Hand Team Census of different cases done .pptx

Hand Team Census of different cases done

1. Hand Unit Census 16-20 September 2024

2. CASE 1. Mr HF (N936423) Continuation of progress Recap from previous census: Traumatic hand injury - amputation of right ring finger at DIP joint Done replantation of distal phalanx of right ring finger

3. Clinical pictures

4. Proceed with refashioning and lateral flap (Kutler) over right middle finger on 13/9/24

5. Clinic follow up on 24/9/24

6. Fingertip amputation Definition The distal part of the thumb or finger is called the thumb-tip or fingertip. Amputation of any structures around or distal to the distal interphalangeal (DIP) joint of the finger, especially those distal to the middle phalanx (distal to the FDS tendon) are considered the fingertip.

7. Various classification systems: Allen 1980 Tamai 1982 Ishikawa 1990 Lister 1991 Fassler geometry system 1996 Elashy 1997 Hirase 1997 PNB 2000

8. Lister Classification

9. Shortening of < 0.5cm Mild decrease in sensation rather than loss of sensation Loss of DIPJ motion of about 20 degrees * Usually cause little functional or cosmetic impairment

10. Optimal repairs strives to achieve: (3 things) Maintain length much as possible- intention of shortening less than 0.5 - 1cm Recovery sensation to grade S3+ or more, best static 2-point discrimination less than 5 or 6mm Restore active range of DIPJ motion or thumb IP joint motion of 40 to 50 degrees, or greater

11. For soft tissue reconstruction of the fingertip, it is required Glabrous skin with similar texture Suitable thickness Durability for pinch and grip The ability to restore sensation

12. Generally treatment strategies follow the reconstructive ladder Reconstruction ladder by Mathes and Nahai (Use the simplest way possible to correct defect) Techniques in order: Self-regeneration without any surgical treatment Primary closure Local and regional flaps Free vascularized tissue transfer

13. Replantation or simple suture of the amputated distal part Clean amputated tip can either; (a) be replanted or (b) sutured back directly as a composite graft (cap technique) *success factors : OT setup, the surgical team, and the experience of individual surgeons.

14. Regenerative potential of digit tips amputation < 1cm may regenerate w/o surgery wound covered with moist dressing for 1-2 months Regeneration over small subcutaneous tissue defect bone loss + exposed distal phalanx will not regrow- soft tissue may regenerate *re-epithelization Cannot apply to large defects Sensory recovery is limited

15. V-Y advancement flaps There are a few types: Atasoy flap Segmuller Vankataswami

16. Atasoy Flap (1970) volar defect of the fingertip triangular flap - edge of the amputation and the apex at DIPJ crease. Skin flap advanced over the exposed bone V shaped donor site closed as a Y

17. Lateral V-Y flaps Divided into 3 types: Unilateral VY flaps (Geissendorf 1943) Bilateral VY flaps (Kutler 1947) Lateral pedicled VY flaps (Segmuller 1976; Biddulph 1979)

18. Oblique V-Y flap (Prof Venkataswami flap) Long oblique V-Y flap is harvested with the apex proximal to PIPJ over one neurovascular bundle of the digit.

19. Homodigital Reverse Pedicle Digital Artery Flap

20. Classical thenar and cross-finger flaps

21. Terminalization or finger shortening Reasons to consider shortening the fingers are such as: Patient not keen for complex surgery Patient health condition does not allow such surgery fingertip is severely infected, contaminated, or crushed economic constraints (eg foreigner) operation with quick recovery with reasonable function, but not a good choice for cosmetics, or function.

22. Case 2. Mrs FB (M350415) 44yo Malay Lady NKMI, No allergies No PSHx Housewife Right handed Under Ortho Hand Team for 1) Left cubital tunnel syndrome 2) Left LHBT tendonitis with impingement syndrome

23. HOPI 3 yrs history of left hand numbness Worsening over the past 1 year Radiating to the medial 2 fingers of the left hand Done physiotherapy but not improving Otherwise, no weakness in grip power

24. O/E Left upper limb examination: Reduced sensation over C8,T1 distribution Tinel positive over the medial elbow at the cubital tunnel Tinel negative at Guyon canal No ulnar claw hand Interossei, FCU power MRC 5 FDP over RF and LF of left hand MRC 4 Froment test negative No ulna nerve subluxation

25. Investigations: Nerve conduction study 2/5/23: Normal findings MRI left elbow 14/8/24 Impression: 1.Intact collateral ligaments of the left elbow joint. 2. Focal flattening of the ulnar nerve within the cubital tunnel likely impinged by the overlying Osborne ligament and underlying UCL. However no abnormal high signal of the nerve or thickening of these ligaments. Suggest for nerve conduction study correlation. 3. Insertional tendinopathy of the triceps tendon.

26. Left cubital tunnel release under WALANT on 20.9.24 Intraoperative findings: Thickening of osborne ligament Osborne ligament and fascia between 2 heads of FCU was released Ulnar nerve not subluxating post release No transposition of ulnar nerve done

27. Anatomy Upper arm - ulna nerve lies posteromedial to brachial artery, posterior to intermuscular septum and anterior to medial head of triceps Arcade of Struthers - 8 cm proximal to medial epicondyle At Elbow - ulna nerve goes posterior to medial epicondyle, and medial to olecranon before entering cubital tunnel Cubital tunnel Roof - Osborne ligament Floor - MCL of elbow, elbow joint, olecranon F orearm - from cubital tunnel ulna nerve travels deep into forearm between two heads of FCU

28. Arcade of Struthers Medial intermuscular septum Medial epicondyle Cubital tunnel FCU fascial bands Sites of compression

29. Diagnosis Symptoms Paraesthesia and numbness in ring and little finger Aching over medial aspect of elbow and forearm Signs Positive Tinel sign over the nerve or proximal to cubital tunnel Provocative test - elbow flexion with digital pressure on the ulna nerve proximal to cubital tunnel ulna claw, atrophy of intrinsic muscles Positive Froment and Wartenberg sign Tests Nerve conduction studies EMG

30. Surgical technique of cubital tunnel release In-situ decompression Subcutaneous anterior transposition of ulna nerve Intramuscular transposition Submuscular transposition Medial epicondylectomy Endoscopic decompression

31. 6-10cm incision made along the course of ulna nerve (midway between medial epicondyle and olecranon)

32. Nerve is exposed between 2 heads of FCU Osborne ligament and FCU fascia was cut and released in this patient

33. Indications for ulnar nerve transposition during cubital tunnel release If ulna nerve subluxates over medial epicondyle when elbow is in flexion Need anterior transposition or medial epicondylectomy

34. Subcutaneous transposition To move ulna nerve anterior to elbow axis of flexion, decrease tension nerve is released through the cubital tunnel and traced distally through the two heads of the FCU Then nerve is lifted from its bed and transposed anterior to the medial epicondyle A small sling can be created to prevent nerve from returning to its anatomic position - via; subcutaneous tissue sutured to the fascia over the medial epicondyle or with a sling of muscle fascia that is sutured to the subcutaneous tissue

35. Intramuscular transposition Similar as subcutaneous transposition but A groove is dissected in the muscle in line with location of ulna nerve in its transposed position Fibrous septa within pronator teres are removed to provide a muscle bed A fascial flap/subcutaneos flap is created to keep nerve in its positin

36. Submuscular transposition Plane is developed distal to medial epicondyle and beneath flexor-pronator muscle mass f lexor -pronator muscle mass then incised 1-2cm distal to medial epicondyle and elevated Ulna nerve transposed anteriorly, adjacent and parallel to median nerve Muscle is then reattached with sutures

37. References Green’s Operative Hand Surgery, 8th Edition Operative Techniques Hand and Wrist Surgery, 2nd Edition Palmer, B. A., & Hughes, T. B. (2010). Cubital tunnel syndrome. The Journal of hand surgery , 35 (1), 153–163. https://doi.org/10.1016/j.jhsa.2009.11.004