Arterialized Posterior Interosseous Nerve Graft for Digital Neuroma Painful neuromas are not uncommon following nerve injury, and are especially bothersome in the hand, with severe cases resulting in significant disability. Outcomes of neuroma surgery are unpredictable regardless of technique. It is recognized that optimal soft tissue environment influences nerve healing more than the specific nerve graft technique, and it is in this context, we present a novel technique of transferring a posterior interosseous nerve graft along with vascularized synovial and fat tissue based on a branch of the posterior interosseous artery to provide healthy soft tissue for nerve healing of neuroma in continuity about the hand and digits.

Combined Pedicled Vascularized and Wedge Nonvascularized Bone Graft for Treating Scaphoid Waist Nonunion With Humpback Deformity Pedicled vascularized bone graft (VBG) is a useful method in treating the scaphoid fracture nonunion, especially when the avascular necrosis exists. Humpback deformity is an important issue that we have to correct it during the treatment. We describe a method by using combined wedge non-VBG to correct the nonunion deformity when treating scaphoid nonunion with pedicled VBG. The wedge bone graft was harvested just proximal to the 2,3 intercompartmental supraretinacular artery VBG and was used as an inlay at the volar site to correct the humpback deformity, whereas the VBG was set at the dorsal site for bone bridging and blood supply. We also present our results of 10 patients with scaphoid fracture nonunion and humpback deformity treated with this method. Bone healing was achieved and the lateral intrascaphoid angles could be improved in all the 10 patients. Functional outcomes, including the Visual Analog Pain Scale for pain during activity, grip strength, the shortened Disabilities of the Arm, Shoulder, and Hand questionnaire (QuickDASH), and the modified Mayo Wrist Scores, were significantly improved.

Fixation of a Type 3 Flexor Digitorum Avulsion Injury This article describes a novel technique for flexor digitorum profundus (FDP) avulsion injuries, useful for Leddy Packer type 3, 4, and 5 injuries. Multidirectional stability is achieved with combination pull-out suture, which neutralizes the deforming force of FDP, and cerclage wire, which holds the bone fragment in an anatomic position and provides interfragmentary compression. Traditional techniques such as interosseous wires, Kirschner wires, or plating risk fragment comminution and loss of reduction due to proximal pull of FDP as demonstrated in this case report of failed Kirschner-wire fixation. The technique presented here eliminates the risk of avulsion fragment comminution and provides stable fixation that allows for early mobilization.

Steindler Flexorplasty: A Description of Current Technique and Case Series This year marks the 100th anniversary of Dr Steindler’s original report of a proximal transfer of the flexor pronator mass to restore elbow flexion. The authors present their updated surgical technique to perform the Steindler flexorplasty. In this procedure, the flexor-pronator mass origin on the medial epicondyle is transferred proximally to the anterior humerus to restore elbow flexion. They also report a retrospective case series of patients from 2007 to 2017 who underwent a Steindler flexorplasty at their institution to restore elbow flexion. In the series, 8 of 9 patients achieved at least 90 degrees of active antigravity (M3) or greater elbow flexion. Outcomes following the Steindler flexorplasty have been reported in the literature over the course of the past 100 years. Although alternative techniques to improve elbow flexion have been developed and performed over the last century, this time tested procedure remains a powerful reconstructive option.

Anteromedial Release for Posttraumatic Flexion-pronation Contracture of the Wrist: Surgical Technique Wrist stiffness can be a complication of trauma. A small percentage of patients fail to improve with nonoperative management and require operative intervention to regain range of motion and function. These group of patients can present with a soft tissue flexion-pronation contracture, which is hypothesized to be caused by capsular contraction of the distal radioulna joint, musculotendinous contracture of the flexor carpi ulnaris, contracture of the volar ulnar carpal ligaments and of the pronator quadratus muscle. This complication significantly restricts functional dart-thrower’s range of motion and is highly disabling. A surgical option to manage this condition is release of pathologic structures with an anteromedial approach to the wrist. We describe a safe, effective, and reproducible technique to treat these patients.

A Novel External Fixation Technique for Injuries of the Proximal Interphalangeal Joint Digital external fixation is often used for the management of complex injuries involving the proximal interphalangeal joint, including pilon fractures of the middle phalanx base and unstable fracture-dislocations. Several dynamic “homemade” constructs have been described which utilize only K-wires and rubber bands and allow early range of motion within the construct. Although these constructs are inexpensive and their application is fairly straightforward, their designs pose a few potential problems when the construct is stressed during rehabilitation efforts. These designs utilize a blocking K-wire which relies on pin-to-pin contact to maintain reduction and creates unnecessary friction that can impede motion and result in pin loosening in bone. Furthermore, rubber band rupture can occur and destabilizes the construct. Here we present a novel technique which utilizes only K-wires and K-wire caps, provides adequate joint distraction and stabilization throughout the arc of motion, and avoids the aforementioned pitfalls of existing designs.

Triquetrum Excision in Radioscapholunate Arthrodesis for Posttraumatic Radiocarpal Osteoarthritis With Ulnar Impaction Syndrome Dependent on fracture type, concomitant carpal injuries, and operative treatment, distal radius fractures can lead to symptomatic radiocarpal osteoarthritis. In addition, radial shortening can cause ulnar impaction syndrome. Radiocarpal arthrodesis and ulnar shortening osteotomy are known and frequently applied surgical procedures for each of those pathologies. There are limited data concerning treatment options for a combined disorder. The presented technique in this article demonstrates that radioscapholunate arthrodesis with distal pole scaphoidectomy and total triquetrum excision successfully treats both symptomatic radiocarpal osteoarthritis and ulnar impaction syndrome without further surgery on the ulna.

Extra-articular Corrective Osteotomy With Bone Grafting to Achieve Lengthening and Regain Alignment for Distal Radius Fracture Malunion Surgical correction of the distal radius fracture malunion is challenging because of the 3-dimensional deformity. We propose a method by using the Kapandji intrafocal pinning in corrective osteotomy for treatment of the distal radius fracture malunion to facilitate the alignment correction while using the bone graft to restore the radial length. The surgery was started with the osteotomy from a volar approach, and the osteotomy gap was expanded gradually. Then, allobone grafting was performed to maintain the corrected radial length. We used the Kapandji intrafocal pinning dorsally to provide dorsal supporting force and radially to correct the radial inclination. Finally, a volar plate was used to buttress and push the distal fragment to fit as to regain the correct volar tilt. We enrolled 10 patients of distal radius fracture malunion with a mean age of 59.3 years. All patients had bone healing within 3 months after surgery. The mean lengthened distance was 5 mm. The radial inclination and volar tilt could be corrected with improved functional results.

Anatomic Considerations and Reconstruction of the Thumb Flexor Pulley System Disruption to the flexor pulley system of the thumb is an infrequent but devastating injury that can lead to significant compromise in both strength and function. Acute rupture leads to pain, weakness, reduced range of motion (ROM), and potential bowstringing of the flexor tendons. Conservative treatment with a pulley ring should be considered in all patients. However, failure of conservative treatment and bowstringing of the thumb are indications for operative intervention. Reconstruction of the oblique pulley system can be performed either in situ or using a free palmaris longus graft. Care should be taken to identify the neurovascular bundles to avoid compression during the reconstruction. Conscious sedation protocols augmented by ultrasound-guided sheath blocks allow the patient to actively and strongly contract the flexor pollicis longus tendon intraoperatively to appropriately tension the construct for optimal results. Rehabilitation should be performed in a stepwise manner beginning with early passive ROM, active ROM, and finally strengthening at around 8 weeks postoperative.