A flap is done to cover expose structures such as bone, tendon and ligament. Chest wall flaps are usually
performed under general anaesthesia due to a fairly large area of surgery and at two different sites which are
the chest and the hand. This is the first known reported case of a chest wall flap for coverage of the hand
under Wide awake local anaesthesia no tourniquet technique (WALANT). We here report the case of a 32-
year-old man who had a firecracker injury over his right hand with bone exposed in his right index and
middle finger and distal amputation of the thumb with first carpometacarpal joint dislocation. Chest wall
flap reconstruction for coverage of a severe blast injury in the hand is possible and safe under WALANT. The
proper technique and administration will lead to a successful surgery without general anesthesia
complications and risks. This alternative option may be useful in districts or smaller hospitals where
resources are limited.

Background: Carpal tunnel syndrome have a considerable economic burden to the health care system. ", the purpose of this study was to evaluate outcome of CTR and to investigate patient’s satisfaction upon using WALANT " Wide-Awake Local Anesthesia No Tournique". Hence, it will support decision making and emphasising hand surgery practice.
Methodology: It’s a descriptive cross-sectional study, November 2019– December 2020 in 3 hospitals in Khartoum state, Sudan. Investigating outcome and patient satisfaction of all open CTR using WALANT technique. Data collected pre and postoperative using two prevailed questionnaires; Boston Carpal Tunnel questionnaire (BCTQ) , and Patients’ perception and satisfaction questionnaire.
Result and Discussion: Total number of 52 hands, with mean follow up period 8.7 month. Our entire patient got significant improvement regarding their hand symptoms, and near all (96.1%) gets improved in function; symptoms improved to 1.26 from 3.03 preoperatively, function to 1.21 from 2.89 preoperatively. The mean wound healing time is 2.5 (SD ±1.6) week, only 3.8% complicated by wound infection. Regarding patients satisfaction; 92.3 % reported that they will choose WALANT again if they had to have the producer again, 90.4% stated that they would definitely recommend WALANT to others. Post-surgery anxiety level significantly reduced (1.65 out of 5), and 86.5% found that their experience was better than expected.
Conclusion: Open CTR using WALANT technique is safe, efficient and effective technique, and associated with significant improvement of hand symptoms and function with high patient satisfaction.

Background
De Quervain’s disease is one of the common causes of wrist pain and disability. Surgical release is preferred when there are persistent symptoms after six weeks of conservative treatment. The aim of this study is to determine the functional outcome of surgical release of de Quervain’s disease using visual analogue scale score and modified mayo wrist score.
Method
This is a prospective observational study conducted among patient with de Quervain’s disease not improved by conservative treatment. Surgical release was performed. Preoperative and postoperative functional outcome was assessed with Finkelstein test, visual analogue scale and modified mayo wrist score at two weeks, three months and six months follow up.
Results
Among 30 patients, 27 (90%) were females and three (10%) were males. Right side was involved in 17 (57 %) and left side on 13 (43%). Majority of the patients (67%) were housewives. All patients returned to job within mean duration of two weeks after surgery. Complication was noted in two patients who had persistent pain over the first dorsal compartment. VAS score decreased from 7.4 preoperatively to 1.13 at six months follow up. Similarly, modified mayo wrist score improved from 59.5 to 93.33 at six months follow-up. Duplication of APL tendon was noted in five patients.
Conclusion
The functional outcome of surgical release of de Quervain’s disease is excellent with minimum complications. Surgery can be considered in those patients who do not respond to conservative treatment up to six weeks.
Keywords: de Quervain’s, disease, tenosynovitis, surgery

Introduction: Radiocarpal fracture dislocation is a rare and severe form of injury. Management is challenging and understanding the patho anatomy forms the basis for achieving good outcome.Materials and Methods: A total of 43 patients with radio-carpal fracture dislocation from 2015 to 2020 were included in the study. Group 1 includes 23 patients, group 2 included twelve patients, group 3 and 4 had two and five patients respectively. Majority were high velocity injuries. Twelve of them sustained open injury with two patients requiring flap cover. Forty-three consecutive patients with radiocarpal dislocation were included and divided into four groups based on the type of treatment given. Group 1 underwent closed reduction and pinning. Group 2 underwent open reduction with pinning along with repair of capsulo-ligamentous structures. Group 3 included patients with open reduction and plating. Group 4 included patients who underwent open reduction and plating along with repair of capsulo-ligamentous. All patients were followed and analysed for radiological and functional outcome. Results: Plating with repair group had better functional outcome (DASH and PRWE score) compared to plating group. (p=0.012).Conclusions: Combined approach for addressing both bony and ligamento-capsular injury is recommended to achieve anatomic reduction of radial styloid and repair of the injured capsule and ligaments for good functional outcome.

Introduction
Osteochondroma usually arise from metaphysis of the long bones.
We present a rare case of a distal phalanx osteochondroma.

Case Report
A 74 year old lady with no known medical illness presented to our centre with history of three years of right middle finger pulp swelling. She denies any prior trauma or infection to the finger.
On examination, her right middle finger pulp is swollen with normal overlying skin.It is round, hard, non-mobile and has a diameter of 0.5cm. Xray of right middle finger reveals a osseous projection from the distal phalanx volarly. No erosions or sclerotic lesion seen within the phalanx.We proceeded to perform an excision biopsy of her right middle finger mass via an incision over the volar aspect. Intraoperatively, the mass has a broad base which is pedunculated and is in continuity with the cortex of the distal phalanx. Its surface is smooth and regular.
The Histopathology examination of the resected bone was reported as dense bone tissue with calcification, surrounded by osteoblasts and spindle shaped fibroblasts. Some chondrocytes seen and minimal perichondrium is present.

Conclusion
Although rare, osteochondroma can still occur after skeletal maturity over the distal phalanx of a finger. If encountered, high index of suspicion for malignancy and excision of the lesion should be considered.

Introduction:Complete dislocation describe complete disassociation of the joint with significant injury to the volar plate. Closed reduction in complete dislocation fails due to soft tissue interposition which includes volar plate, sesamoid bones, bony fracture fragments or FPL.
Case Report:53 yr old manual labour by occupation presented with deformity of right thumb following a trivial injury, neglected for 3 month duration. Pain and swelling was present in the volar aspect of left base of thumb with no range of movements in first MCP. On Examination, MCP in hyperextension and IP joint in flexion. X ray showed complete dorsal dislocation of 1st MCP with sesamoids over the dorsal surface of 1st metacarpal head.
Definitive management under supra-clavicular block. Dorsal incision was made over MCP joint, extensor apparatus divided between EPL and EPB. Fibrous tissue was removed carefully. Volar plate identified in the form of transverse band over the head of metacarpal. A longitudinal split was made and allowed to retract. Reduction was achieved with pressure over the head of meta-carpal dorsally. Post reduction was unstable, hence it was stabilised with K-wire transfixing the MCP.. After 4 weeks, k-wire was removed and physio was started and achieved 0-60 deg flexion at 8 weeks follow up. At 2 yr follow up, near normal range of movements in comparison with normal thumb.
Conclusion
Neglected complex dorsal dislocation is rare and more common in developing countries hence high index of suspicion is needed for early diagnosis and prompt management to preserve function

Introduction: The lacertus is a sheet of ligamentous tissue (lacertus fibrosus or bicipital aponeurosis) just distal the elbow joint where the median nerve can be compressed. Lacertus syndrome, a subset of pronator syndrome is an uncommon diagnosis. Surgical release of the lacertus consists of a small 2cm incision which can be done under local anaesthesia. This study aims to evaluate the outcome of lacertus release in resolving median nerve symptoms. Methodology: This retrospective study was done at Prince Court Medical Centre, Kuala Lumpur, Malaysia from Jan 2020 until June 2021. A total of 93 patient underwent lacertus release by a single surgeon. Quick Dash score, grip strength and pinch strength were tested pre and post surgery. At 6 months post surgery, patients filled up a WALANT satisfactory questionnaire. Results: A total number of 93 patients were included in the study. The mean age of patient was 38.7 years old. Majority of patients were females (77.4%). The mean pre-operative DASH score was 53 and significantly reduced immediately post-op to (7.8) (p<0.001) and remained low at 6 months post-op (10.6). Grip strength increase in mean from pre op level of 16 to post of mean of 24 (p<0.001). Pinch strength increased from a mean of 9 pre op to 13 post op (p<0.001). Conclusion: Lacertus release remains an under diagnosed disease which can be treated efficiently with a minimal surgical incision. Lacertus release under wide-awake local anesthesia has a significant reduction of numbness with markedly improved hand grip and pinch strength.

Acute carpal tunnel syndrome is an uncommon presentation often related to trauma, fractures or acute vascular conditions involving the wrist. Chronic rheumatic conditions such as synovitis can sometimes lead to acute carpal tunnel syndrome. Although rare, acute carpal tunnel syndrome secondary to gouty synovitis has been reported in literature. We present a case of a 47-year-old male flight attendant presenting with acute carpal tunnel syndrome post gouty synovitis. The patient described a first-time onset of acute neuropathic pain in the right wrist radiating along the distribution of the median nerve, associated with swelling, numbness, tingling of the hand and weakness of thumb opposition graded as 4+/5 in the MRC muscle power scale. Tinel and Phalen signs were positive and nerve conduction studies demonstrated moderate sensory and motor slowing of the median nerve fibers. Plain x-ray failed to show any obvious bony abnormalities, but MRI demonstrated severe tenosynovitis of the flexor tendons compressing the median nerve. Rheumatology review did not indicate any rheumatological etiology, but serum uric acid was found to be elevated consistent with acute seronegative synovitis or gouty synovitis causing acute carpal tunnel syndrome. As treatment, the patient underwent urgent surgical decompression of the carpal tunnel after initial steroid injection for temporary relief. Intra-operative findings revealed a severely thick and tight flexor retinaculum compressing the median nerve which was released. At one-month follow-up, all symptoms had resolved. We conclude that gouty synovitis may cause first-time acute carpal tunnel syndrome and urgent diagnosis and surgical release is key.

Carpal coalition is arare cause of ulnar sided wrist pain acase report
Male pt 25,with ulnar sided wrist pain xray show lunotriwuetral coalition mri showing signals in TFCc
We did wrist arthroscopy
Showing central tear Tfcc
Ulnar shortening done for this pt

It was a prospective study of 108 complete intra-articular fractures of AO type B and C in 108 patients over a period of 4years. My surgical technique includes an innovative method of closed reduction of the comminuted fracture distal radius in four steps - distraction, compression, milking of the comminuted fragments and repositioning of DRUJ. Pinning was done by creating two triangles in two planes using 6 k-wires(1.6mm) by encircling the metaphysis without interfering the RCJ through the outer cortical area of the triangular shaped distal radius encircling the comminuted metaphyseal area with crossing at 6 points and thereby preventing metaphyseal collapse by the role of k-wires like the steel scaffolding in cement concreting. The congruity of the RC Joint and negative ulnar variance was maintained by preventing the stepping due to the metaphyseal collapse with the help of 2 transverse pins parallel to the articular surface and 2 proximal pins directing to Radio-lunate facet (die-punch). The patient can do some form of personal works including writing, brushing, dressing, cooking, eating and office works from the immediate postoperative period. The results are evaluated by Clinical scoring system of Green and O’Brien modified by Cooney. The results revealed that painless wrist activities were possible from the immediate postoperative period and 97% of patients returned to their original work within 3 to 6 months. The radiological analysis revealed that radial length, radial inclination, palmar tilt, ulnar variance and articular congruity were maintained to the initial post-operative alignment using this novel pinning method.

Introduction: Carpal tunnel syndrome is the most common nerve entrapment syndrome. Carpal tunnel is composed by carpal bones, transverse carpal ligament, median nerve and digital flexor tendons. A high number of factors are related with disease development, including trauma. Case presentation: We present a case of a 29 years old woman that came to our hospital with pain at thenar region and first finger of her left hand. The pain started after an accident with a sharp glass that made a painfull scar at hand's volar aspect. After that accident, the patient developed pain and some numbness of that area. Curiously, the pain was worst when patient flexed the index finger. Magnetic ressonance imaging displayed tenossynovitis of index finger flexor tendons (Figure 1 and 2) and electromiography was compatible with a mild carpal tunnel syndrome and a partial lesion of a median nerve sensitive branch to first interdigital space.
The patient was submitted to an outpatient surgical procedure that went by without any adversity. The surgery revealed scar fibrosis compressing a branch of median nerve (Figure 3 and 4). The painfull scar and transverse carpal ligament were ressected. Neurolysis and index finger’s flexor tendons tenolysis were also made.
The postoperative period went by with no problems and the patient reported great complaints’ improvement at 3 months follow-up. At this time, the patient had a badly noticed scar and no pain. Discussion: This interesting case serves to highlight the importance of trauma as a risk factor to carpal tunnel syndrome.