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We herein present a case of right triquetral fracture with associated pisiform and flexor carpi ulnaris subluxation in a 29-year-old man. Initial radiography showed a right triquetral fracture. Computed tomography and magnetic resonance imaging demonstrated a triquetral fracture with a subluxated pisiform. Open reduction and lag screw fixation of the right triquetrum was performed, with good subsequent recovery of function. Although triquetral fracture with subluxation of the pisotriquetral joint is uncommon, attending clinicians should bear in mind the possibility of such an injury when managing traumatic ulnar-sided wrist pain.

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INTRODUCTION: The purpose of this paper is to share the outcome of cases of scaphoid non-union treated with 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) vascularised graft at our institution, as well as to identify the possible factors for the failure of the procedure. METHODS: This was a retrospective review of 13 cases of scaphoid fracture non-union treated with 1,2 ICSRA vascularised bone grafting from October 2000 to March 2003. A clinical and radiological review was conducted. Linear regression was performed in order to identify the factors associated with a negative outcome. RESULTS: Out of the 13 patients with scaphoid non-union, ten (77 percent) had avascular necrosis of the proximal pole. The patients were followed up for a mean duration of 13 (range 3-28) months. Ten out of the 13 (77 percent) patients achieved union. CONCLUSION: Our results are comparable to those reported by other studies and indicate that avascular necrosis was associated with failure to achieve union.

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Isolated trapezoid fractures are rare. We present a case of severe isolated trapezoid fracture associated with bone loss and proximal migration of the second metacarpal, which was treated successfully by open reduction and internal fixation with bone grafting and joint fusion.

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Trigger digit release is a common surgical procedure with a low complication rate. One of the potential complications is digital nerve injury. Though uncommon, digital nerve injury can be significantly symptomatic to the patient. We report a case of radial digital nerve neuroma formation following trigger release of the middle finger, which is considered to be safe, in terms of risk of digital nerve injury. We discuss our management of the complication, possible pitfalls which may have resulted in the complication in our case and offer possible means of overcoming these pitfalls.

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Malunions of forearm fractures in adults can present with limitation of forearm rotation, or as distal radioulnar joint instability with functional impairment. This contrasts with paediatric patients in whom malunions of similar severities are often better tolerated. We did a retrospective review of six adult patients after corrective forearm osteotomy for symptomatic malunited forearm shaft fractures. The corrective operations were done between 7 and 168 months after initial injury, using oblique or wedge osteotomies. Median follow-up was 22.5 months. The patients recovered well, with statistically significant improvement in forearm rotation and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. No significant complications occurred.

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A case of total ischemia of the triquetrum after a crushing injury to the right wrist by a dumbbell is reported. He was treated conservatively with splinting and analgesia. There was complete clinical and radiological recovery after a follow-up of one year.

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High pressure injection injuries are well known to cause significant injury to the hand, with high amputation rates and poor functional outcome. Surgical treatment consists of early aggressive debridement followed by secondary closure. Flap reconstruction is a reconstruction option which can increase the chance of digit salvage, as well as give an acceptable functional and cosmetic result. We review three cases of flap reconstruction following high pressure injection injuries, and discuss their role in the treatment of these injuries.

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We have studied the effects of sustained local anaesthesia on postoperative mobilization of the injured hand. Small epidural catheters were placed adjacent to the peripheral nerves providing sensation to the involved part of the hand under direct vision in the distal forearm. Repeated doses of 0.5% bupivacaine were then administered during mobilization therapy to relieve pain. Fourteen out of 24 digits (60%) recorded 30 degrees or more increases in active range of motion after bupivacaine injection. The cases that failed to improve had suffered severe injuries. Complications were few and were easily managed as the catheters were distal, superficial and accessible. This is an effective, specific and safe method of providing sustained postoperative analgesia for mobilization.

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Extraarticular pigmented villonodular synovitis (PVNS) is very rare in the distal forearm. There has only been one previous case report of this disease in the extensor tendons of a child. We report a case of PVNS of the distal forearm that presented as two nodules over the radial aspect and a separate nodule on the ulnar aspect beneath the flexor carpi ulnaris tendon. Surgical exploration revealed an extensive extraarticular PVNS over the first and second dorsal compartment extensor tendons. On the anterior aspect it extended in the deep plane between the flexor tendons and the pronator quadratus and encased the radial artery completely. Complete excision of the tumour with the radial artery was done.

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INTRODUCTION: Sauve-Kapandji procedure is used to treat distal radioulnar joint disorder. MATERIALS AND METHOD: Sixteen patients with distal radioulnar joint (DRUJ) disease treated with Sauve-Kapandji procedure between 1996 and 1998 were available for review at an average follow up period of 32.8 months,ranging from 24 to 48 months. The patients were young and the average age at the time of procedure was 33.6 years. There were eight cases of post-traumatic DRUJ arthritis, two cases of dislocation of DRUJ with malunion of radial fractures and six cases of rheumatoid patients with destruction of DRUJ. The distal end of ulnar shaft was stabilised with a sling created using radial 1/2 slip of extensor carpi ulnaris (ECU) tendon. Functional results were evaluated with Mayo wrist score. RESULTS: Fusion of DRUJ was achieved in all cases by two months. Excellent results were achieved in eight cases, good in six, fair in one and poor in one. All except one case gained increase range of forearm rotation. Complications included one case of closure of pseudoarthrosis and required excision of the ulna head to restore forearm rotation. CONCLUSION: Sauve-Kapandji procedure is recommended in young patients with distal radioulnar joint disorder.

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Major amputations remain a challenge to the replantation surgeon. Proper patient selection, good surgical skills, and cooperation among the patient, surgeon, and rehabilitation team help achieve a better outcome.

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INTRODUCTION: Kapandji described intra-focal pin fixation of distal radial fracture in which the pins pass through the fracture line and anchor to the far cortex. These pins aid reduction of the fracture and maintain reduction by buttressing the distal fragments. MATERIALS AND METHODS: Between January 1996 to December 1997, 186 distal radial fractures were treated with intra-focal pin fixation. One hundred and seventy-seven patients were available for review after an average follow-up of 30.8 months, ranging from 24 to 36 months. In 133 fractures, a trans-styloid pin was inserted to supplement the intra-focal pin fixation. The fractures were classified according to AO classification into 126 A2, 9 A3, 39 C1 and 3 C2. The anatomical results were evaluated by using Sarmento's criteria and the functional results by Mayo wrist score. RESULTS: Radiological union was achieved in 123 fractures by 2 months, 51 fractures by 3 months and 3 fractures by 4 months. Anatomical results were excellent in 46 fractures, good in 118, fair in 10 and poor in 3. Functional results were excellent in 54 cases, good in 109, fair in 9 and poor in 5. Complications included 2 cases of reflex sympathetic dystrophy and 2 cases of rupture extensor pollicis longus. CONCLUSION: Intra-focal pinning with or without supplementation of a trans-styloid pin is an effective method for treating unstable fractures of the distal radius.

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Between January and December 1992, 54 diabetic patients with 60 below knee amputations performed in the Department of Orthopaedic Surgery O, Singapore General Hospital were available for evaluation. The average follow-up period was 16.3 months with a range of 13 to 24 months. Five patients had stump necrosis and above knee amputation was performed. Eight patients had partial stump necrosis and required debridement with or without secondary procedures. The other patients had uneventful stump healing which was defined as healing of the stump wound without complications and remained intact for at least 6 months after surgery. Absence of popliteal pulse, presence of central cardiovascular disease and absence of intraoperative skin flap bleeding were found to be associated with higher incidence of stump necrosis.

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Seven patients who had free vascularized fibular grafts for bone defects > 6 cm (mean, 16.6 cm) were studied retrospectively. There were 5 cases of tumor, 1 pseudoarthrosis, and 1 chronic osteomyelitis. The average followup period was 9.2 years (range, 5.2-11.3 years). Of the 5 patients with grafts to the lower limb, 1 showed a 30% reduction in bone width as seen on anteroposterior radiographs, whereas 4 patients had increases ranging from 44% to 100% (average, 66%). There were 4 graft stress fractures, of which 1 developed eventual shortening of 2.5 cm. One graft had pseudoarthrosis involving the proximal graft-host junction that required secondary procedures with autogenous cancellous bone grafting, with eventual limb-length shortening of 5 cm. All other graft-recipient junctions healed primarily. The Functional Evaluation Score ranged from 60% to 100% of normal function (mean, 85%). Three patients were able to return to sports participation. Mild weakness of the extensor hallucis longus in the donor limb was observed in 5 patients. Two patients had mild loss of plantar flexion, and 4 had limitation of dorsiflexion affecting the ankle of the donor limb.

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