Hand Surgery Research Articles

Hand infections : when to consult a hand surgeon ?

The hand is an anatomical site frequently affected by infection due to its central role in all daily activities. It is therefore regularly the site of wounds (contused, penetrating, insect stings, bites, etc.), all of which are potential entry points for infections. Recognition by the general practitioner of the red flags requiring an urgent specialist consultation is therefore essential in order to improve the patient's functional prognosis, determined by the initial management. In this article, we focus on the most frequent situations encountered in primary care.

Infections and Patient Satisfaction in WALANT Hand Surgery in a Hospital Procedure Room.

Background: Wide-awake hand surgery has allowed many hand procedures to be moved out of the operating room and into minor procedure rooms while increasing efficiency, maintaining safety, and reducing both patient and hospital costs. The goal of this study was to evaluate patient satisfaction and postoperative complications of wide-awake local anesthesia with no tourniquet procedures performed in a community-based hospital procedure room. Methods: A total of 786 patients underwent 948 elective hand procedures in a hospital procedure room. At the conclusion of their surgeries, the patients were surveyed regarding their satisfaction. Following surgery, patients were evaluated for postoperative complications including infections. The trend in postoperative infection rates across 8 age groups was analyzed using a Cochran-Armitage test in R. Results: The overall infection rate was 6.2% (n = 59). All infections were superficial. Carpal tunnel had the highest number of infections (n = 25), followed by trigger finger (n = 8), and the combination trigger finger with carpal tunnel (n = 7). All infections were managed with antibiotics and/or soaks. Three patients did require a return to the operating room for irrigation and debridement. Ninety-nine percent of patients said the procedure room experience was better or the same as going to the dentist, would recommend wide-awake anesthesia to a friend or family member, and would undergo the procedure again. Conclusion: Wide-awake procedures performed in a hospital procedure room have low infection rates with high patient satisfaction.

Removal of soft tissue foreign bodies in the hand under microscopy: a retrospective observational study

Purpose: Numerous studies have focused on techniques for detecting foreign bodies in soft tissue in the hand, but removal remains a subject of interest. In this study, we describe the microscope-assisted removal of foreign bodies in the hand. Methods: We reviewed records of patients treated for foreign bodies in the hand at our department from July 2013 to May 2023. In 16 patients aged 23 to 55 years, the following variables were analyzed: the cause of trauma; the time interval from trauma to surgery; the location, type, size, and number of foreign bodies; patient complaints; imaging technique; and procedure type. Under local anesthesia, a slit incision was made at the suspected site. Foreign bodies were completely removed using micro-instruments under microscopic guidance. Results: Stab injuries were the most common (n=13), and there was one case each of abrasion, traffic accident, and bee sting. The middle finger (n=5) was the most affected, followed by the thumb (n=4), index (n=3), little finger (n=2), ring finger (n=1), and palm (n=1). Foreign bodies included glass (n=6), wood (n=4), seashell (n=2), fish bone, a pencil tip, a bee stinger, and metal. Their size ranged from 1 to 20 mm. Patient complaints included a foreign body sensation, localized pain, swelling, discoloration, and a skin lesion. X-ray examinations were performed in all cases, and ultrasonography was conducted in five cases. Conclusion: A microscopic approach allows precise, safe, and complete removal of foreign bodies without tissue damage, highlighting the efficacy of this technique in hand surgery.

Utilization of Surgical Fixation for Distal Radius Fractures in the United States: A Population-Based Cohort Study

In contrast to younger adult populations, clinical practice guidelines state that there is no difference in long-term functional outcomes in surgically versus nonoperatively treated distal radius fractures in patients ≥65 years old. In this study, we asked the following questions: (1) has treatment for distal radius fractures in younger and older adult populations changed over time? (2) What patient and surgeon factors are associated with treatment trends? Using a national administrative claims database, we identified patients aged ≥18 years with isolated, closed distal radius fractures, subdivided by age (18-64 years, ≥65 years old). We characterized the proportion of patients who underwent open reduction and internal fixation (ORIF) over time. We stratified our analysis by surgeon subspecialty, region, and mean area income. Changes in ORIF utilization over time were evaluated using linear regression models. The proportion of distal radius ORIF, including in patients aged ≥65 years, increased from 10.4% in 2012 to 15.1% in 2020. Of the ORIF procedures performed, hand surgeons accounted for an increasing proportion over time, with a corresponding decrease in those performed by general orthopedic surgeons. The proportion of ORIF increased over time in all US regions, with the largest rate of increase in the Midwest for patients aged ≥65 years and Northeast for patients aged 18-64 years. Patients living in areas with mean family income ≥$65,000 were more likely to undergo ORIF. The proportion of distal radius ORIF including in older adult populations is increasing in all US regions, and an increasing proportion is performed by hand surgeons. Further analysis of the drivers of these trends is warranted, given the rising incidence of surgical treatment in older patients, which could reflect evolving patient activity demands and suggest a need to further evaluate conventional treatment algorithms based on age.

The Ten Test and Sensory Evaluation of Hand and Finger Injuries in the Emergency Department

BackgroundHand and finger injuries are a common presenting complaint to the emergency department and are associated with significant morbidity. Neurologic evaluation of these injuries is a crucial component of the patient assessment and can be done via a variety of testing methods. DiscussionWhile most taught and cited in the emergency department literature, the two-point discrimination (2PD) test for sensation has several drawbacks, including limited reproducibility and reliability. While often utilized by hand surgical specialists, the Semmes-Weinstein monofilament (SWM) test and the Weinstein Enhanced Sensory Test (WEST) are not practical for the emergency physician due to the need for specialized equipment and frequent calibration. The ten test, a relatively new sensory evaluation method, has been shown to be reliable, reproducible, and pragmatic in varying types of clinical environments. ConclusionThe ten test is a pragmatic alternative method of evaluation to two-point that is utilized by specialists in hand surgery and injuries. The emergency physician should consider adding the ten test to their evaluation and reporting of hand and finger injuries in the emergency department.

Intraoperative Cost Comparison of Endoscopic Carpal Tunnel Release With WALANT Versus MAC Anesthesia.

The cost of endoscopic carpal tunnel release (ECTR) has historically been shown to be significantly higher than the cost of open carpal tunnel release (OCTR). Setting and anesthetic technique drive costs in hand surgery; ambulatory surgical center (ASC) settings demonstrate lower costs when compared to hospital-based settings and local-only anesthetic techniques demonstrate savings over general anesthesia. The purpose of this study is to compare wide awake local-only anesthesia technique (WALANT) to monitored anesthetic care (MAC) for ECTR performed in an ASC setting. This study includes 481 ECTR under WALANT and 405 ECTR under MAC, performed between January 2019 and December 2021 in an ASC. Utilizing previously reported direct operating room costs, overhead, and material costs, we calculated a final cost for each procedure. We also report our complication rates: intraoperative conversion to OCTR and late revision to OCTR. Intraoperative times were shortest for ECTR performed under WALANT (22 min) versus ECTR under MAC (25 min). The total cost for ECTR under WALANT was most cost-effective at $1341.28 versus ECTR under MAC at $1634.00. Both techniques demonstrated a low complication profile. Our intraoperative process flow, staffing model, and ASC setting resulted in cost savings making ECTR an economically feasible option.

Hand surgery in Vietnam: development, challenges and future directions.

Hand surgery in Vietnam has evolved significantly, especially in cities like Ho Chi Minh City, Hanoi and Hue. Despite advancements, there remain challenges, including the lack of a unified national hand surgery society. This article highlights the contributions of key figures, advances and the future of the discipline in the country.

Treatment of proximal phalangeal fracture with miniature combined external fixator

To investigate the clinical effect of limited open reduction treatment of proximal phalangeal fracture with miniature external fixator combined with small incision. Between January 2020 and December 2022, 29 patients with proximal phalangeal fracture were treated with micro external fixator combined with small incision in fracture plane, including 23 males and 6 females, aged from 19 to 62 years old with an average of (36.2±21.0) years old. Five patients with open phalangeal fracture were treated with stageⅠsurgery, 24 cases of closed phalangeal fracture were treated with elective surgery. At the 6 month follow-up, the curative effect was evaluated according to the total active flexion scale (TAFS) of the American Hand Surgery Association. The fracture healing, nail path, local soft tissue healing, and complications were observed. All the 29 patients were followed up for 6 to 10 months with an average of(8.3±2.1) months, 3 patients had delayed fracture healing, 1 patient had distal skin numbness, symptoms were relieved after nutritional nerve treatment, no external fixator broken nails, no infection, the nail path and small incision healing was good, bone healing was achieved at the end of follow-up. Fracture healing time ranged from 10 to 24 with an average of (13.7±3.1) weeks. Six months after operation, according to the TAFS standard, 19 cases (227.68±4.23) were excellent, 7 cases (203.86±14.32) were good, and 3 cases (170.33±7.32) were poor. The micro-combined external fixator combined with limited incision with small incision can be used in the treatment of proximal phalangeal fracture. The operation is simple and beneficial to early functional exercise, small extensor tendon irritation, convenient second-stage removal, and high rate of excellent and good functional score in recovery period.

Reconstruction of hand surgical wounds after correction of pseudo-syndactyly or squamous cell carcinoma resection in patients affected from epidermolysis bullosa: a monocentric experience with a collagen-elastin dermal matrix dermal substitute

In patients with Epidermolysis Bullosa (EB), surgery may be required to remove Squamous Cell Carcinoma (SCC) of the hands or to correct pseudo-syndactyly. Dermal substitutes may represent a suitable tool to promote the healing of surgical wounds in EB. We review our experience with a collagen-elastin dermal matrix to promote surgical wound healing due to hand surgery to correct pseudo-syndactyly or SCC resection in patients affected by EB. Overall, 12 patients (mean age, 29±11 years, range 13-51; four females) with EB were considered, with a total of 25 different interventions (16 SCC removals; three amputations for recurrent infiltrating SCC; six pseudo-syndactyly corrections). All patients received a collagen-elastin dermal matrix sheet. Neodermis was achieved in all patients, and no adverse events potentially associated with the graft occurred. No SCC recurrence was reported at sites operated for either SCC resection or amputation. The opening of the first or second commissure appears to be maintained for over 1 year after the procedure, preserving digital function. We believe that the application of a dermal substitute, together with a close dressing protocol, may represent a suitable strategy for obtaining physiological tissue regeneration and maintaining proper hand function in patients with EB.

A Comparative Study between Ultrasound-guided Concomitant Infraclavicular Plus Distal Median, Radial, and Ulnar Nerve Blockade Versus Infraclavicular Block Alone

Abstract Background: Peripheral nerve blocks can be used alone as the sole “surgical” anesthetic technique as the initial step in providing prolonged postoperative analgesia. There are studies, where accurate deposition of local anesthetic perineurally has the potential to improve the success rate and reduce the incidence of complications of the infraclavicular block. We hypothesized whether a combined block of the infraclavicular brachial plexus and distal median, radial, and ulnar nerves would accelerate upper extremity anesthesia compared with an infraclavicular block alone. Materials and Methods: This study was a prospective randomized control study conducted among 60 patients undergoing elective and emergency wrist and hand surgeries. A group of 30 patients received an infraclavicular block with 30 mL of a local anesthetic mixture containing 1% lignocaine with adrenaline and 0.25% bupivacaine from Group A. Group B received an infraclavicular block with 15 mL of local anesthetic mixture containing 1% lignocaine with adrenaline and 0.25% bupivacaine along with distal median, radial, and ulnar nerve blockade with 5 mL each of local anesthetic mixture containing 1% lignocaine with adrenaline and 0.25% bupivacaine. Pain score, assessment of sensory and motor functions, block performance time, and surgical anesthesia were observed. Results: The mean block performance time of Group A was 10.9 ± 1.1 min and Group B was 14.7 ± 0.5 min. The difference between the two groups’ block performance minutes was statistically significant (P < 0.001). The difference in the onset of the sensory block between the two groups was statistically significant (P < 0.001). The mean onset of motor blockade between the two groups was statistically very highly significant (P < 0.001). The mean of Group A was 5.0 ± 0.2 and Group B was 2.1 ± 0.4. Conclusion: From this study, we conclude that using an approximately equivalent dose of local anesthetics, combining ultrasound-guided infraclavicular block with distal median, radial, and ulnar nerve blockade shortens the onset time of sensory and motor block with improved block consistency compared to infraclavicular block alone.

Following carpel tunnel release, what factors affect whether patients return to the same or different hand surgeon for a subsequent procedure?

Following carpal tunnel release (CTR), patients may be indicated for subsequent hand surgery (contralateral CTR and/or trigger finger release [TFR]). While surgeons typically take pride in patient loyalty, the rate of returning to the same hand surgeons has not been previously characterized. Patients undergoing CTR were isolated from 2010-2021 PearlDiver M151 dataset. Subsequent CTR or TFR were identified and characterized as being performed by the same or different surgeon, with patient factors associated with changing to a different surgeon determined by multivariable analyses. In total, 1,121,922 CTR patients were identified. Of these, subsequent surgery was identified for 307,385 (27.4%: CTR 289,455 [94.2%] and TFR 17,930 [5.8%]). Of the patients with a subsequent surgery, 257,027 (83.6%) returned to the same surgeon and 50,358 (16.4%) changed surgeons. Multivariable analysis found factors associated with changing surgeon (in order of decreasing odds ration [OR]) to be: TFR as the second procedure (OR 2.98), time between surgeries greater than 2-years (OR 2.30), Elixhauser-Comorbidity Index (OR 1.14 per 2-point increase), and male sex (OR 1.06), with less likely hood of changing for those with Medicare (OR 0.95 relative to commercial insurance) (p<0.001 for each). Pertinent negatives included: age, Medicaid, and having a 90-day adverse event after the index procedure. Over fifteen percent of patients who required a subsequent CTR or TFR following CTR did not return to the same surgeon. Understanding what factors lead to outmigration of patients form a practice may help direct efforts for patient retention.

Exploration of Establishing Evaluation Indicators for Hand Trauma Rehabilitation Nursing Based on Delphi Method.

This study aimed to develop an evaluation index system for hand surgery rehabilitation nursing using the Delphi method. A survey questionnaire on evaluation indicators for hand surgery rehabilitation nursing was developed, and 18 professionals including orthopedic surgeons, orthopedic nursing, and rehabilitation departments were selected. The survey was conducted using the letter method, and a database was established to screen the items, forming a hand surgery rehabilitation nursing evaluation scale. The expert's positive coefficient, authority coefficient, and coordination coefficient were analyzed, and the mean, standard deviation, coefficient of variation, and weight coefficient were calculated. Based on the correlation assignment results, the Item-level Content Validity Index (I-CVI), Scale-level Content Validity Index (S-CVI), average S-CVI, Probability of random consistency (Pc), and corrected I-CVI Kendall's coefficient of concordance (K*) were determined. In the first round of expert inquiry, a total of 18 questionnaires were distributed, and 15 valid questionnaires were collected, with an effective response rate of 83.33%. In the second round, 15 questionnaires were distributed and 15 valid questionnaires were collected, with an effective response rate of 100%. The two rounds of expert evaluations yielded judgment scores of 0.91 and 0.95, with proficiency levels of 0.83 and 0.87 and authority coefficients of 0.87 and 0.91, respectively. The Kendall's W values for the two rounds were 0.313 and 0.224, respectively, with a statistically significant difference (p < 0.01). After screening, 23 indicators were retained, with a coefficient of variation ranging from 0.072 to 0.166. Among the third-level indicators, 12 had an I-CVI of 1.00, 4 had an I-CVI of 0.93, and 7 had an I-CVI of 0.87. The overall S-CVI was 0.80, with an average S-CVI of 0.95. The K* values for the 23 indicators ranged from 0.8662 to 1.0000. The evaluation index system for hand injury rehabilitation nursing based on the Delphi method is highly scientific, and is expected to be used to guide the clinical evaluation of hand injury rehabilitation nursing.

Characteristics of Patients Utilizing Telemedicine in Hand and Upper-Extremity Surgery.

The impact of social determinants of health on patients' access to medical care and health outcomes is increasingly recognized. Telemedicine's rapid and widespread adoption altered the delivery of care. This study describes the characteristics of patients undergoing telemedicine visits with hand surgeons, without COVID-19 pandemic-related restrictions. All telemedicine encounters for 4 hand surgeons at a single institution between September 2022 and September 2023 were retrospectively reviewed. Patient demographics were recorded as well as the encounter type. The distance of the patients' residential address and the area deprivation index (ADI) were recorded. Sixty patient encounters were recorded. Forty-seven percent were male and 53% were female, 5 (8.3%) were new patients, 44 (73.3%) were established patients, and 11 (18.3%) were postoperative. The mean age was 43, and the mean and median distances from the clinic were 72 and 18 miles, respectively. Forty-three patients (72%) were from high ADI residences. Upon comparison of low ADI (0-50th percentile) and high ADI (50th-100th percentile) patients, no statistically significant differences in age, sex, distance from clinic, or encounter type were found. Telemedicine in hand surgery at this single institution is most frequently used for follow-up encounter types in patients living in high ADI communities, far from clinic sites. Low or high ADI did not correlate with seasonal changes in the use of telemedicine, encounter type, or patient demographics. Telemedicine may improve patient access to hand surgery follow-up care. This may particularly benefit patients facing geographic and economic challenges to healthcare access. Prognostic Level IV.

Artificial intelligence in traumatology.

The aim of this study was to create artificial intelligence (AI) software with the purpose of providing a second opinion to physicians to support distal radius fracture (DRF) detection, and to compare the accuracy of fracture detection of physicians with and without software support. The dataset consisted of 26,121 anonymized anterior-posterior (AP) and lateral standard view radiographs of the wrist, with and without DRF. The convolutional neural network (CNN) model was trained to detect the presence of a DRF by comparing the radiographs containing a fracture to the inconspicuous ones. A total of 11 physicians (six surgeons in training and five hand surgeons) assessed 200 pairs of randomly selected digital radiographs of the wrist (AP and lateral) for the presence of a DRF. The same images were first evaluated without, and then with, the support of the CNN model, and the diagnostic accuracy of the two methods was compared. At the time of the study, the CNN model showed an area under the receiver operating curve of 0.97. AI assistance improved the physician's sensitivity (correct fracture detection) from 80% to 87%, and the specificity (correct fracture exclusion) from 91% to 95%. The overall error rate (combined false positive and false negative) was reduced from 14% without AI to 9% with AI. The use of a CNN model as a second opinion can improve the diagnostic accuracy of DRF detection in the study setting.

Equestrian-associated injuries of the hand: a retrospective analysis of injury mechanisms and patterns.

Hand injuries are frequently caused by sports and are associated with long periods of inability to work and high economic health costs. After ball sports and cycling, the most common cause of hand injuries is horseback riding. Therefore, measures should be taken to prevent these risks and increase safety in sports, however data characterizing equestrian sports-associated injuries are limited. A retrospective monocentric cohort study was performed including 39 patients (mean age: 35 ± 2.6 (range 9-65) years, female 89.7% who sustained an injury to the hand while practicing equestrian sports during 2016-2021 and presented to our hand surgery center. Data analysis was performed to characterize the trauma mechanism and injury patterns by evaluating the clinical information system and conducting telephone interviews. Overall, 53.8% of the injuries occurred while leading the horse owing to traction by bridles or a lead rope on the fingers, whereas only 33.3% were caused by a fall and 12.8% by a bite injury. The majority (87.2%) of cases were injuries to the phalanges (metacarpus: 7.7%; carpus: 5.1%). Fractures were present in 51.3% of cases. The most serious injuries included avulsion amputations in 23.1% of patients (10.3% subtotal; 12.8% total amputation). Equestrian-associated injuries occur more frequently during horse handling than riding, resulting in severe avulsion amputations due to traction of the lunge or bridle, requiring complex microsurgical treatment. We recommend that appropriate protective gloves are worn for prevention of hand injuries. Additionally, the use of self-opening panic hooks with overload protection can prevent excessive traction. III.

AI in plastic surgery: customizing care for each patient

Artificial intelligence (AI) and machine learning (ML) involve the usage of complex algorithms to identify patterns, predict future outcomes, generate new data, and perform other tasks that typically require human intelligence. AI tools have been progressively adopted by multiple disciplines of surgery, enabling increasingly patient-specific care, as well as more precise surgical modeling and assessment. For instance, AI tools such as ChatGPT have been applied to enhance both patient educational materials and patient-surgeon communication. Additionally, AI tools have helped support pre- and postoperative assessment in a diverse set of procedures, including breast reconstructions, facial surgeries, hand surgeries, wound healing operations, and burn surgeries. Further, ML-supported 3D modeling has now been utilized for patient-specific surgical planning and may also be combined with 3D printing technologies to generate patient-customized, implantable constructs. Ultimately, the advent of AI and its intersection with surgical practice have demonstrated immense potential to transform patient care by making multiple facets of the surgical process more efficient, precise, and patient-specific.

Hand Surgical Operating Room Size Allocation: A Comparative Space Utilisation Study.

Background: This study evaluated operating room (OR) space required for various hand surgical procedures. We analysed the size requirements for hand surgical cases divided into four settings: (1) large OR setting requiring fluoroscopy and microsurgical equipment, (2) medium-sized OR setting for cases requiring fluoroscopy, (3) smaller OR setting and (4) minor procedural room without anaesthesia with the aim to describe room size requirements for hand surgery practices. Methods: A variety of hand surgical cases were selected: large cases (microvascular digit replantation), medium-sized cases (closed reduction percutaneous pinning [CRPP] of phalangeal fractures) and smaller cases (carpal tunnel release [CTR]) with and without anaesthesia. Space requirements were compared to general surgery cases (laparoscopic appendectomy) and general orthopaedic surgery cases (cephalomedullary nail [CMN]). Necessary operative equipment was measured (ft2) to calculate requirements for each procedure. Results: Large hand cases such as digit replantation necessitated the most OR space (125 ft2), followed by general orthopaedic cases (CMN; 118 ft2), medium-sized hand cases (CRPP phalanx; 107 ft2), general surgery laparoscopic appendectomy (68 ft2), small hand cases (CTR; 85 ft2) and minor procedures (49 ft2). Conclusions: Hand procedures can be divided into major procedures requiring significant OR space (125 ft2), medium procedures in standard OR suites (107 ft2), procedures in small ORs with anaesthesia (81 ft2) or office-based setting without anaesthesia (49 ft2). These findings help define space utilisation for hand procedures and may have practical implications related to efficiency, cost and patient safety in the hospital and outpatient setting. Level of Evidence: Level IV (Economic and Decision Analyses).

Results of innervated digital artery perforator flap and direct-flow homodigital flap application in fingertip soft tissue amputations

ObjectiveThe purpose of this study is to compare the results of the innervated digital artery perforator (IDAP) flap and the direct-flow homodigital flap as reconstruction methods for fingertip soft tissue amputations. This issue is important in hand surgery, and we aim to identify the method that provides the best functional and cosmetic outcomes.MethodsBetween 2020 and 2022, 32 patients with fingertip amputations were reconstructed by the same surgeon using two different methods. The patients were retrospectively divided into two groups: those who underwent IDAP (n = 14) and those who had a direct-flow homodigital flap (n = 18). We compared the groups in terms of defect size, cold intolerance, venous congestion, Sollerman hand function test scores, Seddon sensory test scores, and follow-up periods, as well as flap viability, flexion contracture, and static two-point discrimination (s2PD).ResultsOf the 32 patients (26 men, 6 females; age: mean 28.72 ± 11.5 years), the injuries were caused by different mechanisms, including sharp (57.1% IDAP), crush (75% IDAP) and entanglement (66.7% homodigital). The average area of tissue loss was approximately 2.70 ± 1.37 cm², while the average s2PD measurement was approximately 4.94 ± 1.04 mm. Postoperatively, the Seddon sensory test results for the homodigital flap group were S4 (61.5%), S3 (23.1%), S3+ (7.7%), and S2 (7.7%), compared to the IDAP group, which showed S4 (57.9%), S3+ (21.1%), and S3 (21.1%). Complications occurred in five patients, though no flap loss or revision was required. The postoperative mean Sollerman hand function scores were higher for the homodigital group than for the IDAP group, with values of 75 ± 2.64 and 73 ± 3.34, respectively. Although not statistically significant, the results numerically suggest that the IDAP flap is better in terms of sensory recovery and hand function compared to the homodigital flap (p > 0.05).ConclusionsThis is the first investigation to compare direct-flow flaps with IDAP. The average follow-up period for patients who underwent homodigital surgery was also shorter than that of the IDAP group. Furthermore, the mean postoperative two-point discrimination and postoperative Sollerman function score were higher in patients who had homodigital surgery.

Surgical Management for Boutonniere Disease

Boutonniere disease is a hand injury causing extension lag or restriction in the proximal interphalangeal joint and hyperextension in the distal interphalangeal joint. This condition often arises from direct laceration or closure damage to the central tendon, rheumatoid arthritis, osteoarthritis, Dupuytren contracture, pulley injury, burns, and other conditions. Surgical management for Boutonniere deformity relies on the expertise of the attending physician and involves both non-surgical and surgical options. In acute cases, conservative therapy should be pursued, while in chronic cases, conservative management may be advised. Surgical intervention is used to transform excessive extension force of the distal interphalangeal joint into extension force of the proximal interphalangeal joint. This is necessary to heal an open rupture of the central tendon. Surgical techniques for chronic deformity are complex due to variables and hand surgeons' expertise. There is no definitive surgical therapy for persistent buttonhole deformity, but several approaches have been documented in case studies. These include terminal tenotomy, collateral band surgery, central tendon surgery, tendon transfer and grafting, stepwise extension mechanism readjustment surgery, and arthrodesis. Central tendon surgery addresses the central tendon, where injured tissue transforms into scar tissue, resulting in delayed extension of the proximal interphalangeal joint. Tendon transfer or grafting have been documented for rotator cuff mechanism rehabilitation, but no definitive guidance exists for these techniques. Curtis treatment introduced a sequential therapy approach for traumatic buttonhole deformity, which involves splinting, excising the transverse reticular ligament, resecting and lengthening the collateral ligament, and repositioning the core tendon. Arthrodesis may be applicable in cases of advanced arthritis, coronal plane deformity, functional impairment, or elderly patients. There are no definitive indications for surgical interventions for persistent buttonhole deformity, and outcomes may be variable or inferior. Understanding the deformity, its progression, and patient's functional constraints is crucial for effective treatment

Evaluation of lateral sagittal infraclavicular block according to inferior vena cava collapsibility index (VCI-CI): An observational study.

Depending on the total amount of fluid, changes occur in the amount of fluid in the peripheral area. The aim of this study was to observe the differences caused by hemodynamic changes after lateral sagittal infraclavicular block (LS-ICB) according to the inferior vena cava collapsibility index (VCI-CI). In this prospective, observational study (Clinical Trial Number: NCT05968105), patients undergoing elective hand and wrist surgery with LS-ICB were classified according to VCI-CI, with Group 1 defined as inferior vena cava (VCI) diameter < 1.5 cm and VCI-CI > 50% and Group 2 defined as VCI diameter > 1.5 cm and VCI-CI < 50%. Groups were compared for demographic characteristics, defined durations, rescue analgesics, and complications. Continuous hemodynamic parameters and pulsed wave Doppler were evaluated within groups. Demographic characteristics and time periods were comparable between the groups. Hemodynamic parameters and pulsed wave Doppler measurements showed no significant differences. However, while Group 1 remained consistent, Group 2 exhibited differences in axillary artery diastolic diameter and axillary artery contractility index. A significant statistical difference was observed in Group 1 for the perfusion index at 30 minutes and postoperatively, whereas Group 2 remained consistent. The dosage and number of patients requiring rescue analgesics were similar across both groups, and no complications were reported. Blood flow increased after LS-ICB without a corresponding increase in axillary artery diameter. Group 1 showed a tendency toward a lower perfusion index in the postoperative period.