Similar outcomes following scarf-Akin osteotomy compared to scarf-alone osteotomy for the treatment of hallux valgus: A systematic review and meta-analysis

BACKGROUND

The purpose of this systematic review and meta-analysis was to compare the clinical and radiographic outcomes between patients undergoing scarf osteotomy and scarf-Akin osteotomy for the management of hallux valgus deformity.

METHODS

A systematic review of the MEDLINE, EMBASE and Cochrane Library databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Studies reporting clinical data following scarf osteotomy and scarf-Akin osteotomy for the treatment of hallux valgus were included and assessed. The level and quality of evidence of the included studies were also evaluated.

RESULTS

Four studies were included. In total, 388 patients (408 toes) underwent scarf osteotomy alone and 287 patients (295 toes) underwent scarf-Akin osteotomy for the treatment of hallux valgus deformity. There was no difference in postoperative American orthopedic foot and ankle society scores (p = 0.7828), visual analog scale scores (p = 0.4558), hallux valgus angle (p = 0.5116), intermetatarsal angle (p = 0.4830), proximal to distal phalangeal articular angle (p = 0.2411) between the scarf alone cohort and the scarf-Akin cohort. Similarly, there was no difference in complication rates (p = 0.6881) nor secondary surgical procedure rates (p = 0.3678) between the 2 cohorts. Finally, there was a higher recurrence rate in the scarf-alone cohort (11.4%) compared to the scarf-Akin cohort (5.7%), but this was not statistically significant (p = 0.4414).

CONCLUSION

This systematic review demonstrates lower recurrence rates following scarf-Akin osteotomy compared to scarf osteotomy alone for the treatment of hallux valgus deformity. No difference in complication rates were noted between the 2 cohorts. Our review demonstrates that both the scarf osteotomy and the scarf-Akin osteotomy may be effective and safe procedures, however, the scarf-Akin osteotomy may provide more long-term benefit in the setting of moderate to severe hallux valgus.

Phalangeal sarcoidosis - A rare case report

We report a case of a 57-year-old woman who presented a rapidly progressing swelling at the base of her right 4th finger, with imaging revealing non-specific lesions suggestive of a malignant tumoral process. Following imaging, resection-biopsy revealed a non-caseating granulomatous inflammatory infiltrate suggesting sarcoidosis. Digital sarcoidosis is an uncommon presentation of the disease, especially in the early stages and without systemic symptoms. Early diagnosis and treatment are advised in order to prevent future complications.

Stress fractures of the hand and wrist in athletes

Stress fractures of the upper extremity are reported less often than their lower extremity counterpart. This review aims to provide a comprehensive overview of an important and often missed diagnosis in pediatric athletes: hand and wrist stress fractures.

Metacarpal and Phalangeal Malunions-Is It all About the Rotation?

Metacarpal and phalanx fractures are common injuries that can often be managed nonoperatively with satisfactory clinical outcomes. However, loss of normal finger alignment including malrotation and severe angulation as well as intra-articular deformities can lead to functional deficits which may benefit from operative intervention. There are numerous surgical options to correct malunions and the correct choice varies based on the injury pattern, concurrent injuries/complications, and surgeon's preference. While these surgeries can be technically demanding, successful treatment can lead to good results with satisfactory deformity correction and patient function.

Acrometastasis: The Tip of the Iceberg of Metastatic Disease from Thyroid Cancer. Two Cases Report

Acrometastasis, especially in the hands and fingers, is a rare clinical condition resulting from primary cancers such as lung, breast, kidney, and, rarely, thyroid cancer. Acrometastasis tends to be the tip of the iceberg in patients with extensive systemic disease, which could be regional, pulmonary, skeletal, neurological, or all of them combined. Even though these tumors are clearly visible and symptomatic, the diagnosis is usually misleading because such distal metastatic disease is not thought of at first. In general, systemic treatments should be given to any patient presenting digital acrometastasis. We describe two cases of papillary thyroid carcinoma and digital acrometastasis as a sign of advanced disease.

Current Outcomes and Treatments of Complex Phalangeal and Metacarpal Fractures

Phalangeal and metacarpal fractures that require operative treatment have documented complications in around 50% of patients. The most common of these complications are stiffness and malunion. These can be highly challenging problems for the hand surgeon. In this article, we discuss complications after phalangeal and metacarpal fractures and treatment strategies for these complications.

Fibrosarcoma of Great Toe Shown with Multimodality Radiologic Imaging Features

INTRODUCTION

Fibrosarcoma of bone is a rare malignant spindle cell tumor.

CASE STUDY

Herein, we present a case of fibrosarcoma in a 40-year-old male who was presented to the clinic with left-sided great toe pain for 20 years. Simple radiographs showed acrolysis at the distal phalanx of great toe. Magnetic resonance imaging (MRI) revealed a 1.5 cm sized heterogenous high signal intensity mass on T2-weighted images and iso signal intensity on T1- weighted images. Dorsal and distal portion of the mass showed markedly dark signal intensity on T1 and T2-weighted images.

CONCLUSION

In an enhanced image, the mass showed heterogenous enhancement. Surgical removal was performed and pathologic analysis revealed fibrosarcoma. Although extremely rare, fibrosarcoma of the bone should be kept in mind as a possibility when a lesion exhibits a black signal intensity component on an MRI with acrolysis.

A rare case of chondroblastoma involving the distal phalanx of the ring finger

Chondroblastoma, a rare benign bone tumor, is typically found in the epiphysis of long bones, with hand involvement being particularly uncommon. We present a case of an 11-year-old female with chondroblastoma involving the fourth distal phalanx of the hand. Imaging revealed a lytic, expansile lesion with sclerotic margins and no soft tissue component. A preoperative differential diagnosis included intraosseous glomus tumor, epidermal inclusion cyst, enchondroma, and chronic infection. The patient underwent open surgical biopsy and curettage for both diagnostic and treatment purpose. The final histopathologic diagnosis was chondroblastoma.

Return to sport following toe phalanx fractures: A systematic review

BACKGROUND

Evidence-based guidance on return to sport following toe phalanx fractures is limited.

AIM

To systemically review all studies recording return to sport following toe phalanx fractures (both acute fractures and stress fractures), and to collate information on return rates to sport (RRS) and mean return times (RTS) to the sport.

METHODS

A systematic search of PubMed, MEDLINE, EMBASE, CINAHL, Cochrane Library, Physiotherapy Evidence Database, and Google Scholar was performed in December 2022 using the keywords ‘Toe’, ‘Phalanx’, ‘Fracture’, ‘injury’, ‘athletes’, ‘sports’, ‘non-operative’, ‘conservative’, ‘operative’, ‘return to sport’. All studies which recorded RRS and RTS following toe phalanx fractures were included.

RESULTS

Thirteen studies were included: one retrospective cohort study and twelve case series. Seven studies reported on acute fractures. Six studies reported on stress fractures. For the acute fractures (n = 156), 63 were treated with primary conservative management (PCM), 6 with primary surgical management (PSM) (all displaced intra-articular (physeal) fractures of the great toe base of the proximal phalanx), 1 with secondary surgical management (SSM) and 87 did not specify treatment modality. For the stress fractures (n = 26), 23 were treated with PCM, 3 with PSM, and 6 with SSM. For acute fractures, RRS with PCM ranged from 0 to 100%, and RTS with PCM ranged from 1.2 to 24 wk. For acute fractures, RRS with PSM were all 100%, and RTS with PSM ranged from 12 to 24 wk. One case of an undisplaced intra-articular (physeal) fracture treated conservatively required conversion to SSM on refracture with a return to sport. For stress fractures, RRS with PCM ranged from 0% to 100%, and RTS with PCM ranged from 5 to 10 wk. For stress fractures, RRS with PSM were all 100%, and RTS with surgical management ranged from 10 to 16 wk. Six cases of conservatively-managed stress fractures required conversion to SSM. Two of these cases were associated with a prolonged delay to diagnosis (1 year, 2 years) and four cases with an underlying deformity [hallux valgus (n = 3), claw toe (n = 1)]. All six cases returned to the sport after SSM.

CONCLUSION

The majority of sport-related toe phalanx fractures (acute and stress) are managed conservatively with overall satisfactory RRS and RTS. For acute fractures, surgical management is indicated for displaced, intra-articular (physeal) fractures, which offers satisfactory RRS and RTS. For stress fractures, surgical management is indicated for cases with delayed diagnosis and established non-union at presentation, or with significant underlying deformity: both can expect satisfactory RRS and RTS.

Cost Analysis of Intramedullary Screw versus Plate Osteosynthesis for Phalangeal and Metacarpal Fractures: An Observational Study

Background: To compare the observed healthcare and societal costs of intramedullary screw (IMS) and plate fixation of extra-articular metacarpal and phalangeal fractures in a contemporary Australian context. Methods: A retrospective analysis, based on previously published data, was performed utilising information from Australian public and private hospitals, the Medicare Benefits Schedule (MBS) and the Australian Bureau of Statistics. Results: Plate fixation demonstrated longer surgical lengths (32 minutes, compared to 25 minutes), greater hardware costs (AUD 1,088 vs. AUD 355), more extended follow-up requirements (6.3 months, compared to 5 months) and higher rates of subsequent hardware removal (24% compared to 4.6%), resulting in an increased healthcare expenditure of AUD 1,519.41 in the public system, and AUD 1,698.59 in the private sector. Wage losses were estimated at AUD 15,515.78 when the fracture cohort is fixed by a plate, and AUD 13,542.43 when using an IMS - a differential of AUD 1,973.35. Conclusions: There is a substantial saving to both the health system and the patient when using IMS fixation over dorsal plating for the fixation of extra-articular metacarpal and phalangeal fractures. Level of Evidence: Level III (Cost Utility).

The bony cap and its distinction from the distal phalanx in humans, cats, and horses

It has been recognized as early as the Victorian era that the apex of the distal phalanx has a distinct embryological development from the main shaft of the distal phalanx. Recent studies in regenerative medicine have placed an emphasis on the role of the apex of the distal phalanx in bone regrowth. Despite knowledge about the unique aspects of the distal phalanx, all phalanges are often treated as equivalent. Our morphological study reiterates and highlights the special anatomical and embryological properties of the apex of the distal phalanx, and names the apex "the bony cap" to distinguish it. We posit that the distal phalanx shaft is endochondral, while the bony cap is intramembranous and derived from the ectodermal wall. During development, the bony cap may be a separate structure that will fuse to the endochondral distal phalanx in the adult, as it ossifies well before the distal phalanges across taxa. Our study describes and revives the identity of the bony cap, and we identify it in three mammalian species: humans, cats, and horses (Homo sapiens, Felis catus domestica, and Equus caballus). During the embryonic period, we show the bony cap has a thimble-like shape that surrounds the proximal endochondral distal phalanx. The bony cap may thus play an inductive role in the differentiation of the corresponding nail, claw, or hoof (keratin structures) of the digit. When it is not present or develops erroneously, the corresponding keratin structures are affected, and regeneration is inhibited. By terming the bony cap, we hope to inspire more attention to its distinct identity and role in regeneration.

Unique Considerations for Paediatric Proximal Phalanx Fractures

Paediatric hand fracture care presents unique considerations and challenges. The proximal phalanx is the most injured location. This review details pearls for the examination of the injured paediatric hand, immobilisation considerations and treatment strategies. Over-treatment can lead to unnecessary stiffness, missed activities, increased healthcare costs or unnecessary surgical morbidity. Undertreatment can promote malunion and dysfunction. Fracture patterns discussed include those of the phalangeal head, neck, shaft and base. The concepts covered will help optimise the evaluation and treatment of children with injured proximal phalanges. Level of Evidence: Level V (Therapeutic).

Temporal trends in the management of metacarpal and phalangeal fractures in the 21st century: an analysis of Australian population-based data

BACKGROUND

Fractures of the hand, specifically the metacarpals and phalanges, are a common injury. Whilst many of these fractures can be treated non-operatively, a number of advances have led to the increase in popularity of surgical intervention. The aim of this study was to assess and describe trends in management of phalangeal and metacarpal fractures in Australia over the last two decades.

METHODS

A review was conducted of the Medicare Benefits Scheme (MBS), specifically querying the item numbers pertaining to the management of metacarpal and phalanx fractures. Data was recorded as the incidence per 100 000 patients.

RESULTS

Overall, there was a statistically significant decrease in the incidence of closed reduction of metacarpal and phalanx fractures, with a converse statistically significant increase in open reduction internal fixation.

CONCLUSION

This study demonstrates that over the last 20 years, there has been a decrease in closed reduction of intra- and extra-articular phalangeal and metacarpal fractures, with a converse but smaller increase in open reduction and fixation. These trends are likely multi-factorial in aetiology, and should be monitored to guide resource allocation and health provision in the future.

Dedifferentiated chondrosarcoma of the middle finger arising from a solitary enchondroma: A case report

BACKGROUND

Dedifferentiated chondrosarcoma (DDCS) accounts for 10% of all chondrosarcomas and has the poorest outcome, with a 5-year survival rate of 7%-25%. DDCS commonly occurs in the femur and pelvis, whereas DDCS of the finger is extremely rare. Furthermore, the histological findings of preexisting solitary enchondroma samples are important and valuable for diagnosing malignant transformations.

CASE SUMMARY

We report our experience with DDCS in the proximal phalanx of the left middle finger of an 87-year-old woman. She had undergone surgery for enchondroma, with curettage and artificial bone grafting, 11 years ago, in the same location. Several years after the primary surgery, the left middle finger gradually started to enlarge, and the growth speed increased in the past year. Plain radiographs showed an expansive osteolytic lesion with calcifications and residual grafting material. Owing to the suspicion of malignancy, we performed ray amputation. Histological findings revealed an abrupt transition between the low-grade chondrosarcoma and dedifferentiated sarcoma components. The dedifferentiated components showed the features of a high-grade undifferentiated pleomorphic sarcoma. The patient was diagnosed with DDCS arising from a preexisting enchondroma. She had no local recurrence or distant metastasis and died of pneumonia 6 years and 10 months after the second surgery.

CONCLUSION

The histological findings of a precursor lesion showed a typical enchondroma, suggesting that DDCS can arise from enchondroma.

Concurrent Ring Finger Middle Phalanx Fracture and Jersey Finger in a Rugby Player

Avulsions of the flexor digitorum profundus (FDP) tendon and phalanx fractures are both common injuries for rugby players, but these concurrent injuries in the same finger have not been previously described. This case describes a 20-year-old female rugby player who sustained a right ring finger comminuted, mildly displaced middle phalanx fracture. The patient was evaluated by a hand surgeon 3 weeks after the injury, and non-operative management with a splint was elected. One week later, upon further examination, the patient demonstrated persistent inability to flex the distal interphalangeal joint (DIPJ) of the ring finger. Ultrasound was inconclusive but an MRI demonstrated avulsion of the FDP tendon from the distal phalanx, consistent with a jersey finger injury. The patient subsequently underwent open repair of the FDP tendon. This case illustrates the importance of careful physical exam and index of suspicion for coexisting injuries.

The Burden of Fingertip Trauma on the US Military

Fingertip injuries in the military are common and often hinder the fighting force and support personnel. Injuries range from small subungual hematomas to proximal finger amputations. Treatment modalities are dictated by injury patterns, anatomic considerations, and the need to return to duty. Nail bed injuries should be repaired when possible and exposed bone or tendon is treated with appropriate soft tissue coverage. If soft tissue coverage is unobtainable, revision amputation should be performed with attention given to maintaining as much finger length as possible. Antibiotics may not be required, however they are often utilized in the deployed setting.

Osteochondroma of the proximal phalanx of toe presenting as widening of third web space- a rare case report

Osteochondromas are the most common benign bone tumors, which usually affect the metaphyseal region of long bones. Foot is an unusual location for these tumors with phalanges being a much rare site. Only a few case reports have been made of phalangeal osteochondromas. A patient with proximal phalangeal osteochondroma of third toe, presenting clinically as widening of the third web space, is described. A simple extraperiosteal excision of the tumor was done which resolved his forefoot deformity. At five years followup the patient had no recurrence or symptoms.

Management of hand fractures

Hand fractures are the most common fractures of the upper extremity, with a reported incidence of 3.7 per 1000 per year for men and 1.3 per 1000 per year for women. Understanding the diagnosis and management of these injuries is vital for any clinician working in the emergency department, plastic or orthopaedic surgery or providing community care. This review identifies the most common presentations and outlines how to assess and manage such fractures appropriately, with an emphasis on clinical and radiographic examination. The majority of hand fractures are managed conservatively and operative management should be carefully considered on a case-by-case basis with analysis of patient and fracture-related factors, in order to achieve optimal hand function following treatment.

Reconstruction of hand in aggressive benign bone tumors by mini JESS fixator

We present two cases of young females with aggressive benign bone tumors of the bone (Enchondroma and Giant Cell Tumor). Giant cell tumors and Enchondromas in hand are commonly found benign tumors, which may be locally aggressive. The primary treatment of these lesions is surgical. The two reported cases were treated successfully by extended curettage, bone grafting, and spanning JESS fixator. There was no recurrence in either case at one year follow-up and good hand function and complete healing of the lesion.

The Emergent Evaluation and Treatment of Hand and Wrist Injuries: An Update

Injury patterns of the hand and wrist can be complex and challenging for the emergency physician to diagnose and treat. The ability of the hand to perform delicate maneuvers requires a very intricate interplay of bones, ligaments, and tendons. Unfortunately, due to the omnipresence of the hand, the hand and wrist are commonly injured. These injuries can be debilitating if not treated correctly and can be both time-consuming and fraught with medicolegal risk. This article provides the necessary knowledge to diagnose and treat common hand and wrist injuries encountered in the emergency department.

A trial on artificial neural networks in predicting sex through bone length measurements on the first and fifth phalanges and metatarsals

BACKGROUND

Predicting sex is an important problem in forensic medicine. The femur, patella, mandible and calcaneus bones are frequently used in predicting sex. In our study, we aimed to use the artificial neural network (ANN) technique to predict sex by measuring the values of the phalanges of the first and fifth toes and the first and fifth metatarsal bones.

METHOD

All bone measurements were conducted on the direct X-ray images of 176 males and 178 females in the age range of 24-60 years. The multilayer perceptron classifier (MLPC) input layer included parameters on the bone length measurements of phalanx proximalis I, phalanx distalis I, metatarsal I, phalanx proximalis V, phalanx medialis V, phalanx distalis V and metatarsal V. The output layer contained two neurons to define the male and female sexes. The present study used an MLPC model that had two hidden layers, and the first and second hidden layers contained 14 and 7 nodes, respectively.

RESULTS

The model had an overall accuracy (Acc) of 0.95, specificity (Spe) of 0.97, sensitivity (Sen) of 0.95 and Matthews correlation coefficient (Mcc) of 0.92. While the sex prediction success of our proposed model was higher in women, the results were more specific in men and more sensitive in women (Acc^Male = 0.93, Acc^Female = 0.98, Sen^Male = 0.93, Spe^Male = 0.98, Sen^Female = 0.98 and Spe^Female = 0.93).

CONCLUSIONS

This study demonstrated that the ANN model for length measurements on small bones is a highly effective instrument for sex prediction.

The difference of subcutaneous digital nerve block method efficacy according to injection location

INTRODUCTION

Finger injuries are commonly attended to in the emergency department, and digital nerve block is a frequently performed procedure for such injuries. This study compared the efficacy levels of the subcutaneous method according to the different injection sites.

METHOD

This was a simulation study for medical students who rendered medical service at the emergency department. One group performed subcutaneous injection of lidocaine at the volar side of the metacarpophalangeal (MCP) joint, while another group injected at the volar side of the proximal interphalangeal (PIP) joint. The time to anesthesia was measured at 30-s intervals. Pain at the injection site was measured using the numeric rating scale (NRS), while the length from the fingertip to the injection site and the circumference of the injection site were measured.

RESULTS

A total of 82 participants were included, with 41 under the MCP joint group and the rest under the PIP joint group. The mean length from the fingertip to the needling point was 3.62 ± 0.63 cm in the PIP joint group and 5.90 ± 0.65 cm in the MCP joint group, while the mean circumference of the needling point was 4.93 ± 0.51 and 5.61 ± 0.58 cm, and the mean time to anesthesia was 2.55 ± 1.11 and 3.79 ± 1.28 min (p-value < 0.001), respectively. The median value of NRS was 4 in both groups (p-value = 0.921). Length was correlated with the time to anesthesia (p-value = 0.018).

CONCLUSION

Injection into the PIP joint showed the same anesthetic effect as injection into the MCP joint, but this effect occurred faster in the former.

Discrimination threshold for haptic volume perception of fingers and phalanges

Humans exhibit a remarkable ability to discriminate variations in object volume based on natural haptic perception. The discrimination thresholds for the haptic volume perception of the whole hand are well known, but the discrimination thresholds for haptic volume perception of fingers and phalanges are still unknown. In the present study, two psychophysical experiments were performed to investigate haptic volume perception in various fingers and phalanges. The configurations of both experiments were completely dependent on haptic volume perception from the fingers and phalanges. The participants were asked to blindly discriminate the volume variation of regular solid objects in a random order by using the distal phalanx, medial phalanx, and proximal phalanx of their index finger, middle finger, ring finger, and little finger. The discrimination threshold of haptic volume perception gradually decreases from the little finger to the index finger as well as from the proximal phalanx to the distal phalanx. Overall, both the shape of the target and the part of the finger in contact with the target significantly influence the precision of haptic perception of volume. This substantial data set provides detailed and compelling perspectives on the haptic system, including for discrimination of the spatial size of objects and for performing more general perceptual processes.

Comparison of low-profile plate-screw and Kirschner-wire osteosynthesis outcomes in extra-articular unstable proximal phalangeal fractures

BACKGROUND

We aimed to present the radiological and clinical results of Kirschner-wire (K-wire) fixation and low-profile plate-screw fixation applied to unstable proximal phalangeal fractures without extension to the joint.

METHODS

Clinical and radiological data of 22 patients who underwent fixation with open reduction and low-profile 1.5-mm titanium mini plate and unlocked screws and 18 patients who underwent fixation with K-wire due to closed, unstable extra-articular proximal phalangeal fractures were retrospectively examined. All evaluation and statistical analyses were based on sixth postoperative month evaluation parameters. Active and passive metacarpophalangeal joint and interphalangeal joint range of motions, total joint range of motion, measurement of grip strength for fractured and healthy hands, visual analog scoring, disabilities of the arm, shoulder, and hand scores, measurement of distance between the pulpa and palmar curve in the operated finger, Belsky score, reoperation, and complications were evaluated.

RESULTS

Radiological union was achieved in all patients in a mean duration of 4.2 (3-6) weeks. When the functional results of the patients were evaluated, the mean active metacarpophalangeal joint flexion was 87.3° (75°-90°), mean proximal interphalangeal joint flexion was 94.3° (65°-100°), mean distal interphalangeal joint flexion was 77.6° (75°-80°), and mean total range of motion was 259° (210°-270°). The grip strength of the fractured hand was 52.7 (40-58) kgW, whereas that of the healthy hand was 54.4 (42-60) kgW. The mean value of visual analog score was 0.8 (0-2), mean score for disabilities of the arm, shoulder, and hand was 7 (2-27), and mean distance between the finger pulpa and finger curve was 3 (0-8) mm.

CONCLUSION

Plate-screw osteosynthesis in the extra-articular, unstable fractures of the proximal phalanx, which is "small" compared with the body but has a "major function" for the hand and upper extremity, allows for rigid fixation, short immobilization, and early motion in spiral/oblique-fragmented fractures. K-wire fixation, an alternative treatment modality, applied to selected fracture patterns with appropriate indications can achieve good-excellent results radiologically and functionally.

The prevalence and ossification pattern of the biphalangeal and triphalangeal lateral toes

Purpose

Biphalangealism of the toes is an exclusively human phenomenon. The aim of this study was to evaluate the development of the lateral toes in childhood by following the ossification pattern of the phalanges.

Methods

Foot radiographs of 913 adults have been evaluated for biphalangealism of 3rd to 5th toe. The pediatric group, aged 6–15 years of age, was assessed for the number of ossification centers in the foot.

Results

In adults, the mean prevalence of biphalangealism in the 5th toe was 41.39%, in the 4th toe was 2.15%, and in the 3rd toe was 0.48%. In children, 45% feet had four ossification centers in the 5th toe. The epiphysis center of the middle and distal phalanx was missing. In the 4th toe, four centers were present in of 2.47% of cases. Those values are similar to the prevalence of the biphalangeal toes in adult population. The remaining toes had 5 or 6 ossification centers. In the 5-center toe, the epiphysis of the middle phalanx was missing.

Conclusion

A missing distal phalanx epiphyseal ossification center is considered indicative of a biphalangeal toe, and the toes with 5 or 6 ossification centers are indicative of triphalangeal toes. The reason for such evolution of the lateral toes is still debated, but the differences in anatomy most likely have no impact on foot function.

Common occurrence of Sharpey's fibres in amphibian phalanges

Sharpey’s fibres are known mainly as providing anchorage between tooth and the periodontal ligament but they occur also in other types of bones. In the postcranial skeleton these fibres are usually present at the muscle or tendon attachment sites. They were reported in all major groups of extant vertebrates, as well as in putative lissamphibian ancestors—temnospondyls and lepospondyls. However, it was recently stated that their presence was very rarely described in extant amphibians. In limbs, they were reported predominantly from proximal bones. They have not yet been reported from phalanges, which are the most commonly sectioned amphibian bones. Here, we describe phalangeal histology of nine species representing most major clades of lissamphibians. These results show that Sharpey’s fibres occur commonly in lissamphibian phalanges. In shaft, they are radially oriented and occur in the periosteal bone, at sites of tendon attachment. They can also occur in the metaphysis and contact the cartilage. This may provide a basis for foot muscle reconstructions in fossil amphibians.

[MODIFIED INTRAMEDULLARY FIXATION WITH TWO Kirschner WIRES FOR EXTRA-ARTICULAR FRACTURE OF PROXIMAL PHALANGEAL BASE]

OBJECTIVE

To evaluate the effectiveness of the modified intramedullary fixation with two Kirschner wires for extra-articular fracture of the proximal phalangeal base.

METHODS

Between June 2012 and November 2015, 18 cases (18 fingers) of fresh extra-articular fracture of the proximal phalangeal base were treated, including 16 males and 2 females with an average age of 31 years (range, 21-57 years). The causes included strike injury in 10 cases, fall injury in 4 cases, mechanical injury in 1 case, twist injury in 1 case, crush injury in 1 case, and cutting injury in 1 case. The injured fingers were little finger in 16 cases, ring finger in 1 case, and index finger in 1 case. Of the 18 cases, 17 had closed fractures and 1 had open fracture. X-ray film showed transverse fracture in 14 cases and transverse-oblique fracture in 4 cases. The time between injury and operation was 3 hours to 4 days (mean, 2 days). After anatomical reduction, two Kirschner wires were used for intramedullary fixation. Functional exercises were done at 2 days after operation. The Kirschner wires were removed at 4 weeks after operation.

RESULTS

All the wounds healed by first intention. There were no deformation, loosening or breakage of Kirschner wires, and pin tract infection. Postoperative X-ray films showed anatomical reduction of fracture in all cases; no re-displacement happened, and clinical healing was obtained at 4 weeks; bony union was obtained at 8 weeks. All patients were followed up 6-12 months with an average of 8 months. There was no pain in the metacarpophalangeal joint; the range of motion was (88.1±2.3)° at 3 months after operation, showing no significant difference when compared with normal side [(88.8±2.6)°] (t=1.73, P=0.10). The finger flexion and extension were normal; according to the criteria of total active motion of finger, the results were excellent in all cases.

CONCLUSIONS

The technique of modified intramedullary fixation with two Kirschner wires for extra-articular fractures of the proximal phalangeal base has the merits of convenient operation, little injury, reliable fixation,and excellent effectiveness. This technique is conducive to the recovery of hand function due to the early functional exercises.

Extensive Periosteal Chondroma in the Middle Phalanx with Pathological Fracture Reconstructed with Strut Bone Grafting

We report of a pathological fracture of the middle phalanx of the little finger due to periosteal chondroma. The periosteal chondroma occupied an extensive area of the middle phalanx extending to the proximal interphalangeal joint, and the fracture involved the distal interphalangeal articular surface. The fracture was internally fixed using a strut bone grafting after resection of the chondroma. One year and four months after the operation, remodeling of the phalanx had completed without recurrence and functional loss.

Quantitative 3-dimensional CT analyses of fractures of the middle phalanx base

BACKGROUND

Quantitative 3-dimensional computed tomography (3DCT) analyses can provide a more detailed understanding of fracture morphology. For fracture-dislocation of the proximal interphalangeal joint, the extent of fragmentation of the volar lip of the middle phalanx-a factor that might influence treatment-is not always apparent from radiographs. We hypothesized that there is no correlation between number of fracture fragments and the percentage of articular surface area involved in intra-articular fractures of the base of the middle phalanx using quantitative 3DCT analyses.

METHODS

We used 13 computed tomography scans with a slice thickness of 1.25 mm or less to create 3-dimensional models of 15 intra-articular fractures of the base of the middle phalanx in 13 patients. We resized 3-dimensional models of a non-fractured middle phalanx of the same hand to fit the fractured middle phalanx in order to approximate the size and shape of the fractured middle phalanx in its pre-injury state. We created a heatmap to demonstrate the location of the fractured articular surface.

RESULTS

With the number of scans available, we did not find a significant correlation between the percentage of articular surface area involved and the number of fracture fragments. The median percentage of articular surface area involved was 46 % (range, 21-90 %). The heatmap demonstrated that the radio-volar side of the articular surface seems to be more involved than the ulnar-volar side in intra-articular fractures of the base of the middle phalanx.

CONCLUSION

Quantitative 3DCT analysis of fracture fragments provides useful information that could facilitate surgery and analysis of complex fractures of the base of the middle phalanx.

LEVEL OF EVIDENCE

IV, Basic Science Study, Anatomic Study, Imaging.

In-out-in pinning for phalangeal fractures

Although a commonly used technique, percutaneous pinning of phalangeal fractures is tricky because of the difficulties associated with getting the correction pin orientation when entering the medullary canal of one fragment from the outer cortex of the other fragment. This has led us to develop the "in-out-in" pinning technique. The principle consists of entering the medullary canal of one of the fragments directly from the fracture site. The pin is inserted and drilled outward through the outer cortex. The second pin is inserted in the same manner. The fragments are then aligned and the pins pushed forward in the medullary canal of the other fragment.

Surgical exposures of the hand

Surgical approaches to the hand are commonly executed in the treatment of fractures, ligament injuries, and less commonly in the resection of bony tumors. Careful design and execution of these surgical approaches translates into superior functional and aesthetic outcomes. We have provided a thorough review of commonly used approaches to the hand by evaluating each of these approaches in the context of core principles including safety, versatility, preservation of stability, and aesthetic outcomes.

Radiotherapy for a phalanx bone metastasis of a lung adenocarcinoma

Phalanx bone metastasis as the initial presenting sign of lung cancer is a rare presentation. Lung cancer is known to metastasize to the bone, but rarely to the fingers. A 61-year-old male smoker presented with pain in the left ring finger. Severe pain discouraged the patient from using his left hand. An X-ray of the left hand showed a lytic bone lesion. The patient was treated with finger radiotherapy. Analgesics were no longer needed and the patient was able to reuse his left hand in his everyday life. Palliative radiotherapy relieved our patient and improved his quality of life.

Pseudomyogenic (Epithelioid sarcoma-like) hemangioendothelioma with bone invasion

AIM

Pseudomyogenic (epithelioid sarcoma-like) hemangioendothelioma is a rare local aggressive vascular tumor. Herein we present a 54-year-old male patient with a tumor on his index finger.

CASE

The patient presented with a 1-year history of pain and swelling that progressively exacerbated. Bone invasion was observed on the middle phalanx via direct radiography. Histopathological examination findings were compatible with epithelioid sarcoma-like hemangioendothelioma.

CONCLUSION

To the best of our knowledge is the first case report of epithelioid sarcoma-like hemangioendothelioma with bone invasion.

Iodophilic synchronous phalangeal and choroidal metastasis from follicular thyroid carcinoma: a case report and review

BACKGROUND

Follicular thyroid cancers constitute 15-20% of all thyroid tumors. The usual mode of dissemination is via the hematogenous route. The most common sites of distant metastasis are to the lungs and bones.

OBJECTIVE

A case is presented to demonstrate the unusual presentation of follicular cancer with synchronous digital (distal phalanx of the little finger) and choroidal metastasis that was responsive to radioiodine treatment.

CASE REPORT

A 54-year-old female presented with swelling over the terminal part of the left little finger with thyromegaly. Investigations revealed metastasis from follicular thyroid cancer to the little finger along with pulmonary metastases. She underwent total thyroidectomy with central compartment clearance followed by (131)I therapy. Subsequent follow-up demonstrated complete regression of the digital metastasis and partial regression of the choroidal metastasis which was evaluated after the radioiodine scan that picked up the choroidal metastasis.

CONCLUSION

Follicular thyroid cancers can rarely spread to unusual sites like the digits and choroid. This report highlights the synchronous presentation of digital and choroidal metastasis which responded to (131)I therapy.

Simultaneous Dorsal Base Fracture and FDP Avulsion of Distal Phalanx of the Little Finger

Avulsion injury of the flexor digitorum profundus (FDP) with concomitant fracture of the distal phalanx dorsal base is uncommon. Simultaneous avulsion fractures of the insertion of this tendon associated with rupture of the tendon from the bony fragment and combination with dorsal base fracture is very rare and also complicated. A 36- year- old man fell and injured his right little finger. FDP avulsion with simultaneous dorsal base fracture (containing extensor Tendon insertion) was detected. Our surgical repair by a single midlateral incision the avulsed fragment was replaced on the palmar base of the distal phalanx and successfully immobilized with 1.5 mm screw. After three months, patient had 20 degrees range of motion in the DIP joint. The digit was pain free and also relatively functional. It seems that FDP avulsion classification need to be extended and include this uncommon type as described in this case report for better management of these uncommon type.

Extra-articular fractures of the digital metacarpals and phalanges of the long fingers

Metacarpal and phalangeal fractures of the long fingers are the result of trauma occurring under extremely varied circumstances. As a consequence, the clinical presentation varies greatly, with every bone and joint potentially being involved. Each step of their treatment is crucial, although the benign appearance of these injuries can lead to steps being missed: diagnostic phase with clinical examination and radiographs; therapeutic phase where the most suitable treatment is chosen, which combines mobilization of the digital chains as soon as possible and in every patient; follow-up phase with regular monitoring to detect any complications, especially secondary displacement, and verify that good progress is being made during rehabilitation. The goal of any fracture treatment is to preserve or restore the anatomy, with the emphasis here being on the stability and mobility of the digital chains. The potential progression towards serious functional sequelae (pain, instability or stiffness in hand) and the resulting significant socio-economic repercussions must be at the forefront of a surgeon's mind early on during the initial care of any finger or hand trauma.

Minimally invasive finger fracture management: wide-awake closed reduction, K-wire fixation, and early protected movement

We prefer wide-awake finger fracture reduction, closed percutaneous K-wire fixation, and early protected movement to treat phalangeal fractures. This approach allows intraoperative visualization of active movement after K-wire fixation with the possibility of adjustments during the case. It also negates the need for extensive dissection with subsequent scar formation between the tendons and the bone. It provides the same advantages that are provided by early protected movement after flexor tendon repair.

The palmar metric: A novel radiographic assessment of the equine distal phalanx

Digital radiographs are often used to subjectively assess the equine digit. Recently, quantitative and objective radiographic measurements have been reported that give new insight into the form and function of the equine digit. We investigated a radio-dense curvilinear profile along the distal phalanx on lateral radiographs we term the Palmar Curve (PC) that we believe provides a measurement of the concavity of the distal phalanx of the horse. A second quantitative measurement, the Palmar Metric (PM) was defined as the percent area under the PC. We correlated the PM and age from 544 radiographs of the distal phalanx from the left and right front feet of various breed horses of known age, and 278 radiographs of the front feet of Quarter Horses. The PM was negatively correlated with age and decreased at a rate of 0.28 % per year for horses of various breeds and 0.33 % per year for Quarter Horses. Therefore, veterinarians should be aware of age related change in the concave, parietal solar aspect of the distal phalanx in the horse.

Treatment of phalangeal fractures

Treatment of phalangeal fractures depends on the characteristics of the fracture, condition of the soft tissue envelope, associated injuries, patient functional requirements, and surgeon familiarity and comfort with various techniques. Most phalangeal fractures can be treated successfully with nonoperative means. Surgery is considered to treat unstable injuries, articular incongruity, concomitant soft tissue damage, or other situations in which restoration of anatomy and preservation of function are achieved only via operative stabilization. Careful soft tissue handling and early mobilization are premises on which surgical phalangeal fracture treatment is based.

[Intramedullary fixation of displaced middle phalangeal neck fractures]

Middle phalanx neck fracture is an unusual injury. In order to prevent malunion and stiffness, a surgical treatment is usually recommended. Owing to the distal localization of the fracture, internal fixation is demanding. Open reduction can further damage the soft tissues and the bone itself, resulting in stiffness or condylar necrosis. The bulk of plate and screws can interfere with the extensor apparatus and transarticular or cross K-wires may damage the joint surfaces or ligaments. An intramedullary pinning technique is reported minimizing these pitfalls. The technique is described and illustrated by two clinical cases with good result.

[Pseudo-tumor digital tuberculosis: A case report and review of the literature]

We report a case of a 66-year-old woman, who was treated for a circumferential tumefaction of the middle phalanx of the third finger, evolving for one year. The excision-biopsy of the phalanx led to the diagnosis of an osseous tuberculosis. Through this exceptional case, the authors made a review of the literature on the clinical, radiological and evolutionary aspects of the digital osseous tuberculosis.

Prosthetic hemi-arthroplasty for post-traumatic articular cartilage loss in the proximal interphalangeal joint

This article discusses the indications, contra-indications, and technique for proximal interphalangeal joint prosthetic hemi-arthroplasty in the setting of sub-acute or chronic post-traumatic articular cartilage loss. Two case examples are provided: one for replacement of the head of the proximal phalanx, the other for replacement of the base of the middle phalanx.This procedure serves as a recently available alternative to fusion, silicone total joint replacement, total joint arthroplasty with unlinked surface replacements, volar plate arthroplasty, hemi-condylar osteochondral autograft reconstruction, or free vascularized joint transfer.

Giant cell reparative granuloma of the proximal phalanx: A case report and literature review

The present article is a case report of a 16-year-old boy who presented with a benign bony tumour, which on histological analysis suggested giant cell reparative granuloma (GCRG), but was not corroborate by blood tests. The implications of this type of tumour and the correct diagnostic requirements were investigated. The correct identification of GCRG from other giant cell-containing tumours is important because the treatment modalities for these tumours significantly differ from one another. In most cases, histological findings are sufficient to identify the tumours. In most GCRG cases, curettage is usually a curative treatment option. However, due to high recurrence rates of GCRGs, close follow-up of these patients is warranted. Also, due to osteoclastic activity of the giant cells in GCRGs, the use of drugs such as calcitonin or bisphosphonates, which inhibit osteoclast differentiation and activation, may have an important influence on future treatments or in reducing the recurrence rate of these tumours.

Osteoid osteoma of the thumb: a case report

Osteoid osteoma is a rare occurrence in the hand, and only a small percentage affects the thumb and distal phalanges. An 18-year-old right-hand-dominant man presented to our office with an approximately 1-year history of left thumb pain without any history of trauma. He had seen several doctors previously and undergone multiple diagnostic tests with no definitive diagnosis. Plain radiographs and computed tomography at our institution were consistent with the diagnosis of osteoid osteoma. The patient was treated with surgical excision of the lesion without bone grafting. The diagnosis of osteoid osteoma was confirmed by pathology. At 6 months follow-up, the patient showed complete resolution of pain and full restoration of hand function. This case demonstrates that osteoid osteoma should not be forgotten as a differential diagnosis in patients with finger pain, especially in individuals who have not yet or just recently have reached skeletal maturity.