Medial Arm Research Articles

Loco-Regional Perforator Flaps for Reconstruction of Post Burn Contracted Elbow

Context: the post-burn scar is inevitable problem even with the best treatment as it depends on the depth of the burn injury, so only superficial dermal burns, heal with no scarring, but the contracture is preventable problem especially with the best treatment. The post-burn elbow flexion contracture may be associated with heterotropic calcification of the elbow joint which needs orthopedic team consultation. The elbow reconstruction represents a demanding procedure for the plastic surgeon. Objective: aim of this study was to evaluate the validity and application of local arm forearm and regional chest perforator flaps for coverage after release of post burn elbow contractures. Patients and Methods: this prospective randomized study was done on 20 patients aged from 6 to 54 years old. All of them were asking for elective release of postburn flexion contracture of the elbow at outpatient clinics of Al Azhar University and Al-Ahrar Teaching Hospitals. It was done from March 2018 to March 2019. Results: we have performed in our study the local and regional perforator flaps as lateral arm flap, medial arm flap, PBUF flap, PBRF flap, thoracoabdominal pedicle flap. Skin grafting is an easy procedure, however, success is limited with the technique because there is always the risk of incomplete graft take and prolonged splinting and physiotherapy is imperative in the postoperative period. Conclusion: flaps are better for resurfacing the defects after post-burn contractures release. Flaps do not need vigorous post-operative physiotherapy or splint age and grow with age especially in children.

Neurovascular anatomy of the adult female medial arm in relationship to potential sites for insertion of the etonogestrel contraceptive implant

ObjectiveAnatomic assessment of the medial upper arm to identify potential sites for insertion of the etonogestrel (ENG) implant. Study designForty female cadaveric arms were dissected. Two rows of 1×2-cm dissection windows were created in the inner arm overlying the triceps approximately 2–3 and 4–5 cm posterior to the bicipital sulcus (sulcus). The primary window was 8–10 cm proximal to the medial epicondyle and approximately 2–3 cm posterior to the sulcus. Neurovascular structures within each window were identified. The entire medial upper arm was dissected to visualize underlying structures. ResultsMean age (± SD) of cadavers at death was 72.0±11.0 years. Arm measurements at the primary window were circumference 28.2±4.8 cm [range: 21–41], skin thickness 0.6±0.2 mm [0.3–1.0] and subcutaneous tissue thickness: 12.3±4.9 mm [4.7–21]. The basilic vein and the medial brachial cutaneous, ulnar and medial antebrachial cutaneous nerves were located in 40%, 58%, 40% and 18% of the primary windows, respectively. No major neurovascular structures were located 3–5 cm posterior to the sulcus. More neurovascular structures were identified overlying the biceps than triceps. Elbow flexion with the hand underneath the head displaced the ulnar nerve anteriorly towards the sulcus. ConclusionAs no major neurovascular structures were identified overlying the triceps 8–10 cm proximal to the medial epicondyle and 3–5 cm posterior to the sulcus, ENG implant insertion at this location may minimize risk of injury associated with improper deep insertion. Elbow flexion deflects the ulnar nerve away from this area and may further decrease risk of injury secondary to inadvertent deep insertion. ImplicationsAlthough a limited cadaver study, this anatomic assessment provides rationale for insertion of the ENG implant overlying the triceps 8–10 cm proximal to the medial epicondyle and 3–5 cm posterior to the sulcus. This area is theoretically safer for insertion of the ENG implant than areas of the inner arm where major neurovascular structures are commonly located.

Septocutaneous perforator mapping and clinical applications of the medial arm flap

The medial arm flap has a long history but remains underused despite providing multiple advantages. We reviewed our experience with using the medial arm flap to clarify the distribution of septocutaneous perforators and its relationship with pedicled flap design. This retrospective study included 36 consecutive patients who underwent reconstructive surgery with a medial arm flap (42 arms). Septocutaneous perforator mapping was conducted using a refined coordinate system originating at the medial epicondyle, with the y-axis running to the axillary apex. At least three perforators were identified along the medial intermuscular septum of the arm, located densely at 88 ± 8%, 49 ± 9%, and 20 ± 6% of the distance between the medial epicondyle and axillary apex (i.e., arm length), with a prevalence of 95.2%, 100%, and 85.7%, respectively. All arms had at least one medium- or large-sized perforator, and 90.5% of arms had at least two such perforators. Twenty-nine flaps were transferred as pedicled distant flaps for head and neck reconstruction or hand reconstruction, while the remaining 13 were transferred as perforator-based propeller flaps for axillary, elbow, or chest wall reconstruction. Thirty-six flaps underwent pre-transfer expansion. The average flap size was 157.9 ± 64.5cm2 (range: 40-330cm2). All flaps were successful, except for one perforator-based flap, which was replaced due to partial loss. Donor site morbidity was minimal. Given its rich septocutaneous perforator distribution, the medial arm flap can be harvested reliably with versatile design and minimal donor site morbidity, thus deserving more attention in reconstructive surgery.

Capsular plication in the non-deformity hip: impact on post-operative joint stability

Purpose and hypothesisThe aim of this study was to evaluate the hip joint range of motion after different capsular plication. The study hypothesis proposed that capsular plication after hip arthroscopy may reduce hip external rotation and thus prevent the hip joint instability created by arthroscopic capsulotomies.MethodsSix fresh frozen human cadavers were studied in the intact state (5 males, 1 females) for a total of 12 non-deformity hips tested. They were fixed to the operating room table using a custom-made apparatus. Three Steinman pins were inserted, the first into ASIS, a parallel pin into the distal femur proximal to inter-epicondylar axis and the third pin into the lateral epicondyle. Simulation of arthroscopic capsulotomies was done progressively with simulation of three capsular plication techniques. The first plication technique consisted of a primary plication shift of the antero-lateral capsule. The distal-medial arm of the iliofemoral ligament was shifted toward the proximal-lateral arm. The second plication technique consisted in adding a longitudinal arm to the capsulotomy, between the lateral arm and the medial arm of the iliofemoral ligament, to create a T-shaped capsulotomy. The resulting two triangular capsular flaps were overlaid onto each other by approximately 5 mm, plicated fully and tighly sutured in a double-breast manner. The third plication technique, called redrapping, consisted in excising the inferior capsular triangular flap (previously made in the second technique), and suturing the latero-anterior superior capsular flap to the medial arm of the iliofemoral ligament, superimposing the capsular edges for closure. External rotation of the hip at 0°, 15° and 30° of flexion were obtained after the capsulotomy and each capsular plication technique to quantify the increase in hip stability after plication. Data were assessed using a two-way repeated measure analysis of variance (ANOVAs) and Student’s T-test when necessary to determine if the change in external rotation was significantly different.ResultsAfter capsulotomy, external rotation averaged 26.3°, 29.1° and 31.1° at 0°, 15° and 30° of flexion. With the primary plication shift, external rotation averaged 24.9°, 30.3° and 34.0°. With the two-triangle technique, external rotation averaged 26.1°, 31.9° and 33.3°. With the re-draping technique, external rotation averaged 25.8°, 30.9° and 32.0°. A significant relationship was found between «Plication Technique» and «Angle of flexion» factors for the measured angle of external rotation (P = 0.04).A decomposition of the interaction showed that external rotation decreased at 0° of hip flexion and increased as the hip flexion angle increased. The only significant difference found corresponded to the two triangles technique at 15° flexion (mean difference compared to the non-repaired state = 2.8° ± 3.8° or 8.8% increase in external rotation; P = 0.03).ConclusionsDifferent techniques of capsular plication result in a non-significant increase in hip external rotation when compared to unrepaired capsulotomies. Therefore, special attention should be paid at the time of capsular plication, which could be disadvantageous when done overzealously aiming to increase postoperative stability.

Thermal Manikin of Infant

Compared to an adult, an infant requires more consideration regarding the thermal environment so it is necessary to evaluate the thermal environment as it affects infants. However, experiments on infant subjects regarding their thermal environment based on the different heat balance of their body cannot ethically be conducted. We could instead consider using a thermal model for the human body, but thermal manikins based on heat transfer per unit area are rare. Therefore, this study aims to develop a thermal manikin to model the heat transfer per unit area and the body form of an infant in order to evaluate the infant’s thermal environment. When evaluating the thermal environment or heat balance of the body in the outside environment, it is essential to consider the asymmetry and unevenness of the temperature of the skin, as an element of the human body, and not just the unevenness and asymmetry of physical factors in the environment. Moreover, when receiving short wavelength direct solar radiation, light and shaded areas have significant differences in skin temperature. The following 20 body parts were investigated in the study: anterior head, posterior head, ventral trunk, dorsal trunk (including buttocks), right medial arm, right lateral arm, left medial arm, left lateral arm, right dorsal hand, right palmar hand, left dorsal hand, left palmar hand, right anterior leg, right posterior leg, left anterior leg, left posterior leg, right dorsal foot, right plantar foot, left dorsal foot, and left plantar foot. This paper measured the body surface area for each part of an infant’s body in order to establish the form of an infant model from the view of the heat transfer area, and verified the validity of the model.

Introducing the craniocervical Y-ligament.

We examined the accessory atlantoaxial ligaments and found them to be a part of a complex ligamentous structure, which we named craniocervical Y-ligament with respect to its shape. The ligaments of the upper cervical spine were dissected in ten Thiel embalmed human cadavers. Origin and attachment of the Y-ligament were described and a detailed photo and video-documentation was carried out with the head in the neutral position, flexion, extension and rotation to study the ligament during these movements. The Y-ligaments were found to be paired and symmetric in all specimens. The shape of the ligament is similar to an Y, its lateral arm connecting the atlas to the axis, its medial arm connecting the occipital bone to the axis, fusing with the two main ligaments, the alar and transverse ligaments. The lateral arm of the Y-ligament was found to be analogous to the accessory atlantoaxial ligament. During cervical flexion, both arms of the Y-ligament became taut while extension made the Y-ligaments relaxed. During rotation both Y-ligaments became taut, moving in the opposite directions in the sagittal plane while following the gliding movements of the lateral masses of the atlas. The craniocervical Y-ligament is a complex ligamentous structure and has a constant anatomy. Because of its shape and special arrangement, it probably plays a role in limiting both atlantooccipital and atlantoaxial movements. Acknowledgement of this ligamentous structure will help understand upper cervical stability. The present study should serve as a basis for future biomechanical and radiological studies.

Comparing Z-Plasty versus Z-Plasty and Skin Grafting for Surgical Tension-Free Treatment of Post-Burn Elbow Contractures: A Randomized Clinical Trial

Background: Elbow contracture is a common incidence. It has surgical treatments such as scar release and skin graft, Z or V-Y plasty, and lateral or medial arm flap. In this study, we compared Z-plasty versus Z-plasty and skin grafting in the surgical tensionfree treatment of post-burn elbow contractures. Methods: 30 patients with elbow joint extension restriction participated in this randomized clinical trial in two groups: experimental (Z-plasty with skin graft) and control (Z-plasty alone) groups. In both groups, Z-plasty was designed with a 60 angle. In the experimental group, the flaps were rotated without tension, and then the upper and lower parts of the flaps were grafted by a midsplit-thickness skin graft. The surgery area was examined regarding infections, wound healing time, necrosis, and scar. Significant differences were evaluated using unpaired student t-test. Results: Only seven participants in the control group had complications. The statistical analysis of all variables in both groups showed that Z-plasty with skin graft treatment had a significantly better result than the Z-plasty alone (P = 0.006). However, the two groups showed no significant differences in terms of infection, flap tip necrosis, surgery site infection, and feeling of pressure in joint extension or scar recurrence (P = 0.273). Conclusions: Tension-free flap must be used in patients with mild or moderate wide elbow scar contracture. Combining Z-plasty with skin graft is easy and has better results than Z-plasty alone. It is recommended using this technique in patients with intraoperative flap tension.

Procurement of Extended Vascularized Skin Flaps from the Donor Enables Hand Transplantation in Severe Upper Extremity Burns: An Anatomical Study.

Hand transplantation in patients with severe upper extremity burns can be associated with an increased risk of exposure of vessels, tendons, and nerves because of extensive skin and soft-tissue deficit. This study evaluated how to reliably transfer additional extended skin flaps with a standard hand allograft. Twenty-five upper extremities were used. Sixteen were injected with latex to map the perforating branches of the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries. Nine hand allografts were procured, injected with blue ink through the brachial artery to assess the perfusion of the skin flaps, and then mock transplanted. Sizable perforators from the brachial, superior ulnar collateral, radial, ulnar, and posterior interosseous arteries were used to augment the vascularization of the skin flaps. The average stained area of the medial arm flap was between 85.7 and 93.9 percent. The stained area of the volar forearm flap was the smallest when based on perforators within 6 cm from the wrist crease (51.22 percent). The dorsal forearm flap showed the least amount of staining (34.7 to 46.1 percent). The average time to repair tendons, nerves, and vessels was longer when a single volar forearm-arm flap was harvested (171.6 minutes). Harvest of the allograft associated with a distally based forearm flap and islanded arm flap was the fastest (181.6 ± 17.55 minutes). Extended skin flaps, based on perforators of the main axial vessels, can be reliably transplanted with a standard hand allograft based on the brachial or axillary vascular pedicle.

Relationship Between Pitcher Fatigue and Medial Elbow Torque in Baseball Pitchers: A Simulated Game Analysis

Objectives:The incidence of overuse injury to the elbow in baseball pitchers continues to rise, despite exhaustive efforts at pitch count regulations and emphasis on proper throwing mechanics. The goal of this study was to determine if the medial elbow experiences increased torque levels as the pitcher fatigues through the course of a simulated game.Methods:Competitive baseball pitchers were recruited for this simulated game study. Medial elbow torque was assessed using a validated mobile sensor that recorded medial elbow torque during the throwing motion. A radar gun was used to capture pitch velocity for each recorded pitch. Each pitcher completed a simulated game consisting of 6 innings and a standardized pitching scheme of fastballs, curveballs, and change-ups. Visual analog scores (VAS) measuring fatigue were recorded in between each inning. In total, each pitcher threw 90 pitches. Data was recorded every pitch to include ball velocity, medial elbow torque, arm speed, arm rotation, and arm slot.Results:A total of 11 pitchers (average age 17.6 years; range 15-20 years) completed the study. No adverse outcomes were noted with use of the mobile sensor. VAS scores increased 0.716 points per inning pitched (p<0.001). Medial elbow torque also was found to increase with successive innings, with an increase of 0.836 Nm each inning (p<0.001), while average pitch velocity was found to decrease as the game progressed (0.28 mile per hour decrease per inning; p<0.001). Fastballs generated the highest amount of medial elbow torque. There were no differences found in arm rotation or arm speed as the game progressed. However, the arm slot was found to decrease with each successive inning (0.731 degree decrease per inning; p<0.001).Conclusion:In this simulated game analysis, pitchers were noted to experience increase fatigue after each successive inning. While the average fastball velocity decreased from inning-to-inning, the medial elbow torque was found to increase, signifying a possible risk factor for overuse injury to the medial elbow.

Effect of Fatigue on Medial Elbow Torque in Baseball Pitchers: A Simulated Game Analysis

Background: The incidence of overuse injury to the elbow among baseball pitchers continues to rise, despite extensive efforts at pitch count regulations and emphasis on proper throwing mechanics. Purpose: To determine if the medial elbow experiences increased torque levels as a baseball pitcher fatigues through the course of a simulated game. Study Design: Descriptive laboratory study. Methods: High school and collegiate baseball pitchers were recruited for this simulated game study. Each pitcher completed a simulated game consisting of 6 innings and a standardized pitching scheme of fastballs, curveballs, and changeups. In total, each pitcher threw 90 pitches. Fatigue was reported per inning with a visual analog scale, and pitch velocity was captured per pitch with a radar gun. Outcome measures were assessed with a validated mobile sensor and included medial elbow torque, arm speed, arm rotation, and arm slot. Linear and quadratic regression modeling was used to evaluate the relationship between pitcher fatigue and pitching kinematics. Results: A total of 11 pitchers (mean age, 17.6 years; range, 15-20 years) completed the study. Visual analog scale fatigue scores increased 0.72 points per inning pitched (P < .01, effect size = 0.64). Medial elbow torque also increased beyond inning 3, with an increase of 0.84 N·m each inning (P < .01, effect size = 0.08), while pitch velocity decreased (0.28 mph per inning, P < .01, effect size = 0.27). Fastballs generated the greatest amount of medial elbow torque (49.3 ± 1.4 N·m, P < .01, effect size = 0.24). There were no differences in arm rotation (P = .42) or arm speed (P = .80) as the game progressed. However, arm slot decreased with each successive inning (0.73° on average per inning, P = .03, effect size = 0.12). No adverse outcomes were noted with use of the mobile sensor. Conclusion: In this simulated game analysis, pitchers experienced increased fatigue after each successive inning. While the average pitch velocity declined with each successive inning, the torque on the medial elbow increased after inning 3. These findings signify a possible relationship between fatigue and injury risk.

Total Cheek Reconstruction Using the Pre-Expanded Medial Arm Flap With Functional and Aesthetic Donor Site Closure.

This clinical study aimed at introducing a reconstructive method for total cheek soft tissue defects using the pre-expanded medial arm flap and to maximally reduce donor site morbidities simultaneously. A retrospective review of data was performed for 3 patients requiring the pre-expanded medial arm flap to reconstruct total cheek defects. The donor site in the medial arm was primarily closed using a pedicle parascapular or thoracodorsal artery perforator flap. All patients had a total unilateral cheek defect after lesion removal. Three pre-expanded medial arm flaps measuring 17 × 11 cm, 22 × 15 cm, and 20 × 15 cm were separately used for cheek defect reconstruction. The donor sites in the medial arm were closed using a pedicle parascapular flap, measuring 22 × 9.5 cm, and 2 pedicle thoracodorsal artery perforator flaps, measuring 22 × 10 cm and 23 × 10 cm. No major complications occurred in any patient. Patients were followed up for 3, 12, and 18 months. Patients (and/or their family members) were satisfied with the final outcomes. Total cheek defect reconstruction using a pre-expanded medial arm flap, with the donor site closed using a pedicle axial back flap, can not only provide sufficient tissue for cheek resurfacing, but also guarantee primary donor site closure and could be an alternative reconstructive option for patients who have a total cheek defect.

A multilateral modelling of Youth Soccer Performance Index (YSPI)

This study aims to identify the most dominant factors that influencing performance of soccer player and to predict group performance for soccer players. A total of 184 of youth soccer players from Malaysia sport school and six soccer academy encompasses as respondence of the study. Exploratory factor analysis (EFA) and Confirmatory factor analysis (CFA) were computed to identify the most dominant factors whereas reducing the initial 26 parameters with recommended >0.5 of factor loading. Meanwhile, prediction of the soccer performance was predicted by regression model. CFA revealed that sit and reach, vertical jump, VO2max, age, weight, height, sitting height, calf circumference (cc), medial upper arm circumference (muac), maturation, bicep, triceps, subscapular, suprailiac, 5M, 10M, and 20M speed were the most dominant factors. Further index analysis forming Youth Soccer Performance Index (YSPI) resulting by categorizing three groups namely, high, moderate, and low. The regression model for this study was significant set as p < 0.001 and R2 is 0.8222 which explained that the model contributed a total of 82% prediction ability to predict the whole set of the variables. The significant parameters in contributing prediction of YSPI are discussed. As a conclusion, the precision of the prediction models by integrating a multilateral factor reflecting for predicting potential soccer player and hopefully can create a competitive soccer games.

Green tea moisturizer improves skin hydration in elderly

BACKGROUNDDry skin is a major skin health problem in elderly. Green tea, which has an antioxidant effect, has recently been used as an active ingredient in moisturizing creams; yet the effect has not been well studied. This study compares the skin hydration effect of green tea and vitamin E moisturizer among elderly.METHODSThis quasi-experimental study involved 60 elderly living in Tresna Werda Budi Mulia 4 Social Institution, Jakarta. Using the Runve HL 611 skin analyzer, skin capacitance was measured prior to experiment and every following week during the 5-week application of green tea and vitamin E skin moisturizer on both forearms. The consecutive measurement data was analyzed using Generalized Estimating Equation to compare the relative changes in skin hydration between the two moisturizer groups over 5 weeks of intervention. RESULTSThe green tea moisturizer showed more significant increases in skin hydration level than the vitamin E moisturizer at all measurement sites on right arm and proximal left arm (p= 0.021), and medial and distal left arm (p= 0.034). Skin hydration levels significantly changed over time at proximal (p=0.021), medial (p=0.006) and distal (p=0.006) right arm, and medial left arm (p=0.021). A parallel trend of skin hydration improvements for both moisturizer groups indicated no correlation between the moisturizer type and the duration of usage (p &gt;0.05) in all measurement locations. No side effects were observed during application period in both groups.CONCLUSIONRoutine use of moisturizer containing green tea may improve skin hydration in elderly.

Use of medial upper arm free flap in oral cavity reconstruction: a preliminary study

The medial upper arm has previously been proposed as a potential free flap donor site, but the clinical application of such flaps in head and neck reconstruction has not been popular. The preliminary results of the clinical application of medial upper arm free flaps in oral cavity reconstruction are reported here. Five patients with oral cancer underwent surgical resection and neck dissection, with simultaneous reconstruction using a medial upper arm free flap. Functional outcomes were investigated using the University of Washington Quality of Life Questionnaire. Sensory-motor functions of the upper arm donor site were recorded before and after surgery. Four flaps were successfully transferred. One flap was abandoned during surgery because of a lack of perforators, and a forearm flap was used instead. All patients survived without loco-regional recurrence or distant metastasis. Functional outcomes, especially swallowing and speech, were satisfactory. The donor site scar was well hidden, with no functional impairment. This initial experience shows that the medial upper arm free flap represents an alternative perforator flap for oral cavity microsurgical reconstruction. The well-hidden scar and better texture match compared with other flaps make it suitable for oral cavity reconstruction.

Adding a PECS II block for proximal arm arteriovenous access - a randomised study.

Brachial plexus block is often utilised for proximal arm arteriovenous access creation. However, the medial upper arm and axilla are often inadequately anaesthetised, requiring repeated, intraoperative local anaesthetic supplementation, or conversion into general anaesthesia. We hypothesised that the addition of a PECS II block would improve anaesthesia and analgesia for proximal arm arteriovenous access surgery. In this prospective, double-blinded, randomised proof-of-concept study, 36 consenting adults with end-stage renal disease aged between 21 and 90 years received either a combined supraclavicular and PECS II block (Group PECS, n = 18), or combined supraclavicular and sham block (Group SCB, n = 18) for proximal arm arteriovenous access surgery. Primary outcome was whether patients required intraoperative local anaesthetic supplementation by the surgeon. In Group PECS, 33.3% (6/18) needed local anaesthetic supplementation vs. 100% (18/18) in Group SCB. Group SCB had three times (RR 3.0, 95% CI 1.6-5.8; P < 0.001) the risk of requiring intraoperative local anaesthetic supplementation. Group PECS required lower volume of supplemental local anaesthetic compared to Group SCB (0.0 ml, IQR 0.0-6.3 ml vs. 15.0 ml, IQR 7.4-17.8 ml; P < 0.001). Group SCB had twice [RR 2.2, 95% CI 1.1-4.4; (P = 0.019)] the risk of needing additional sedation or analgesia. There were no significant differences between the groups with respect to postoperative visual analogue scale pain scores, time to first rescue analgesia or patient satisfaction. The results suggest that adding a PECS II block to a supraclavicular block improves regional anaesthesia for patients with end-stage renal disease undergoing proximal arm arteriovenous access surgery.

Anatomical and Clinical Perspective of Medial Arm Region Perforators-A Potential Flap for Reconstructive Surgeries

Anatomical and Clinical Perspective of Medial Arm Region Perforators-A Potential Flap for Reconstructive Surgeries

Ulnar Thumb Pulp Reconstruction Using the Anterograde Homodigital Neurovascular Island Flap.

The thumb ulnar pulp is a critical component of key pinch and precision manipulation. Injuries to this area should be reconstructed with robust, sensate tissue that restores bulk and contour. The existing reconstructive options, however, have substantial risks and drawbacks. We describe an anterograde homodigital neurovascular island flap that provides both sensate and durable coverage of the ulnar thumb pulp. The flap uses innervated glabrous tissue, limits donor site morbidity to the thumb and first web space, and does not require microvascular anastomoses or nerve coaptation. The flap has been previously described for nonthumb fingertip injuries, but it has not been applied to the thumb. We discuss several important technical modifications that are essential to raising and insetting this flap in the thumb, review potential pitfalls, and highlight key steps to ensuring judicious intraoperative decision making and success.

Lipomas of the Brachial Plexus: A Case Series and Review of the Literature.

Lipomas are common benign tumors. When they develop in proximity to peripheral nerves, they can cause neurologic symptoms secondary to mass effect. Previous reports have shown symptom resolution after removal of lipomas compressing various upper extremity peripheral nerves. However, brachial plexus lipomas are relatively rare. Our multidisciplinary experience with brachial plexus lipoma resection is reviewed in the largest case series to date. A retrospective chart review of all patients undergoing resection of brachial plexus lipomatous tumors between 2006 and 2016 was performed. Patient demographic data, diagnostic imaging, clinical presentation, operative details, surgical pathology, and clinical outcomes were reviewed. Twelve brachial plexus lipomatous tumors were resected in 11 patients: 10 lipomas, 1 hibernoma, and 1 atypical lipomatous tumor. The most common tumor location was supraclavicular (50%), followed by axillary (42%), and proximal medial arm (8%). The most common brachial plexus segment involved was the upper trunk (50%), followed by posterior cord (25%), lateral pectoral nerve (8%), lower trunk (8%), and proximal median nerve (8%). Most patients presented with an enlarging painless mass (58%). Of the patients who presented with neurologic symptoms, symptoms resolved in the majority (80%). Brachial plexus lipomas are rare causes of compression neuropathy in the upper extremity. Careful resection and knowledge of brachial plexus anatomy, which may be distorted by the tumor, are critical to achieving a successful surgical outcome with predictable symptom resolution. Finally, surveillance magnetic resonance imaging may be warranted for atypical lesions.

Abstract: Hand Transplantation in Patients with Extensive Burns of the Upper Extremities: Anatomical Study on Feasibility

INTRODUCTION: Hand transplantation in patients with severe burns of the upper extremity presents unique challenges because of extensive skin and soft tissue deficit. In skin grafted recipient limbs there is an increased risk of exposure of vascular anastomosis, tendons and nerves. The aim of this anatomical study was to evaluate how to reliably transfer increased amounts of skin from the upper extremity based on the perforators of the main axial vessels to replace the scarred recipient skin. METHODS: 25 upper limbs were studied. Based on the vascular anatomy of the perforators, forearm based hand allografts were harvested with 3 different patterns: A) volar and dorsal forearm flaps based only on distal perforators of Radial (RA), Ulnar (UA) and Posterior Interosseous (PIA) arteries and islanded medial arm flap based on Brachial and/or Superior Ulnar Collateral (SUCA) arteries; B) volar and dorsal forearm flaps with preservation of proximal RA perforators with only distal UA perforators and the islanded medial arm flap C) dorsal forearm flap and extended medial arm-volar forearm skin flap. 16 samples were injected with latex to map the perforating branches of the BA, SUCA, RA, UA and PIA. 3 samples for each group were dissected and injected with blue ink from the proximal BA to assess the retained perfusion of the flaps. RESULTS: The medial arm flap was constantly supplied by perforators from the BA and the SUCA (respectively 4.35 ± 1.64, diameter 1.03 ± 0.34mm and 2.6 ± 0.76, diameter 0.90 ± 0.34mm) and adequately perfused when the perforators from the BA or SUCA were preserved (90.8% stained). Perforators from RA (9.3 ± 1.62) if preserved, proved to be adequate to supply the total volar forearm skin (87.6% stained). The harvesting of the PIA with its perforators (5.25 ± 0.95) provided vascularization to the proximal half of the posterior flap. CONCLUSION: The medial arm flap should be safely based on perforators from the BA and/or SUCA. The design of the specimens in group B proved higher vascularization reliability and versatility as they provided adequate vascularization to the skin flaps with minimal interference with the dissection and repair of vessels, tendons and nerves.

P262 Contraceptive implant induced ulnar neuropathy

Significant complications from subdermal insertion of a contraceptive implant in the medial upper arm are rare; a UK Government drug safety update indicating the risk of intravascular insertion was published in 2016.We report the introduction of an implant into the ulnar nerve sheath. Introduction of a contraceptive implant into the medial aspect of the distal left upper arm was followed 5 min later by the patient reporting pins and needles in the arm and tips of the left ring and little fingers. The implant was not palpable. 2 h later loss of sensation was apparent in these fingers; clinical review was unrevealing. Ultrasound suggested the implant was lying between the ulnar nerve and blood vessel in the medial upper arm. At surgery the implant was found within the left ulnar nerve sheath and removed.3 months post surgery the numbness in the little finger had resolved but reduced sensation was still evident over the dorso-ulnar hand and distal forearm with hypersensitivity over the ulnar styloid, weakness was not apparent. Nerve conduction studies revealed the left dorsal ulnar sensory NAP was small when compared to the right side (13 vs. 31 microvolts).The left digit 5 sensory NAP was normal amplitude. Motor studies showed mild slowing in the left ulnar nerve around the elbow. While publications and warnings have highlighted the rare occurrence of intravascular insertion, the neurovascular bundle is at risk hence drug company advice to avoid the sulcus between biceps and triceps. This case indicates fascicular damage to the ulnar nerve.