Introduction: Hand trauma is a vast area to explore. There are many aspects we need to study to determine ideal treatment. Distal radial mutifragmented fractures which include volar Barton, Dorsal Barton fractures are one of those area which we need to study. From September 2019 to January, 2021. We applied mini external fixators to all the patients who presented with distal radial mutifragmented fracture to Our institute.

Method: It is an Observational Study. We applied Mini external fixator to 63 patients who presented with mutifragmented distal radial fracture.

Results: We observed that about 47(74.60%) patients showed adequate union by imaging and adequate function in 2 months after operation. 11(17.46%) patient showed adequate union by imaging but restricted movement and pain 2 months after operation. 5(7.94%) showed delayed union or non union.

Background: Scapholunate advanced collapse (SLAC) is a pattern of degenerative wrist arthritis that develops as a result of scapholunate dissociation with progressive instability, deformity and finally arthritis. In stage III SLAC wrists the most established treatment are four-corner fusion and total wrist fusion. These techniques lead to predictable wrist motion loss. Motion-sparing techniques allow to obtain good pain relief while preserving some of the wrist range of motion. Case Presentation: We present a clinical case of a 79-year-old male diagnosed with a SLAC stage III wrist. The patient was submitted to an arthroscopic interpositional arthroplasty of the radiocarpal joint and arthroscopic capito-hamate-lunate joint arthrodesis. We did an arthroscopic radial column ressection and after preparing the articular surfaces we applied a tendinous allograft with an anchor in the ulnar border of the scaphoid fossa and fixed to the radial wrist capsule. Then we used bone autograft to support two percutaneous headless compression screws in an arthroscopic capito-hamate-lunate arthrodesis. Clinical Outcomes: Two years after surgery the patient is extremely satisfied with the results having returned to his construction work. He now has a pain visual analog scale of 1/10 (8/10 before surgery) and a grip strenght of 17,5 Kg (5Kg more than before surgery). He presents a wrist flexion of 80º, 10º of extension, radial deviation of 20º and ulnar deviation of 30º. Discussion: This arthroscopic technique has been developed having in mind the joint-preserving and soft tissue sparing principles allowing less surgical aggression, faster healing and maintain wrist function preservation.

BACKGROUND
This is a retrospective study to better understand differences in patient satisfaction after carpal tunnel release under WALANT or general anaesthesia. The authors hypothesized that WALANT would offer a better intra-hospitalar experience and at least similar functional outcomes comparing to general anaesthesia.

METHODS
Two groups of fifty patients undergoing unilateral carpal tunnel release under WALANT or general anaesthesia were consecutively collected from 2019. Data included demographic data, laterality, dominance, ASA classification, duration of hospital stay, duration of surgery, complications, recurrence or relapse at one year, functionality at first day and Boston Carpal Tunnel Questionnaire during the first month. The results were compared for the two anesthesia methods.

RESULTS
The duration of hospital stay was statistically different between surgeries with WALANT or general anesthesia (240 minutes vs 301 minutes, p<0.05). However, the procedures with general anesthesia were on average three minutes faster (19 minutes vs 16 minutes, p=0.09). There were no significant differences in the results of Boston Carpal Tunnel Questionnaires, neither about the symptoms nor the function during the first month postoperative. Subjectively, the patients reported better function in the WALANT group (p<0.05). There were one recurrence in each group.

DISCUSSION
This study showed that WALANT is a valuable technique for tunnel carpal release with similar symptoms and function in the first month, less time in hospital, and similar one-year outcomes. Nevertheless, the anesthetic technique should be consciously chosen considering patient comorbidities, disease to be treated and surgeon and patient preferences.

The avulsion of the ulnar collateral ligament (UCL) of the metacarpophalangeal joint (MCP) of the thumb, with or without bony attachment, displaced above the aponeurosis of the adductor pollicis muscle, is known as Stener Lesion. This injury is prevalent in skiers and goalkeepers. The ligament rupture occurs with a fall on an outstretched hand when a thumb in abduction suffers an extra valgus stress. Clinical case of a former goalkeeper in professional and national teams, documented with images of the clinical examination, valgus stress x-rays, 1 year follow-up. Male, 51 years-old, came to emergency department referring pain at the base of the thumb, after a sports trauma in an exhibition game. On clinical examination, the MCP joint proved to be unstable upon abduction. Stress x-rays: 42º valgus angle at MCP which correlates with complete rupture of both proper and accessory collateral ligaments. Intra-operatively: interposition of the adductor pollicis aponeurosis between the ruptured end of UCL and the site of its attachment on the proximal phalanx - Stener Lesion. UCL was then fixed to the phalanx with a 2.5 mm PushLock Knotless Suture Anchor and it was performed a temporary K-wire arthrodesis of the MCP and interphalangeal joints. Cast for 6 weeks. After one-year follow-up the patient is playing again, with no limitations (DASH score: 10). This is a typical case which with a rigorous clinical examination and a plain-film exam, as it was described 52 years ago, is still enough to make the right diagnosis and to treat a patient.

Compartment syndrome after intravenous fluid administration is a rare complication and few cases have been described in the literature. Failing to diagnose and treat early may result in severe functional deficits. We present a case of a 61-year-old female in whom intravenous contrast was injected in the dorsum of the hand during a computed tomography. The patient had history of diabetic neuropathy. Shortly after, she developed painful swelling and blisters in the area which, despite icing and elevation, rapidly progressed. A few hours later, the patient developed compartment syndrome of the hand and forearm, with impaired sensitivity and severe pain with passive extension of the wrist and fingers. The diagnosis was confirmed through measurement of the volar and dorsal compartments of the hand and forearm in the emergency operating room. Right hand and forearm decompressive fasciotomies were then performed, leading to a swift recovery and a good functional outcome.

Dislocations of the carpometacarpal (CMC) joints without fracture are rare injuries which often have subtle radiographic findings that may be overlooked. They commonly involve the fourth and fifth metacarpals of the dominant hand.
A 25-years-old male injured himself by punching a wall with his dominant right hand. He experienced immediate pain and tenderness with minimal swelling in the dorsal-ulnar wrist. The radiographs confirmed the dorsal displacement of the fourth and fifth CMC joints without fracture. Closed reduction and percutaneous pinning were performed. Full range of wrist motion and grip strength were regained.
A high index of suspicion is necessary when a patient presents with a history of punching a hard object resulting in ulnar-sided wrist pain. Untreated cases may result in chronic disability.

Intraneural lipomas are rare soft tissue tumors of adipose cells, located within the epineurium. These tumors are benign but may cause neuropathic symptoms by displacing the nerve fascicles. Although they are usually easy to resect due to a clear plane of dissection between the lipoma and the nerve, there are reports of "hybrid" cases in which fatty tissue interdigitates the nerve fibers. We present the case of a 52-year-old woman with a right-sided volar wrist mass that had been slowly growing for a period of several years. She seeked medical attention after developing symptoms of pain and paresthesia in the radial 3 fingers and subjective loss of hand strength. Tinel and Durkan signs were negative and Phalen sign was positive. A palpable painless soft mass was present proximal to the wrist crease. Ultrasound was suggestive of a lipoma and nerve conduction study revealed increased sensory and motor latency and reduced amplitude of the potentials of the median nerve, compatible with carpal tunnel syndrome. The patient was submitted to excision of the intraneural lipoma and transverse carpal ligament release. Histological study showed a 30x15x15mm encapsulated mass of mature adipose tissue without cell atypia, compatible with an intraneural lipoma. The patient experienced symptomatic relief and no recurrence of the pathology. This case shows a rare cause of median nerve compression, which should be considered and correctly treated, usually with good results.

Chronic dislocations of the trapeziometacarpal joint are rare in young patients. The following clinical report describes the case of a 24-year-old male flight attendant who suffered a right thumb sprain in 2016 and sought medical care in 2019 for pain at the base of his right thumb and lack of grip strength. Imaging studies showed dorsal subluxation and degenerative changes of the trapeziometacarpal joint. For these reasons, he underwent reconstruction of the dorsoradial ligament with a flexor carpi radialis autograft. One year after surgery, there is a symptomatic and imaging relapse, with progression of degenerative changes and subluxation, reflecting reconstruction failure. In January 2021 a trapeziometacarpal arthroplasty is performed with a metallic prosthesis. The patient is undergoing active rehabilitation without pain and a Kapandji score of 8. Treatment of these chronic instabilities mostly feature joint-sparing surgeries like the Eaton-Littler procedure. In cases of recurrence, the choice of procedure is considerably more difficult. A revision ligament reconstruction could result in a painful thumb, trapezectomy can lead to significant limitation in the young adult, and arthrodesis is usually reserved for selected patients. Prosthetic arthroplasty has gained popularity due to its rapid recovery, good mobility and reasonable grip strength. The main criticisms of this technique concern its longevity, however some studies describe an implant survival of 90% at 10 years of follow-up. It is the opinion of the authors that the age of the patient is not a major limiting factor for arthroplasty in the treatment of instabilities with degenerative changes.

Elbow dislocation associated with ipsilateral distal radius fracture is a rare pattern of injury, although it is common for elbow dislocation and forearm fractures to occur separately. Only few cases of elbow dislocation with ipsilateral distal radius fracture have been reported in the literature. We report a rare case of a 57-year-old female who had a posterior elbow dislocation and ipsilateral distal wrist fracture. The patient presented to our emergency department after falling and landing on his outstretched left hand. She complained of pain over left elbow joint and wrist joint. On physical examination, left wrist was grossly deformed and tenderness was present. There was no distal neurovascular deficit. Plain radiographs showed posterior elbow dislocation and distal radius and distal ulnar fractures totally dorsally translated. Closed reduction of the dislocated elbow joint was immediately performed. Distal radius fracture was managed by open reduction and internal fixation with a volar plate. At 6 months of follow up patient had full range of movement of the elbow joint and complete union of the distal radius fracture. Most probable mechanism to cause this injury would be a fall on the outstretched hand. First, the distal radius fracture occurred due to direct contact of wrist with the ground, and then hyperextension of the elbow causing posterior dislocation. Therefore, clinical and radiological assessment of one joint above and below should be done in every case so that these injuries, although rare, should not be missed.

Scaphoid fractures are treated frequently in everyday and some cases are associated with perilunate dislocations. The most frequent is the dorsal trans-scaphoid perilunate dislocation We report a case of a combined scaphoid and lunate fracture that was not associated with perilunate dislocation. A 24-year-old man was injured while cycling, resulting in hand trauma with wrist in maximal extension. Immediately after the injury he felt pain, swelling, and limitation of motion in the left wrist. The patient was examined after the injury. X-ray showed scaphoid and lunate fractures, but there was no clear evidence of dislocation. A CT scan was performed demonstrating a scaphoid fracture in the middle third with no displacement and a transverse fracture of the lunate equally well aligned. There were no dislocation of the carpal bones. These fractures were treated with cast immobilization for 8 weeks and 6 months after treatment the patient was asymptomatic with both fractures consolidated. Probably, forceful hyperextension with ulnar deviation resulted in axial loading of the capitate on the lunate resulting in a lunate fracture. This maximal extension presses the scaphoid against the dorsal rim of the radius causing a scaphoid fracture. So, those fractures are independent, caused by the same wrist hyperextension and they not associated with carpal instability which normally results in trans-scaphoid perilunate fracture dislocation.

Introduction: Fingertip amputations normally have poor functional outcomes. Cross-Finger Flap (CFF) is one of the techniques used to cover defects, allowing for finger preservation and improvement of pain, healing time and functional outcomes. Methods: A sixty-year-old male suffered a work-related injury with partial amputation of fingertip on the ring finger (Type III - Allen’s Classification). On physical examination there was bone exposure, diminished vascularization on the ulnar side and vascular compromise on the radial side. The fingertip was preserved but as it progressed to necrosis, on the fifth day after admission, a CFF was made using the dorsal side of the middle finger as a graft, folding it over a dorsopalmar hinge to cover the volar defect and preserve vascularization. The volar side of the forearm was used as a skin graft to cover the defect left on the donor finger. Results: At eight days postoperatively, the flap and skin graft had both good vascularization. The CFF was released after four weeks and at nine months postoperatively, the patient’s only complaint was the loss of sensitivity over the skin graft on the middle finger. The patient resumed work as a carpenter and did not report any limitation on professional or daily life activities (Quick DASH Score 2.3%). There were no complications reported such as necrosis, infection, wound dehiscence or neuroma. Discussion: In cases of fingertip amputation, the CFF still is one of the most simple and effective techniques in clinical practice, achieving good functional and aesthetical results.

Stress fractures are common injuries in athletes, representing 10% of all overuse injuries in sport. This injury occurs when periods of repetitive and submaximal loads are applied without adequate rest. Fifth metatarsal stress fracture comprises only 2% of all metatarsal stress fractures and typically occurs at the proximal diaphyseal region (zone 3). A high index of suspicion is fundamental for early diagnosis and prevent complications. We present a case of a 13-year-old female patient with a stress fracture of proximal fifth metatarsal. The patient practises skating between six and ten hours per week. She was referred with foot pain with 7 months and recent worsening after sprain. A radiograph was showing a proximal fifth metatarsal stress fracture (zone 3). We proposed a nonoperative treatment with non-weight-bearing cast immobilization during 6 weeks and partial weight-bearing until 12 weeks. The patient had a decrease in her pain, and she returned to sport 10 months after lesion. Discussion: Typically, fifth metatarsal stress fracture occurs in zone 3. Plain radiographic often are negative in the early stages of injury, and CT has good specificity when a fracture line exists. MRI has become recommended advanced imaging modality. According to the literature, in the athletes managed nonoperatively, the meantime to return to sport was around 20 weeks, nonunion rate was 7,1% and refracture rate was 17,9%. In our case, we used a nonoperative protocol and the follow up was showing a good radiograph evolution buT she only returned to sport 10 months after lesion.

Giant cell tumour of tendon sheath (GCTTS) is the second most common soft tissue tumour of the hand, second to a ganglion cyst. GCTTS is a true benign tumour with local aggressive behaviour, located within the tendon. Usually, they are well-circumscribed, encapsulated masses with smooth but lobulated contour. It rarely affects the pediatric population. A 13-year-old child presented to our institution with a two years history of a painless ingrowth mass of the little finger of the hand with enlargement in the past few months. At the physical examination, a multinodular tumefaction on the volar side of phalanx of the little finger was noted. A Magnetic resonance was performed, demonstrated a hypodense multilobulated mass, on the palmar aspect of the middle and distal phalanx and greater diameter of 13mm. Wide excision of the lesion was performed. The excised nodular lesion was sent for pathological anatomy, which confirmed the diagnosis of GCTTS. At the 6 months, the child had complete range of motion, without any sensory deficit. There wasn't any sign of recurrence. GCTTS is a common benign soft tissue tumour found in the hand that originates in the synovium of the flexor tendon sheath and often has extensions that go around and under several structures. This makes it difficult for the lesion to be completely excised and the recurrence rate is reported up to 45%. In the pediatric population, GCTTS is a rare entity. Early diagnosis and treatment with wide excision offer an excellent prognosis.

The incidence of scaphoid non-union is 5-15%. The treatment of this condition represents a surgical challenge - the surgical strategy is to re-establish the coronal alignment of the scaphoid and the carpal homeostasis. The authors present a case of a 29-year-old male with scaphoid non-union, accompanied by carpal instability with humpback deformity and DISI. Surgical treatment was chosen, according to the Fisk-Fernandez technique. Simple non-union, without degenerative changes, as shown in this case, the goal is anatomical reduction; when there are degenerative changes, treatment is palliative (arthrodesis, arthroplasty). There are several surgical techniques, namely Matti-Russe, Fisk-Fernandez, use of vascularized graft, etc. In this case, the Fisk-Fernandez technique was used – using bone graft and fixation with Herbert screw - with an advantage over Matti- Russe technique - it can be used in patients with humpback deformity and allows early mobilization. The realignment of the scaphoid fragments creates a volar defect, which is filled by a volar graft that allows to recover not only the normal scaphoid anatomy but also the alignment of carpal bones. The screw fixation allows greater stability, which allows a shorter post-operative immobilization time. The patient initiated rehabilitation exercises and was revaluated at 7 months, with complete recovery evident. This entity offers surgical challenges because the correction of carpal deformity is fundamental – is important to re-establish the proper intracarpal and radiocarpal relations, in order to preserve the function and prevent post-traumatic arthrosis. This option ensured a good functional and radiological result.

Macrodactyly is a descriptive term referring to a disproportionately large digit. Most cases are sporadic without evidence of inheritance. Others may belong to a systemic disease or syndrome, such as neurofibromatosis. Osseous growth and finger deviation usually continue until physis closure, but soft tissue enlargement may continue into adulthood. Sometimes, the condition can be severe enough to produce compressive neuropathies. While diagnosis may be straightforward, treatment is very challenging. Options include growth-limiting procedures, digit size reduction, deviation correction and amputation.
This is a clinical case of a 27-year-old patient referred to Hand Surgery due to middle finger macrodactyly of the right hand. Eight years earlier, he was submitted to second ray amputation also due to macrodactyly in a different institution. Other surgeries were performed in the thumb, but reason was unknown. Gradual third digit overgrowth occurred afterwards. Major complaints were finger pain, stiffness and functional limitation of the whole hand. Additionally, second ray stump was painful, no sensation existed in median nerve territory and thenar lipodystrophy was apparent. Third ray amputation, revision of second ray stump and thumb scar tissue with soft tissue emptying were performed. Distal median nerve endings appeared hypertrophied and were excised. Pathological analysis describes a benign neoplasia of nervous tissue with plexiform neurofibroma features. After surgery, hand function improved and the patient was satisfied. Thumb opposition was possible against the ring finger although with decreased pinch strength. Surprisingly, median nerve territory sensation also improved and he was later submitted to median nerve release, with further improvement.

Giant cell tumor of the tendon sheath is the second most common lesion of the hand and wrist, slow growing, firm, non tender fixed and often multi nodular. I face some complex presentations as follow: 1- Male patient 29 years old with slow growing swelling non tender in volar aspect of Rt 3rd finger interrupting the function. X-ray revealed compression effect at proximal phalanx neck and base of middle phalanx. Using Bruner incision removal the swelling on the radial side of the finger volar to tendon sheath not reaching the bone looks like the double hump of a camel where the neurovascular bundle passing in between. There is another lesion located deep to the tendon sheath which causing the compression cavity in shaft and neck of middle phalanx and erosion of base of middle phalanx extending inside the medulla. Complete removal as one unit of each lesion with no residual. Intact neurovascular bundle. Normal shape and function with follow up for 3 years with no recurrence. MRI not done for both patients for different reasons. 2- Female patient 52 years old, with painless swelling in volar aspect of lt index mainly and middle phalanx and extended to distal one. Normal X-ray. The lesion removed with Bruner incision removed as one unit. The final shape looks like a fish as it has head, body and fish like long tail. This part extended to dorsum of the finger. Intact neurovascular bundle, normal function and follow up for 3.5 years with no recurrence.

Zone I flexor tendon injuries affect the flexor digitorum profundus tendon distal to the insertion of the superficialis tendon and common in young adults. The tendon will retract proximally in case of injury proximal to vinicula or distal but ruptured. To avoid any dissection proximally in zone II by opening an incision just proximal to distal palmar crease (In Zone III). Small opening in side of the sheath and must be kept intact to be as a guide. The proximal part of is pulled out for sutures Krackow suture. Usning Nelaton catheter or Ryles tube prefered size 12; inserting through the sheath and under the superficialis tendon pushing it gently to exit from the injury site. Attaching suture threads to it then pulled gently bringing the proximal part of the tendon to distal part making end to end repair. Tips and tricks: Small stitch grip to avoid kinking, making gentile pull on FDS to help passing below and correctly between Camper’s Chiasma. Before end to end repair the proximal part motion tested; smooth and soft denotes correct pathway. Wrong pathway will cause triggering or heavy motion. Catheter can be inserted retrograde but more difficult. This technique used in the flexor pollicis longus injury in zone TI or TII to avoid dissection in Zone TIII. The incision done in Zone V. The technique can be done under local anaesthesia and without tourniquet. Decreasing operative time and less tissue trauma giving rapid tissue healing, rapid recovery and good results.

INTRODUCTION: Mallet finger injury results from the disruption of the extensor mechanism on the dorsal aspect of the distal interphalangeal (DIP) joint of the finger. Most of such injuries are treated conservatively. However, there is a small sub-group where the DIP joint is unstable and in whom surgical stabilisation may be indicated.METHODS: We present a 65-year-old lady who attended A&E having injured her right ring finger following a simple fall. Radiographs showed a bony avulsion of the extensor tendon at the DIP joint. X-ray revealed 1/3 rd of the articular surface and there was no subluxation of the DIP joint. She was discharged with a stack splint. She was referred back to the Orthopaedic clinic three months after the injury due to persistent symptoms with pain, swelling and stiffness of her right ring finger DIP. There were no features of inflammation or infection. A repeat x-ray revealed volar subluxation of the DIP joint with degenerative changes in the DIP joint in addition to a bony mallet fragment.
RESULTS: Patient opted for conservative management with the option to have a surgical fusion in future. DISCUSSION & CONCLUSIONS: Larger bony fragment injuries are a predictive factor for instability. Hence, patients with bony mallet injury involving more than 1/3 rd of the articular surface should be reviewed in a week’s time. This guidance could be incorporated to the virtual Fracture Clinic pathway for bony mallet finger injuries so that this small subgroup of patients could be identified.

Background: Carpometacarpal joint dislocations are rare injuries, comprising 1-2% of all wrist and carpal traumatic injuries. Hand compartment syndrome is a possible complication, that should be detected early and decompressed as an emergency.
Case Presentation: A 43 years old male suffered a high energy motorcycle accident. On the ER he has pain, marked swelling and deformity of his left hand. X-ray assessment confirmed a dorsal dislocation of the 2nd to 4th carpometacarpal joints. The injury was unstable and the patient had significant and progressively worsening of the pain on passive mobilization. Hand compartment syndrome was diagnosed and the patient was taken to the OR. Decompressive fasciotomies (two dorsal, one thenar and one hypothenar) and open reduction and fixation of the carpometacarpal joints with retrograde Kirschner wires were performed.
Clinical Outcomes: Acute compartment pressure release was immediately obtained. The patient initiated antibiotherapy, cryotherapy and limb elevation. The fasciotomies were closed at 2 weeks, K-wires removal at 4 weeks. The patient wore a sling immobilization for six weeks. After the follow-up clinic the patient has initiated a rehabilitation program. In forth month of follow up, the patient had pain (VAS 2) and limitation of 15º flexion the affected CMC joints. After 18 months of follow up the patient has no significant pain and has full range of motion.
Discussion: This clinical case intends to show a rare but severe complication that orthopedic surgeons must recognize and decompress. Early intervention was crucial to obtain a good clinical outcome.

As ligamentotaxis allow gradual distraction, it could provide better functional and anatomical results in comminuted intraarticular wrist fractures. The aim of this study was to evaluate the functional outcome of operative management of comminuted distal radius intra-articular fractures. All patients who presented during the period of June 2019 to June 2020 were treated at our center, which is a tertiary care hospital, under a fellowship trained hand surgeon. A total of 50 cases treated using ligamentotaxis as the primary mechanism of reduction of the fracture fragments were captured during the study period. Modified Gartland and Werley scoring system was used to assess the functional outcomes at 6weeks, 3months and 6 months. Majority of patients (76%) had good to excellent results, an overall 16% of the patients had fair results, while only 8% of the patients had a poor result. Most common complication seen in our study was pin tract infection (4%), all of which improved subsequently without any long-term adverse effects. We concluded that external fixation using ligamentotaxis could offer a good method of reduction of comminuted intraarticular fractures not amenable to plate fixation. It could be a safe and effective method of treatment of comminuted intra articular distal radius fractures

Background: Tuberculous tenosynovitis of the hand constitutes less than 1% of skeletal tuberculosis, early diagnosis and treatment are essential. The disease is slowly progressive, which causes difficulties in early diagnosis, often undetected because of microbiological proves negative. Surgical treatment is reserved por specific indications. Case Presentation: A 84-year-old woman presented painful swelling of the right wrist gradually evolving for 1 year with paresthesias in the territory of the median nerve. Ultrasound and MRI revealed severe tenosynovitis with significant synovial thickening and nodular aspect affecting the flexor sheath. ESR was 27 mm/hAn, Complete blood count, CRP values, Liver enzymes and kidney function were normal. HIV, HBV and HCV, rheumatoid factor, and antinuclear antibodies were also negative. Arthrocentesis was performed, mycobacterium tuberculosis complex was identified in mycobacterial culture. Due to significant synovial thickening with carpal tunnel compression, tenosynovectomy and extensive debridement were performed. Using volar wrist approach, a large granulomatous proliferation of the synovium was found, affecting the flexor tendons and the median nerve. Sinovial samples were taken for pathological and microbiological study that confirmed necrotic epithelioid granulomas and the growth of mycobacterium tuberculosis complex. Clinical Outcomes: clinical follow-up at 6 months, the patient was pain-free; swelling and paresthesia decreased. Discussion: Isolated tenosynovitis should be known as a rare but possible extrapulmonary tuberculosis presentation. The treatment is generally non-operative. Surgery should be reserved for specific indications: biopsy, abscess drainage, debridement, fusion of a disorganised joint, carpal tunnel decompression, and patients who does not initially show a good response to medical treatment.

Glomus tumors are a rare, benign vascular neoplasm originating from the glomus body, a neuromioarterial contractile structure found in the dermis. Glomus tumors are most commonly found in the hand particularly in the subungueal region. They appear as a blue or pinkish discoloration of the nail with an associated triad of pinpoint pain, paroxystic pain and hypersensitivity to cold. Different clinical tests, as well as imaging tools, such as ultrasound or magnetic resonance, help make the diagnosis with good accuracy.  A 64 year old man presented long-standing complaints on his right thumb nail, of paroxystic, pinpoint pain, that aggravated when exposed to cold. The patient’s nail was deformed and had a pinkish discoloration. Based on the clinical findings and the magnetic resonance, the diagnosis of a glomus tumor was made. The patient was submitted to surgical excision of the lesion. Histologic examination of the lesion confirmed the diagnosis.  Although symptoms and clinical findings are typical and imaging tests have a good accuracy, glomus tumors are still misdiagnosed or have their diagnosis delayed. The authors aim at presenting a case of subungual glomus tumor, reviewing the main characteristics of these tumors,and clinical tests necessary for a timely diagnosis.

Metacarpophalangeal dislocations are a rare entity. Most of them can be treated with closed reduction, with a simple hyperextension maneuver. However, in some cases, such as the Kaplan lesion, the dislocation is irreducible, making open reduction necessary. We present a retrospective case study of a woman, 49y.o.,who presented to the ED with pain and deformity of the 1st left metacarpophalangeal joint. A metacarpal-phalangeal dislocation was diagnosed, with volar deviation of the metacarpal head.
Closed reduction was unsuccesful, making surgical intervention mandatory.(Kaplan Lesion) Open reduction was performed through the dorsal approach and the joint was immobilized at 30ºflexion. After 3 months, she had normal ROM, VAS0 and QuickDASH11.4 and radiography showed joint congruence. She recovered without sequelae. The irreducible dislocations of the metacarpophalangeal joint represent a subtype of this entity, which is already uncommon. They usually result from hyperextension of the joint, with collateral ligament rupture and interposition of the volar plate, with the metacarpal head buttonholing between the thenar muscles, making the dislocation irreducible. Both volar and dorsal approaches have been described. In the volar approach, an extensive release of the volar structures, including the volar plate, is necessary. The risk to the neurovascular bundles is therefore high. By using the dorsal approach, there is less risk of injuring the bundle, thus permitting a safer and simpler reduction. In conclusion, Kaplan's injury is a rare entity, with a straightforward surgical treatment and good prognosis, if correctly diagnosed, but we must be aware of its existence to avoid cumbersome complications.

Background: Painter et al first described painful periarticular soft-tissue calcium deposits in 1907(1). Further research has led to a variety of nomenclature, including calcareous tendinitis, pseudopodagra and rheumatism(2)–(4). This report details the journey of a patient with Acute Calcific Periarthritis (ACP) and explores issues concerning diagnosis, management, and provides possible preventative strategies. Case: A 39-year-old female presented to the emergency department (ED) after developing severe pain and swelling at the base of the first metacarpal in her right dominant hand. A slight pain over the radial aspect of the first metacarpal was noticed 5 months prior to her acute hospital attendance. Discussion: ACP of the thumb is commonly misdiagnosed due to its comparably low prevalence and clinical features that mimic more common conditions. Our case highlights the need for radiological imaging in patients with acute atraumatic thumb pain and evidences a connection between chronic behavioural patterns and the development of ACP.

Introduction: Kienböck's disease is characterized by avascular necrosis of the semilunar usually progressive if left untreated, with unknown etiology. A case of Kienböck's disease stage IIIa of Lichtman who underwent semilunar arthroplasty is described. Methods: 55-year-old female, domestic, in consultation for yearlong pain in the left wrist, coupled with functional limitation, with no history of trauma. Presented pain at rest and on exertion, as well as on palpation of the lunate, with slight swelling of the dorsum of the wrist. Active and passive mobilities decreased, causing severe pain (VAS 8/10). Sclerosis and collapse of the lunate observed, with maintenance of the carpal height and intercarpal alignment, on radiographs and computed tomography. Magnetic resonance imaging confirmed avascular necrosis compatible with Kienböck's disease stage IIIa of Lichtman. Semilunar arthroplasty was performed. Results: Cast removed four weeks postoperatively, starting progressive active mobilization. Patient reports (four months follow-up) a significant improvement in pain (denies pain at rest) and oedema, having resumed daily activities; slight pain on mobilization (VAS 3), minor active mobility deficit. Following prescribed rehabilitation plan. Radiographically well positioned prosthesis. Patient satisfied with the functional result obtained (Quick-Dash score 11.4). Conclusion: There are a variety of treatment options for Kienböck's disease. In strictly selected cases, namely stages IIIa, opting for semilunar arthroplasty, allows the normal anatomy of the first row of the carpus to be maintained, preventing its collapse, which can culminate in osteoarthritis. Although the follow-up time is short in this case, the patient is satisfied with the result obtained.

Carpal Tunnel Syndrome is the most common compressive neuropathy, affecting about 4% of the general population, usually idiopathic. Lipomas constitute less than 5% of benign tumors of the hand. 63-year-old female with complaints of paresthesias on the first three fingers of the right hand and palm of the hand since 8 months ago, with edema and pain in the palm of the hand and flexed posture of the 4th and 5th fingers. Positive Tinel and Phalen. Electromyogram was compatible with Carpal Tunnel Syndrome. CT revealed a structure in the hypotenar space that exerted compression of the flexors of the 4th and 5th fingers and extended between the interosseous muscles from the 2nd to the 5th finger. In surgery, a lipomatous mass, was identified in the subfascial plane with involvment of the various palmar spaces of the hand. The mass was extrinsic to the tendon sheaths and the median nerve. Histopathological examination showed a lipoma.
In a series of patients with unilateral complaints and changes in the conduction of the median nerve, also unilateral, the majority had secondary causes of compression of the median nerve. Lipomas are rare in the wrist and hand and are rarer below the palmar fascia , making them difficult to palpate and recognize as a cause of functional changes in the hand. Diagnosing soft tissue tumors as a cause of Carpal Tunnel Syndrome requires a high index of suspicion, and the use of imaging tests and surgical exploration are essential.

Cartilaginous tumours that involve the small bones of the hand are generally benign, such as the enchondroma, the chondromyxoid fibroma or the chondroblastoma. At this location, a chondrosarcoma diagnosis is rare, but should always be considered because it is locally aggressive and has the potential for metastatic dissemination, being associated with a worse prognosis.
An 81-year-old woman presented with a tumour at the proximal phalanx of the 4th finger of the right hand. She noted the lesion 18 months before and it has been progressively growing and recently she complained of pain and stiffness of the metacarpal-phalangeal joint. Objectively there was a painful hard mass, adherent to the deep tissues, limited to the phalanx area.
X-Ray revealed a lytic lesion with cortical destruction and calcified areas suggesting chondroid matrix. MRI showed a 3,5cm locally destructive lesion, including soft tissue components, T1 hypointense and T2 Hyperintense, with lobulation areas typical of cartilaginous tissue.
Scintigraphy and Thoracoabdominal CT scan did not show any distant lesions. A CT guided fine-needle biopsy was performed, and it revealed a Grade I Chondrosarcoma.
Given the characteristics of the tumour, we chose to do a radical excision of the 4th ray, with excellent functional and cosmetic outcomes.
Although its metastatic potential is low, phalanx chondrosarcoma is extremely locally aggressive. Once localized disease is confirmed, treatment consists in radical or enlarged resection.
Digital ray amputations have better functional and cosmetic results than metacarpal-phalangeal amputation, and allows for a larger margin of resection, with higher limb salvaging probability.

Glomus tumors are rare lesions, most often solitary and with a predilection for the subungual located. The clinical presentation is diverse, from asymptomatic to, more often, painful and hypersensitive to cold. Multiple glomus tumors are a very rare entity. We present a case of multiple painful glomus tumors, in the same radius of the hand. A 40-year-old healthy man presented at the consultation complaining of progressive pain in the distal left thumb, with 4 months of evolution, without history of trauma. The pain was disabling. He had previously been treated with anti-inflammatories with marginal relief. The objective examination showed no inflammatory signs and no limitation of mobility. Radiography revealed a circumscribed osteolytic lesion in the proximal phalanx. Magnetic resonance imaging showed a subcortical lesion, conditioning a rarefaction and an endosteal excavation of the radial cortex, without significant extra-bony extension. In the distal phalanx of the thumb, another subungual lesion is observed, with cortical efraction. In the thenar eminence, another intramuscular lesion is observed, evidencing uptake of contrast in a similar way of other lesions. An excisional biopsy was performed. Intraoperatively, 3 well-defined lesions were found, easily distinguishable from the surrounding tissue, compatible. Histological examination showed a glomus tumor in all samples. One month after surgery, the patient is asymptomatic. The recognition and treatment of these injuries quickly is essential, since despite their benign nature, these injuries can be the cause of pain that is difficult to control.

The closed rupture of the tendons of the hand is caused by traumatic avulsion, middle substance rupture, rupture by attrition, rheumatoid arthritis or other chronic infiltrative conditions and iatrogeny (related to medications/infiltrations). We present a case of spontaneous rupture of the long flexor tendon of the thumb, with no apparent extrinsic cause, treated surgically. A 70-year-old woman consults her orthopedics due to pain and incapacity for active flexion of thumb interphalangeal, with a month of evolution. The examination reveals a loss of the tenodesis grasp of the thumb. She denies relevant antecedents, namely inflammatory disease. No previous history of trauma or infiltration. The radiographic study did not reveal any changes in the bones or joints of the hand / wrist. The ultrasound study confirmed complete rupture of the long flexor pollicis at the level of the TIII zone with a tendinous gap of 3 cm. A carpal approach extending to the TIII zone were pweformed with identification of the distal top of the tendon. An incision was made at the level of zone V for exploration and the proximal top was identified. Degenerative tendon rupture was verified, with no possibility of direct suture. Tenoplasties were performed with long palmar and Pulvertaft sutures. Spontaneous ruptures of the tendon of the long flexor pollicis are rare and when they occur it is mostly due to an extrinsic cause. Rupture due to intrinsic id only reported in the literature in one caset, attributed to a tendolipomatosis process, which makes this case unique.

Osteoarthritis of the carpometacarpal joint of the thumb is a common condition. The thumb is responsible for 60% of the grip strength and is the defining characteristic of the hand specialization in the human race allowing opposition. Osteoarthritis of the carpometacarpal joint of the thumb is the most frequent cause of thumb disability with great impact in everyday activities.
The authors report a case of a 64 year old woman that presented to the hospital with base thumb deformity, pain and loss of grip strength. The radiograph revealed osteoarthritis of the carpometacarpal joint of the thumb (grade III in the Eaton and Littler classification). She was treated with a resection arthroplasty of the trapezium with suspensionplasty using the Welby technique. At 8 months of follow-up the patient remain with complaints of pain, decreased thumb abduction and extension capacity. Revision surgery was the performed with an endobutton type fixation of the base of the first and second metacarpals to prevent shortening and provide stability, tenodesis of the extensor pollicis brevis to the extensor pollicis longus to correct extension and tensioning (shortening) of the abductor pollicis longus to correct abduction.
After two months there was no pain, increase in extension an abduction capacity, the opposition of the thumb was maintained, and the radiograph show there was no loss in length.
The authors present a problem after the initial surgery which represented a surgical challenge and describe the revision surgery applied with good functional and radiological outcome.

Introduction: The Boutonniere Deformity (BD) is a complex finger deformity that results from extensor tendon central slip injury over PIP with secondary volar migration of the lateral bands. Usually occurs after acute trauma or as a sequela of an inflammatory arthritis. It may take several weeks to manifest and imposes significant functional hand impairment. The goal of treatment is to correct deformity and regain full range of motion of the affected finger. Several techniques have been described with variable reported results. Depending on severity of the injury and if left untreated for more than 3 weeks, a complete recovery of range of motion is infrequently seen and there will be more difficulty to achieve complete deformity correction.
Methods: The authors present the case of a 68 year-old-patient with a flexible BD after to 2 months of a laceration over PIP. The central slip rupture was unnoticed. Due to long-standing tendon degeneration, a hemi-flexor digitorum superficialis tendon transfer to central slip and lateral bands relocation were performed.
Results: Immediate full extension was accomplished. 1 year post-operative the patient as a satisfactory DIP and PIP flexion, but is able to achieve grip and prehension, with return to activities of daily life with little limitation.
Conclusion: hemi-FSD tendon transfer is a possible procedure for correction of BD without arthritis. Satisfactory results may be accomplished with a close follow-up and hand therapy. Since rarely the patient returns to hand baseline functionality, the physician plays an important role in managing the patient’s expectations.

Introduction: ‘Four-corner’ fusion (4-CF) is the most common intercarpal arthrodesis. The main indications for 4-CF are post-traumatic or degenerative radio-scaphoid and luno-capitate arthrosis, stage 2 or 3 carpal instability after scaphoid non-union (SNAC) or scapholunate dissociation (SLAC) and other failed intercarpal partial arthrodesis.
The goal of this salvage procedure is to maximize wrist motion and strength while minimizing or eliminating pain. In comparison with proximal row carpectomy (PRC), a well-stablished alternative procedure, grip strength, pain relief and subjective outcomes are similar with both procedures. PRC may provide better post-operative ROM and lacks the potential complications of 4-CF. However, the risk of osteoarthritis progression is significantly higher in PCR at 10-20 years after procedure, therefore, for this reason, 4-CF may be a better alternative for younger patients.
Methods: The authors present 4 cases in which 4-CF was performed. The indications were SNAC 3, undiagnosed lunate dislocation with 1 year of evolution, and radio-scaphoid and scapho-capitate primary arthrosis. The implants used were spider plate or compression screws (headless or non-headless), bi-column or three-column.
Results: Clinical and radiological outcomes are presented at 1-year follow-up. All patients were satisfied, with wrist pain control and return of strength, and better hand performance.
Conclusion: 4-CF is a reliable technique for carpal arthritis or instability without arthritis, with satisfactory results. In younger patients, despite the risk of hardware failure and non-union, it may be a better alternative to PRC since the much lower long-term risk of osteoarthritis progression.

Comminuted intra-articular phalanx fractures are challenging and can lead to complications with functional impact. Dynamic skeletal traction systems are considered optimal to allow fragment reduction by ligamentotaxis. The aim is to review the literature based on a case. A 77-year-old man with hand trauma with a chainsaw, resulting in an injury to the extensor apparatus of the thumb and a comminuted open fracture of the proximal interphalangeal joint of the middle finger. He underwent extensor pollicis longus tenorraphy and external fixation with 2 Kirschner wires placed parallel to the joint, one in the proximal phalanx and the other in the middle phalanx in an architecture of the modified Suzuki dynamic skeletal traction system. In the postoperative period, he maintained the reduction and immediately started to mobilize middle finger. He was discharged after undergoing antibiotic therapy. At follow-up, there was a gradual improvement in range of motion, without pain/stiffness. Radiologically, remained with correct alignment and joint congruence. There are several reported treatment, since closed reduction and percutaneous Kirschner wire fixation, to open reduction and internal fixation (ORIF) and dynamic external fixation, with the last two with better functional results. ORIF can achieve anatomic reduction if approached carefully, but extensive dissection can disrupt the vascularity of the fragments. The dynamic external fixator allows correct fracture alignment, through ligamentotaxis, in addition to permit early mobilization. The system described by Suzuki proved to be the most comfortable, simple and effective with a minimally invasive surgical technique, allowing early mobilization that promotes osteochondral remodeling.

The injury of the ligament complex that stabilizes the scaphoid and the semilunar, scapholunate dissociation (SLD), belongs to a spectrum of traumatic carpal instabilities, being the most frequent. It may appear isolated or with an associated lesion. The common associated injuries are distal radius fractures, perilunar dislocations and scaphoid fractures. We present a case of a rare association with Bennett's fracture-dislocation. 49-year-old man with wrist and hand trauma after motorcycle accident resulting in pain, edema and functional disability. SLD was found radiologically with scapholunate interval >5 mm, associated with Bennett's fracture dislocation. He underwent dorsal ligament repair with two suture anchors and closed reduction with Kirschner wire (K-wire) fixation, associating closed reduction and percutaneous K-wire fixation of Bennett's fracture. The plaster cast was maintained for 6 weeks. In the third week, the K-wires were removed, after radiological confirmation of correct alignment, joint congruence and union. In the 8th week, he kept the scapholunate reduction. The thumb range of motion had a Kapadji score 8. The patient was referred to physiotherapy. There are several studies of the association of SLD with distal radius fractures, the reported prevalence is 4.7%-54%, with 13.4% in a recent study with a significant sample. In the literature, other associations are reported, such as perilunar dislocations and scaphoid fractures, although there are no cases of association with Bennett's fracture dislocation. The ideal treatment for these injuries remains controversial. Surgical treatment of these injuries in the acute phase is essential to achieve a good functional result.

The "skier's thumb" is an acute injury of the ulnar collateral ligament of the metacarpophalangeal joint of the thumb, which is one of the static stabilizers, produced by hyperextension and hyperabduction. The aim is to review the literature from a case. We presented a 22-year-old male cyclist with trauma to the thumb of his right (dominant) hand, after falling off his bicycle. Radiologically, an avulsion fracture of the thumb ulnar collateral ligament was found with 2 mm of displacement. He was immobilized with plaster cast and underwent open reduction and ligamentous repair with suture anchor using a dorsal-ulnar approach. In the immediate postoperative period, the patient was without instability in the valgus stress test and without signs of neurovascular compromise. He remained without instability and with good grip strength with orthosis during the follow-up. The return-to-play was 3 months after surgery. There is some controversy about the indications for surgical treatment. The characteristics of the injury must be taken into account, such as the interposition of the aponevrosis of the adductors (Stener lesion), the acute ("skier's thumb") or chronic ("gamekeeper's thumb") evolution time, the degree of severity, the location of the tear, and associated injuries. Patient factos like dominant hand, professional job and competitive level also must be considered. The delay in adequate treatment could lead to chronic injury and worse functional outcomes. Anchor repair was effective in stabilizing the joint, which improved the patient's quality of life.

McGregor flap is an axial pattern flap, also known as a pedicled groin flap. It is a highly reliable flap for large tissue defect of the hand (dorsal or palmar surfaces), the wrist or the forearm, up to the elbow. Based on its own arteriovenous pedicle (the superficial iliac circumflex artery), with a constant vascular system, it can be easily transferred with acceptable aesthetic changes. Therefore, McGregor flap remains a flap of choice in the therapeutic arsenal of emergency hand surgery. We present the case of a patient presenting an amputation injury following an industrial accident, the lesions involve the index finger at the metacarpophalangeal joint associated with the section of the extensor tendons of the index, middle, and ring fingers and large cutaneous defect, affecting the dorsal surface of the hand in zones 5 and 6 of Verdan. Through this study, we try to present the anatomical basis as well as the different operating steps with their technical requirements allowing the safe and easy performance of this flap. McGregor flap offers a larger coverage surface than the regional forearm flaps. Being a distant flap, it does not require a major vascular sacrifice as is the case with the radial ‘chinese’ flap. With a very low likelihood of retraction, it can indifferently cover dorsal or palmar defects. It can be three times longer than it is wide, which can offer a long pedicle and subsequently enables early and active rehabilitation of the wrist and the hand.

Introduction: An exostosis is a benign growth of bone, which when capped with cartilage, is called osteochondroma, which can appear as solitary or multiple, mostly affecting the long bones, pelvis and shoulder region. The prevalence of known solitary exostosis is 1–2 % in the general population. They are slow growing lesions with rare malignant transformation. In patients with a solitary exostosis, the chance of developing a chondrosarcoma out of an exostosis is around 1%. Case report: A 12 year-old boy, presented to our outpatient department with complaints of pain, and swelling at the right wrist since 1 year and tingling numbness on and around palmar aspect of index and middle finger since 6 months. The swelling was of size 3x2 cm, Tinnel’s sign was positive. His blood parameters were normal. X-ray showed exostoses. MRI was suggestive of osteochondroma. Nerve conduction study was normal. Excision biopsy confirmed the diagnosis and also relieved all symptoms.Conclusion:
Our case report is unique in it’s own way as it reminds us that when presented with a case of osteochondroma of the distal radius in children, carpal tunnel syndrome can also occur.

Fibroma of the tendon sheath (FTS) is a rare benign fibroblastic nodular slow growing neoplasm that arises from the synovium of a tendon sheath. Diagnosis can be challenging since it can overlap with nodular fasciitis or giant cell tumor of tendon sheath (GCTTS). Regarding treatment, a marginal resection is usually performed, which can explain the high rate of local recurrence (24%). The authors present a clinical case of a 14 years-old boy. Otherwise healthy, he presented with complains of a painful, firm in consistency, non-adherent to the superficial plane and non-pulsatile mass in his right hand, with 2 months evolution and no history of trauma. Ultrasound revealed a “hypoechoic nodule with 2,1x0,9 cm, superficial to the flexor tendons”. MRI was ordered and showed “1,9cm nodule, hypointense in T1, hyperintense in T2, covered by a fibrous capsule, infra-aponeurotic, in continuity with the synovial of the 3rd to 5th fingers flexors; it peripherally enhanced after contrast”. Differential diagnosis considered FTS and GCTTS and surgery was proposed. The lesion was in closed relation with the 3rd and 4th finger flexors, and median nerve. A careful dissection was performed, and the mass sent to anatomopathological exam. Surgery and the p period were uneventful wich was compatible with the diagnosis of FTS and with a complete excision. On the follow-up appointments the patient presented with no pain, complete healing of the scar, and no neurovascular deficits. The symptoms immediately and completely regressed after surgery, and at the 12 months there were no signs of relapse.

Schwannoma is a benign tumor that originates from proliferation of the schwann cells, located in the peripheral nerve sheaths. Despite representing a small percentage of the benign tumors of the upper limb, it is the most frequent of neural origin. The authors present a case report of a schwannoma of the superficial radial nerve (SRN). A 73 year old woman with no relevant medical history, presenting with pain and a tingling sensation on the dorsal side of the left hand and wrist. A positive tinel sign was detected and a small mass was noticed on the radial side of the distal forearm. A ganglion cyst was suspected and surgical removal planned. During the procedure, the authors noticed that the lesion originated from the SRN. Resection was performed by separating the nerve fibers from the tumor without complications. Histological examination confirmed the diagnosis of schwannoma. After 7 months of follow-up, the patient has no symptoms besides hyposthesia in the nerve distribution area. Schwannomas usually present as an encapsulated slow growing non-invasive single lesion. While most cases are asymptomatic, neurological symptoms and mass effect occasionally occur. Oftentimes diagnosis is established only after excision and histologic study, as imagiological exams have a scarce contribution and physical examination can be misleading. We conclude that schwannoma should be considered as a diagnostic hypothesis when evaluating subcutaneous nodes associated with neurologic symptoms. Moreover, the surgeon ought to consider the benefits of the surgery compared to the potential iatrogenic damage to the nerve.

One of the most difficult problems in hand surgery is skin coverage after complete hand and finger disgloving. Important structures such as tendons, nerves and bones are exposed and will necroses if they are not adequately covered. The aim of treatment should be to cover with a soft, sensitive and cosmetically similar tissue that will allow early mobilization.

Materials and methods: After a work accident (industrial machine), a case of complete skin disgloved hand and fingers is reported in a 28-year-old man. arrived 5 days after his accident with an over-infected wound and fingers stuck to each other, first goals were: disinfection of the wound and separation of the fingers then an autologus graft of thin skin surfacing.

Results: The postoperative course was straightforward and a thin skin graft was performed after 21 days. The patient healed in five weeks followed by wearing a compression glove and adequate functional rehabilitation. At one year of follow-up, the scar quality was good with satisfactory mobility. as well as a return to work.

Discussion: Traditionally, skin grafting has been the standard method of reconstruction in such injuries. However, skin grafting also has many drawbacks and for this you need a good bed preparation.

Conclusion: The skin coverage of such a lesion should in no case be delayed, the risk of infection, tissue necrosis, stiffness as well as inter digital bands are to be feared.

Introduction: Dupuytren's disease, or retractile fibrosis of the palmar aponevrosis. It is a benign affection, affecting the hands, with progressive retraction of the fingers, by pulling on the tendons.
Materials and methods: We report a series of 12 cases (10 patients) of Dupuytren's disease in its digitopalmar form (7 men, 03 women), the mean age was at 61 years, we note the absence of association with a Peyronie's disease. On the other hand we find a case of Ledderhose disease. All our patients were classified according to Tubiana Michon and Thomine, of which 10 cases were stage III. The surgical indication was made from the moment there was functional discomfort and the test of the hand lying flat on the table is very useful. Palmar fascia was limited to macroscopically affected tissues. Dissection from proximal to distal respects the vasculo-nervous elements, the closure was incomplete with points of approximation.
Results: Skin healing was obtained with two cases of necrosis (very severe stage IV form), extension was obtained in 9 patients, one case of which was incomplete, allowing a PPI deficit not to exceed 20 ° to persist. At the last follow-up, which is on average 4.5 years, the subjective results are good with one case of recurrence.
Discussion: Surgical treatment will remain the treatment of choice for this pathology. Extensive fascia remains the technique that best meets the requirements of this pathology.
Conclusion: This technique is reliable, causes few complications with a good functional result lasting over time.

Introduction: There are less than thirty cases of volar thumb metacarpophalangeal dislocation described in the English literature. A case of a delayed diagnosed volar dislocation is presented. Case report: a 60-year-old male sustained a fall from high, with resultant closed head and maxillofacial trauma and fractures of the medial clavicle and scapular body. All of these injuries were treated conservatively. Four weeks later, at the orthopedic outpatient consultation, he complained about pain and functional impairment of his right thumb. Plain radiographs showed a volar dislocation of the first metacarpophalangeal joint. Closed reduction was attempted without success, so surgical treatment was decided. An irreducible volar dislocation due to retraction of the volar plate was confirmed. There was also a ruptured ulnar collateral ligament. The volar plate was released, after which the joint was easily reduced. A repair of the ulnar collateral ligament and a dorsal capsulodesis were performed, using suture anchors. The thumb was immobilized for 4 weeks. After three months, the joint remained reduced and stable, with residual stiffness. Conclusion: volar dislocations of the thumb metacarpophalangeal joint are usually irreducible by closed means (if interposed soft tissue prevents reduction), or highly unstable if reducible (rupture of collateral ligaments). A chronic injury is almost certainly irreducible due to fibrosis, so open reduction is mandatory to debride the interposed tissue and repair of the injured structures. Final outcome will most likely be worse than in acute injuries, being subluxation and stiffness the most frequent complications described in literature.

Distal radius fractures are the most frequent orthopedic injuries in the emergency department. We present a case of an open distal forearm fracture (GA I), complicated by delay consolidation and vicious consolidation. External fixation was first performed. At 9 weeks, still without signs of consolidation on radiographs and CT, the ex-fix was removed and an ORIF was performed for radius and ulna, with autologous graft placement. Immobilization with splint was kept for 6 weeks, after which started rehabilitation. During follow-up, he maintained pain, mainly on the ulna, deficit of prono-supination and developed paraesthesias in the territory of the median nerve being diagnosed with carpal tunnel syndrome. Radiographically, fractures evolved to vicious consolidation with radial shortening and dorsal ulna dislocation. One year after ORIF, he underwent removal of the material, Darrach procedure and neurolysis of the median nerve. He was immobilized with a splint for 3 weeks, after which he resumed rehabilitation. 5 weeks after, during a physiotherapy session, he injured the wrist, but didn’t seek medical assistance. At 8 weeks, he presented dorsal wrist deformity compatible with distal radius fracture, with radiographic signs of partial consolidation, so a new intervention was delayed. 6 months after the last surgical intervention, he underwent a dorsal radius subtraction osteotomy using a combined approach, autologous graft was placed and fixation with volar plate. He was immobilized with plaster cast for 8 weeks. Currently the osteotomy is consolidated and after functional rehabilitation, there is an improvement in pain and joint mobility. He resumed work activity.

Background: We present results for the hand unit during COVID-19 pandemic at a single site in a UK tertiary hospital in the Greater Manchester region. Methods: Patients records were reviewed 01st March to 26th June 2020. All patients referred for treatment during this period were included. Patients who missed their first referral appointment were excluded. Results: 173 patients were reviewed. Referral rate reduced to 44% during pandemic. Most patients with injuries were from 2nd - 4th decade. There were 30 distal radius fractures, 47 metacarpal fractures, 41 phalangeal fractures, 15 scaphoid fractures, 11 mallet fingers injuries, 6 carpal bone injuries and 23 other conditions. 13 patients were COVID-19 positive. We noted huge variation in practice as 25 (80%) of distal radius fracture needed surgical intervention though 14 (45%) patients chose non-operative treatment due to perceived complications of COVID-19. 11 (35%) agreed for surgery. Similarly, for scaphoid fracture 12 (80%) patients chose non-op treatment when COVID-19 complications were discussed. No patient developed COVID-19 related complications post-operatively. Possibly because they were all day cases and young. 125/173 patients were treated with nonoperatively while 18/173 had surgery. 20 patients did not attend follow up appointment. Most of the patients with metacarpal, phalangeal and mallet injuries had a good outcome. Detailed outcomes of these and other injuries will be presented in the meeting. Conclusion: We expect an increase in number of patients with malunion of fractures requiring corrective osteotomies in the future. The delayed morbidity outcome of these fractures we don’t know yet.

Introduction: We retrospectively evaluated the clinical and radiological outcomes of radial closing wedge osteotomy (RCWO) for the advanced stages of Kienböck disease.
Methods: We performed an RCWO for ten patients with ten wrists with advanced stages of Kienböck disease in 2010–2018. The mean patient age at surgery was 45.5 years. The average follow-up was 31.7 months. Two patients were stage III-A, and eight were stage III-B by Lichtman classification. They were evaluated clinically and radiographically pre- and postoperatively.
Results: Pain score using the numerical rating scale improved from 8.0 to 1.4 (p<0.05). Grip strength improved (non-significantly) from 53.9% to 81.7% of the opposite wrist. The flexion/extension angle improved from 93.5° to 119.5° and the pronation/supination angle improved from 174° to 175° (both non-significantly). The Nakamura score was excellent in two patients, good in seven, and fair in one. Nonsignificant decreases occurred in the carpal height ratio (47.4% to 46.8%) and Stahl's index (30.4% to 26.4%). At six months after surgery, the decrease in Stahl's index had stopped. The lunate-covering ratio increased from 76% to 96.1% (p<0.05). The sigmoid notch inclination decreased from 8.6° to −3.4° (p<0.05). No wrists showed the osteoarthritic change in distal radioulnar joints (DRUJs).
Discussion: RCWO produced favorable clinical results in patients at advanced stages of Kienböck disease. The lunate collapse stopped because this procedure reduces the pressure on the lunate. No patients showed complications such as the osteoarthritis of DRUJ and the limitation in pronation-supination.