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The arterial anatomy, coverage area, and potential donor site morbidity of the anconeus muscle flap are described. Using 17 cadaveric upper extremities, we investigated the muscle's arterial anatomy in 12 specimens and defined the coverage area of the anconeus flap in 5 specimens. We also reviewed the records of 9 patients who underwent a pedicle anconeus muscle flap for elbow coverage to assess clinical results of the procedure. The anconeus muscle is supplied from 3 arterial pedicles: the recurrent posterior interosseus artery, the medial collateral artery, and the posterior branch of the radial collateral artery. The recurrent posterior interosseus artery and the medial collateral artery were present in all dissected cadavers and consistently anastomosed with each other underneath the anconeus muscle. By harvesting the muscle on the medial collateral artery, the anconeus muscle flap can be expected to cover a 7.3 cm2 defect over the radiocapitellar joint, a 6.1 cm2 defect over the distal triceps tendon, and a 7.2 cm2 defect over the olecranon. In this series, none of the patients experienced loss of elbow motion, stability, or extension strength. The results of this study indicate that the anconeus can be harvested with minimal risk of morbidity and provides effective coverage for soft tissue defects of the elbow.

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The hypothenar fat pad flap interposes adipose tissue from the hypothenar eminence between the median nerve and overlying transverse carpal ligament and surgical scar. This retrospective study reviews 62 hands in 58 patients (46 non-workers' compensation and 16 workers' compensation) with recurrent symptoms after failed open carpal tunnel release who underwent revision carpal tunnel decompression and in whom a hypothenar fat pad flap was used. The follow-up period averaged 33 months. Patient satisfaction was 6 in the non-workers' compensation group and 4 in the workers' compensation group. Average time to return to work for the non-workers' compensation group was 12 weeks, compared to 37 weeks for the workers' compensation group. Study results indicate that the hypothenar fat pad flap produces excellent results in procedures designed to alleviate recalcitrant idiopathic carpal tunnel syndrome.

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Open decompression of the median nerve generally is so effective that little is mentioned of the surgical treatment options for recalcitrant or unrelieved carpal tunnel syndrome. The hypothenar fat pad flap has been shown to be a reliable local source of well-vascularized adipose tissue that can be used for coverage of the median nerve during re-exploration of recurrent or persistent idiopathic carpal tunnel syndrome. The hypothenar fat pad flap is a technically simple procedure that allows the fat pad to be mobilized easily and placed across the palm as a barrier between the nerve and the radial leaf of the transverse carpal ligament, effectively preventing median nerve readherence. This flap hopefully will improve the tissue environment for the median nerve, permitting it to have normal excursion during wrist motion. Our results to date have been better than previously described for other techniques. We believe the hypothenar fat pad flap should be considered in the hand surgeon's armamentarium for recalcitrant idiopathic carpal tunnel syndrome.

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Cubital tunnel syndrome is reported to be the second most common entrapment neuropathy in the upper extremity. We can now easily appreciate how ulnar nerve pathology can occur at the elbow in the absence of trauma. We can also appreciate the role of conservative management in the treatment of a condition that previously was thought to be a surgical disease.

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Persistent symptoms following surgical release for entrapment neuropathy are a source of great frustration for both the surgeon and patient. Fundamentals of management require review of the patient's history and examination in an attempt to confirm the initial diagnosis and to rule out elements of the differential diagnosis. Persistent symptomatology may be a reflection of an incorrect diagnosis or double crush syndrome. If the initial diagnosis can be reconfirmed, then it is reasonable to reinstitute conservative management and to objectively re-evaluate the entrapment neuropathy by electrodiagnostic testing. This electrodiagnostic testing must be comprehensive in order to evaluate all potential entrapment neuropathies within the differential diagnosis. Individuals who demonstrate a transient response to conservative management or evidence of further deterioration on electrodiagnostic testing may be considered candidates for revision surgery. These individuals may be found to have had an incomplete release, error of technique, or iatrogenic compression. Persistence of symptoms on the basis of end-stage disease must be recognized to avoid further surgery that is unlikely to be of benefit to the patient. If surgical intervention is chosen, the procedure must address issues of residual compression, preservation of nerve vascularity, prevention of neurodesis, and protective padding in the presence of nerve hypersensitivity.

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A case of functional replacement for traumatic thenar muscle loss using an innervated pronator quadratus free flap is reported. The pronator quadratus matched the damaged thenar muscle in size and excursion and provided satisfactory thumb opposition in long-term follow-up.

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Tumors of peripheral nerves in the upper extremity are uncommon. All too frequently this diagnosis is made intraoperatively or postoperatively with the potential to compromise the outcome of treatment. An appropriate index of suspicion is necessary for inclusion of peripheral nerve tumors and a differential diagnosis of an upper extremity mass. Knowledge of this group of neoplasms will help direct evaluation and treatment.

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This study aimed to determine whether there is an age below which flexor tenolysis may not be beneficial and whether there is any detriment to waiting for a more appropriate age. In this study, patients in their first decade had minimal improvement in their active flexion after flexor tenolysis. Six patients were tenolysed more than 1 year after their original operation and none appeared to have been compromised by the prolonged interval between injury repair and tenolysis. Significant improvement in active flexion after tenolysis can be confidently expected only in children over 11 years old.

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We undertook this study to better define the anatomy of the radial aspect of the wrist and to establish a zone of safety for the placement of Kirschner wires, cannulated screws, and arthroscopes within the anatomic snuff box. Twenty fresh frozen cadaver upper extremities underwent placement of three percutaneous Kirschner wires under fluoroscopic guidance through the anatomic snuff box. In each extremity, one Kirschner wire was placed into the radial styloid, one across the scaphocapitate joint, and one across the scapholunate joint. A safe zone of mean 0.68 sq cm was found deep to the subcutaneous tissue bordered by the radial styloid, the first dorsal compartment, the radial artery, and the superficial radial nerve. Kirschner wires placed distal, dorsal, or palmar to the borders of the safe zone were at great risk of injuring neurovascular structures. To minimize the risk of injury to adjacent structures, we advise a limited incision in the safe zone with blunt dissection to the wrist capsule. Though improved anatomic understanding, we established a new location for the arthroscopic 1,2 portal within the snuff box.

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A retrospective review of 175 patients treated with forearm bone plating for acute diaphyseal fractures, nonunions, and malunions was undertaken to identify problems related to plate removal as opposed to plate retention. One hundred thirteen patients retained their forearm plates, of which five patients experienced complications related to the plate, including infection, bone failure, plate failure, and loosening. Patients retaining forearm bone plates reported minimal discomfort or functional limitation. Sixty-two patients had plate removal at an average of 19 months after insertion. Ten patients suffered major complication, including seven refractures through screw holes, osteotomy, or original fracture sites. Fractures occurred at an average of six months after plate removal. The difference in complication rates between patients treated with plate removal and patients retaining plates was statistically significant.

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Preoperative factors and outcome were studied after lunate decompression for Kienböck's disease. Twenty-three patients treated with radial shortening or scaphoid-trapezium-trapezoid fusion were evaluated. The mean follow-up was 59 months. Neither good nor excellent outcomes were found with either lunate-preserving procedure when the preoperative radioscaphoid angle was greater than 60 degrees. Outcomes in the radial shortening osteotomy group were superior to those in the group treated with scaphoid-trapezium-trapezoid fusion. Lunate collapse was not prevented by either treatment method. Lunate index, carpal height, and staging did not correlate with outcome. Measurement of radioscaphoid angle provides predictive information regarding the outcome of stage III (Decoulx/Lichtman) Kienböck's disease treated with radial shortening or scaphoid-trapezium-trapezoid fusion.

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Potential complications after replantation surgery are numerous and varied in their nature. The average replantation patient can expect somewhere between two to three subsequent operations to maximize function. Many surgical complications and unsatisfactory functional outcomes can be avoided through careful assessment of patients and their injuries.

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A case in which a patient sustained a closed rupture of the radial nerve at the lateral intramuscular septum from a traction injury is presented. No humeral fracture occurred, and the patient regained substantial function after delayed primary repair.

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