB], monitored anesthesia care [MAC], or general [GA]) for De Quervain release (DQR). Patients and Methods Consecutive adult patients undergoing isolated unilateral DQR at a single academic medical center were identified retrospectively by Current Procedural Terminology code (25000). Using our institution's information technology value tools, we calculated total direct costs for each surgical encounter. Costs were adjusted to January 2016 dollars using the Consumer Price Index, normalized using each participant's surgical encounter cost divided by the median cost in the PR group, then compared across each group using Kruskal–Wallis and Nemenyi's post hoc pair-wise tests. Multivariable gamma regression analysis with a log link was performed to identify factors associated with surgical costs. QuickDASH (disabilities of the arm, shoulder, and the hand) scores were compared using a t-test at final follow-up. Results Among 58 included patients, 29% (17/58) were treated in the PR and 71% (41/58) in the OR. Compared with local only in the PR, all other groups were significantly more costly. Multivariable gamma regression indicated that use of OR/BB, OR/MAC, or OR/GA independently led to 211, 222, and 357% greater surgical costs as compared with the PR with local only while controlling for provider and patient age. Furthermore, QuickDASH scores were similar between PR and OR groups at final follow-up. Conclusion Performing DQR in the PR setting under local only anesthesia yields greater value than the OR, as patient-reported outcomes are similar despite significantly lower surgical costs. Level of Evidence This is a Level III, cost analysis study.

OBJECTIVES This study aims to clinically evaluate the efficacy of pedicle bone flap treatment in stage II Kienbock's disease. PATIENTS AND METHODS This retrospective study included 10 patients (8 males, 2 females; mean age 33.3 years; range, 23 to 46 years) treated with pedicle bone flap between January 2012 and June 2016. In all patients, a fourth extensor compartment artery (ECA) pedicle bone flap from the dorsal surface of the radius was prepared and placed through a window opened on the lunate bone. Clinical results of the patients were evaluated according to the Mayo wrist score. RESULTS All patients could return to their daily activities after surgery. No superficial or deep infection developed requiring debridement or antibiotic use other than prophylaxis. None of the patients required reoperation due to complications or the progression of the disease. The mean Mayo wrist score was measured as 81 (good). CONCLUSION In this study, results of the fourth ECA pedicle bone flap application were found to be effective in the treatment of avascular necrosis of the lunate bone. Further comparative and long-term follow-up studies are required including large and homogeneous patient groups.

Stenosing tenosynovitis of the extensor carpi ulnaris is one of the causes of dorsoulnar wrist pain. Conservative treatment is usually effective to alleviate the pain. Surgical release of the retinaculum of the sixth extensor compartment is indicated if conservative treatment cannot alleviate the pain. The purpose of this Technical Note is to describe the technical details of endoscopic release of the sixth extensor compartment via a 2-portal approach. Endoscopic resection of a ganglion over the sixth compartment can also be performed via the same approach.

Persistent pain despite previous surgery for de Quervain's disease might be due to an overlooked septum between the abductor pollicis longus tendon slips and the extensor pollicis brevis tendon, or an overlooked completely separate compartment for the extensor pollicis brevis tendon alone. In both of these instances, extension of the MP joint of the thumb against resistance elicits pain at the distal level of the first extensor compartment of the wrist. When this sign is positive, revisional surgery and decompression of the remaining septum or separate compartment is indicated.Anhaltende Beschwerden nach vorausgegangener Spaltung des ersten Streckerfaches zur Behandlung einer Tendovaginitis de Quervain können auf eine übersehene Septierung zwischen Abductor-pollicis-longus- und Extensor-pollicis-brevis-Sehne oder auf ein übersehenes eigenständiges Fach für die Extensor-pollicis-brevis-Sehne innerhalb des ersten Streckerfaches zurückgeführt werden. In solchen Fällen ist die Streckung des Daumengrundgelenkes gegen Widerstand mit Schmerzen am Ausgang des ersten Streckerfaches verbunden. Wenn dieses Zeichen positiv ist, sollte das erste Streckerfach revidiert und das Septum oder eigenständige Fach für die Extensor-pollicis-brevis-Sehne dekomprimiert werden.

Highlights • Our study is the third case report about radial styloid fracture accompanying with first extensor compartment muscles rupture. • Our study will be the first study in this issue because of some privileges. • Other case report did not have long term follow-up time, mean that just 8 month follow-up time. • Our study also has preoperative MRI views and intraoperative photographs. • First case report; which was about this issue, muscle strength test was not applied by authors., Introduction Radial styloid fracture and concomitant first dorsal compartment proximal musculotendinous avulsion is extremely rare injury. This togetherness is difficult to diagnose fully on routine physical examination. Presentation of case In this study, we present a thirty nine year old male patient who suffered musculotendinous avulsion injury of the extensor pollicis brevis (EPB) tendon and abduc- tor pollicis longus (APL) tendon that is rarely accompanied by a closed, non-displaced radial styloid fracture developed following an in-car traffic accident. Diagnosis of avulsion was made with preop- erative magnetic resonance imaging (MRI) and the fracture was fixed with open reduction. The measurements of isometric APL and EPL muscle strength for two thumb were performed using a digital hand dynamometer, no statistically significant difference was found between the muscle strengths of the affected and non-affected thumbs at the postoperative second year follow- up (p > 0.05). Discussion The literature does not hold enough cases to establish the grounds for hypotheses related to the injury mechanism in the 1 st extensor tendon musculotendinous injuries ac- companying radial styloid fractures. Although the diagnosis of the injury in our case was inadver- tently made with preoperative MRI, the routine application of MRI does not seem to be cost-effec- tive. Conclusion We suggest that checking and assuring the intactness of the 1 st extensor compartment with a gentle traction during surgery should be a routine step in the treatment of radial styloid fractures treated with open reduction.

AIM To determine which of the common used incision techniques has the lowest chance of iatrogenic damage to the nerves which at risk are the superficial branch of the radial nerve (SBRN) and the Lateral Antebrachial Cutaneous Nerve (LABCN). METHODS Twenty embalmed arms were dissected and the course of the SBRN and the LABCN in each individual arm was marked and the distance between the two branches of the SBRN at the location of the First Extensor Compartment (FEC) was measured. This data was used as input in a visualization tool called Computer Assisted Anatomy Mapping (CASAM) to map the course of the nerves in each individual arm. RESULTS This image visualizes that in 90% of the arms, one branch of the SBRN crosses the FEC and one branch runs volar to the compartment. The distance between the two branches was 7.8 mm at the beginning of the FEC and 10.2 mm at the end. Finally the angle of incision at which the chance of damage to the nerves is lowest, is 19.4 degrees volar to the radius. CONCLUSION CASAM shows the complexity of the course of the SBRN over the FEC. None of the four widely used incision techniques has a significantly lower chance of iatrogenic nerve damage. Surgical skills are paramount to prevent iatrogenic nerve damage.

Aim: To withdraw the attention to the possible complication of tendons rupture in cases of intramedullary flexible nail fixating cases of pediatric both bone forearm fractures. Presentation of Case: A 16 years old boy with a history of right forearm both bones mid shaft fracture was managed with closed reduction and flexible intra-medullary nail fixation. The patient