Finger Web Space Research Articles

Classic Timothy Syndrome Associated With Bilateral Border Digit Syndactyly: A Case Series

Timothy syndrome (TS) is characterized by congenital long-QT arrhythmia and limb syndactyly. Patients who undergo syndactyly repair with undiagnosed TS may have their abnormal cardiac electrical activity unmasked during surgery. The purpose of this study was to detail the extremity phenotype seen in patients with TS, which may help hand surgeons in their preoperative assessment. This was a retrospective review of all patients with TS seen at our institution from 1998 to 2022. Descriptive statistics regarding their demographics, medical and surgical histories, and syndactyly phenotypes were obtained. Seven patients (5 males and 2 females) with TS were seen at our institution for multidisciplinary evaluation (median age at presentation was 23 months). Six patients had finger syndactyly and 5 had toe syndactyly. One patient did not have any extremity syndactyly and was noted to have a specific TS mutation known to lack musculoskeletal abnormalities. All patients with finger syndactyly had border digit involvement, with 5 out of 6 patients displaying syndactyly of the middle-ring and ring-little finger web spaces. Toe syndactyly was more heterogeneous, with 1 patient lacking any lower extremity syndactyly and others having variable involvement of the second-third, third-fourth, and fourth-little toe web spaces. Complexity ranged from simple to complete. Four patients had intraoperative cardiac events leading to TS diagnoses after surgery. Bilateral border digit hand syndactyly, with or without bilateral toe syndactyly, should raise concerns for TS and prompt further investigation into potential cardiac disease to avoid perioperative cardiac morbidity and mortality. Therapeutic V.

Separation of congenital embryonic syndactylies in children: dorsal or volar flap? About a comparative retrospective series.

Congenital syndactylies account for 1 to 2 out of 2000 birth defects. Although several types of syndactylies exist, we only studied embryonic syndactylies. The goal of our study was to compare 2 types of coverage flap for the reconstruction of the finger web spaces: a volar flap described by Blauth and a dorsal flap described by Gilbert. Between 1993 and 2015, children affected by simple and complex syndactylies (partial or complete) were treated in 2 french pediatric hospitals and were selected for our analytic, comparative, retrospective review. The 2 hospitals used different surgical techniques: one used a volar flap described by Blauth and the other a dorsal flap described by Gilbert. The children were followed up to look for signs according to the stages of the Classification of Withey and to evaluate a global result according to the score of Withey. Our secondary criteria of judgement were the aspect of the surgical scar according to the VSS (Vancouver Scar Scale) and the satisfaction of the parents and children. The age of the children, need for a surgical revision and time of last follow- up were also studied. We found statistically significant differences between group I (volar flap) and group II (dorsal flap) in favor of the volar flap: higher scores of Withey (even when the number of commissures was increasing) and better VSS (regardless of the number of web spaces treated). There was no statistically significant difference between the 2 groups in terms of age, follow-up, or rate of surgical revision. All in all, the volar flap presented less sequelae in terms of scar retraction. Regardless of the flap used, the cosmetic results of the full-thickness skin graft used impacted the result both on the receiving site (dyschromia, hairiness) and the donor site.

Control of Scabies in a Boarding School Using 5% Permethrin Applied on Lesion Only

Scabies is one of the most neglected tropical skin diseases in Indonesia. It is usually found in overcrowded communities with poor hygiene. The gold standard for scabies treatment is the whole-body topical application of 5% permethrin cream. However, the treatment causes inconvenience and stickiness for a prolonged period. The modification of topical treatment by applying only to the lesion yielded results similar with whole-body topical application. We consider using this mode of treatment to control the disease in a boarding school. The study was conducted from June to August 2019. All students were examined by dermatologists, and individuals who were diagnosed with scabies were treated using 5% permethrin for 12 h before wash-off (week 0) applied on the lesion only and reapplied a week after. The evaluation was conducted on weeks 4 and 8 by observing scabies lesions. Local health cadres were also trained, and environmental interventions were also performed. A total of 75 participants were analyzed. Most lesions were found on predilection sites such as finger web spaces of the left (57.3%) and right (58.7%) hands, gluteal region (60%), and penis (40%). The cure rate (CR) was 83%–100% of the lesions in week 4, which increased to 95%–100% in week 8. The CR on week 8 compared with baseline was 94.7% (p < 0.001). A total of 23 cadres were trained, and from post-test, 84% of the cadres showed good knowledge of scabies management. This novel application of 5% permethrin cream on the lesion only is an effective alternative to the conventional whole-body topical application.

The body distribution of scabies skin lesions

AbstractBackgroundThe clinical diagnosis of scabies relies on the assessment of signs and symptoms and an improved understanding of the distribution of skin lesions may lead to improved diagnostic performance.ObjectivesTo investigate the detailed body distribution of scabies lesions and to explore the accuracy of simplified, focused examination approaches.MethodsWe did a prospective, cross‐sectional study in the Western Province of Solomon Islands (2019). Consenting individuals of all ages were eligible. The entire skin surface was examined, and the presence and number of typical scabies lesions were recorded at 98 topographic body sites, corresponding to 5 regions and 16 subregions. We compared the distribution at sites, regions and subregions overall, and by age and sex. We also calculated the expected sensitivity of examination of limited body areas. Choropleth maps were generated to provide detailed descriptions of the distribution of lesions.ResultsA total of 467 individuals were enrolled (median age: 9 years [range: 0–86]; female: 54.6%) of whom 269 (57.6%) participants had typical scabies lesions. The most common sites for scabies lesions were the dorsal fingers (65.7% of participants with scabies lesions), dorsal finger web spaces (62.1%) and dorsal hands (61.7%). Of those less than 2 years old with scabies, eight (30.8%) had lesions at the head and neck region compared to 10.8% of those aged 2–5. Genital lesions were more common in males than females (27.3% vs. 7%, relative risk 3.9, 95% confidence interval: 1.2–2.1). Simplified, focused examinations were estimated have very high sensitivity (hands and wrists only: 93.3%; exposed arms and legs: 99.3%) compared to whole‐body examinations.ConclusionWe report highly detailed descriptions of the body distribution of scabies lesions, including differences by age and sex. These data are valuable for training and diagnosis and support the use of simplified, focused examinations for scabies mapping.

Enlarging painful tumor on finger webspace

Enlarging painful tumor on finger webspace

MRSA colonization in health care professionals with varying degrees of exposure to the hospital environment and its susceptibility to mupirocin in a tertiary care centre

Methicillin-resistant (MRSA) is one of the major causes of healthcare associated infections with significant morbidity and mortality. Health care workers act as a carrier in spread of MRSA in hospitals. Use of Mupirocin to eradicate the carrier state is the need of the hour.: This study was undertaken to assess the prevalence of MRSA colonization among health care workers with varying degree of exposure to hospital environment and to know the susceptibility of Mupirocin to MRSA. : Swabs were collected from anterior nares and finger web spaces of 100 health care workers (HCWs). The specimens were processed and colonies of were identified by standard methods. The strains of MRSA were identified by using Cefoxitin (30µg) disk on Muller Hinton agar. The MRSA isolates were then tested for Mupirocin susceptibility.In the present study, 100 nasal and inter digital spaces swabs yielded 15 and 10 MRSA strains respectively. Among the 100 HCWs screened, the majority of MRSA colonization was seen in HCWs with a history of exposure to hospital environment for around 5-10 years or more. All 30 with 15 MRSA strains isolated was sensitive to both 5µg and 200µg Mupirocin disc by Kirby-Bauer disc diffusion method.The high rate of Nasal MRSA carriage among health care workers is alarming. HCWs with long duration of exposure to hospital environment were more colonized with MRSA. More awareness and training sessions on the importance of MRSA and hand hygiene measures to be implemented to prevent MRSA transmission from HCWs to vulnerable patients. We suggest that MRSA screening should be performed for all HCWs and detection of susceptibility of Mupirocin will result in appropriate use of this antibiotic in decolonization.

Evaluation of hot and cold sensation of hand in type 2 diabetic patients in age group of 40-80 years

Introduction: The aim of the study is to find out the effect of Type 2 diabetes (T2DM) on the hot and cold sensation of hand. Material and Method: Total100 subjects in the age group of 40-80 year, both male and female were included in this study. Subjects were divided into 2 groups. Group A: 50 subjects diagnosed type 2 diabetic mellitus. Group B: 50 normal healthy subjects investigated and diagnosed Non-diabetic mellitus. Before the start of the procedure, detailed neuro-musculoskeletal evaluation was done to meet inclusion and exclusion criteria and those who were ready to be part of the study, the written informed consent was obtained from them. Rolyan hot and cold discrimination kit was used to examine hot and cold sensation of both handsat pulp of index finger, little finger and dorsal web space. Result: There was loss of hot & cold sensation in 10% subjects of T2DM group at index and little finger bilaterally and all these subjects have the duration of diabetes >15yr. Conclusion: loss of sensation may lead to injuries of diabetic hands. Hand care should be thought to the patients to prevent injuries to the hand. Keywords: Type 2 diabetes, Hot and cold sensation, Diabetic hand.

Pitted keratolysis - a study of various clinical manifestations.

Pitted keratolysis (PK) is a common bacterial infection of skin characterized by noninflammatory superficial pits. Very few studies have focused on variations in clinical manifestations of PK. We conducted this study so that diagnosis of this treatable condition is not missed when it presents in an uncommonly perceived way. Assessment of PK patients for various sites and morphologies. A total of 30 patients with PK were assessed for various sites and morphologies. Bacterial and fungal cultures along with histopathology were performed. Of 30 patients, 24 were females. Hyperhidrosis and malodour were the most common symptoms. Interdigital interface skin of the toes was the first site affected in most patients. Plantar skin was affected in all patients with involvement of interface skin of the toes in 29 patients. Other sites affected were palms, finger web spaces, nonglabrous skin, paronychium, and nail. Other than classical pits, scaly crusted inflammatory lesions with post-inflammatory hyperpigmentation (PIH) were noted. Associated keratoderma was also reported in some patients. The presence of hyperhidrosis, malodour, and plantar lesions is consistent with previous studies. Interface skin between toes as the first site affected, involvement of toe web spaces, and associated keratoderma have been reported rarely. However, female preponderance, involvement of finger web spaces, nonglabrous skin, paronychium, nail changes, the presence of inflammation with crusting, and PIH have never been reported previously. PK can involve web spaces, nonglabrous skin, and paronychium, and can cause nail changes. The lesions can be inflammatory with crusting and PIH.

Indications and Predictors for Reconstructive Surgery After Hand Burns

The objective of this study was to analyze the prevalence, indications, and type of reconstructive surgery and predictors of the outcomes of reconstructive surgery after hand burns. A retrospective cohort study was conducted that included all patients admitted with acute hand burns in the Dutch burn centers from January 1998 through December 2002. The details of reconstruction including frequency, timing, indication, and techniques were collected over a 10-year follow-up period. Hand burns were seen in 42% (n= 562 of 1,334) of all patients admitted with acute burns. Reconstructive surgery during the 10-year follow-up period was required in 15%. Contractures, especially of the first web space and little finger, were the most frequent indications for reconstructive surgery. Web spaces 1 to 3 and the little finger were the location most frequently operated on. The most frequently performed surgical technique was release of the contractures and the use of a random flap. Eighty percent of the reconstructive surgery patients required more than 1 reconstructive procedure, most often within 2 years of the initial injury. Secondary operations at the same location were required in 12%. In 40% of the patients, the first reconstructive surgery was performed within the first postburn year. Significant independent factors related to the need for reconstructive hand surgery were a larger area of full-thickness burns and surgical treatment of the hand during the acute phase. Reconstructive surgery was required in 15% of patients who sustained hand burns. The majority of the patients requiring reconstructive surgery of the hand needed 2 or more operations to correct the contractures of the hand. Contractures of the little finger and first web space were the locations most frequently operated on. Patients with more extensive burns and who required hand surgery during the acute phase were more likely to need reconstructive surgery. Prognostic IV.

Classic porokeratosis of Mibelli.

A 47-year-old homemaker presented with recurrent ulcer over left palm and mildly painful fingertip swelling over left thumb and middle finger for past 1 year. She had noticed ring like skin lesion over her left palm since childhood. There was no family history of similar skin lesion. On examination, multiple annular plaques with central atrophy and keratotic ridge at the margin were seen over left side of face, lips, neck, upper back, abdomen, left forearm and left palm. Over the palm, the keratotic ridge ran over thenar and hypothenar eminence, base of fingers, first finger web space and along the thumb and middle finger causing constriction band with bulbous swelling distally at finger tips [Figure 1]; and nails of the two fingers were dystrophic at the sites adjoining the ridges [Figure ​[Figure2a2a-​-c].c]. Annular plaque with keratotic ridge was seen over the left eyelid margins, left side of lower lip involving the mucosal surfaces of lip and lower eyelid and right side buccal mucosa. However, she did not have any discomfort in the oral cavity or eye. There was fissuring at the site of ridge over thenar eminence of left palm [Figure 1]. On dermoscopy, the ridge of the annular plaques was prominently seen along with a thin groove in the keratotic ridge [Figure 2d]. Radiography of the affected hand revealed distal digital narrowing in the left thumb [Figure 2e]. Histopathology from the ridge showed keratin-filled epidermal invaginations [Figure 3]. There was no evidence of malignancy from the biopsy taken from the fissure or the bulbous projection. Patient was started on acitretin and planned for CO2 laser ablation of the lesions. Figure 1 Plaque with central atrophy and threadlike keratotic ridge at the margin over the palm, first finger web space, along the thumb and middle finger causing constriction band with bulbous swelling distally at finger tips Figure 2 (a and b) dystrophic nails of the thumb and middle finger with adjoining keratotic ridges, (c) keratotic ridge at adjoining sites of thumb and index finger, (d) its dermoscopic image showing the groove in the keratotic ridge and (e) radiographic image ... Figure 3 Keratin-filled epidermal invagination with rising parakeratotic column (H and E ×40) and inset showing higher magnification of keratin filled epidermal invaginations with irregularly arranged keratinocytes with pyknotic nuclei (H and E ×200) ...

Supra-valvular aortic stenosis in a patient with homozygous familial hypercholesterolaemia

An 18-year-old female was referred for a cardiac murmur before surgical excision of large subcutaneous swellings over bi-lateral trochanteric areas ( Panel A ). On evaluation they were found to be tendon-xanthomas, that also involved the gluteal-folds, finger web-spaces ( Panel B ), and tendons of the foot. Corneal arcus was also noted ( Panel C ). Her total cholesterol of 696 mg% and low-density lipoprotein (LDL) cholesterol of 648 mg% were consistent with familial …

Web reconstruction with dorsal metacarpal rhombus advancement flap in the treatment of syndactyly

Objective To report the clinical outcomes of reconstructing the web with dorsal metacarpal rhombus advancement flap in the treatment of syndactyly. Methods Five children with syndactyly were operated. After the digits were divided, a dorsal rhombus flap was designed between the metacarpal heads and advanced to reconstruct the web space. The following aspects were evaluated during postoperaive follow-up:finger function, web space and appearance, and patients' satisfaction. Results The area of flaps ranged from 1.5 cm× 0.6 cm to 2.0 cm× 0.9 cm. All the flaps healed primarily without flap congestion and marginal necrosis. The patients were follow-up for 6 to 12 months with an average of 8.5 months. Finger flexion and extension was good. The contour of the web was satisfactory with appropriate width and depth. The patients' parents were satisfied with both finger function and web appearance. Conclusion Dorsal metacarpal rhombus advancement flap is a reliable flap with easy dissection and good texture for web reconstruction in syndactyly surgery. Key words: Hand deformities,congenital; Syndactyly; Surgical flaps

Application of dorsal pentagonal flap for reconstruction of the web space in congenital syndactyly

To investigate the therapeutic effect of dorsal pentagonal flap for reconstruction of the web space in congenital syndactyly. From October 2007 to August 2009, 10 patients with congenital syndactyly were treated with dorsal pentagonal flap for web space reconstruction. During the follow-up period, the patients underwent finger functional assessment and web space appearance examination. The satisfactory rate of patients was also investigated. 10 patients with 17 reconstructed web spaces were followed up for 4-25 months (median, 15 months). Normal passive flexion and extension of fingers were achieved with good cosmetic result at web space. The abduction angle of fingers ranged from 30 degrees to 45 degrees. No web creep occurred and no secondary procedures were required. All the parents of the patients were satisfied with the results. Web space reconstruction with dorsal pentagonal flap is easily performed with reliable blood supply and low re-operated rate. The cosmetic and functional result is satisfactory.

Pilonidal sinus of the penis

Pilonidal sinus is a well recognised chronic inflammatory condition which commonly affects the natal cleft and finger web space. Pilonidal sinus of the penis is a rare clinical entity; few cases have been reported previously. The treatment strategy is almost the same as treating any pilonidal sinus and involves total excision of the sinus. Our diagnosis was established on the histopathological findings rather than a clinical-based diagnosis, Follow-up is advisable since the recurrence rate is high. Our case report is one of few cases reported on pilonidal sinus all over the world. Our patient had total excision of the sinus with complete recovery.

Reverse thenar perforator flap for volar hand reconstruction

The glabrous skin of the palm provides the best colour and texture match for reconstructing volar hand defects, but only a limited number of local axial pattern flaps of the palm have been described in the literature. This report describes a new reverse thenar perforator flap harvested from the midpalm and the thenar region. A total of 12 patients with volar hand defects of the index finger, palm, or first web space were reconstructed with this flap between August 2005 and August 2007. The causes of the defects were trauma (one patient), burn contracture release of the first web and index finger (four patients), and Dupuytren contracture release (seven patients). The flap was supplied from one or two of the perforating branches of the terminal branch of the superficial palmar arch or the superficial palmar branch of the radial artery. Flap sizes ranged from 1.5 x 3.0 cm to 2.5 x 6.5 cm. The donor sites were repaired primarily in all patients. There were no major postoperative problems: 11 flaps out of 12 survived completely with just one partial loss. Excellent functional and cosmetic results were observed during a mean follow up of 12.6 months. The reverse thenar perforator flap offers glabrous skin for defects of the palm, first web and index finger. Donor scarring of the flap is minimal and it is suitable for the 'replacement with similar tissue' concept.

Pedicled and Free Radial Forearm Flaps for Reconstruction of the Elbow, Wrist, and Hand

A single surgeon's experience with 67 pedicled and free radial forearm flaps for reconstruction of the elbow, wrist, and hand was analyzed retrospectively. Fifty-seven pedicled (43 reverse and 14 antegrade flow) and 10 free radial forearm flaps were performed in 66 patients, including seven fascial flaps and one osteocutaneous flap. Indications involved soft-tissue coverage of the elbow (n = 11), dorsal wrist and hand (n = 24), palmar wrist and hand (n = 12), and thumb amputations (n = 5); after release of thumb-index finger web space contractures (n = 6) and radioulnar synostosis (n = 2); before toe-to-thumb transfers (n = 3); for reconstruction following tumor excision (n = 13); and for wrapping of the median, ulnar, and radial nerves for traction neuritis (n = 5). Primary healing of the soft-tissue defect of the elbow, wrist, and hand was successful in 95 percent of patients. There was one flap dehiscence, partial loss of two reverse radial forearm flaps, and complete loss of one free radial forearm flap. Eleven donor sites were closed primarily and 56 were covered with a split-thickness skin graft. No patients complained specifically of cold intolerance of the hand or dysesthesias in the superficial radial nerve or lateral antebrachial nerve distribution. This is the largest reported series of radial forearm flaps for reconstruction of the upper extremity. The authors believe the antegrade pedicled radial forearm flap is the optimal flap for coverage of defects around the elbow, and the reverse radial forearm flap is the optimal choice for coverage of moderate-sized defects of the wrist and hand.

Focal Fibronodular Heterotopic Ossification

Progressive extraskeletal ossification is the defining feature of a group of very rare genetic syndromes, including fibrodysplasia ossificans progressiva and progressive osseous heteroplasia. Recent advances in human molecular genetics have enabled the molecular characterization of disease-causing mutations for some of these conditions1,2. Despite our increasing understanding of the biochemical etiology of heterotopic ossification syndromes and newly applicable molecular genetic screening tools, individual patients with progressive heterotopic ossification still pose a difficult diagnostic challenge. We report the case of a female patient with a four-decade history of recurrent, progressive heterotopic ossification limited to the right hemicorporeum. This condition, which does not meet the clinical or molecular diagnostic criteria of any known syndrome, represents a new syndrome of heterotopic ossification, which we have named focal fibronodular heterotopic ossification. Our patient was informed that data concerning the case would be submitted for publication. A sixty-three-year-old right-hand-dominant woman presented to our institution for evaluation and treatment of a complex deformity of the right upper extremity. Distinctive features of the deformity at the time of presentation included multiple firm nodular soft-tissue masses located on the dorsal and volar surfaces of the right hand and wrist, involving the thumb, index finger, and long fingers. The patient had severe contractures of the index finger and first web space in areas of particularly large and dense nodule formation; small skin ulcerations that appeared to be chronic and infected were seen in these areas and at the volar base of the first metacarpal (Figs. 1-A, 1-B, and 2). The patient had a concomitant dense sensory and motor neuropathy of the median nerve of the right hand. Full physical examination revealed other areas of hard, nodular swelling, specifically in the patient's right shoulder, right upper arm, right lateral forefoot, and right iliac crest. Notably, the …

The Reverse Radial Forearm Flap for Soft Tissue Reconstruction of the Wrist and Hand

Soft tissue defects of the upper extremity must be carefully assessed to determine the most appropriate method of coverage. Direct closure and local flaps represent the most basic techniques on the reconstructive ladder; however, they are inadequate for large or complex defects. Split thickness skin grafts are appropriate for granulating wounds with a bed of vascularized tissue; however, if there is an exposed joint or bone devoid of periosteum or tendon devoid of paratenon, there will be insufficient neovascularization, and the graft will inevitably fail. The reconstructive hand surgeon must then pursue more complicated techniques for wound coverage based upon knowledge of the available pedicled and free flaps. The reverse radial forearm flap potentially offers thin, mobile skin with similar characteristics to the skin over the dorsum of the hand. This flap is more versatile than the groin flap and probably more reliable than the posterior interosseous artery flap for coverage of moderate-sized defects of the dorsal or palmar wrist and hand and is specifically indicated for coverage of degloving injuries of the dorsal wrist and hand, after release of thumb-index finger web space, and for coverage of amputations of the thumb in preparation for toe-to-thumb transfer.

Clinical application of the reversed pedicled venous flap containing perivenous areolar tissue and/or nerve in the hand

A reversed pedicled venous flap containing perivenous areolar tissue and/or nerve was used to cover traumatic skin defects of seven fingers in six patients. The series consisted of six men, ranging in age from 20 to 57 years (average: 39 years). The reconstructed sites were four dorsal skin defects and three volar skin defects of the finger. The flap was designed on the dorsum of the hand, in such a way as to place a vein at the centre of the flap and not to involve the dorsal metacarpal artery. The flap contained a dorsal vein, perivenous areolar tissue and fascia of the interosseous muscle. Cutaneous nerves were present in three of the seven flaps. The pedicle of the flap was dissected distally to the finger web space and the flap was transferred to the skin defect. The size of the flap ranged from 1.4x4.5 cm to 6.0x7.0 cm. The average length of the pedicle was 1.6 cm. Skin grafting was needed at the donor site in one case (flap size: 6.0x7.0 cm), but primary closure was possible in the remaining cases. Postoperatively, the largest flap showed superficial necrosis, although it survived. The remaining flaps survived completely. This suggests that in a large flap the skin should be attached to the pedicle to prevent congestion. The flap can be elevated without reference to the dorsal metacarpal artery at the ulnar side of the dorsum of the hand. The flap is an effective option to reconstruct skin defects of the finger, especially the little finger.

Innervation density of the base of the palm.

Cutaneous nerves of the palm were localized and quantitated by longitudinal axis, proximity to the distal palmar crease, and tissue layer to identify an incision that would avoid injury to the palmar branches of cutaneous nerves. Cadaveric palms (n = 10) harvested en bloc were fixed at physiologic tension and prepared using the celloidin method and hematoxylin-eosin staining. The cutaneous nerves of the palm were counted and classified by their size and location within each tissue layer and longitudinal axis as well as by proximal, middle, and distal locations within each axis. The mean number of large nerves identified within regions of the palm differed by tissue layer and longitudinal axis but not by longitudinal location within axes. The long/ring finger web space was characterized by the lowest innervation density; the index/long finger web space and ring finger axis were characterized by the greatest innervation density. An incision in the long/ring finger web space 2 cm proximal to Kaplan's cardinal line should result in injury to fewer nerves and reduce the incidence of painful neuromas during open carpal tunnel release.