Review and update on the management of triangular fibrocartilage complex injuries in professional athletes

Triangular fibrocartilage complex injuries are common in amateur and professional sports.These injuries are mainly caused by acute or chronic repetitive axial loads on the wrist,particularly on the ulnar side and in association with rotations or radial/ulnar deviations.In order to treat professional athletes,a detailed specific knowledge of the pathology is needed.Moreover,the clinician should fully understand the specific and unique environment and needs of the athletes,their priorities and goals,the type of sport,the time of the season,and the position played.An early diagnosis and appropriate management with the quickest possible recovery time are the uppermost goals for both the athlete and the surgeon.A compromise between conservative vs surgical indications,athletes’needs and expectations,and financial implications should be achieved.Arthroscopic procedures should be timely planned when indicated as they could allow early diagnosis and treatment at the same time.Conservative measures are often used as first line treatment when possible.Peripheral lesions are treated by arthroscopic repair,whilst central lesions are treated by arthroscopic debridement.Further procedures(such as the Wafer procedure,ulnar osteotomies,etc.)have specific indications and great implications with regard to rehabilitation.

Chondrosarcoma of the Hand: A Literature Review

Chondrosarcoma (CS) is a malignant neoplasm of mesenchymal origin characterized by the formation of cartilaginous matrix by neoplastic cells. It is very variable in presentation, clinical, genetic and anatomo-pathological features. CS is more often found in the pelvis and the proximal long bones (femur, humerus). Localization to the small bones of the hand is very rare and it represents a diagnostic and therapeutic challenge. CSs are malignancies resistant to both radiation and chemotherapy . Surgical treatment is the only mean available. As opposed to CSs located elsewhere, CS of the hand is characterized by local recurrence and very low metastatic potential. In order to definitely set a diagnosis of chondrosarcoma in this region, comparison of histological and radiological findings is paramount. The principle goal of surgery shall be minimizing functional impairment. This provides the rationale for performing curettage, local adjuvant therapy and bone grafting in low-grade lesions.

Triggering,clicking,locking and crepitus of the finger:A comprehensive overview

Triggering,locking,clicking,and crepitus of the fingers are common symptoms patients present with.Even though crepitus and triggering can occur as part of the same underlying diagnosis,it is important to differentiate between them,as they usually indicate different possible diagnoses.The differential diagnoses that should be considered include trigger finger,metacarpophalangeal joint(MCPJ)arthritis,fractures or dislocations,extensor digitorum communis subluxation or dislocation,locked MCPJ,avascular necrosis of the metacarpal head,and Dupuytren’s disease.A thorough clinical examination with appropriate special investigations can permit the clinician to make the correct diagnosis.Appropriate management of a confirmed diagnosis is successful in providing symptomatic improvement.

Distal radius volar rim plate: Technical and radiographic considerations

AIM To determine technical considerations and radiographic outcomes of the Synthes volar rim distal radius plate to treat complex intra-articular fractures. METHODS This review highlights technical considerations learnt using this implant since it was introduced in a major trauma unit in November 2011, including anatomical reduction and whether this was maintained radiographically. RESULTS Twenty-six of the 382 internally fixed distal radial fractures at our unit(6.8%) were deemed to require this plate in order to achieve optimal fracture fixation between November 2011 and May 2014. A further dorsal and/or radial plate was necessary in 35% and variable angle screws were used in 54% of cases. Postoperatively, mean radial height, inclination, volar tilt and ulnar variance restored were 11.7 mm, 21o, 4.3o and-1.2 mm respectively. There were no cases of non-union or flexor/extensor tendon rupture; one case of loss of fracture reduction. Overall incidence of plate removal was 15% with one plate removed for flexor and one for extensor tendon irritation CONCLUSION The use of a rim plate enables control of challenging fardistal fracture patterns. However, additional plates were required to improve and maintain reduction. Variable angle screws were necessary in half the cases to avoid intra-articular screw penetration. If used judiciously, this implant can achieve stable fixation despite the complexity of the fracture pattern.

Should aspirin be stopped before carpal tunnel surgery? A prospective study

AIM: To determine whether patients taking aspirin during carpal tunnel release had an increase of complications.METHODS: Between January 2008 and January 2010, 150 patients underwent standard open carpal tunnel release(CTR) under intravenous regional anaesthesia. They were divided into three groups: groups 1 and 2 were made of 50 patients each, on aspirin 100 mg/d for at least a year. In group 1 the aspirin was never stopped. In group 2 it was stopped at least 5 d before surgery and resumed 3 d after. Group 3 acted as a control, with 50 patients who did not take aspirin. The incidence of clinically significant peror post-operative complications was recorded and divided into local and cardio-cerebro-vascular complications. Local complications were then divided into minor and major according to Page and Stern. Local haematomas were assessed at 2 d(before resuming aspirin in group 2) and 14 d(after resuming aspirin in group 2) postoperatively. Patients were reviewed at 2, 14 and 90 d after surgery.RESULTS: There was no significant difference in the incidence of complications in the three groups. A total of 3 complications(2 major and 1 minor) and 27 visible haematomas were recorded. Two major complications were observed respectively in group 1(non stop aspirin) and in group 3(never antiaggregated). The minor complication, observed in one patient of group 2(stop aspirin), consisted of a wound dehiscence, which only led to delayed healing. All haematomas were observed in the first 48 h, no haematoma lasted for more than 2 wk and all resolved spontaneously. A major haematoma(score > 20 cm2) was observed in 8 patients. A minor haematoma(score < 20 cm2) was recorded in 19 patients. All patients at 90 d after surgery were satisfied with the result in terms of relief of their preoperative symptoms. Major and minor haematomas did not impair hand function or require any specific therapy.CONCLUSION: Our study demonstrates that continuation of aspirin did not increase the risk of complications. It is unnecessary to stop aspirin before CTR with good surgical techniques.

FK-506 ointment： an effective adjuvant therapy to treat a dramatic case of pyoderma gangrenosum of unilateral hand

Pyoderma gangrenosum （PG） is a cutaneous ulcer developing so rapidly that may mimic a fulminating infection. The correct treatment is nonsurgical, and surgery may get the condition worse.^1 FK-506 ointment （0.1% Protopic, Astellas Pharma AG, Fribourg） is usually indicated for inflammatory skin diseases, such as atopic dermatitis and psoriasis^2 or for acute rejection reversal of human hand transplantation^3. Afew reports of PG affecting the functions of hands can be found in the scientific literature and this report describes the first case treated by FK-506 ointment as an adjuvant therapy.

Reconstruction of tendon losses

This review discusses the latest literature-based evidence on reconstructive strategies following tendon losses,with a final focus on the innovative regenerative approach.Significant improvements in primary tendon repair techniques have radically reduced the failure rate and therefore decreased the use of reconstructive procedures.However,in specific conditions,such as crush injuries with loss of substance,avulsion injuries and inveterate injuries,the tendon gap cannot be repaired with a primary suture,making the procedure much more challenging for the surgeon.This article aims to guide the treatment of tendon losses,which is still a complex topic in hand surgery.

Treatment of type III middle phalangeal neck fractures through a palmar approach： a case report

Phalangeal neck fractures occur almost exclusively in children. We present the case of a 49 years old man with a dislocated fracture of the neck of the middle phalanx with the distal fragment rotated at 180~, due to a traumatic circular saw injury to the left index, which was solved by anatomical reduction and bone fixation with two 1.5 mm Synthes screws and a temporary transarticular K- wire at the distal interphalangeal joint. Zone I flexor digitorum profundus repair was performed using a modification of the Kessler 4-strands core suture and a full-thickness skin graft from the hypothenar eminence was taken to cover the skin gap. At 6-month follow-up the patient was pain-free and with a total active movement equivalent to 190~. No radio-logical signs of avascular necrosis of the head of the middle phalanx or nonunion of the distal fragment was detectable with recovery to the previous manual work. Owing to the position of the phalangeal head maintained in position by the collateral ligaments an anatomic reduction from dorsal approach is difficult to be performed and a longitudinal trac- tion can render the reduction harder too. The volar approach permits an easier reduction of the fracture through a derotation of the distal fragment facing palmar.

Transient bone resorption following finger replantation： a report of 3 cases

Radiographic changes consisting of al- terations in mineral content, osteopaenia or destructive neuropathy that occur following successful finger replantation have already been described. We report our experience about four fingers in three individuals in whom bone changes developed in the first three months postoperatively with complete ＂restitution ad integrum＂. Three patients, 21-49 years old （average 36 years） sustained a clean-cut amputation of four fingers. The first patient had an amputation at the base of the middle phalanx of the index finger and the second patient at the base of the proximal phalanx of the ring finger. The third had an amputation at the base of the first metacarpal bone and the proxi- mal phalanx of the small finger in a five finger amputation. In the first case, two dorsal veins and two palmar digital arteries and nerves were repaired. In the second case, one pal- mar artery and one dorsal vein were reanastomosed. In the third case at the thumb, two dorsal veins and two palmar digital arteries and nerves were reconstructed. At the small finger, one dorsal vein, one palmar digital artery and twodigital nerves were reconstructed. Bone fixation was achieved with two and three K-wires or tension-band wiring. Replantation was successful in all cases. Three weeks after replantation, the X-rays showed rapid development of osteopaenia in the juxtaarticular region and metaphyses of the bone. These changes were followed by subperiosteal, intracortical and endosteal bone resorption. No further surgical procedures or splintage were needed and hand therapy was not discontinued. At 10-13 weeks （average 12 weeks） postoperatively, the X-rays showed a complete recovery with new periosteal bone formation. We suggest that the radiographic changes after finger replantation are transient, first evident subperiosteally and progressing centrally. They may reflect small-vessel compromise and microinfarction and transient hyperemia secondary to neurovascular damage or to sympathetic progressive recovery.

Is early hardware removal compulsory after retention of angled drill guides in palmar locking plates？ The role of pronator quadratus reconstruction

Palmar plate fixation is becoming a well recognized treatment for distal radial fracture. Tendon ruptures or irritations have been reported after this procedure. Inadvertent retention of angled drill guides useful for easy placement of locking screws in proper direction in volar plating can represent a high risk of secondary tendon rupture. In this case, we presented our experience in one patient in whom drill guides removal could be delayed for one year and summarized our techniques to prevent the aforementioned complications.

Surgical vacuum-assisted closure for treatment of dramatic case of stonefish envenomation

Skin necrosis of the foot, oedema and lymphangitis from stonefish （Synanceia verrucosa） sting are complications well known for a tong time and with potential long-term sequelae. Literature reports of stonefish envenomation give no specific reference on soft tissue management and surgical reconstruction. This is the first report describing a case of foot stonefish envenomation treated by vacuum-assisted closure therapy as an easy to use, accessible and simple adjuvant tool for management of large soft tissue necrosis.

手部肿块

一名40多岁的男子因多年的左手皮肤变化和两处肿块去看全科医生。他认为这些症状是由于工作中反复搬运沉重的水桶造成的病变。这些结节性肿块最近变大了。在转诊前的数月,患者手部结节开始有严重的烧灼感,这影响了他的睡眠。