Jagannath B Kamath

Current concepts in managing fractures of metacarpal and phalangess

Fractures of the metacarpal and phalanges constitute 10% of all fractures. No where in the body, the form and function are so closely related to each other than in hand. Too often these fractures are treated as minor injuries resulting in major disabilities. Diagnosis of skeletal injuries of the hand usually does not pose major problems if proper clinical examination is supplemented with appropriate radiological investigations. Proper preoperative planning, surgical intervention wherever needed at a centre with backing of equipment and implants, selection of appropriate anaesthesia and application of the principle of biological fixation, rigid enough to allow early mobilisation are all very important for a good functional outcome. This article reviews the current concepts in management of metacarpal and phalangeal fractures incorporating tips and indications for fixation of these fractures. The advantages and disadvantages of various approaches, anaesthesia, technique and mode of fixation have been discussed. The take-home message is that hand fractures are equally or more worthy of expertise as major extremity trauma are, and the final outcome depends upon the fracture personality, appropriate and timely intervention followed by proper rehabilitation. Hand being the third eye of the body, when injured it needs a multidisciplinary approach from the beginning. Though the surgeons work appears to be of paramount importance in the early phase, the contribution from anaesthetist, physiotherapist, occupational therapist, orthotist and above all a highly motivated patient cannot be overemphasised.

Soft tissue coverage in open fractures of tibia.

Background: The treatment of Gustilo Anderson type 3B open fracture tibia is a major challenge and it needs aggressive debridement, adequate fixation, and early flap coverage of soft tissue defect. The flaps could be either nonmicrovascular which are technically less demanding or microvascular which has steep learning curve and available only in few centers. An orthopedic surgeon with basic knowledge of the local vascular anatomy required to harvest an appropriate local or regional flap will be able to manage a vast majority of open fracture tibia, leaving the very few complicated cases needing a free microvascular flap to be referred to specialized tertiary center. This logical approach to the common problem will also lessen the burden on the higher tertiary centers. We report a retrospective study of open fractures of leg treated by nonmicrovascular flaps to analyze (1) the role of nonmicrovascular flap coverage in type 3B open tibial fractures; (2) to suggest a simple algorithm of different nonmicrovascular flaps in different zones and compartment of the leg, and to (3) analyze the final outcome with regards to time taken for union and complications. Materials and Methods: One hundered and fifty one cases of Gustilo Anderson type 3B open fracture tibia which needed flap cover for soft tissue injury were included in the study. Ninety four cases were treated in acute stage by debridement; fracture fixation and early flap cover within 10 days. Thirty-eight cases were treated between 10 days to 6 weeks in subacute stage. The rest 19 cases were treated in chronic stage after 6 weeks. The soft tissue defect was treated by various nonmicrovascular flaps depending on the location of the defect. Results: All 151 cases were followed till the raw areas were covered. In seven cases secondary flaps were required when the primary flaps failed either totally or partially. Ten patients underwent amputation. Twenty-two patients were lost to followup after the wound coverage. Out of the remaining 119 patients, 76 achieved primary acceptable union and 43 patients went into delayed or nonunion. These 43 patients needed secondary reconstructive surgery for fracture union. Conclusion: open fracture of the tibia which needs flap coverage should be treated with high priority of radical early debridement, rigid fixation, and early flap coverage. A majority of these wounds can be satisfactorily covered with local or regional nonmicrovascular flaps.

Role of Guided Ultrasound in the Treatment of De Quervain Tenosynovitis by Local Steroid Infiltration.

Ultrasound guidance for steroid injection in de Quervain disease is useful in identifying the presence of subcompartments and effectively injecting the drug into tendon sheath. We prospectively studied 50 patients with features of de Quervain disease to determine the effectiveness of ultrasound in positioning of needle for steroid injection and effectiveness of single versus multiple injections in the presence of subcompartments. Scalp vein set was inserted into the tendon sheath under ultrasound guidance and sterile conditions. Mixture containing 1 mL of methylprednisolone 40 mg with 1 mL of 2% lignocaine was injected and the patient followed for 6 months. In patients having subcompartments, improvement was better when two separate injections into each subcompartment were given compared with single. Ultrasound guidance is helpful in identifying the existence of subcompartment and injecting the subcompartments separately. Scalp vein set may be very effective in ultrasound-guided injection. This is a level III study.

Modified bone tie: a new method to achieve interfragmentary compression in unstable oblique metacarpal and phalangeal fractures.

Oblique fractures of the metacarpal and phalanx are inherently unstable especially when there is comminution at the fracture site. Nonoperative management of these fractures requires prolonged immobilization and results in poor outcome. Internal fixation is the preferred method of treatment for these fractures. The various methods used for internal fixation are the Kirschner wires, intraosseous wiring, tension band wiring, minifragment screws and plates. Kirschner wires are the most commonly used fixation device because of their versatility and easy availability. The main disadvantage is lack of rigid fixation as it does not provide interfragmentary compression and pin track infection, if left outside the skin. To overcome these problems intraosseous wiring and tension band wiring were used. The main disadvantage of these procedures is the need for multiple drilling and extensive soft tissue dissection which is detrimental for a comminuted oblique fracture. Minifragment screws and plates provide rigid fixation but the screw can split the small bone fragment and also does not allow any adjustment once it is inserted. Plates tend to be bulky. Bone tie was described as a method of interfragmentary compression with some advantages over the interosseous wiring techniques and tension band wiring. We have modified the original bone tie to make it easier to use and to provide more stable fixation. We present our experience with its use in unstable oblique fractures of the metacarpal and phalanges, which are challenging to treat.

A Simple, Inexpensive Nerve Approximator

Technical precision during nerve repair is important for a successful surgical outcome. In fact, it is the only factor over which the surgeon has control. Establishing nearly normal coaptation and maintenance of coaptation with the least tension at the anastomotic site is at the heart of the surgeon’s task. A simple nerve approximator can aid peripheral neurorrhaphy with optimal tension at the anastomotic site, thus achieving better maintenance of coaptation of the fascicles. There are some objections to one of the accepted methods of nerve repair, which utilizes stay sutures at 0 and 160 degrees with the help of 6-0 suture material, particularly during secondary neurorrhaphy before the anterior wall is repaired, and then swaps the stay sutures on to the opposite side to repair the posterior wall. It is usually difficult to get a satisfactory coaptation of the nerve endings by this technique, it may be traumatic to the nerve endings, and it may result in unequal tension at the repair site. The stress concentration at some sutures may not be favorable for recovery. Some of these drawbacks are partly mitigated with the use of a nerve approximator, which can also obviate the need of an expert assistant.

Lipofibromatous Hamartoma of the Median Nerve in Association with or without Macrodactyly

Lipofibromatous hamartoma is a rare tumour-like condition involving the peripheral nerves, particularly the median nerve. It commonly affects the volar aspect of the hands, wrists and forearms of young adults. Most patients present either early with macrodactyly or later with a forearm mass lesion or symptoms consistent with compressive neuropathy of the involved nerve. The clinical and histomorphological findings of five patients with lipofibromatous hamartoma of the median nerve are analysed. The presentation, pathological features and differential diagnosis of neural lipofibromas are discussed along with a brief review of the literature. Of the five cases of lipofibromatous hamartoma, all were seen to involve the median nerve, occurring in four women and one man. Three of these cases had associated macrodactyly which was congenital in two and was seen from childhood in one. Microscopic examination showed fibrofatty tissue surrounding and infiltrating along the epineurium and perineurium. The nerve bundles were splayed apart by the infiltrating adipose tissue. Neural fibrolipomatous hamartoma is a benign condition. Most respond to conservative management with surgical exploration, biopsy and carpal tunnel release to decompress the nerve. Correct diagnosis of this uncommon lesion is important as surgical excision of the lesion may lead to loss of neurological function.

Fully automated radiogrammetric measurement of third metacarpal bone from hand radiograph

Osteoporosis is a disease caused by reduction of bone mass, bone strength and deterioration of bone structure. The gold standard method for diagnosis of osteoporosis is measurement of bone mineral density (BMD) using Dual X-ray Absorptiometry (DXA). However, DXA is expensive and not widely available in developing countries. An alternative cost-effective method for measurement of bone loss and strength is metacarpal radiogrammetry, by which geometric measurements of cortical bone of the metacarpal bone are measured. In this paper, we propose a fully automated method for segmentation of third metacarpal bone from hand radiograph and radiogrammetric measurements using mathematical morphology. Cortical width and thickness are measured from the endosteal and periosteal edges of the metacarpal bone using which bone indices which help in diagnosis of osteoporosis can be computed. The proposed segmentation method was tested on 157 hand X-ray images. A success rate of 94.9% is obtained for automatic detection of third metacarpal bone. Evaluation of cortical measurements of 3 calibrated images is done by comparing the results with ground truth. The mean accuracy error obtained was 0.02cm and 0.04cm for cortical width and medullary width, respectively.

Compressive neuropathy of the palmar cutaneous branch of the median nerve after a malunited fracture of the distal radius.

a baseline level before the contrast agent reaches the region. The remaining 920 frames record an increase on the baseline signal believed to result from passage of the contrast medium through the region of interest, and the area under the curve (AUC) for these 920 frames was calculated and expressed as a ratio to the baseline measurement. All data are presented as mean ± standard error of mean. Statistical significance was determined using the unpaired t-test. P < 0.05 was considered significant. The mean AUC for the control subjects was 37 SD 7.8 units and for the CTS subjects 108 SD 22 units, suggesting that intraneural blood flow is significantly increased in the median nerve in CTS (p = 0.002). We found no significant correlations between the AUC and clinical or neurophysiological variables. High-resolution CEUS makes it possible to obtain images of the intraneural low-volume, slow blood flow in the median nerve (Funakoshi et al., 2010). Although several studies of intraneural vascularity have been reported using colour Doppler ultrasonography, they appeared not to correctly detect the intraneural blood flow using conventional methods (Ghasemi-Esfe et al., 2011; Joy et al., 2011). Further studies with this technique are probably warranted to determine if there is a relationship between intraneural vascularity and the disease severity, progression or prognosis in CTS.

Ideas and innovations: a simple biplanar double Kessler core stitch for flexor tendon repair.

Quest for a technique to get a stronger repair to allow early mobilization after primary flexor tenorraphy continues in the field of hand surgery. A new, easy, and surgeon-friendly method of tenorraphy has been described based on strong mechanical and biological principles with the advantage of enabling the surgeon to mobilize actively in early postoperative period to obtain better overall results.

A modular tension-adjusting splint for tendon transfer in reconstructive surgeries of extremities

Optimal tension during tendon transfer is the most important surgeon-controlled factor, which determines the final outcome of surgery. To attain optimal tension, the joints have to be maintained in proper position during the final attachment of the transferred tendon. Maintaining this desired position requires one extra assistant and is difficult. We herein describe a modular splint designed by us, which can be used for most of the commonly done tendon transfers in practice. It is very versatile as it can be used for all the age groups and for both right and left sides. A single splint, which is autoclavable and can be used for most commonly done tendon transfers, makes it user-friendly.