Introduction: Glomus tumors are rare vascular lesions, located in the dermis, very difficult to diagnose.
Case presentation: We present a case of a 55 years old female patient with pain at first finger of her right hand, which erradiated to the forearm, with several years of evolution. The pain was worst when the woman rode her motorcycle, specially on winter season. On physical examination there was extreme pain touching the first righ fingernail (without any deformity). An hand magnetic ressonance imaging (MRI) was requested and showed a lesion in subungual zone of the first finger, compatible with a glomus tumor. The patient was submitted to a surgical ressection of the lesion by a lateral latero-ungual approach. The histopathological analysis confirmed the diagnosis and the patient complaints disappeared after the procedure. Six months after the procedure the patient was pain' free, with a surgical scar badly noticed and was discharged from orthopaedic appointments.
Discussion: Tipically, the presentation of glomus tumor include a clinical triad (pain, located tenderness and sensitivity to cold). The diagnosis of this disease is usually not easy, but can be confirmed with MRI. However, surgical treatment is usually curative and the surgical lateral latero-ungual approach, although it isn’t the most commonly used, coud be a good alternative to standard approach (transungual).

Introduction-The scaphoid bone is the most commonly fractured carpal bone, accounting for 50% to 80% of all carpal bone fractures and approximately 11% of all hand fractures. Mainly young, active individu- als sustain scaphoid fractures.Herbert and Fisher classifi- cation has been used most frequently.Material and method-Materials and Methods-study was carried out between Jan 2020 to Feb 2022, the authors treated 10 scaphoid fractures using the percutaneous scaphoid fixation technique. There were 8 men and 2 women in the study with a mean age of 25 years.7 fractures on the right side and 3 on the left side. Mechanisms of trauma were fall on out- stretched hands for 9 patients and road traffic accident for 1 patient. 7 fractures were on the dominant side and 3 were on the nondominant side. Mean time from injury to surgery was 2 weeks.Plain radiographs re- vealed the fractures in all cases. All patients had a preoperative plete fracture configuration. A computed tomography scan is strongly recommended if a per- cutaneous procedure is planned. Intraoperative Technique-The patient was placed supine with the affected up- per limb abducted 90°. Hyperextension and ulnar deviation of the wrist accompanied by thumb traction facilitated any necessary reduction of the fracture. The end of the screw was buried beneath the distal surface of the scaphoid to avoid more damage to the scaphotrapezial joint.A 22-mm screw was sufficient in almost all of the cases, with an 20 and 24 mm screw being used in one patient respectively.

Quad bike is the leading cause of injuries and traumatic deaths among Australian farmers. About one thousand of Australians are injured and fifteen die every year. To reduce these numbers ACCC recently introduced safety standards applying to all new quadbikes/ATV. All terrain vehicles have to be equipped with an ATV Lifeguard, a Quadbar or similar device. i.e. cage to provide protection to operator in case of roll over. Other trend is noticeable shift consumer preference from quad bikes to side-by-side vehicles. This type of vehicle has similar protective cage surrounding driver.
We observed dominance of upper limb injuries (57%) simultaneously with increased popularity of quad bike or ATV. Wrist or hand injury constituted 43% of all referrals to orthopaedic department after ATV/quadbike associated injury in Cairns Base Hospital in 2018-2021.
The injuries from ATV were quite unique with the most common mechanism: crush injury of the hand against metal roll cage. We also investigated the demographics of these patients; number of surgeries and result of outpatient follow ups. Traumatic transmetacarpal amputation was included for discussion and sharing our multidisciplinary approach of treatment.

Introduction:
Dupuytren's disease is a retractile fibreuse sclerosis of the middle palmar aponeurosis, resulting in progressive and irreducible flexion of one or more fingers. The etiology remains unknown. The diagnosis is clinical. The treatment is resolutely surgical.

Patients and Methods: This is a retrospective study of 30 patients, over a period of 4 years (2015-2020)

Results: The mean age was 54 years with male predominance. They were mainly manual workers, some of whom had diabetes. The involvement of the right hand in 82% of the cases, predominated on the 5th and 4th finger, more often in the 2nd stage according to the classification of Tubiana and Michon. All of our patients underwent aponeurotomy. All patients presented favorable results at last recoil.

Discussion: Dupuytren's disease is characterized by a fibrosis of the superficial palmar aponeurosis that can lead to a flexural deformity of the fingers. The main risk factors are family background, age, male sex, diabetes, alcohol and tobacco consumption. Its familial distribution is autosomal dominant. In spite of a certain genetic determinism, the pathogenesis of the disease is only partially known. The main objectives of the treatment of Dupuytren's disease are the reduction of the flexion and of the associated disability. It remains symptomatic and does not prevent recurrence. The means available are needle aponeurotomy, surgery, the reference procedure of which is aponeurectomy, and recently collagenase.


Conclusion:
Open aponeurotomy retains a primary place in the treatment of Duyputren's disease. The functional result depends on the evolutionary stage of the disease.

Introduction-Bilateral distal end radius and scaphoid fracture in a single patient is rare.Managing such a case itself it’s a challenge in terms of operative time ,wound management and preop investigation.Case report-30 year old male came with pain and swelling in bilateral wrist with history of Road traffic accident.Ap,lateral and scaphoid view was done.radiographs showed displaced waist fracture and comminuted Der fracture with dorsal tilt on right side.on the left side there was undisplaced proximal pole scaphoid and intra articular undisplaced Der fracture.preop ct scan was done for fracture orientation.on right side we planned for ORIF with Der plating and bone grafting with Herbert screw and casting on the left side.Modified Henry’s approach was used extending into the hand. Fracture was identified and reduction was confirmed under fluoroscopy. We used 4 hole Der plate and 22 size Herbert screw for fixation.Wound was closed in layers. Procedure was uneventful.followup was done 1 year and it showed union on both side with good functional outcome discussion- bilateral scaphoid fracture with bilateral distal end radius fracture is a rare entity and one should be prepared for operative intervention as soon as possible depending upon fracture orientation and patients clinical status.it is better to treat displaced fractures with operative intervention and give a conservative trial for undisplaced fractures.conclusion- Operative vs conservative management of the fracture depends on Fracture orientation,age of the patient,clinical profile of the patient,surgeon’s compatibility.

Background: Glomus tumour is a benign tumour that originates from the neuromyoarterial cells of the glomus apparatus in the reticular dermis. 80% of these tumours are located in the upper extremities, especially the subungual area of the nail. They account for 2% of all hand tumours. It is typically under one centimetre in size and consists histologically of glomus bodies. The tumour presents as a faint, blue-red subungual papule associated with a classic symptoms: local sensitivity, pain with cold exposure.
Case presentation: We reported the diagnosis and successful surgical management of a case of a classic glomus tumour in a 49-year-old female. She had a 2-year history of pain and tenderness around the nail bed of her left middle finger, which was worse in cold weather or when lightly touched. The pain was excruciating, constant, and extremely debilitating. The clinical diagnosis was made based on history and examination. She has normal ultrasound and MRI findings.
The lesion was surgically excised under ring block, leading to the
complete resolution of symptoms. Histology confirmed the lesion to be a glomus tumour.
Conclusions: Glomus tumour has a classic clinical presentation and typical symptoms of severe pain and touch sensitivity. A high index of suspicion and careful clinical examination is crucial, and the presence of normal ultrasound/ MRI does not exclude the diagnosis. Delayed or misdiagnosis can result in undue
patient suffering. Surgical removal of the lesion leads to a complete cure, although the patient must be counseled about the low rate of recurrence.

Background: To assess long term clinical and radiological outcomes of modified Matti-Russe technique in 46 cases of established proximal pole scaphoid non-union who underwent open reduction and surgical fixation with non-vascularized autologous distal end radius bone grafting and K wire fixation.
Introduction: Factors which are involved in scaphoid non union are tenuous blood supply, failure to recognize the fracture, Inadequate initial treatment and improper assessment of bone healing. Untreated scaphoid non-union over years leads to increase in displacement of fragments, increased carpal instability and eventually patients ends in osteoarthritis. Despite several treatment modalities, optimal treatment remains controversial. Matti-Russe is effective, simple after a learning curve and inexpensive. Methods: Prospective study conducted from 2005 to 2021 included 46 patients. Demographics, time since injury, mechanism of injury and prior treatment taken were documented. Standard posteroanterior with ulnar deviation, lateral, supination oblique and pronation oblique obtained.
Patients treated within 12 weeks, significant proximal pole fragmentation, degenerative changes in wrist, VISI/DISI deformities were excluded. Results: Majority were males(92.4%) and sports injury was most common mechanism. Union occurred in 44 patients(95.66%) radiologically and functionally. Mean Mayo wrist score was 80.0 ± 8.8 in all the subjects at 3 year follow-up. Conclusion: Our results suggest that proximal pole scaphoid nonunion when treated with surgical fixation and autologous local bone graft heal without the need for more complex vascularized procedures. Distal radius as a donor site, reduces operative time, can be performed with single approach, less donor site morbidity, and allows the use of regional anaesthesia.

Subcutaneous emphysema is a rare occurrence of infiltration of air in the subcutaneous layer of the skin. Benign subcutaneous emphysema is an uncommon condition that may occur secondary to trauma. It has a similar presentation to necrotizing fasciitis. The latter is caused by gas forming organisms where infection of the subcutaneous layer extends into the deeper tissue plane. Early and prolonged antibiotic therapy with extensive wound debridement are often necessary to counter the aggressive nature of the condition. Benign subcutaneous emphysema on the other hand, is limited to the subcutaneous tissue, with absence of systemic symptoms. We present a case report and review of the literature of this rare condition. This case highlights the importance of differentiating benign subcutaneous emphysema from life-threatening soft-tissue infections. Oftentimes, medical management successfully resolves symptoms in cases of subcutaneous emphysema in patients who are systemically well, minimal pain and in the absence of extensive cellulitis or wound. It is noteworthy that surgical debridement of puncture sites and surrounding fibrotic tissues are proposed for those with persistent symptoms or obvious wounds. Good clinical judgement is key to avoid unnecessary surgical exploration in such cases.

Background: Current evidence for flexor tendon repair management and outcomes performed at peripheral centres is unclear. Most studies are based on evidence from specialist hand centres. This study evaluated a peripheral hospital in New Zealand; where all flexor tendon repairs were performed by a generalist Orthopaedic service. The purpose of the study was to benchmark management and outcomes from a peripheral hospital in comparison to international standards.

Methods: A single-centre consecutive case series of zone I and II flexor tendon repairs was extracted between January 1, 2014 and January 1, 2018. Medical records were used to find data relating to management and outcomes. Hand therapy notes were analysed to document rehabilitation protocols used. The primary objective was to evaluate re-rupture and re-operation rates. Secondary objectives include operative technique standards and hand therapy compliance.

Results: Forty-six patients (76 anastamoses) were included in final analysis. Mean follow up time to last clinical appointment was 11.8 weeks, and to last patient episode was 4.9 years. Most patients received timely surgery with a four-core repair using 3-0 or larger suture. All hand therapy followed a controlled active motion protocol. The re-operation rate was 19.6% (P = <0.05) and the re-rupture rate was 8.7% (P = 0.28).

Conclusions: Most flexor tendon injuries at this peripheral centre were managed according to international standards. However, high complication rates including re-operation and re-rupture occurred. Due to a lack of local comparison studies, confounding factors cannot be excluded as a contributor for these results.

The scaphocapitate fracture-dislocation (Fenton syndrome) consists of a variation of a greater-arc dislocation in which the scaphoid and the capitate are fractured, the latter being displaced with the proximal pole rotating 90 or 180 degrees. To reduce the capitate fragment an open reduction is necessary. Treatment options include excision of the fragment, replacement, reduction of the scaphoid and capitate fractures and maintain them with internal fixation or cast immobilization. Complications such as osteonecrosis may follow such injuries. Isolated fractures of the capitate are an unusual presentation. In contrast to nondisplaced fractures, displaced fractures usually require open reduction and internal fixation with Kirschner wires or screws. We present a case of a 22 year old male who presented to our emergency department, after a fall, with wrist pain. On clinical examination, there was swelling, painful mobility and no neurovascular deficits. He had no significant past medical history. The patient underwent a standard radiographic assessment which showed a scaphocapitate fracture-dislocation with the proximal fragment of the capitate into 180º degrees of rotation and a small volar schaphoid fracture. The patient was treated with open reduction and internal fixation by a dorsal approach, with reduction of dislocation, osteosynthesis of the capitate with a Herbert screw from proximal to distal and three Kirschner wires. Post-operative immobilization was performed with an antebrachiopalmary splint for 8 weeks. The k-wires were extracted at 8 weeks.
At 6 months the Modified Mayo Wrist score was 100. On the radiological level there was complete consolidation without intracarpal misalignment.

INTRODUCTION: Gout, trigger finger and carpal tunnel syndrome are common diseases in Malaysia. Nonetheless, concurrent presentation of all these at once is uncommon.

REPORT: A gentleman with underlying hypertension, dyslipidemia and diabetes mellitus, presented with right ring finger trigger finger which unresolved even after A1 pulley release, associated with palmar swelling and carpal tunnel syndrome. Magnetic Resonance Imaging (MRI) showed tumour-like lesion consistent with tenosynovial Giant Cell Tumour. However, during excision biopsy and carpal tunnel release, noted a well-circumscribed lesion with chalky white deposits encasing 4th flexor digitorum superficialis tendon and compressing median nerve. Biopsy was reported as gouty tophi. Uric acid sent post-operatively noted elevated (774 µmol/L).

DISCUSSION: Gout is a subset of metabolic syndrome caused by intra-articular monosodium urate crystal deposition. Carpal tunnel syndrome and trigger finger are unusual presentations of gout. In carpal tunnel syndrome related to gout, there is an increase in the content of carpal tunnel due to gouty deposits on the median nerve and bulky tendons due to tophaceous infiltration. Gouty deposition on tendons may affect tendon gliding thus cause trigger finger. Gout should be treated with urate-lowering therapy (first-line is allopurinol). Surgical excision of tophi may be considered when there is uncontrolled infection, entrapment neuropathy and risk of permanent joint damage.

CONCLUSION: Although gout is a rare cause of carpal tunnel syndrome and trigger finger, high index of suspicion of gout is required, especially in patients with underlying metabolic syndrome.

Introduction: Vicious callus is the most frequent complication of fractures of the distal end of the radius. It is the cause of pain, deformity, limitation of joint mobility and a modification of carpal kinetics which will affect the biomechanics of the wrist.

Materials and Methods: This is a retrospective study on 20 patients, between the year 2015 and 2019 in the department of Traumatology-Orthopedics wing 4 CHU of Casablanca.

Results: We found a male predominance, The average delay of consultation was 7 months, All our patients had extra-articular callus, a decrease in joint amplitudes and angular measurements.
The anterior approach of Henry was performed in all our patients. Radial addition osteotomy was performed in 7 patients and subtraction in 3.
All our patients were immobilized for 4 to 6 weeks followed by rehabilitation. The evaluation of our patients was done according to the quotation inspired by the Lille school. The pain disappeared in 62% and 71% had satisfactory mobility, with improvement in radial inclination amplitudes, glenoid anteversion and radio-ulnar index.

Discussion: According to the literature pain and/or functional discomfort are the formal indications for surgical treatment. Rothenfluh et al found better results in the group operated on via the palmar approach.
Opening osteotomies have long been opposed to closing osteotomies whose advantage was the absence of need for a bone graft.
conclusion: The management of distal radius callus is based on a prior clinical and radiological analysis and once the indication is made the treatment is surgical.

Introduction: Finger osteomyelitis can be a devastating and challenging problem which often result in amputation. Fortunately, the induced membrane technique ( Masquelet technique) which was recently introduced for surgical treatment of hand and wrist infection has become more popular.

Report: 17 year old right handed male was referred to our center for right middle finger proximal phalanx osteomyelitis. Initially, he sustained laceration wound over his right middle finger one month prior to presentation and subsequently self medicated with store bought traditional ointment. He had persistant pus discharge over dorsum and volar aspect of right middle finger despite multiple debridement and intravenous antibiotics at another hospital. Xray shows destruction of the PIPJ with osteolysis and periosteal changes over the proximal phalanx of middle finger. Masquelet technique involves two stage, the first surgery/ initial stage involved radical debridement of the infected tissue and bone, placement of a cement spacer and external fixator. Second stage surgery involves external fixator and cement spacer removal. Cortico-cancellous iliac crest bone graft was harvested and fixed with Kirschner wires and cerclage wires. He was also given antibiotics based on intraoperative cultures. 6 months postoperatively, patient has a well healed scar and no pain of over his right middle finger (QuickDash score 6.8%).

Conclusion:The induced membrane technique is a simple and useful technique in treating osteomyelitis in the hand with massive diaphyseal bone defect. It makes finger preserving surgery feasible in these situations with acceptable hand function and outcome.

The distal radius is the second most common fractured bone in elderly persons and the most frequent upper extremity fracture in women > 50 years. In 2017. The BOA published the BOAST guidelines for the management of distal radius fracture. Methods: Retrospective study of cases with distal radial fractures in Worcestershire Acute Hospitals NHS Trust from 1/3/2017-31/8/2017. Radiographs were studied by 2 independent orthopaedic registrars to assess feasibility of cases and to classify them according to type, direction of displacement and stability according to Lafontaine criteria, 1989. All adults were included. Physeal injuries, other radius fracture, duplicates and incomplete records were excluded. The compliance to recently published BOAST guidelines was assessed. Results: Data of 241 wrists during that period was collected. 184 wrists were included, 2 cases had bilateral fractures. Age range was 17 to 95 years, average 66 years. 113 patients were older than 65 years. 69 patients had hematoma block for manipulation and 62 patients did not have any manipulation. 27 of the extra-articular dorsally displaced stable fractures (33 wrists) were immobilised in plaster cast for 3-6 weeks. In dorsally displaced fractures managed surgically, 48% were fixed with plates and 52% were fixed with K wires. Conclusion: Improvement in the use of the regional anaesthesia, prolonged time in cast and the use of K wires in dorsally displaced fractures were needed. Minimisation the time of immobilisation and to consider K wires more in the fixation of extra-articular distal radius fractures were advised.

WALANT or Wide awake local anaesthesia with no tourniquet is a simple yet efficient method to perform open reduction and internal fixation for bony fractures in the hand and upper limb. Procedures can be done under local anaesthesia in Daycare facilities without need for admission for complex blood investigations, chest xrays, ECGs and general anaesthesia. Pain relief lasts for up to 8 hours. Stability of fracture fixation and checking for malrotation can be done immediately. Just as important, patients are able to move their fingers / wrist and see how stable the fracture is allowing for education for physiotherapy. We will demonstrate how to mix the WALANT injection, technique of injection and videos of surgical technique of K-wiring of phalanges, plating of metacarpal, plating olecranon and plating of radius.