Objective. Carpal tunnel release surgery is a commonly performed procedure for alleviating symptoms of median nerve compression and restoring hand function. With pressure on theatre time these procedures are now commonly performed in a step-down out-patient facility under local anaesthetic. The choice of suture for skin closure in this procedure can impact the quality of wound healing, patient outcomes and the follow-up required however the question of the best type of suture remains unanswered. The purpose of this study was to compare the outcomes of absorbable and non-absorbable sutures using a randomised control trial design. Methods. Eighty patients diagnosed with bilateral carpal tunnel syndrome were enrolled and underwent outpatient carpal tunnel release surgery under local anaesthetic in a staged fashion. Random number generation was used to assign each hand to receive interrupted nylon or Vicryl Rapide sutures. Pre-operative data collection included patient demographics, ASA, inflammatory conditions, smoking status as well as a Boston Carpal Tunnel Questionnaire (BCTQ) for each hand. Patients were followed up at 2 and 6 weeks after each operation and the BCTQ was repeated along with the Patient and Observer Scar Assessment Scale and the VAS score for wound discomfort. This study has approval from the DHB ethics committee, Local Iwi, HDC and ANZ Clinical Trials:ACTRN12623000100695. Results. Statistical analysis assessed patient preference and the scores between the groups. Multi-variate analysis was performed to assess the factors that may be contributing to patient choice. Conclusion. Insights into patient preference and clinical outcomes associated with absorbable sutures and non-absorbable sutures in the setting of out-patient surgery are discussed

Background. It was hypothesised that preserving a layer of gliding tissue, the parietal layer of the ulnar bursa, between the contents of the carpal tunnel and the soft tissues incised during carpal tunnel surgery might reduce scar pain and improve grip strength and function following open carpal tunnel decompression. Methods. Patients consented to randomisation to treatment with either preservation of the parietal layer of the ulnar bursa beneath the flexor retinaculum at the time of open carpal tunnel decompression (57 patients) or division of this gliding layer as part of a standard open carpal tunnel decompression (61 patients). Grip strength was measured, scar pain was rated and the validated Patient Evaluation Measure questionnaire was used to assess symptoms and disability pre-operatively and at eight to nine weeks following surgery in seventy-seven women and thirty-four men; the remaining seven patients were lost to follow-up. Results. There was no difference between the groups with respect to age, sex, hand dominance or side of surgery. Grip strength, scar pain and Patient Evaluation Measure score were not significantly different between the two groups, although there was a trend towards poorer subjective outcome as demonstrated by the questionnaire in the group in which the ulnar bursa within the carpal tunnel had been preserved. Preserving the ulnar bursa within the carpal tunnel did however result in a lower prevalence of suspected wound infection or inflammation (p=0.04). Conclusions. In this group of patients, preservation of the ulnar bursa around the median nerve during open carpal tunnel release produced no significant difference in grip strength or self-rated symptoms. We recommend incision of the ulnar bursa during open carpal tunnel decompression to allow complete visualisation of the median nerve and carpal tunnel contents

A total of 38 patients with leprosy and localised nerve damage (11 median at the wrist and 37 posterior tibial at the ankle) were treated by 48 freeze-thawed skeletal muscle autografts ranging between 2.5 cm and 14 cm in length. Sensory recovery was noted in 34 patients (89%) and was maintained during a mean period of follow-up of 12.6 years (4 to 14). After grafting the median nerve all patients remained free of ulcers and blisters, ten demonstrated perception of texture and eight recognised weighted pins. In the posterior tibial nerve group, 24 of 30 repairs (80%) resulted in improved healing of the ulcers and 26 (87%) demonstrated discrimination of texture. Quality of life and hand and foot questionnaires showed improvement; the activities of daily living scores improved in six of seven after operations on the hand, and in 14 of 22 after procedures on the foot. Another benefit was subjective improvement in the opposite limb, probably because of the protective effect of better function in the operated side. This study demonstrates that nerve/muscle interposition grafting in leprosy results in consistent sensory recovery and high levels of patient satisfaction. Ten of 11 patients with hand operations and 22 of 25 with procedures to the foot showed sensory recovery in at least one modality

Carpal tunnel syndrome is the most frequent form of median nerve entrapment, accounting for 90% of all entrapment neuropathies. Routinely nerve conduction study (NCS) tests are ordered to confirm the diagnosis however; there are issues of long waiting periods and costs with it. We aimed to compare carpal tunnel questionnaire score (CTQS) by Kamath and Stothard (2003) to nerve conduction study result in the diagnosis of carpal tunnel syndrome. This prospective study involved analysis of data from all the patients referred to NHS Tayside (Dundee) hand clinic with signs and symptoms of Carpal tunnel syndrome (CTS) from September 2016 to February 2017. Statistical analysis was done using SPSS and sensitivity and specificity was calculated. The questionnaires were filled in by a team of specialist physiotherapists. Nerve conduction study tests were done by a team of consultant neurophysiologists. Both the groups were blinded to each other's assessment. We analysed 88 patients who filled in CTQS and also underwent NCS. We noted that CTQS of less than 3 correlated 100% to negative nerve conduction result. When the carpal tunnel questionnaire score was more than or equal to 5, 54 patients had positive NCS result and 6 patients had negative NCS result, giving a 90% predictability of a positive NCS result. Mean waiting period of carpal tunnel patients for NCS was 141 days. We noted from this prospective study that CTQS was sensitive enough to exclude carpal tunnel syndrome when the questionnaire score was less than 3. In addition, the questionnaire revealed a 90% probability of having carpal tunnel syndrome when CTQS was more than or equal to 5. Based on the present study, we would recommend that patients in grey zone of 3 to 4 on questionnaire should undergo NCS, resulting in only 20% of patients (based on the figures from the current study) being referred for NCS. The questionnaire can be used in primary health care or specialist physiotherapy screening clinic as a tool for diagnosing CTS with implications of cost saving and avoiding long waiting periods

Purpose of study:. The treatment goals in diaphyseal radius fractures are to regain and maintain length and rotational stability. Open reduction and plating remains the gold standard but carries the inherent problems of soft tissue disruption and periosteal stripping. Intramedullary nailing offers advantages of minimally invasive surgery and minimal soft tissue trauma. The purpose of this study is to describe the results of locked intramedullary nailing for adult gunshot diaphyseal radius fractures. Methods:. A retrospective review of clinical and radiological records was performed on patients with intramedullary nailing of isolated gunshot radius fractures between 2009 and 2013. Results:. Twenty-two nails were inserted in 22 patients, all males with a mean age of 28.9 years (range 19–40). Follow-up was for an average period of 11 weeks (range 6–24). One patient had a median nerve palsy and 2 a posterior interosseous nerve palsy pre-operatively. All operations were performed within 3 to 12 days of the injury. No primary bone grafting was performed. All fractures united with the index procedure. Average time to union was 10 weeks (range 8–24). Fourteen patients (64%) had their radial bow restored and maintained; these patients had minimal comminution in the middle to distal third of the radius. The bow could not be satisfactorily restored in severely comminuted fractures in the proximal third of the radius. Using the Anderson classification outcome was excellent in 14 patients (64%), satisfactory in 6 (27%) and unsatisfactory in 2 (9%). There were no complications associated with the surgery and one patient required nail removal for implant migration. Conclusion:. Intramedullary nail fixation of gunshot radius fractures has shown promising results in our hands with no significant complications. The fracture site and zone of comminution directly influenced our ability to restore radial bow

Aim. Fixation of distal radial fractures via the volar approach has become a commonly performed procedure over the past few years. This study is to highlight potential pitfalls with this ‘everyday’ procedure and to perhaps temper over-enthusiasm for plating all wrist fractures. Method and materials. 164 consecutive cases of wrist fracture treated by means of fixed angle volar fixation were looked at. In each case any recorded complication prior to completion of treatment was documented. The complications were divided into major and minor depending on the severity and long-term outcome and overall result. Results. With critical analysis there were 32 major complications: 12 required further surgery; 1 iatrogenic radial artery injury; 1 iatrogenic palmar branch of median nerve injury; 2 complex regional pain syndromes; 16 patients with less than 60 arc of movement. In addition 12 minor complications including hypertrophic scars, suture abscess and intermittent minor discomfort were also recorded. Conclusion. While volar distal radial fixation is well accepted and indeed commonly performed, the procedure is not without complications. We must pay meticulous attention to detail and technique to optimise results

Introduction. Management of painful scarring of a nerve after surgery or trauma is challenging. Wrapping with a vein or adhesion barriers such as silicone have been reported with some success. This is a retrospective review of application of a xenograft collagen wrap around a peripheral nerve following neurolysis. There is no report in English literature of use of a collagen wrap for this purpose. Materials/Methods. 12 patients underwent use of the Neuragen™ bovine collagen nerve conduit or NeuraWrap™ (Integra Life Sciences, Plainsboro, NJ) over a 6 year period. The causes were, scarring after carpal tunnel (n=5) or cubital tunnel release (n=3) or partial nerve injury (n=4, radial, median, dorsal ulnar, digital nerves). Follow up ranged from 6–12 months. Outcome was assessed by VAS or functional improvement. Results. No patient developed adverse reaction to the xenograft conduit. All 10 patients with painful scarring reported improvement of pain with reduction in mean VAS from 7 to 2 at final follow-up. The patient with radial palsy with scarring of the nerve had full recovery of radial nerve function by 6 months. The partially injured sensory branch of median nerve and digital nerve regained normal 2PD. The patients with scarring after decompression surgery had improvement in pain and range of motion of adjacent joints but did not show any change in clinical neurological status. Conclusions. A collagen conduit wrapped around a partially injured or scarred nerve is safe and associated with clinical improvement in pain and nerve function

The aim of this study is to compare functional, clinical and radiological outcomes in K-wire fixation versus volar fixed-angle plate fixation in unstable, dorsally angulated distal radius fractures. Fifty-four adult patients with an isolated closed, unilateral, unstable, distal radius fracture were recruited to participate in the study. Only dorsally displaced fractures with no articular comminution were included. Patients were randomised to have their fracture treated with either closed reduction and K-wire fixation (3 wires) or fixed-angle volar plating. Both groups were immobilised in a below elbow cast for six weeks. The wires removed in the outpatients at six weeks and both groups were referred for physiotherapy. Independent clinical review was performed at three and six months post injury. Functional scoring was performed using the DASH and Gartland and Werley scoring systems. Radiographs were evaluated by an independent orthopaedic surgeon. Twenty-five patients were treated with a plate and twenty-nine with wires. There were no complications in the plate group. There were 9 complications in the K-wire group with 3 patients requiring a second operation (1 corrective osteotomy for malunion, 1 median nerve decompression and 1 retrieval of a migrated wire). The remaining complications included: 5 pin site infections (3 treated with early pin removal and 2 with oral antibiotics only), and 1 superficial radial nerve palsy. There were no tendon ruptures. Both groups scored satisfactory functional results with no statistical difference. There was a statistically significant difference in the radiological outcomes with the plate group achieving better results. We conclude that in unstable dorsally angulated distal radius fractures volar fixed-angle plate fixation is able to achieve comparable functional results to K-wire fixation with better radiological results and fewer complications. This has resulted in a change in our clinical practice

Hypothesis. Does the result of steroid injection in the carpal tunnel in a patient with recurrent carpal tunnel symptoms provide a good predictor of the outcome of later carpal tunnel release (CTR). Methods. A retrospective review of all patients who underwent revision CTR for recurrent or persistent carpal tunnel syndrome (CTS) over a two year period was conducted. A total of 23 patients and 28 wrists met inclusion criteria. Patients were evaluated to determine if pre-operative factors or result of injection predicted the outcome of revision CTR. A multivariate logistic regression analysis (MLRA) was used to predict surgical success when multiple pre-operative findings were considered. Results. No patient characteristic or physical exam finding was found to predict successful revision CTR. Twenty-two (86.4%) of patients who had relief from injection had symptom relief/improvement with revision CTR whereas only 4 (13.6%) were not improved by the surgery; the difference was not statistically significant. The sensitivity and positive predictive value for injection alone predicting outcome of revision CTR was 86.4%. MLRA combining injection results with physical exam findings (Numbness and/or motor weakness in median nerve distribution, Positive Durkin's, and Positive Phalen's test) provided a sensitivity of 100% and specificity of 80%. Conclusions. In contrast to primary CTS, cortisone injection into the carpal tunnel in the face of recurrent CTS is not, by itself, a statistically significant predictor of successful revision surgery. However, patients with a positive result from injection had an 86.4% success with revision CTR with an average DASH score of 28.87. Relief from injection as a diagnostic test for success from revision CTR was found to have both high sensitivity and positive predictive value. Coupled with the components of the physical examination, injection provides a good screening test to establish success with revision CTR, sensitivity of 100% and specificity of 80%

We reviewed 234 benign solitary schwannomas treated between 1984 and 2004. The mean age of the patients was 45.2 years (11 to 82). There were 170 tumours (73%) in the upper limb, of which 94 (40%) arose from the brachial plexus or other nerves within the posterior triangle of the neck. Six (2.6%) were located within muscle or bone. Four patients (1.7%) presented with tetraparesis due to an intraspinal extension.

There were 198 primary referrals (19 of whom had a needle biopsy in the referring unit) and in these patients the tumour was excised. After having surgery or an open biopsy at another hospital, a further 36 patients were seen because of increased neurological deficit, pain or incomplete excision. In these, a nerve repair was performed in 18 and treatment for pain or paralysis was offered to another 14.

A tender mass was found in 194 (98%) of the primary referrals. A Tinel-like sign was recorded in 155 (81%). Persistent spontaneous pain occurred in 60 (31%) of the 194 with tender mass, impairment of cutaneous sensibility in 39 (20%), and muscle weakness in 24 (12%).

After apparently adequate excision, two tumours recurred. No case of malignant transformation was seen.