Posteraustellung SGH

Introduction

Due to the lack of adaptability of existing tubular gauze applicators for digital wounds, a user-friendly device was developed to fit different finger sizes and reduce the time of bandaging for the healthcare professional and for the patient. 

Methods: 

The device consists of two separate 3D printed parts. The device itself, designed as a tripod, and the plunger. The plunger is inserted into the main part. The plunger can be moved to several positions with a progressive change of the diameter of the tripod. We used this device in 58 patients with finger injuries. Patients with digital re-implants were excluded. Patients with multidigital injuries were included in the study. 

Results

In all patients, the TRIpod was useful and speeded up the application of the tubular bandages. After a brief introduction, each patient was able to perform the daily dressing change independently. The mean time of dressing was 15 seconds. 

Conclusions

TRIpod is an ergonomic and adaptable bandage aid that is easy to use for both medical professionals and the patients themselves. The advantage of the 3D printing makes the applicator a tool with potentially wide spread

Pisotriquetral (PT) instability and consecutive arthritis is a common differential diagnosis of an ulnar sided wrist pain. When conservative treatment fails, a pisiformectomy remains as the treatment of choice. Pistotriquetral arthrodesis as an alternative was described in 2006 for high demand patients. Thus far an arthroscopic approach to PT joint has been described and a case report has been published regarding an arthroscopic resection of a loose body of PT joint.

We present a case series of 3 well documented arthroscopic assisted PT arthrodesis that we performed from April 2022 till January 2023.

A 20-year-old MMA fighter presented with ulnar sided wrist pain in motion due to instability of both PT-joints. We performed an arthroscopic assisted PT-fusion with two cannulated screws. A cock-up wrist splint was given for 6 weeks. A CT-scan was preformed 6 and 12 weeks postoperatively. After 3 months a consolidation of PT-fusion was seen and the patient was allowed to strengthen his hand. After 5 months he could return to preforming martial arts.

A 45-year-old office worker presented with ulnar sided wrist pain which was incapacitating her right hand. An arthroscopic-assisted PT-fusion was performed after diagnostic infiltration. 3 months postoperatively advanced consolidation was to be seen in CT-Scan with merely pain of the scar.

Both patients reported a significant reduction of pain without loss of strength.

Arthroscopic assisted PT-arthrodesis offer a safe and minimally invasive procedure to address a symptomatic instability and arthritis of the PT-joint. Wrist arthroscopy is a mighty tool in the arsenal of a hand surgeon and this procedure enhances the spectrum of minimal invasive procedures of carpal surgery. Literature also suggests higher satisfaction rates with patients preferring an arthroscopic procedure versus open surgery. This helps us as surgeons to provide broader spectrum of minimally invasive surgical procedures with increased satisfaction of patients, good outcome results and low complication rates.

Introduction:

Isolated compression of the deep ulnar motor branch is uncommon. Muscular atrophy of the hypothenar, as well as reduced force in abduction of the fingers and positive Froment sign are typical clinical symptoms, whereas cutaneous innervation of the hand is not affected. Causative factors can be fracture of the hamate’s hook, diseases of neighboring vessels, degenerative diseases in the wrist, or as in our cases a ganglion cyst. We will describe two cases with its clinical, neurophysiological and radiological findings, as well as its therapies applied.

Material and Methods:

Two elderly people presented in our clinical outpatient department for hand surgery based on progressive loss of strength of their hand. Additionally, we could observe atrophy of the first webspace and the hypothenar area, as well as positive Froment sign. Neurophysiological studies showed distal injury of the Ramus profundus Nervus ulnaris. Radiographic examination with magnetic resonance imaging (MRI) was initiated. Both cases presented cystic formation compressing the deep branch of the ulnar nerve against the hamulus of the hamate. Furthermore, edema of denervation of the intrinsic muscles was observed. In a synopsis of the present findings, surgical decompression of the nerve at Guyon’s canal was indicated.

Results:

Intraoperative findings were congruent with previous MRI examination. In both cases, the deep ulnar motor branch was compressed by a tumor in the piso-hamate hiatus. Histological investigation confirmed the presence of a ganglion cyst in both cases. After having performed the operation, both patients improved in their motor function of the ulnar nerve, whereas no sign of recurrence have been observed.

Discussion:

Heavy compression of the motor branch of the ulnar nerve is of significant limitation in hand function. Therefore, patients with a decrease in hand strength should undergo further diagnostics such as neurophysiological and radiological studies. Even tough, compression by a ganglion cyst in the Guyon’s canal is a rare condition, one should think about when examining patients with pure motoric ulnar nerve deficit. If these conditions are existing, early decompression is recommended to achieve best outcome with high probability of rehabilitation.

The Motec^® wrist prosthesis is a cementless, modular, metal-on-metal wrist arthroplasty. Threaded stems are used to achieve immediate primary fixation in the cortical bone at two-thirds of the proximal length. Coating stems with Bonit^®enables long-term implant fixation and osseous integration.

In case of a third metacarpal fracture occurring in a traumatic context, internal fixation may be limited by the restricted space available due to the stem prosthesis. Solid internal fixation for early rehabilitation may help reduce secondary stiffness and impacts on wrist prosthesis function.

A 65-year-old right-handed nurse presented following a fall onto her left hand, 2 years after wrist prosthesis implantation. She had undergone a Motec^® total wrist arthroplasty after a failed proximal row carpectomy. At the two-year follow-up, she reported complete pain relief and an improved range of motion with a gain in grip strength. Radiological imaging did not show any complications.

Two years post prosthesis implant, patient presented following a fall. Imaging showed short oblique fractures of 3rd, 4th and 5th metacarpals (Fig 1A/B). Internal fixation used locking T-plate 2.0 at 3rd metacarpal, 1.0 wire cerclages at the distal epiphysis to secure the plate to the diaphysis (Fig 1C). Solid fixation ensured without malrotation. Immediate rehabilitation was initiated with buddy taping, with 4 weeks protective wrist free splint, 2-week night splint. Bony fusion was achieved at 3 months; hardware removed 7 months later.

At 2-year follow-up: wrist flexion: 80°, extension: 50°, radial deviation 20°, ulnar deviation 40° with a stable pain-free wrist. Metacarpophalangeal joint motion: flexion: 110°, extension: 0°. Grip strength: 20 kg.

Fixing a fracture at the metacarpal stem of a prosthetic implant remains a technical challenge, requiring a solid fixation to enable early rehabilitation and prevent stiffness or damage to the wrist prosthesis.

A 65 year old patient presented at the emergency department after experiencing a syncope with prolonged period of impaired consciousness thereafter. The anamnesis was devoid of similar incidents. On examination a tumor in the left submandibular regionstood out. The medical history revealed this tumor being present since 4 years, growing slowly and having been verified as a schwannoma through fine needle biopsy three months before. The patient reported lightheadedness with head reclination and a feeling of pressure when turning his head to the left. Having eliminated other probable causes for the syncope, compression of the bulbus carotis by the tumor, depending on position of the head, was diagnosed. The patient was operated and a tumor of 4,5x4x2,5cm, originating from the sympathetic trunk, was removed. The histologic examination confirmed the tumor as being a schwannoma. The patient experienced prompt relief of the disabling neurological symptoms and exhibited only mild miosis and ptosis postoperatively.

Introduction: Capitate necrosis is a rare condition characterized by sclerosis, fragmentation, and cyst formation in radiographic imaging. Patients present with chronic wrist pain and limited joint function. The cause is multifactorial. There are no guidelines for treatment of capitate necrosis, but surgery is commonly offered to patients. This case study presents the incidental finding of early-stage capitate necrosis in the proximal pole of a 21-year-old patient classified Milliez Type 1a during follow-up X-rays after a scaphoid fracture sustained in a fall.

Hypothesis: We hypothesize that conservative treatment, involving reduced weightbearing and close monitoring, may effectively heal early-stage capitate necrosis, leading to restored osteointegration and joint function.

Methods: A comprehensive assessment, radiographic imaging such as X-rays, CT scan, and specific perfusion MRI was performed. During the 7 months follow-up X-ray after conservative treatment of the scaphoid fracture, the capitate necrosis was diagnosed incidentally, which was defined as time zero. The latest follow-up occurred after 1.5 years. Follow-ups included repeated radiographic imaging and clinical evaluation of wrist flexion-extension and grip strength.

Results: Conservative treatment of capitate necrosis in the proximal pole resulted in sufficient healing with no signs of progression, while maintaining continuous perfusion. At the latest follow-up, the patient presented pain-free, regained full wrist joint function in flexion-extension (75-0-60°) and grip strength (Jamar II 45kg). Radiographic findings showed osseous reintegration.

Discussion: The present clinical course highlights the importance of early detection and power of conservative treatment strategies for early-stage capitate necrosis without osteoarthritic signs and with preserved perfusion. Due to the limited number of reported cases in the literature, guidelines for staging and therapeutic approaches are currently lacking. Surgical intervention is typically considered for capitate necrosis; however, taking into account the staged therapy of lunate necrosis, we recommend conservative treatment as a viable option in early-stage cases of capitate necrosis, reducing the need for surgery and associated risks. Specific perfusion MRI protocols may help in decision-making. Long-term follow-up is crucial to assess the success of the treatment outcomes and potential complications.

Abstract

We report the case of a forest ranger who developed a polymicrobial infection with Mucor circinelloides after traumatic forearm amputation. Based on our case report we discuss epidemiology and management of this rare and potentially fatal infection.

Introduction

Most commonly fungal osteomyelitis is associated with aspergillus or candida species. Osteomyelitis with mucor species is a rare and exceptionally life-threatening condition as mucor spores  cause angioinvasive infections in patients with immunosuppressive conditions such as poorly controlled diabetes mellitus, malignancies, neutropenia, transplants, and chronic renal failure. Mucor osteomyelitis is most commonly associated with trauma or a surgical intervention. A hematogenous spread causing osteomyelitis is extremely rare. There is a male-to-female ratio of > 2:1 in Mucormycosis of bones and joints.

Case presentation

A 38-year-old Patient was transported to our emergency department by air ambulance after accidental traumatic forearm amputation. During replantation, multiple samples for microbiological testing were taken. On day 7 after replantation the patient developed progressive swelling, increasing skin necrosis, and venous congestion. An emergent re-exploration took place. Intraoperatively multiple thrombosis of all blood vessels was demonstrated with avital extensor and flexor muscles with visible superficial fungal contamination. Eventually the decision had to be taken to amputate at the level of the proximal forearm. The microbiological and histological bone samples revealed polymicrobial infection with Mucor circinelloides. Systemic additional antifungal therapy was implemented. Repeated surgical debridement were performed over the following 14 days. Eventually closure of the skin defect by a fasciocutaneous hatchet flap and meshed skingraft took place 5 weeks after the initial trauma.

Discussion

As Mucormycosis infections are exceptionally rare and potentially lethal, a multidisciplinary approach is mandatory. Early diagnosis, a combination of antifungal therapy and aggressive serial debridement as well as treatment of underlying medical conditions such as diabetes mellitus are mandatory. Early differentiation between colonization and invasiveness can reduce side effects by shortening the time of treatment with antifungal agents as colonization can be treated additionally with local antiseptics.

Background:

With partners in the National Referral Hospital in Honiara (Solomon Islands), Hand surgeons from a Swiss tertiary hospital have started a cooperation with the aim to sustainably improve hand and reconstructive surgical care in this country with a light house effect for the entire South Pacific region. The widely dispersed population of these small island states, 25% of which live below the poverty line, with significant geographical distances between the individual islands, often only reached by the simplest means of transportation, lead to a situation with very limited medical and special surgical care, as well as major challenges and needs for support in long-term development.

Aim:

The aim of this study is to report on progress since the start of an 8-module training cooperation.

Material & Methods:

The dynamics of the numbers of hand surgical patients, delays from injury to referral and from initial specialist review to definitive treatment are presented since the start of the training program. Success of treatment is evaluated via pathology-specific outcome measures, and general outcomes such as complications, re-operations and secondary procedures. The data is extracted from the local Trauma and Orthopedic Database.

Results:

The data extraction is still ongoing at the date of abstract submission and will be critically evaluated and presented at the time of the Annual SGH Meeting November 2023.

Conclusion:

International cooperations in low and middle income countries such as HandsON need to be ongoing subject to critical evaluation in order to meet the aim to progressively and sustainably support and enable surgeons in training on site with local, national and international networking, using local infrastructure and resources, in order to guarantee sustainable change and excellence in surgical patient care. This includes the collection of all relevant data for the measurement of change and progress, and their critical evaluation including audits and research projects.