Universiti Sains Malaysia
Butterworth, Penang | Malaysia
Main Specialties: Hand Surgery, Orthopaedic Trauma, Orthopaedics
Additional Specialties: Upper limb, Hand and Micro surgery
Primary Affiliation: Universiti Sains Malaysia - Butterworth, Penang , Malaysia
Med & Health Jun 2019; 14(1): 203-208
ABSTRACTPaediatric hand fractures are common and prompt management is mandatory to achieve a good functional outcome. However many fail to realize that treating a fracture does not only involve bones but the soft tissues, as well. K-wiring itself can be difficult with multiple attempts inadvertently injuring the flexor or extensor tendons and resulting in adhesions. We highlight this possible complication of K-wiring which we believe is under reported due to the perception that K-wiring is a simple procedure. We present a case of a 9-year-old child, who sustained a closed displaced fracture of the base of the proximal phalanx (Salter Harris type 2) of the left index finger. He underwent percutaneous K-wiring but was complicated with severe adhesions of the flexor digitorum profundus (FDP) and flexor digitorum superficialis tendons (FDS). He was unable to flex the proximal and distal interphalangeal joints of the affected finger. We subsequently performed tendon adhesiolysis twice together with A2 pulley reconstruction, to restore movement of the finger. K-wiring of the fingers are not just simple bony procedures but also involve soft tissue components which can be prone to adhesions.Keywords: adhesions, flexor tendon, fracture, percutaneous K–wire, phalanx, proximalcomplication of K-wiring which we believe is under reported due to the perception that K-wiring is a simple, uncomplicated procedure.INTRODUCTIONThe most common type of fracture of the proximal phalanx is the Salter Harris type 2, also known as a juxta epiphyseal fracture (Noguiera et al. 1999). It is a fracture involving most of the growth plate and extending towards the metaphysis (Peter & Seth 2009). The management of the fracture depends on the degree of displacement and stability. It can be treated conservatively by closed manual reduction and immobilization. In few cases, closed manual reduction and K-wiring are done. K-wiring itself can be difficult with multiple attempts inadvertently injuring the flexor or extensor tendons and resulting in adhesions. We highlight this possible Figure 1: Radiograph of the left hand showing a displaced and angulated fracture of the base of the proximal phalanx of the left index finger (Salter Harris Type 2) (yellow arrow)205Adhesions as an Uncommon Complication of K-wiring Med & Health Jun 2019;14(1): 203-208CASE REPORTA 9-year-old boy fell off his bicycle and sustained a closed displaced fracture of the base of the proximal phalanx of his left index finger (Figure 1). He underwent closed reduction and percutaneous K-wiring to fix the fracture (Figure 2). Intra-operatively there was no documented difficulty in reduction or instability. The K-wire was removed after 3 weeks and physiotherapy commenced with tendon gliding exercises. A month later, the child had full passive range of motion at both the proximal interphalangeal joint (PIPJ) and the distal interphalangeal joint (DIPJ). However, he was still unable to flex the PIPJ actively at all but able to flex the DIPJ from 0 to 30 degrees. Ultrasound showed minimal movement between the FDS and FDP tendons and are most likely due to adhesions. At three months postoperative, we proceeded to a second surgery. We found severe adhesions between both flexor digitorum superficialis (FDS) tendons and flexor digitorum profundus (FDP) tendons and also at the A1 and A2 pulley systems. The FDP appeared to also be adherent to new callus formation. We performed adhesiolysis followed by aggressive physiotherapy. The range of movement improved slightly with proximal and distal interphalangeal joint flexion from 0-30˚. Unfortunately, three weeks later, there was an episode of wound infection and the patient underwent a third surgery of incision and drainage where 3 ml of pus was drained. One month after the third surgery, the active motion at the PIPJ had now Figure 2: Post operative radiograph showing percutaneous cross K-wires, following closed manual reduction. Figure 3: Intra-operative picture showing bowstringing (green arrow) of both flexor tendons due to absence of the A2 pulley with severe adhesions (yellow arrow) in the surrounding area.Figure 4: After adhesiolysis was done, we performed an A2 pulley reconstruction (yellow arrow) using a part of the extensor retinaculum.206Med & Health Jun 2019;14(1): 203-208 Nanchappan S. et al.decreased to 0-20˚ and at the DIPJ from 0-10˚. Four months after the third surgery, active motion was even more limited at both PIPJ and DIPJ at 0-5˚, only. With such a poor range of motion, we proceeded to a fourth surgery and re-exploration of the finger was done (Figure 3) and we noted severe adhesions. The A2 pulley was absent and the flexor tendons were bowstringing across the joints. A repeat adhesiolysis was performed together with reconstruction of the A2 pulley using a small portion of the extensor retinaculum (Figure 4). Immediate physiotherapy was commenced to prevent further adhesions. Initially a month after the last surgery, he had no active motion at the PIPJ but at the DIPJ, he had 0-15˚. But at 6 months post surgery, active motion at the PIPJ remained zero and active motion at the DIPJ had decreased to only 0-5˚. However, at all times, the proximal and distal interphalangeal joints remained supple with full passive range of movement of both joints. DISCUSSION The proximal phalanx fracture is a common fracture in children with Type II Salter Harris as the most common fracture pattern (Nogueira et al. 1999). However, few authors have suggested that the fracture line may be entirely metaphyseal, 1 to 2 mm distal to the physis, hence the more appropriate termed is juxtaepiphyseal fractures (Peter & Seth 2009; Rodriguez-Vega et al. 2012). These growth plate injuries are generally simple to be reduced and are stable following reduction (Noguiera et al. 1999). The method of reduction is by counter force applied to the digit using a pencil as a lever at the web space (Peter & Seth 2009). Acceptable reduction is when there is no lateral or rotation angulation. Immobilization is performed by placing a buddy splint and plaster of paris slab in intrinsic plus position. Growth arrest is rare and most often, there is no problem in remodelling because of proximity of the physis and multiplanar movements of metacarpal phalangeal joint (Noguiera et al. 1999). A long-term follow-up in a 5-year-old boy showed that a 90˚ rotated epiphysis in a SalterHarris Type IV fracture in the proximal phalanx of the thumb reduced by K-wiring resulted in a narrower thumb with no loss of length after 10 years (Al-Qattan 2017). Complications post-K-wiring are not uncommon. Hsu et al. (2011) reported on insertion of 408 K-wires in 189 patients and categorized complications into infection, pin loosening, pin migration, skin overgrowth, nonunion, malunion and fracture across the pin track. This is similar to Stahl & Schwartz (2001) who performed 590 K-wire fixation on 236 patients reporting 15.2% complications of osteomyelitis, tendon rupture, nerve lesion, pin tract infection, pin loosening and migration. They attributed the cause of complication to inexperienced surgeons and poor patient compliance. Both papers do not mention adhesions as a complication. In the event of a difficult reduction, multiple attempt of closed reduction 207Adhesions as an Uncommon Complication of K-wiring Med & Health Jun 2019;14(1): 203-208may lead to further swelling and more soft tissue entrapment between the fracture site. Soft tissue entrapment can be the cause of difficult reduction. Hence, open reduction is recommended to clear the soft tissue, and achieve anatomical reduction by augmenting with a cross K-wire. It is important to achieve anatomical reduction to ensure proper gliding of the tendons in the finger (RodriguezVega et al. 2012) The most common soft tissue injured are the flexor tendons especially the flexor digitorium profundus (Pandey et al. 2008). This is due to the proximity of the tendon towards the bone. In some cases, tendon entrapment will remain unnoticed and will present late as tendon dysfunction. Hence, a high index of suspicion is required when dealing with these fractures. There are few reports of displaced irreducible phalangeal growth plate fractures in children due to different anatomic structure such as extensor hoodperiosteal, fibrous tissue infolding, lumbricals and interosseous tendons (Peter et al. 2009). Suspicion of soft tissue entrapment at the fracture site can be diagnosed by ultrasound (Pandey et al. 2008). For flexor tendon adhesions after phalangeal fractures, only the total passive range of motion before tenolysis was significant in affecting the results of tenolysis. The fracture type, the time to mobilization and time between injury and tenolysis had no effect (Yamazaki et al. 2008). There is mention of extensor tendon adherence and joint contracture as a common complication following phalangeal fractures (Creighton & Steichen 1994). Multiple attempts of K-wire placement, can also cause injury to the soft tissue especially flexor tendons. The K wire can cause tendons to be entangled or punctured due to the penetrating injury. Although this is rare but such cases have been reported (Sharma et al. 2007). We believe that this is under reported due to the perception that K-wiring is a simple procedure. This can be prevented by making a small incision, and ensuring the wire is appropriately placed on the bone prior to entry. The recommended size of the wire is 0.8mm or 1mm to prevent insult to the soft tissue yet with adequate stability and reduction of phalanges. All of the articles mentioned above generalized the phalangeal fractures as one category. A more detailed study confined phalangeal fractures to only the proximal third region (Faruqui et al. 2012) dividing patients into those receiving extra-articular cross K-wiring or transarticular wiring. The PIPJ was notably affected with half of their patients losing on average 27˚ of flexion at the joint. Nearly a third had a fixed flexion contracture greater than 15˚ at the PIPJ. This poor outcome appears to be reflected in our patient who has no active motion at all at the PIPJ but full passive motion. This is better than a fixed flexion contracture. A recent cadaveric study showed that K-wires placed away from the extensor tendon has less tethering effect than those placed through or adjacent to the extensor tendon (Sela et al. 2016). However, there is still much debate as to whether there is a significant 208Med & Health Jun 2019;14(1): 203-208 Nanchappan S. et al.difference between periarticular or transarticular wire placement (Logters et al. 2017). In a case of toe lengthening in brachymetatarsia, an axial K-wire was inserted into the phalanges of the fourth toe and a distraction type external fixator into the metatarsal for 5 months. A complication of nonunion occurred but a further two axial K-wires facilitated union a month later. The patient mobilized well. There was no complications of adhesions. However, this may be unnoticeable in the foot compared to the hand (Norliyana et al. 2018). Possibility of multiple K-wire entry injuring the flexor tendon, aggressive manipulation during the closed reduction and inadequate physiotherapy could have resulted in adhesions at the proximal phalanx pertaining to this case. Complications sustained by the child resulted in dysfunction of the finger in terms of grip strength and pincer grasp. CONCLUSION Displaced proximal phalangeal fractures of the finger which are not easily reduced or are unstable requires a high index of suspicion of soft tissue interposition. Hence, open reduction and K-wiring is suggested. Additionally, we should restrain from multiple attempts of K-wiring to avoid soft tissue injury.REFERENCES Al-Qattan, M. 2017. Salter-Harris Type IV fracture of the proximal phalanx of the thumb with rotation of the epiphysis: Outcome 10 years following open reduction and K-wire fixation. Int J Surg Case Rep 31: 14-16. Creighton, J.J., Steichen, J.B. 1994. Complications in phalangeal and metacarpal fracture management. Results of extensor tenolysis. Hand Clin 10(1): 111-6. Faruqui, S., Stern, P.J., Kiefhaber, T.R. 2012. Percutaneous pinning of fractures in the proximal third of the proximal phalanx : complications and outcomes. J Hand Surg Am 37(7): 1342-8 Hsu, L.P., Schwartz, E.G., Kalainov, D.M., Chen, F., Makowiec, R.L. 2011. Complications of K-wire fixation in procedures involving the hand and wrist. J Hand Surg Am 36(4): 610-6. Logters, T.T., Lee, H.H., Gehrmann, S., Windolf, J., Kaufmann, R.A. 2017. Proximal phalanx fracture management. Hand 13(4): 376-83. Nogueira, A., Alvarez, R., Iglesias, F. 1999. Irreducible phalangeal fracture in a child due to flexor tendon entrapment. J Hand Surg Am 24(5): 9247. Norliyana, M., Mohd Yazid, B., Abdul Muhaimin, A. 2018. Bilateral brachymetatarsia: A rare case report. Med & Health 13(1): 279-85. Pandey, T., Al Kandari, S.R., Al Shammari, S.A. 2008. Sonographic diagnosis of the entrapment of the flexor digitorum profundus tendon complicating a fracture of the index finger. J Clin Ultrasound 36(6): 371-3. Peter, C., Seth, D. 2009. Paediatric Hand fractures. Techniques in Orthopaedics 24(3): 150-60. Rodríguez-Vega, V., Pretell-Mazzini, J., MartiCiruelos, R., Jorge-Mora, A., de la Mano, A.C. 2013. Simultaneous Juxta-epiphyseal Proximal Phalanx Fracture with Flexor Tendon Entrapment in a Child. A Case Report and Review of Literature. J Pediatr Orthop B 22(2): 148-52. Sela, Y., Peterson, C., Baratz, M.E. 2016. Tethering the extensor apparatus limits PIP flexion following K-wire placement for pinning extra-articular fractures at the base of the proximal phalanx. Hand 11(4): 433-7. Sharma, H., Taylor, G.R., Clarke, N.M. 2007. A review of K-wire related complications in emergency management of pediatrics upper extremity trauma. Ann R. Coll Surg Engl 89(3): 252-8. Stahl, S., Schwartz, O. 2001. Complications of K-wire fixation of fractures and dislocations in the hand and wrist. Arch Orthop Trauma Surg 121(9): 527-30. Yamazaki, H., Kato, H., Uchiyama, S., Ohmoto, H., Minami, A. 2008. Results of tenolysis for flexor tendon adhesion after phalangeal fractures. J Hand Surg Eur Vol 33(5): 557-60.Received: 27 June 2018 Accepted: 28 Jan 2019
Med & Health Jun 2019; 14(1): 197-202
ABSTRACTMany anatomical variations exist in and around the carpal tunnel. However, symptomatic anomalies causing carpal tunnel syndrome is rare. Additionally, carpal tunnel surgery is considered a simple operation commonly done by junior surgeons who are usually unaware of variations resulting in unfavorable surgical outcomes. We highlight a case of lumbrical muscle variation causing carpal tunnel syndrome. A 73-year-old male presented with numbness and pain of both hands associated with abnormal fullness over both wrists and distal forearms. Initially the right hand was numb and subsequently a year later, the left hand became numb. Physical examination was positive for Durkan, Phalen and Tinel signs at the carpal tunnel. Magnetic Resonance Imaging (MRI) showed abnormal muscle tissues in the carpal tunnel. During the carpal tunnel release and exploratory surgery, we noted an abnormally proximal origin of the lumbrical muscles in the forearm rather than the typical palmar origin. He also had lumbrical muscle hypertrophy in the left side. These two factors resulted in overcrowding within the carpal tunnel. Postoperatively the patient recovered well with pain relief and gradual improvement of his numbness. Variations in the anatomy of the lumbrical muscles is not uncommon and may result in carpal tunnel syndrome. Hence, carpal tunnel release surgeries may not be as straight forward as expected and surgeons should be aware of this possibility.Keywords: anatomical, carpal tunnel syndrome, hypertrophy, lumbrical, median nerve, muscle, variations syndrome (Cartwright et al. 2014). The majority of the muscle aberrations are from the first or second lumbricals, palmaris longus, flexor digitorum superficialis of the index finger and atypically, palmaris profundus muscles (Redondo et al. 2011). The lumbrical muscles typically originate from the flexor tendons in the palm and insert into the extensor expansions. Variations are not uncommon and the present study depicts a case where the lumbricals originate much more proximally in the forearm. We report a patient with carpal tunnel syndrome (CTS) of both hands INTRODUCTION The occurrence of anomalous muscles in the region of the wrist is not uncommon but they are seldom associated with compression neuropathy. Anomalous proximal muscle origins or hypertrophy of the lumbrical muscles may limit space available for the median nerve within the carpal tunnel causing compressive neuropathy (Ragoonwansi et al. 2002). Aberrant muscles in relation to the carpal tunnel have been previously described, some of which were directly implicated in median nerve compression resulting in carpal tunnel 199Lumbrical Muscles Causing Carpal Tunnel Syndrome Med & Health Jun 2019;14(1): 197-202resulting from an abnormal origin of the lumbrical muscles proximal to the carpal tunnel in the forearm arising from both flexor digitorum profundus (FDP) and superficialis (FDS) tendons. Additionally on the left side, there was hypertrophy of the lumbricals to the left ring finger.CASE REPORT A 73-year-old retired army veteran presented with numbness, pain, night pain and clumsiness on his right hand for past one year. There was thenar muscle atrophy and numbness over the median nerve area, together with soft tissue fullness proximal to the wrist crease. Numbness was aggravated by active flexion of his fingers. Tinel sign over the carpal tunnel area and Phalen test were positive. Open carpal tunnel release was performed under general anesthesia in anticipation of exploratory surgery. Intraoperatively, the transverse carpal ligament had no overlying mass or fibrotic thickening. After incising the transverse carpal ligament, a hypertrophic muscle was found compressing on the median nerve. A gentle pull of this muscle confirmed its origin from the first and second lumbricals extending into the carpal tunnel attaching to the transverse carpal ligament as well as the FDP. Additionally, the second lumbrical was hypertrophic causing overcrowding in the carpal tunnel (Figure 1). Other structures in the carpal tunnel were normal. This anomalous muscle was later excised to reduce the compression to the median nerve. Symptoms were relived post-operatively. One year later, the patient presented with similar complaints and physical findings over his left hand. Magnetic Resonance Imaging (MRI) revealed abnormal muscle tissue within the carpal tunnel. The median nerve was compressed between the transverse carpal ligament and the anomalous muscle. An open carpal tunnel release was performed under general anesthesia. Hypertrophied lumbrical muscles were noted inside the carpal Figure 1: Hypertrophic first lumbrical muscle (blue arrow) and second lumbrical muscle (green arrow) compressing on the median nerve (deep to the lumbrical muscle).Figure 2: Note the abnormal lumbrical muscles (blue arrow) with abnormal proximal insertion to both the tendons of FDS and FDP (green arrow). The median nerve is marked with a yellow arrow.200Med & Health Jun 2019;14(1): 197-202 Benne E. et al.tunnel overcrowding the carpal tunnel (Figure 2), with an abnormal origin from the tendons of both FDP and FDS of ring finger, proximal to the wrist (Figure 3). No median nerve abnormality was noted. The abnormal lumbrical muscle belly was excised (Figure 3). Post-operatively the patient was satisfied as his pain was relieved. On follow-up, he underwent physiotherapy and his symptoms of numbness gradually improved.DISCUSSION The median nerve course and its surrounding anatomical structures are vital while discussing on median nerve compression. The median nerve arises from the C5-T1 roots and enters the arm lateral to the brachial artery between biceps brachii and brachialis. It then crosses the artery descending medial to it before entering the cubital fossa. Once in the cubital fossa, it is medial to the brachial artery and enters between the two heads of pronator teres, deep to the bicipital aponeurosis but superficial to the brachialis. Proximal median nerve compression can be due to pronator teres, lacertus fibrosus and tendinous origin of flexor digitorum superficialis. An anomalous third head of biceps brachii has been reported in a cadaveric dissection tightly encasing the median nerve and brachial artery restricting motion of the two structures (Zar Chi et al. 2017). The median nerve then continues in the forearm passing between the flexor digitorum superficialis and and flexor digitorum profundus muscles before emerging between the flexor digitorum superficialis and flexor carpi radialis muscle just about 5cm proximal to the carpal tunnel. In the carpal tunnel, the median nerve shares an enclosed space with nine other structures namely the four FDS, four FDP and one flexor pollicis longus tendon. Hence, it is commonly compressed resulting in CTS. There are four groups of median nerve variations i.e. I-the course of the thenar branches, II-accessory branches at the distal carpal tunnel, III-high division of the nerve including bifid median nerve and IV-accessory branches proximal to the carpal tunnel (Lanz 1977). In a bifid median nerve, an accessory muscle or a median artery may run in-between the division. The accessory muscles reported include the first lumbrical, palmaris longus, FDS muscle (Park et al. 2017; Atoni et al. 2017) and palmaris profundus. Presence of these anatomical variations are frequently associated with median nerve compression (Al-Qattan et al. 2009). Lumbrical muscles are important for finger movements and is part of Figure 3: The abnormal lumbrical muscles (blue arrow) are being dissected from the tendons of the FDS and FDP (green arrow).201Lumbrical Muscles Causing Carpal Tunnel Syndrome Med & Health Jun 2019;14(1): 197-202the intrinsic muscles of the hand. They are different from other muscles as they connect muscle to muscle forming a connection from the digit flexors to the extensors. Usually, they originate from the FDP tendon, distal to the carpal tunnel, and the muscle belly moves proximally on finger flexion. It is common to encounter variations in lumbrical attachment. Few variations include originating from a metacarpal, from the forearm or from a superficial flexor tendon (instead of FDP). Additionally, the third and fourth lumbricals normally originate from two tendons but may originate from a single tendon (Mehta et al. 1961). An additional muscle belly for the lumbrical muscle of the left ring finger was seen in our case where the hypertrophic muscle belly compressed the median nerve within the carpal tunnel. CTS can be caused by median nerve compression by anomalous and additional lumbrical muscles (Chaudruc et al. 2000). A similar observation was seen in a study showing a bipennate origin of the first lumbrical, extending from the distal part of forearm with a split insertion (Singh et al. 2001). Several other authors also reported that lumbrical muscle intrusion is a potential cause of CTS (Jabaley 1978; Joshi et al. 2005). In our case, the lumbrical muscle of the left ring finger had a proximal origin in the carpal tunnel as well as in the forearm. Siegel et al. reported that those patients with idiopathic CTS had lumbrical muscle origins located significantly more proximally in the carpal tunnel. Additionally, the lumbrical muscles were larger and had more proximal origins in those with jobs requiring repetitive hand motions (Siegel et al. 1995). Other than the abnormal attachments, those with repetitive hand movements and those with CTS were reported to have significantly larger and hypertrophied lumbricals (Joshi et al. 2005). Shimizu et al. reported a case of CTS caused by a hypertrophied lumbrical muscle with flexor synovitis (Shimizu et al. 2015). Such hypertrophied muscle belly can cause overcrowding of the carpal tunnel as they glide proximally along with the flexor tendon during flexion of the fingers or when making a fist. Some reports suggest that it is not the existence of an anomalous muscle per se producing symptoms but hypertrophy due to manual work (Redondo et al. 2011; Ragoonwansi et al. 2002). Operative treatment is preferred for CTS associated with lumbrical muscle anomaly rather than conservative management. Carpal tunnel release is usually performed, as well as resection of the abnormal muscle belly. It is preferably done under general anesthesia due to the larger surgical exposure. The prognosis is good after operative treatment once the abnormal muscle is resected as this prevents overcrowding of the carpal tunnel. It is best performed at an early stage before irreversible pathological changes occur on the median nerve.CONCLUSION Variations in the anatomy of the lumbrical muscles may produce 202Med & Health Jun 2019;14(1): 197-202 Benne E. et al.CTS. Surgeons performing carpal tunnel surgeries should have a sound knowledge of carpal tunnel anatomy and not consider them as simple straight forward operations.REFERENCES Al-Qattan, M.M., Al-Zahrani, K., Al-Omawi, M. 2009. The bifid median nerve re-visited. J Hand Surg 34: 212-4. Atoni, A.D., Oyinbo, C.A. 2017. Anatomic variation of the median nerve associated with an anomalous muscle of the forearm. Folia Medica 59: 106-7. Cartwright, M.S., Walker, F.O., Newman, J.C. Arcury, T.A., Mora, D.C., Haiying, C., Quandt, S.A. 2014. Muscle intrusion as a potential cause of carpal tunnel syndrome. Muscle Nerve 50(4): 517-22. Chaudruc, J.M., Florenza, F., Riviere, C., Arnaud, J.P. 2000. White finger and hypertrophy of the lumbrical muscles. Chir Main 19(4): 232-4. Jabaley, M.E. 1978. Personal observations on the role of the lumbrical muscles in carpal tunnel syndrome. J Hand Surg Am 3(1): 82-4. Joshi, S.D., Joshi, S.S., Athavale, S.A. 2005. Lumbrical muscles and carpal tunnel. J Anat Soc India 54(1): 12-5. Lanz, U. 1977. Anatomical variations of the median nerve in the carpal tunnel. J Hand Surg Am 2(1): 44-53 Mehta, H.J., Gardner, W.U. 1961. A study of lumbrical muscles in the human hand. Am J Anat 109: 227-38.Park, J.J, Choi, J.G., Son B.C. 2017. Carpal tunnel syndrome caused by bifid median nerve in association with anomalous course of the flexor digitorum superficialis muscle at the wrist. Nerve 3(1): 21-3. Ragoonwansi, R., Adeniran, A., Moss, A.L. 2002. Anomalous muscle of the wrist. Clinical Anat 15(5): 363-5. Redondo, M.G., Garcia-Guilarte, R.F., de Castro, A.B. 2011. Carpal tunnel syndrome caused by an anomalous muscle belly of the index finger lumbrical. Eur J Plast Surg 34(1): 61-3. Shimizu, A., Ikeda, M., Kobayashi, Y., Saito, I., Mochida, J. 2015. Carpal tunnel syndrome with wrist trigger caused by hypertrophied lumbrical and tenosynovitis. Case Rep Ortho 2015: 1-3. Siegel, D.B., Kuzma, G., Eakins, D. 1995. Anatomic investigation of the role of the lumbrical muscles in carpal tunnel syndrome. J Hand Surg Am 20(5): 860-3. Singh, G., Bay, B.H., Yip, G.W., Tay, S. 2001. Lumbrical muscle with an additional origin in the forearm. ANZ J Surg 71(5); 301-2. Zar Chi, T., Ahmad Ruzain, S., Mohammad Johari, I., Syed Baharom, S.A.F. 2017. Anomalous third head of biceps brachii muscle and its variant insertion compresses surronding neurovascular structure: a rare case Report. Med Health 12(2): 368-74Received: 20 June 2018 Accepted: 28 Jan 2019
J Hand Microsurg 2016 Aug 1;8(2):106-8. Epub 2016 Jul 1.
Institute of Micro and Hand Surgery, Duson Hospital, Gyeonggi-do, Korea.
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Arch Reconstr Microsurg 2016;25(1):12-14.
Archieves of Reconstructive Microsurgery
In cases of replantation, accurate closure of all structures, including bone, tendons, arteries, nerves, and veins is essential. Among these, the vein is a weaker structure and is damaged severely in most amputation cases. After fixation of bone, repair of tendons, nerves, and arteries, surgeons often experience difficulty in performing venous anastomoses. We found that in such cases, venous anastomosis is easy to perform using an additional incision after closure of the original wound. In a 33-year-old male patient with amputation of all four fingers at the metacarpophalangeal joint level, venous anastomoses were performed with dorsal veins using additional incisions after completion of the fixation of bones and repair of all other structures and closure of the skin due to surgical site tension.Key Words: Metacarpophalangeal joint, Amputation, VeinThe metacarpophalangeal joints (MCPJ) refer to the joints between the metacarpals and the proximal phalanges of the digits whose dorsal portion is composed of dorsal expansion of extensor tendons, skin and dorsal veins.1 In case of digital replantation, typical sequences of repair are fixation of bone, repair of tendons, arterial anastomosis, nerve repair and venous anastomosis followed by skin closure.2 In a 33-yearold male patient with all four fingers MCPJ level amputation, replantation was attempted accordingly. But while we tried to perform venous anastomosis, due to surgical site tension from crushing injury, it was impossible to perform adequate anastomosis without tension. So venous anastomoses were conducted through addition incisions on the dorsum of the hand with dorsal metacarpal and digital veins, after closure of the original wound and gained a relatively satisfactory result.CASE REPORTA 33-year-old male patient attended emergency department with complete amputation of all four fingers of left hand at MCPJ level following a work place injury (Fig. 1). There were no specific findings in respect to past medical history. He was thoroughly examined and on local examination it was found that there were complete amputations of all four fingers of the left hand with crushing injury mostly on dorsal side. On radiographic examination, the proximal phalanx of index, ring and small fingers showed severe comminution and the long finger was amputated at MCPJ level. Replantation of the fingers were implemented starting with fixation of fractured bone using K-wires, and then did extensor and flexor tendons repair, arterial anastomoses, and nerve repair subsequently. After dorsal expansion of extensor tendons repair, we attempted to perform venous anastomoses. But it was impossible to do a tension free venous anastomoses. So we closed the wound first. After checking circulation of the hand, we made additional incisions on the web space where dorsal veins were expected to be present and performed the venous anastomoses using the dorsal metacarpal and digital veins. We mobilized the veins proximally before anastomoses to relieve tension over repair site and conducted anastomoses of total five veins. After completion of venous anastomoses, we attempted to suture the skin over venous anastomoses site. But due to surgical site tension, which was producing compression over the anastomosed veins, full thickness skin graf were applied over the five venous anastomoses sites harvested from the ipsilateral forearm (Fig. 2, 3). We observed scar hypertrophy over the area of skin grafting, and applied pressure garments and scar massage and considered intralesional steroid injection. Intralesional excision will be performed, if the scar persisted even after one year. After three months of replantation, the patient was followed-up to check the functional outcome. At that time range of movement was 0o to 10o at proximal and distal interphalangeal joints and 15o to 40o at MCPJ. Physiotherapy and occupational therapy were continued to improve the range of movements of the joints. If it will not improve within one year we will consider tenolysis to improve the joints movement. So at three months, in respect of survivability and functional point of view, result of the replantation of our case is quite satisfactory (Fig. 4).DISCUSSIONDorsal digital veins run along the side of the digits and meet with the cross-branches in oblique line and meet each other at the side of the digits forming three dorsal metacarpal veins and a dorsal venous network at the middle of the metacarpals.1,3 The radial side of dorsal venous network meets the dorsal digital veins of the thumb and the index finger, and heading to the cephalic vein whereas the ulnar side is connected to the ulnar dorsal digital veins of the little finger, heading towards the basilic vein. Routine running of vein presents a tendency to run through the side of MCPJ.1,4 In this case, due to significant surgical site tension venous anastomoses was difficult to perform. So we closed the initial wound without performing the venous anastomoses. Then through additional incisions on both sides of the MCPJ, which are the expected sites of the dorsal veins, tried to find out good caliber, comparatively less injured veins. Then after adequate proximal mobilization venous anastomoses were done with five dorsal veins among them three were metacarpal veins and two were digital veins. The sequence of procedures of replantation may differ depending on the site or shape of amputation. Typical sequences of digital replantation are starting with confirmation of locations of blood vessels and nerves, followed by debridement. Thereafter, surgery proceeds as bone fixation, repair of extensor and flexion tendons. Subsequently, arterial anastomosis and nerve repair are to be conducted. Then lastly venous anastomoses was done followed by skin closure.2,5,6 In this case, due to surgical site tension from crushing injury venous anastomosis could not be done before skin closure. So venous anastomoses were conducted with dorsal veins through additional incisions over the web spaces after original wound closure and gained a relatively satisfactory result. It has been known that if there is tension at surgical site, usually it requires vein graft.7,8 When distal veins are not available distal arteries are also anastomosed with the proximal veins. However, as this case had the issue of multiple veins anastomoses as all four fingers were amputated, we made some additional incisions over expected sites of the metacarpal and digital veins, mobilized the veins adequately to gain enough lengths to minimize anastomoses sites tension and then performed the anastomoses. And we got satisfactory results in terms of outcome. So it can be considered that venous anastomosis with the dorsal veins through additional skin incisions over expected sites of them, after performing original wound closure, can reduce the anastomosis site tension and can be a good option in cases where due to surgical site tension, venous anastomosis is difficult to perform, in MCPJ level digital replantation.REFERENCES1. Gray H. The veins. In: Clemente CD, editor. Gray’s anatomy. 30th ed. Philadelphia: Lea & Febiger; 1985. p. 788-865. 2. Goldner RD, Urbaniak JR. Replantation. In: Green DP, Hotchkiss RN, Pederson WC, Wolfe SW, editors. Green's operative hand surgery. 5th ed. Philadephia: Elsevier Churchill Livingstone; 2005. p. 1569-86. 3. Lee BI, Chung HY, Kim WK, Kim SW, Dhong ES. The effects of the number and ratio of repaired arteries and veins on the survival rate in digital replantation. Ann Plast Surg 2000;44:28894. 4. Matsuda M, Chikamatsu E, Shimizu Y. Correlation between number of anastomosed vessels and survival rate in finger replantation. J Reconstr Microsurg 1993;9:1-4. 5. Urbaniak JR, Hayes MG, Bright DS. Management of bone in digital replantation: free vascularized and composite bone grafts. Clin Orthop Relat Res 1978;(133):184-94. 6. Whitney TM, Lineaweaver WC, Buncke HJ, Nugent K. Clinical results of bony fixation methods in digital replantation. J Hand Surg Am 1990;15:328-34. 7. Suzuki Y, Ishikawa K, Isshiki N, Takami S. Fingertip replantation with an efferent A-V anastomosis for venous drainage: clinical reports. Br J Plast Surg 1993;46:187-91. 8. Lima JQ Jr, Carli AD, Nakamoto HA, Bersani G, Crepaldi BE, de Rezende MR. Prognostic factors on survival rate of fingers replantation. Acta Ortop Bras 2015;23:16-8.
J Hand Microsurg 2014 Dec 16;6(2):102-5. Epub 2014 Mar 16.
Department of Orthopedic Surgery, Woori General Hospital, 116-11 Songwoo, Soheul, Pocheon, Gyeonggi-do 487-820 Korea.
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J Hand Microsurg 2013 Jun 14;5(1):4-8. Epub 2012 Nov 14.
Department of Orthopaedic Surgery, Seoul Micro Hospital, 365-1 Dosun-dong Sungdong Gu Seoul, Seoul, 133-040 Korea.
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