Journal of Hand Surgery-Asian-Pacific Volume最新文献

Congenital infantile fibrosarcoma (CIF) is a rare prenatal malignant tumour that occurs in infants and can be difficult to distinguish from vascular malformation or haemangiomas. Early diagnosis and treatment are crucial for saving both limb and life. We report a 4-month-old infant with CIF of the left forearm and arm which presented with a bleeding ulcer over the swelling. During admission, the child developed disseminated intravascular coagulation (DIC) necessitating a life-saving above-elbow amputation. Level of Evidence: Level V (Therapeutic).

The wrist is affected in all the forms of arthrogryposis and is a common site requiring surgical intervention. The wrist usually has a flexion and ulnar deviation deformity of varying severity. A flexion deformity of >40° results in a weak hand grip and gives an 'abnormal' look to the patient as a whole and hence, is a common reason for patients to desire surgical correction. However, as children tend to adjust to whatever posture they have as they grow, the most important thing a surgeon should be aware of, is when and whom not to operate. This article discusses all these possibilities in detail and provides authors preferred surgical plan. We have found a combination of volar fascia release, intercarpal wedge resection osteotomy and extensor carpi ulnaris to extensor carpi radialis brevis tendon transfer to be most effective and reliable. Patient and parental satisfaction with early surgical intervention is often satisfactory. Level of Evidence: Level V (Therapeutic).

Background: Revision surgery after syndactyly separation is challenging. Web creep and scarring have a great impact on function and appearance of the hand. There is a paucity of literature on revision surgery for syndactyly. The aim of this study is to present the outcomes of revision surgery for syndactyly. Methods: This retrospective study included patients who required revision surgery after syndactyly release for web creep, scar contracture affecting motion and/or bony deformities. Web creep was graded using the Withey classification and scars were graded as minimal, mild, moderate and severe based on the impact on range of motion (ROM). All patients underwent dorsal and volar triangular flaps for correction for web creep, multiple Z-plasty and/or proximal interphalangeal joint (PIPJ) release for correction of scar contractures and osteotomy for correction of angular/rotational bony deformities. Improvement in web creep grading, scar contracture and change in angular and/or rotational deformities were recorded. Results: The study included 9 hands in 7 patients who required surgery for 13 web creeps (four grade 2, four grade 3 and five grade 4), 20 scar contractures (five mild, seven moderate and eight severe), 6 angular (five ≤15° and one = 40°) and 1 rotational deformity. All web creeps improved to grade 1. Out of the 20 scar contractures, 14 improved to mild and 6 to moderate. Two patients underwent corrective osteotomy, one for rotational deformity and one for a 40° angular deformity which improved to 5°. Conclusions: Double opposing triangular flap presents a good option for revision of the web with no recurrence of web creep after a 1-year follow-up period. We suggest a grading system which assesses the effect of scarring on finger motion. Finally, avoiding straight volar suture lines decreases the incidence of recurrence. Level of Evidence: Level IV (Therapeutic).

Lack of specific guidelines in the literature renders management of radial longitudinal deficiency (RLD) exceedingly diverse. This diversity in treatment approaches can lead to variability in outcomes and pose a challenge in determining the most effective interventions for each individual case of RLD. Surgeons must carefully consider the unique characteristics and needs of each patient when developing a treatment plan for this complex condition. Around 40% of cases are linked to syndromes like Holt-Oram syndrome, thrombocytopenia absent radius (TAR) syndrome, Fanconi anaemia and VACTERL. Hand surgeons must be knowledgeable about these conditions, as they may be the first to identify these syndromes in children. Associated elbow stiffness can also be a crucial factor in treatment decision-making. Although this condition has been studied for more than 10 decades, the surgical treatment that is currently available is not completely successful in restoring 'normal' wrist function and appearance. Centralisation and radialisation procedures continue to be the cornerstones of surgical treatment. Many innovative approaches include altering the biomechanics of this condition with bony or soft tissue procedures and microvascular techniques. Understanding the proximal limb changes is crucial in the holistic management of this challenging malformation. This article presents a treatment algorithm based on literature evidence and our clinical experience. Level of Evidence: Level V (Therapeutic).

Major limb amputation in a child is a rare but devastating injury associated with significant psychosocial and financial burden. This, combined with the higher growth and remodelling potential despite segmental limb loss, decreases the threshold for replantation in children. Advances in microsurgical techniques and a better understanding of such injuries have led to lower limb replantation becoming a feasible option, with good long-term functional outcomes, even in bilateral amputations. However, long-term sequelae such as limb length discrepancy (LLD) are common, and patients are often subject to multiple surgical interventions. We present a case of replantation in a 2-year-old child following traumatic right below knee amputation, followed up over a period of 5 years. After multiple surgeries, the patient gained good functional recovery and sensibility of the replanted limb. We reviewed and discussed the management of subsequent long-term sequelae, including LLD, lower limb contractures and valgus deformity. Level of Evidence: Level V (Therapeutic).

Paediatric hand fractures account for approximately 25% of hand-related emergency department visits, making them the second most common childhood fractures after distal forearm fractures. These injuries are more prevalent in boys and peak ages between 9 and 14 years. Hand fractures in children are primarily caused by crushing injuries and, increasingly in older children, by sports-related activities. The little finger (52%) and thumb (23%) are the most frequently fractured digits, with phalangeal fractures, especially of the proximal phalanx, being common. Metacarpal fractures are more prevalent in adolescents (13-16 years) compared to younger children. Accurate diagnosis in the paediatric population is complicated by difficult clinical examinations and the presence of growth plates, leading to an 8% misdiagnosis rate, mainly due to misinterpretation of the ossification centres and physes. High-quality radiographic evaluation combined with a thorough clinical assessment is critical for correct diagnosis and appropriate management. The robust periosteum and high remodelling potential of paediatric bones allow most hand fractures to be managed non-operatively with splinting or casting. However, fractures with significant angulation, rotation, intra-articular involvement or open wounds may require surgical intervention, such as closed or open reduction and internal fixation with Kirschner wires. Most paediatric hand fractures heal well with excellent functional outcomes due to the high remodelling capacity of paediatric bones. Early mobilisation and appropriate immobilisation are key to preventing stiffness. Despite the generally favourable prognosis, certain fractures remain challenging to diagnose and treat, highlighting the need for specialised care. The aim of this review article is to discuss the epidemiology, fracture patterns, diagnostic challenges and management strategies essential for optimising functional outcomes and minimising long-term complications in treating paediatric hand fractures. Level of Evidence: Level V (Therapeutic).

Background: Supracondylar humerus fractures (SCHF) in children are common and can lead to serious complications, including neurovascular injury. The optimal management of children with a 'pink pulseless' hand following such a fracture is unclear. This study aimed to ascertain an appropriate therapeutic approach for children with SCHF and a pink pulseless hand. Methods: A retrospective analysis of medical records from paediatric patients under 16 years old with SCHF and clinically perfused but pulseless hands between 1 January 2016 and 30 June 2021 was conducted. Clinical characteristics, imaging, treatment processes and follow-up results were analysed to predict arterial injuries requiring vascular repair and determine the optimal timing for exploratory surgery. Results: The study included 88 patients, predominantly male (58%) with an average age of 6 years. Most fractures resulted from falls onto outstretched arms. Satisfactory outcomes, indicated by the return of the pulse following closed reduction and percutaneous pinning (CRPP) alone, were seen in 66% of patients, negating the necessity for vascular exploration. Amongst patients with a persistently absent radial pulse 72 hours after CRPP, 83% were diagnosed with brachial artery injuries, with all such patients experiencing recurrent pulse loss after surgery. Conclusions: Urgent reduction and CRPP are effective initial treatments for children with SCHF and a pink pulseless hand. Immediate vascular exploration is generally not necessary in these patients. Further research is needed to determine the optimal management for persistent pulselessness and recurrent pulse loss. Level of Evidence: Level IV (Therapeutic).

Background: Surgical correction of chronic anterior dislocation of the radial head in paediatric patients is challenging, and they may experience re-dislocation or subluxation even after corrective surgery. We have been performing a radial shortening osteotomy combined with reconstruction of the annular and lateral collateral ligaments, and a corrective osteotomy of the ulna. The aim of this article is to describe our technique and outcomes at mid-term follow-up. Methods: This retrospective review included 10 paediatric patients with chronic anterior dislocation of the radial head that were surgically treated at our unit from January 2016 to July 2022. The dislocations were congenital in two patients, resulted from neglected Monteggia fractures in seven patients, and was idiopathic in one patient. The average age at surgery was 8.3 years. All patients underwent radial shortening osteotomy combined with reconstruction of the annular and lateral collateral ligaments, and a corrective osteotomy of the ulna. Outcomes with regards to period of follow-up, complications, arc of motion and the Kim elbow performance score were assessed. Results: The reduction of the radial head was maintained at the final follow-up (mean: 55 months). No acute or chronic complications occurred. The mean arc of flexion-extension improved from 124° to 140° while the arc of prono-supination decreased from 124° to 113°. The Kim elbow performance score was excellent in eight patients, fair in one and poor in one. Conclusions: A combination of radial shortening osteotomy, reconstruction of the annular and lateral collateral ligaments and corrective osteotomy of the ulna was able to maintain a stable reduction of the radial head with satisfactory elbow motion in the mid-term in paediatric patients with chronic anterior dislocation of the radial head regardless of the underlying cause. Level of Evidence: Level IV (Therapeutic).

Clinical registries are increasingly common and have value in conditions such as congenital upper limb differences where collection of adequate data for scientific study can be challenging due to small numbers and clinical, surgical and psychosocial heterogeneity. This article discusses the motivation, purpose and development of the Australian Hand Differences Register before examining some of the challenges faced during its implementation and considering limitations of registry-derived data. Level of Evidence: Level V (Diagnostic).