Fourth Web Space Research Articles

Anatomic Relationship of Hand Intrinsic Tendons at the Metacarpal Head as It Relates to the Diagnosis of Saddle Syndrome: A Cadaveric Study

The purpose of this cadaveric study was to investigate the intrinsic anatomy surrounding the metacarpal head and the relationship between the interosseous-lumbrical junction (ILJ) and transverse metacarpal ligament (TML) as it pertains to saddle deformity-posttraumatic adhesions at the ILJ that cause impingement during intrinsic activation. Ten fresh frozen cadaveric arms underwent dissections, identifying the intrinsic musculature within the second through fourth webspaces. The TML and ILJ, or "true tendon," were identified. A separate area of nontendinous fibrous tissue identified proximal to the ILJ was referred to as "pseudotendon." Measurements were made within each webspace to identify distances between these structures in full finger extension and intrinsic plus position to assess for changes during simulated motion. The true tendon to TML distance progressively decreased toward the ulnar digits. In the intrinsic plus position, the pseudotendon to TML distance was 0 mm at all webspaces for each specimen. When moving from neutral to intrinsic plus, the true tendon to TML distance decreased the most in the third and fourth webspaces compared with the second, consistent with the trend toward a smaller ILJ to TML gap in the ulnar digits. There is a fibrous pseudotendinous region proximal to the ILJ that abuts the TML in the intrinsic plus position, which may cause impingement when inflamed in the setting of saddle syndrome. Furthermore, a decreased ILJ to TML gap in the ulnar digits may be related to an increased predilection for saddle deformity in those areas. These results suggest that there is a fibrous region present proximal to the ILJ that may be implicated in the pathology of saddle deformity. Furthermore, decreased distances found between the ILJ and TML invivo may be an explanation for increased occurrence of saddle syndrome in the third and fourth webspaces in clinical practice.

Oblique Axis Hypothenar Free Flaps: Tips for Harvesting Larger Flaps with Minimal Donor Site Morbidity

Background Hypothenar free flaps (HTFFs) have been widely used for reconstructing palmar defects. Although previous anatomical and clinical studies of HTFF have been conducted, this technique still has some limitations. In this study, we describe some tips for large flap design that allows for easy harvesting of HTFFs with minimal donor site morbidity. Methods A total of 14 HTFF for hand defect reconstruction were recorded. The oblique flap was designed in the proximal HT area following relaxed skin tension line along the axis between fourth web space and 10 mm ulnar side of pisiform. A flap pedicle includes one or two perforators with ulnar digital artery and HT branch of basilic vein. In addition, innervated HTFF can be harvested with a branch of ulnar digital nerve. Electronic medical records were reviewed to obtain data on patients' information, operative details, and follow-up period. In addition, surgical outcome score was obtained from the patient, up to 10 points, at the last follow-up. Results Mean harvest time was 46 minutes, and two perforators were included in 10 cases. The mean flap area was 10.84 cm 2 . There were no problems such as donor site depression, scar contracture, keloids, wound dehiscence, numbness or neuroma pain at donor sites, and hypersensitivity or cold intolerance at flap site, either functionally or aesthetically. Conclusion Palmar defect reconstruction is challenging for hand surgeons. However, large HTFF can be harvested without complications using the oblique axis HTFF technique. We believe our surgical tips increase utility of HTFF for palmar defect reconstruction.

Subcutaneous extraskeletal osteosarcoma of the foot: A case report

Extraskeletal osteosarcoma (ESOS) is a rare variant of osteosarcoma which occurs exclusively in the soft tissue without any bone involvement. Subcutaneous ESOS, in particular, is very rare and is seen in <10% of cases. Here, we report a case of a subcutaneous tumor in the fourth web space of the left foot in a 73-year-old man. The diagnosis of ESOS was made on histology and by immunohistochemical reactivity to special AT-rich sequence-binding protein 2 (SATB2), which is a sensitive, nuclear marker of osteoblastic differentiation. We present this case because of its rarity and the use of SATB2 immunohistochemistry to confirm the diagnosis.

Use of photoacoustic imaging to determine the effects of aging on lower extremity lymphatic vessel function

ObjectiveAging is one of the causes of primary lymphedema. However, the effects of aging on the lymphatic system are still not completely understood. We investigated the effects of aging on the lymphatic vessels in the lower extremities of healthy volunteers using photoacoustic imaging. MethodsHealthy volunteers who underwent photoacoustic lymphangiography between March 2018 and January 2019 were enrolled. To visualize lymphatics, indocyanine green (ICG, 5.0 mg/mL) was injected subcutaneously into the first and fourth web spaces of the foot and under the lateral malleolus. Subsequently, near-infrared fluorescence lymphography was performed to confirm good ICG flow, and photoacoustic lymphangiography was performed on the medial side of the lower leg. Ti sapphire laser irradiation at 797 and 835 nm, the optimal wavelengths for visualizing ICG and blood, was applied. The number of lymphatic vessels shown at areas 10 cm (L10) and 20 cm (L20) cranially from the internal malleolus was counted. ResultsNineteen healthy volunteers (4 males and 15 females) were enrolled in the study. Their mean age was 42.9 ± 12.8 years. One volunteer was bilaterally imaged; 15 left lower limbs and 5 right lower limbs were imaged. The number of lymphatic vessels visualized increased with age. There were strong positive correlations between age and L10 (R = 0.729, P < .001) and between age and L20 (R = 0.570, P = .009). ConclusionsPhotoacoustic imaging indicates that the number of lymphatic vessels increases with age. Lymphatic stasis resulted in visualization of not only normal drainage pathways but also nonfunctional lymphatic pathways.

Surgical Outcomes and Predictive Factors of Medial Toe Excision for Polysyndactyly of the Fifth Toe.

We aimed to report surgical outcomes and analyze prognostic factors of medial toe excision for polysyndactyly of the fifth toe. We reviewed the details of 139 consecutive patients who underwent surgery for postaxial polydactyly of the foot from 2009 to 2018. Among these, 83 patients (90 feet) with polysyndactyly of the fifth toe, treated by medial toe excision (between the duplicated toes) and reconstruction of the fourth web space using a dorsal rectangular flap, were included. The toe alignment and stability were restored by chondroplasty and soft tissue balancing without an osteotomy. A full-thickness skin graft was performed in 52 feet. The mean age at surgery was 27.1 ± 17.5 months and the mean duration of follow-up was 42.8 ± 24.9 months. At the last follow-up, a relatively small size of the reconstructed toe was observed in 19 feet (19/90, 21.1%). Proximal duplication level (metatarsal or proximal phalanx type) and preoperative hypoplasia of the remaining toe were related to the small postoperative size. Valgus deformity of the remaining toe was observed in 2 feet (2/90, 2.2%). We observed 17 cases with delayed healing or early postoperative wound infection. Among these, 7 cases (7/90, 7.8%) showed postoperative thickening or advancement of the web, which was not observed in cases without wound problems. No cases had functional disturbance or pain. The overall surgical outcomes were satisfactory without an osteotomy. Patients with a proximal duplication level or preoperative hypoplasia of the remaining toe should be informed of its possible small size postoperatively. Level IV, retrospective case series.

Successful recovery of sensation loss in upper brachial plexus injuries.

Injuries of the upper trunk of the brachial plexus may trigger motor and sensory deficits. There exists a growing body of literature with respect to the reconstruction of motor deficits in upper trunk brachial plexus injuries by using nerve transfers; albeit to date, very few old reports have focused on the reconstruction of sensory loss resulting from upper trunk injuries. In this case series, we review six cases (five males and one female) with upper trunk brachial plexus injuries undergoing sensory nerve transfers. Sensory reconstruction was carried out by using transfer of the ulnar to the median nerves, innervating adjacent aspects of the little and ring fingers (the fourth web space) and adjacent aspects of the thumb and the index finger (the first web space), respectively. The mean age of our six patients was 30.5 ± 9years old (range 20-45). The mean time interval between the injury and subsequent surgery was 6.6 ± 1.8months (range 5-10). Five patients achieved S3 or S3+ in both the thumb and the index finger while the sixth one regained S2+ in the index finger while also achieving S3 in the thumb according to the Highet-Zachary system scoring scale. These results suggest that nerve transfers can achieve satisfactory outcomes in patients having sensory reconstruction after upper brachial plexus injuries, and thus, we lay emphasis on reviving the use of sensory nerve transfer techniques in such patients.

Variations in the origins and absence of the common digital arteries of the hand: a cadaveric study.

We studied anomalies of the common digital arteries by dissecting 33 fresh cadaver hands under magnification. In the majority of the dissected hands (25 hands), common digital arteries took off from the superficial palmar arch and ran superficial and parallel to the flexor tendons. Variations were found in eight out of 33 hands. In four hands the common digital artery to the second web space was replaced by an atypical vessel, originating from the deep palmar arch, that crossed posterior to the index flexor tendons proximal to the A1 pulley. In eight hands, the common digital artery to the fourth web space was replaced by an atypical deeper vessel, originating from the superficial palmar arch and crossing posterior to the little finger flexors. No nerve anomalies were identified. Unrecognized, these atypical arteries to the second and/or fourth web spaces could lead to vascular complications during surgery, especially pollicization.

Hand burns surface area: A rule of thumb

IntroductionRapid estimation of acute hand burns is important for communication, standardisation of assessment, rehabilitation and research. Use of an individual’s own thumbprint area as a fraction of their total hand surface area was evaluated to assess potential utility in hand burn evaluation. Materials and methodsTen health professionals used an ink-covered dominant thumb pulp to cover the surfaces of their own non-dominant hand using the contralateral thumb. Thumbprints were assessed on the web spaces, sides of digits and dorsum and palm beyond the distal wrist crease. Hand surface area was estimated using the Banerjee and Sen method, and thumbprint ellipse area calculated to assess correlation. ResultsMean estimated total hand surface area was 390.0cm2±SD 51.5 (328.3–469.0), mean thumbprint ellipse area was 5.5cm2±SD 1.3 (3.7–8.4), and mean estimated print number was 73.5±SD 11.0 (range 53.1–87.8, 95% CI 6.8). The mean observed number of thumbprints on one hand was 80.1±SD 5.9 (range 70.0–88.0, 95% CI 3.7), χ2=0.009.The combined mean of digital prints was 42, comprising a mean of two prints each on volar, dorsal, radial and ulnar digit surfaces, except volar middle and ring (3 prints each). Palmar prints were 15 (11–19), dorsal 15 (11–19), ulnar palm border 3, first web space 2, and second, third and fourth web spaces one each.Using the surface of the palm alone, excluding digits, as 0.5% of total body surface area, the area of one thumbprint was approximated as 1/30th of 1%. ConclusionsWe have demonstrated how thumbprint area serves as a simple method for evaluating hand burn surface area.

The Cutaneous Branch of the Deep Ulnar Artery

Aim: Hypothenar vascular anatomy has been approached by several authors due to its importance in flap design. The aim of this research is to describe the vascular anatomy of the proximal hypothenar eminence (HE), focusing on a cutaneous branch (CB) of the deep ulnar artery and its possible applications to flap designs. Materials and Methods: Fourteen fresh-frozen hands were studied. Red latex solution was injected previous to dissection. Gross dissection was performed under 3× to 6× magnification. The HE was approached through a longitudinal incision at the fourth web space line reaching the proximal wrist crease. A CB of the deep ulnar artery was identified. Its anatomic variations and relationship to the ulnar nerve were registered as well as its anatomic territory. A theoretical flap was designed and transposed to the volar aspect of the wrist and the interthenar region. Results: A constant CB was identified in the sample. Its origin was at the anteromedial aspect of the deep ulnar artery on the first segment of the artery. At this point, the deep ulnar artery passed over the ulnar nerve and the ulnar digital nerve of the fifth finger in 9 of 14 cases. In the remaining 5 cases, the deep ulnar artery passed behind the nerve; in 4 of these cases, the CB passed behind the nerve as well. In 1 case, the deep ulnar artery passed behind the ulnar nerve, but the CB passed over it. The deep ulnar artery origin was located at a mean of 9 mm distal to the pisiform (range, 3-12 mm). The CB origin was identified at a mean of 3 mm distal to the deep ulnar artery (range, 1-6 mm). The CB irrigated the supra-aponeurotic aspect of the proximal half of the HE by 3 to 5 collateral branches. The arterial diameter at its origin was 0.4 mm average and the distance between the origin and the first collateral branch was 9 mm average. This study shows that it is feasible to harvest a hypothenar cutaneous flap based on the CB. This flap may measure up to 7 × 3 cm. We also showed that it could be rotated as a propeller flap to cover a volar interthenar and wrist skin loss or a resected fibrosis. The donor area could be close by first intention. Conclusion: A constant CB from the deep ulnar artery was identified. This artery supplies the proximal half of the HE and features connections proximally and distally. In spite of the anatomic variations of the deep ulnar artery, in almost all of the cases the CB passed anterior to the ulnar nerve. According to the results of this research, a flap based on this CB may be raised to cover the volar wrist and palm in case of recalcitrant carpal tunnel and other deficits of coverage tissue.

An Assessment of 2 Objective Measurements of Web Space Position

To describe 2 simple objective clinical methods of measuring the web position between fingers and to determine their intra-observer and inter-observer reliabilities. Two observers examined the second, third, and fourth web spaces on both hands of 30 adult healthy volunteers. The web index measured the web height as a relative ratio to constant anatomical landmarks on both fingers subtending the web. The dorsal web index took reference from the distance between the metacarpophalangeal and proximal interphalangeal joints, whereas the palmar web index was measured in relation to the distance between the most proximal basal digital and proximal interphalangeal joint creases. The intraclass correlation coefficient was used to determine intra-observer and inter-observer reliability. Intraclass correlation coefficient values for intra-observer and inter-observer reliability were greater than 0.80, indicating excellent agreement. There was no statistically significant difference between the dorsal or palmar measurement methods in terms of reliability. The dorsal or palmar measurement method may be reliably used in healthy adults to establish a web index that describes the web position. The palmar method is considered easier to perform. Diagnostic III.

Plantar verrucous carcinoma masquerading as toe web intertrigo

A 77-year-old man presented with a 6-month history of intractable toe web intertrigo located in the third and fourth web spaces of his left foot. Biopsy and histological examination confirmed the presence of a verrucous carcinoma. Verrucous carcinoma of the foot has been called epithelioma cuniculatum, a case arising in the intertriginous area of the foot is presented.

The Correction of Postburn Contractures of the Second Through Fourth Web Spaces

The release of postburn contractures in the hand is one of the most commonly performed procedures in burn injuries. Contractures of the web space may involve palmar, dorsal, or both sides of the web skin and require various surgical techniques. In this report we provide general guidelines for the release of these contractures, with special emphasis on reconstruction of the second through fourth web spaces.

Intraneural hemangioma of digital nerve diagnosed with MR imaging

Hemangioma may occur at any location. Although the imaging findings of hemangioma are well known, it may be difficult to differentiate this entity from other soft-tissue tumors. Intraneural hemangiomas are extremely rare. We present a girl with a painful swelling in the fourth web space of her right hand. Since it was painful, the referring clinician considered the possibility of a glomus tumor. However, demonstration of dilated feeding or draining vessels suggested the diagnosis of hemangioma. At surgery a hemangioma of the ulnar digital nerve of the ring finger was resected marginally.

The anatomy of the dorsal cutaneous branch of the ulnar nerve – a safe zone for positioning of the 6R portal in wrist arthroscopy

The dorsal branch of the ulnar nerve passes close to the 6 Radial portal used in wrist arthroscopy. We examined 20 cadaveric limbs to establish the course of this nerve. We found it consistently crossed a line between the ulnar styloid and the fourth web space at an average of 2.4 cm from the ulnar styloid (range 1.8-2.8 cm). This represented 23% (+/- 2.5 STD range 19-27%) of the distance from the styloid process to the fourth web space. Recommendations are made to help avoid iatrogenic injury to the nerve during arthroscopy. The literature on the anatomy of this nerve and its variations and the clinical relevance of this knowledge are discussed.

Algorithm for Treatment of Apert Hand

The hand in Apert syndrome is one of the most complex examples of congenital deformity of the upper limb. The management is difficult, and mny different approaches have been published. The hands demonstrate many disturbances of soft tissue and bony structures. These include a short thumb with radial clinodactyly, complex syndactyly with a bony fusion involving the index, long and ring fingers, and symphalangism and simple syndactyly of the fourth web space. The soft tissue anomalies involve the intrinsic muscles, the extrinsic tendon insertions, and the neurovascular bundles. Correction of the appearance of the operated hand is readily apparent, but the complexity of the disorders in the bones and soft tissues explains the difficulty of the surgical management. The aim of this study is to propose a better surgical management: on the basis of the experience of our multidisciplinary team (188 procedures in 53 patients) in the light of recent publications and a better comprehension of the syndrome, we attempt to reduce the number of procedures and to select the best possible procedures for each patient. When possible, we perform a 3-step procedure (the first is bilateral, the others are unilateral) between 9 months and 2 years of age. Separation of the fingers improves function even though we must expect an inevitable stiffness in extension of the interphalangeal joints.

Anatomic correction of polysyndactyly of the fifth toe fused with the fourth toe

A new surgical technique for correction of polysyndactyly with the fifth toe fused with the fourth toe was devised. The technique consists of the creation of a dorsal rectangular flap on the dorsum of the syndactyly web for the new fourth web, making a medially based plantar rectangular flap on the plantar surface of the fifth toe, and a sixth toe-tip-based rectangular hinge flap to reconstruct the lateral side of the fourth toe and medial side of the new fifth toe, respectively. All suture lines are intended to be located in the transition of the plantar and dorsal surfaces of the web and digit. This technique is characterised by accurate anatomic reconstruction, which produces better aesthetic results with no wasting of any skin components.

Bacterial skin contamination and bacterial recolonization, after surgical preparation, in foot operations and prevalence of postoperative early wound infection: a prospective study

Effective presurgical preparation is an important step in limiting surgical wound contamination and prevention of surgical site infection. The purpose of this study is to evaluate bacterial skin contamination after surgical skin preparation in foot surgery prior to surgery and at the end of surgery, in order to determine if current techniques are satisfactory in eliminating harmful pathogens, and to compare the results of the cultures obtained pre- and postoperatively with infection rate. Twenty consecutive patients scheduled for hallux valgus procedures were studied. Each lower extremity was prepared in the regular method with a two-step technique, septal scrub (chlorhexidine gluconate 4%) followed by a alcohol chlorhexidine antiseptic solution. After preparation and draping, cultures were obtained at three locations: the hallux nailfold, first, second, third and fourth web spaces, and the anterior ankle (control). Prior to surgery, positive cultures were obtained from 80% of hallux nailfolds and 5% of web spaces. At the end of surgery, positive cultures were obtained from 80% of hallux nailfolds and 25% of web spaces. None of the control sites had positive culture. Five percent of all cases developed postoperative infection. Based on the findings of the current study, presurgical skin preparation with a two-step septal scrub (chlorhexidine gluconate 4%) followed by a alcohol chlorhexidine antiseptic solution is not sufficient in eliminating pathogens in foot and ankle surgery. No statistical correlation was found between the results of the cultures obtained pre- or postoperatively with postoperative infection rate. The unique environment of the foot and its resident organisms probably plays a role in the higher infection rates associated with surgery of the foot. Better methods of preparing the surgical site should be searched for.

A New Skin Flap Design for the Repair of Proximal Phalanx Base Defects in Flexion Contractures of Adjacent Fingers

A random-pattern cutaneous flap with its base at the highly vascularized dorsal web space has been designed to decrease donor site deformity and to increase securely flap mobilization in contractures involving more than 1 adjacent proximal phalanx base. Rectangular flaps facing each other on the lateral sides of adjacent fingers have been raised on a single pedicle in the second, third, or fourth web space. The anatomic integrity of the web space was maintained and exposure of the metacarpophalangeal joints was avoided. Flap donor sites were reconstructed with full-thickness skin grafts. Since September 2000, 22 flaps were raised during a single-stage operation in 13 patients with an average age of 11 years at the time of surgery, and a total of 38 fingers have been reconstructed. The follow-up period averaged 24 months. The postoperative course was uneventful for all patients; all the flaps survived and the donor sites healed without complications. This flap, with its wide arc of rotation and minimal donor site morbidity, is easy to perform and is a good alternative in the reconstruction of multiple proximal phalanx base region flexion contractures of adjacent second, third, fourth, or fifth fingers.

The septa of Legueu and Juvara: an anatomic study

Purpose To study the anatomy of the septa of Legueu and Juvara and interpalmar plate ligaments (IPPLs) of the hand. Materials Eleven cadaver hands were dissected. The number, attachments, dimensions, and relationships of the septa and IPPLs to other structures were determined. Results Eight septa were identified radial and ulnar for each digit. The radial were longer than the ulnar septa. The septa attached to the transverse ligament of the palmar aponeurosis superficially and to the soft-tissue confluence deeper and distally. They formed 7 compartments of 2 types flexor septal canals that contained the flexor tendons and web space canals that contained common digital nerves and arteries and lumbrical muscles. Grossly and histologically the septa were thicker and consisted of organized collagen distally but not proximally. Three IPPLs were identified: radial, central, and ulnar. These formed the floors of the second, third, and fourth web space canals. The IPPLs were more substantial, thicker, and had more fibrous appearance from radial to ulnar. The fibers of the radial and central IPPLs were oriented transversely, whereas those of the ulnar IPPL were oriented obliquely. Conclusions Awareness of the anatomy of deep retinacular structures of the hand is important for surgical exposure in this area and possible involvement in conditions such as Dupuytren’s disease.

Surgical management of the hand in Apert syndrome.

In patients with Apert syndrome, the hands demonstrate many disturbances of soft tissue and bony structures. These include a short thumb with radial clinodactyly, complex syndactyly with a bony fusion involving the index, long and ring fingers, symphalangism and simple syndactyly of the fourth web space. The soft tissue anomalies involve the intrinsic muscles, the extrinsic tendon insertions and the neurovascular bundles. We have reviewed 52 patients who underwent surgical reconstruction of their hands. The aim of this study is to propose a better surgical management in the light of recent publications and to improve our understanding of the syndrome, attempting to reduce the number of procedures and to select the best possible procedures for each patient.