Hussein Choughri

Atypical squamous cell carcinoma of the nail bed with phalangeal involvement.

Abstract We report an atypical presentation of squamous cell carcinoma (SCC) of the distal phalanx of the left thumb. On physical examination, there was no clinical evidence of a local lesion, but magnetic resonance imaging (MRI) showed multiple intraosseous cavities filled with fluid. A biopsy specimen showed a well-differentiated SCC, which was treated by amputation of the distal phalanx.

Double crush syndrome of the median nerve revealing a primary non-Hodgkin's lymphoma of the flexor digitorum superficialis muscle.

Extranodal manifestations of lymphoma are well described in the literature and occur in 20 to 30% of patients. Skeletal muscle involvement is rare. We describe the case of a patient with non-Hodgkins lymphoma in a forearm muscle. At the age of 86, the featured patient started experiencing continuous, progressive and high intensity pain that was more frequent at night and localized in the right dominant hand. It was associated with paresthesia and hypoesthesia, primarily in the thumb, index finger and middle finger. Clinical examination and electrodiagnosis led to the diagnosis of carpal tunnel syndrome. The patient underwent carpal tunnel release at a private hand center. The progression was unfavorable. Additional clinical examination and electrodiagnosis showed compression of the anterior interosseous nerve (double crush syndrome). The patient was referred to our university hand center for further management. Magnetic resonance imaging showed a large mass of about 20cm occupying the entire anterior compartment of the forearm and enclosing the median nerve. Biopsies were performed and revealed a diffuse large B-cell primary non-Hodgkins lymphoma. The patient underwent chemotherapy and radiotherapy. Six months later, the patient was in complete remission. Muscular involvement during lymphoma is rare. Biopsy is mandatory; needless radical surgery can be avoided because lymphoma is primarily a non-surgical disease. The key points of the treatment process are reviewed.

Arterial vascularization of the flexor digitorum superficialis synovial flap. An anatomical study.

Among the various techniques proposed to protect the median nerve from scarring and to provide it with a vascular supply, the synovial flap represents a simple and effective method. The flap is taken from the flexor tendons sheath and results in a thin and richly vascularized tissue that will act as a barrier to scarring and provide neovascularization to improve nerve regeneration and gliding. The aim of this study was to evaluate the arterial vascularization of this flap to assess its reliability. An anatomic study was carried out on 24 fresh upper limbs infused with colored and radiopaque solutions before or after flap elevation. Anatomical findings showed the synovial flap to be supplied by a consistent vascular pedicle arising from the ulnar artery 2 to 5 centimeters proximal to the pisiform bone and running between the flexor tendons of the ring and little fingers. The synovial flap is known to be a simple and effective method for protecting the median nerve. The present study shows that its consistent vascularization makes it a reliable technique. We believe this procedure is relevant for the treatment of recurring carpal tunnel syndrome.

Blue finger: An unusual clinical presentation

A 51-year-old man was referred to our hand surgery department because the fifth finger of his right hand turned a blue color within a few hours without trauma. Clinical examination found the pulp of the fifth finger to be blue without neurovascular disorders. While taking the patient’s history, he recounted an injury involving glass 6 months before that was not addressed surgically. X-rays showed two fragments of glass close to the radial edge of the 5th metacarpal bone and on the volar side of the 4th intermetacarpal space. We decided to treat this patient surgically by removing the glass fragment and checking of the neurovascular pedicles. The procedure, under regional anesthesia with a tourniquet, began with removal of the first piece of glass through a dorsal approach. Then, a volar incision was performed to remove the second fragment. We found a hematoma in the soft tissues and inside the flexor tendons sheath (Fig. 1). The hematoma was evacuated and the neurovascular pedicles were intact. Then, the patient told us that he had gone to the theater 4 days earlier and applauded for nearly the entire performance, which induced trauma by the glass fragments at the flexor tendon sheath. No complications were noticed during the postoperative period, and his hand function was not affect by the trauma or the surgical procedure. The case is original because of the appearance of an unusual clinical sign far from the foreign body: bluish color of the pulp of the 5th finger due to diffusion of a hematoma in the distal part of the flexor tendon sheath. Complications due to glass fragments in the hand are well known but the fragments are not always removed. Glass fragments can cause tendon rupture, nerve transection and vascular complications because of the continued hand movements [1–7].