P091 Osteoid osteoma of the trapezoid bone: a diagnostic pitfall of a wrist chronic monoarthritis

Background Osteoid osteoma is a benign bone tumor representing ∼10% of all benign bone tumors. Although osteoid osteoma of the long bones is usual, the location in the carpus, especially, in the trapezoid bone is rare [1,2]. The Objective is toreport a case of osteoid osteoma of the trapezoid bone with extension to the adjacent second metacarpal bone that was missed diagnosis at initial presentation. Methods We describe the clinical, radiological features and outcomes after surgical resection. Results A 24-year-old right-handed female, presented with a three-year history of pain at the left wrist, particularly, in the radial-side. She didn’t report any trauma to the wrist. The pain increased over time. She couldn’t use her hand in daily activities and could hardly sleep because of increasing pain at night. Before being referred to our department, she consulted a surgeon. She was treated with oral anti-inflammatory drugs, steroids, several intraarticular steroid injections without relieving pain. The Magnetic resonance imaging (MRI) showed bone marrow oedema in the trapezium and the trapezoid bone, synovial effusion, and tenosynovitis of the flexors of the thumb. A synovectomy was performed and the histopathology revealed non-specific chronic inflammation. One year later in our department, examination showed wrist swelling, tenderness and pain on palpation. The erythrocyte sedimentation rate was 12 mm/h and the mean C-reactive protein was 2 mg/l. Autoantibodies testing were negative. Initial radiography was read as normal. Initially, Naproxen (550 mg/day) and Morphine (60 mg/day) were prescribed with partially relieving pain. Scintigraphy showed increased uptake of 99mTc in the radial-side of the left wrist. Then, a bone tumor was suspected. The Computed tomography (CT) images revealed a well-demarcated sclerotic nidus surrounded by a halo of radiolucent osteoid tissue, consistent with an osteoid osteoma of the trapezoid bone and the adjacent second metacarpal bone. Surgical resection of the osteoid osteoma was performed. Histopathological examination confirmed the diagnosis. The patient reported complete pain relief since her surgery. She had no recurrence to date. Conclusion Osteoid osteoma should be in the differential diagnosis list of chronic wrist pain/arthritis. In this case, careful attention is necessary for patients unresponsive to treatment with long-lasting symptoms. If radiographs are inconclusive, CT or MRI should be considered to better visualize the nidus of osteoid osteoma in the small bones of the hand.

Functional Restoration of a Midforearm Level Amputation using the Second Toe Transfer

Unilateral midforearm level amputation is a severely debilitating situation. The present solution for this problem is either restoration of function using a prosthetic hand, or a vascularized composite allotransplant (VCA) in some very selected cases. In cases of distal forearm level amputations, even vascularized second toe transfer could be done on the radial side of the hand to achieve good functional restoration. We present a case of midforearm level amputation in which the second toe transfer has been done above the level of insertion of pronator teres muscle to achieve meaningful function. This report highlights the fact that a single toe transfer could be helpful in achieving meaningful prehension, even at this proximal.

Radial Club Hand Treated by Paley Ulnarization Generation 3: Is this the New Centralization?

(1) Background: Patients treated with the two previous generations of ulnarization developed a bump related to the ulnar head becoming prominent on the radial side of the hand. To finally remedy this problem, a third generation of ulnarization was developed to keep the ulnar head contained. While still ulnar to the wrist center, the center of the wrist remains ulnar to the ulnar head, with the ulnar head articulating directly with the trapezoid and when present the trapezium. (2) Methods: Between 2019 and 2021, 22 radial club hands in 17 patients were surgically corrected with this modified version of ulnarization. (3) Results: In all 17 patients, the mean HFA (hand–forearm-angle) correction was 68.5° (range 12.2°–88.7°). The mean ulna growth was 1.3 cm per year (range 0.2–2 cm). There were no recurrent radial deviation deformities more than 15° of the HFA. (4) Conclusions: This new version of ulnarization may solve the problem of the ulna growing past the carpus creating a prominent ulnar bump. The results presented are preliminary but promising. Longer-term follow-up is needed to fully evaluate this procedure.

Widespread Mechanic's Hands in Antisynthetase Syndrome With Anti-OJ Antibody

Mechanic's hand is a representative manifestation of antisynthetase syndrome (AS) but is observed in other forms of dermatomyositis1. This is a nonpruritic, hyperkeratotic, and scaly eruption on the ulnar side of the thumb and radial side of other fingers; occasionally the palms, fingertips, and feet are involved. However, a widespread type affecting the whole palm and fingers is extremely rare in anti-OJ antibody.

Utilization of the autologous vein on the ulnar side of the dorsal hand for arteriovenous fistula creation

We previously described the success and usefulness of two operative techniques for creating a radial artery-first or second dorsal metacarpal vein arteriovenous fistula (AVF) in the first interdigital space of the dorsal hand using the most distal site and autologous veins in the upper limb. These techniques utilize the dorsal metacarpal veins on the radial side of the dorsal hand. Developing these ideas, we devised a novel operative technique for creating a transposed radial artery-third metacarpal vein AVF in the first interdigital space of the dorsal hand using the most distal vein on the ulnar side of the upper limb and most distal site in the upper limb. The distinctive advantage of this technique is that it can be applied to patients whose cephalic vein in the forearm and the dorsal metacarpal veins on the radial side of the dorsal hand are of a poor quality. We herein report the steps of this technique and describe its successful performance in a patient who has been on hemodialysis for 14 months without any additional vascular access interventions or postoperative complications. We consider this technique to be a valuable option in select patients who meet the applicable conditions. The creation of the first AVF as distally as possible is ideal, and it offers a further viable option of distal native vascular access that may be overlooked.

Peripheral Intravenous Line Access

A peripheral intravenous catheter is used to access a peripheral vein. To start a peripheral intravenous line, identify the site, place a tourniquet, clean the skin, stabilize the vein, and insert the catheter. When a “flash” is obtained, thread off the catheter, connect it to the tubing, and secure. This chapter describes tips for finding common intravenous access sites in children, which are the metacarpal, saphenous, cephalic, median, and scalp veins. These veins vary in size, depth, and difficulty. Metacarpal/dorsal hand veins are on the dorsal aspect of the hand and typically arise from adjacent digital veins and form a network that usually provides several targets for access, although there is significant variation. These veins form the cephalic vein (radial side) and basilic vein (ulnar side) as they converge. The cephalic vein arises from the lateral (radial) side of the dorsal venous network before curving around the wrist to run along the anterolateral forearm, where it is frequently easily accessed. It continues on this course up the arm, but more proximally it is less superficial. The median cubital vein runs from the cephalic vein medially toward the basilic vein diagonally across the antecubital fossa and is reliably present if not always visible. The greater saphenous vein is formed on the foot from the dorsal vein of the great toe and the dorsal venous arch of the foot. It ascends anteriorly to the medial malleolus and superiorly up the medial calf.

The pull-out reparation technique for ulnar collateral ligament (UCL) of the thumb

Introduction: Ulnar collateral ligament (UCL) of the thumb injury is a very common injury. However, due to the complexity of the ligament anatomy, the inexperience of doctors and unavailability of diagnostic procedures, the ulnar collateral ligament of the thumb injury is most commonly overseen. The consequences are loss of thumb function, instability and pain in the metacarpophalangeal joint, and accelerated osteoarthrosis. For these precise reasons, there is a clear consensus that this injury should be treated operatively. Objective: The objective of this paper is to present the results of the pull-out technique for reconstructing the UCL ligament. Methodology: In between 2018 and 2020, we have operated on 11 patients with the UCL of the thumb rupture in our department. We approached the dorsoulnar side of the metacarpophalangeal (MCP) joint of the thumb using the standard lazy S incision. In 9 out of 11 patients, a Stener ligament lesion was discovered. All patients had their ligament reconstructed using the pull-out technique, where the ligament was sewn through, then guided through a channel created using a K needle on the radial side of the base of the thumb. Postoperatively, a spica plaster orthosis was placed on the thumb. Results: The patients returned for re-evaluation 6, 12 and 24 weeks after surgery. Upon 24 weeks, the patients had no complaints regarding their thumb, they had full grip strength and could perform all the various grips. Two of the patients had a limited abduction amplitude of the thumb in the MCP joint, which didn't affect the outcome. There was no injury to the sensory branch of the radial nerve. Conclusion: The pull-out technique is a safe, quick and cheap operative technique for UCL of the thumb reconstruction.

On-Top-Plasty for Atypical Thumb Duplication: A Case Report With 10 Year Follow-up

Background: A very uncommon pattern of thumb duplication consists of an ulnar-side floating thumb and a radial-side distally hypoplastic thumb. Methods: We report the case of a 15-month-old child with this type of thumb duplication on his right hand treated with an on-top-plasty technique. The ulnar-side segment was pedicled and transferred to the lateral thumb, which was distally resected. Results: A well-aligned and widely mobile thumb with a wide first web and an excellent cosmetic appearance was exhibited 10 years after surgery. Conclusions: On-top-plasty technique might be amenable to reconstruct certain atypical thumb duplications.

The anatomy of Wassel type IV-D thumb duplication

We describe Wassel type IV-D thumb duplication anatomy after surgery on 11 affected children (12 hands, seven boys (eight hands) and four girls). We studied the structure and course of the flexor pollicis longus tendon and its action at the joint. Four patients had secondary deformity associated with an absent A2 pulley and a tendon that clung to the radial side of a small thumb. In patients with primary deformity, the flexor tendon sheath became membranous in the A2 area and attached to neighbouring sites on the opposite side of the proximal phalanx. In the proximal A2 area, the tendon divided – one division attached on the ulnar side of the distal phalanx base; the other, the base of the radial side. There was slight ulnar angulation of the distal phalanx on the radial portion of the duplication and slight ulnar angulation on the radial portion. Level of evidence: V

Ultrasound Assessment of Synovial Thickness of Some of the Metacarpophalangeal Joints of Hand in Rheumatoid Arthritis Patients and the Normal Population

Objective. To compare ultrasound synovial thickness of the 2nd, 3rd and 4th metacarpophalangeal joints (MCPJ) in a group of patients with proven rheumatoid arthritis (RA) and a control group of normal individuals.Materials and Methods. This is a cross-sectional study comprising 30 rheumatoid arthritis patients and 30 healthy individuals. Ultrasound scans were performed at the dorsal side of 2nd, 3rd, and 4th MCPJ of both hands in RA patients and the healthy individuals. Synovial thickness was measured according to quantitative method. The synovial thickness of RA patients and healthy individuals was compared and statistical cut-off was identified.Results. Maximum synovial thickness was most often detected at the radial side of the 2nd MCPJ and 3rd MCPJ and ulnar side of the 4th MCPJ of both hands which is significantly higher (p<0.05) in RA patients compared to healthy individuals. With high specificity (96%) and sensitivity (90%) the optimum cut-off value to distinguish RA patients and healthy individuals’ synovial thickness differs for the radial side of the 2nd and 3rd MCPJ and ulnar side of the 4th MCPJ.Conclusion. Patients with early RA appear to exhibit a characteristic pattern of synovitis which shows radial side predominance in the 2nd and 3rd MCPJ and ulnar side in the 4th MCPJ.