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INTRODUCTION: Computer vision syndrome (CVS) is a condition in which a person experiences one or more of eye symptoms as a result of prolonged working on a computer. OBJECTIVES: To determine the prevalence of CVS symptoms, knowledge and practices of computer use in students studying in different universities in Malaysia, and to evaluate the association of various factors in computer use with the occurrence of symptoms. MATERIAL AND METHODS: In a cross sectional, questionnaire survey study, data was collected in college students regarding the demography, use of spectacles, duration of daily continuous use of computer, symptoms of CVS, preventive measures taken to reduce the symptoms, use of radiation filter on the computer screen, and lighting in the room. RESULTS: A total of 795 students, aged between 18 and 25 years, from five universities in Malaysia were surveyed. The prevalence of symptoms of CVS (one or more) was found to be 89.9%; the most disturbing symptom was headache (19.7%) followed by eye strain (16.4%). Students who used computer for more than 2 hours per day experienced significantly more symptoms of CVS (p=0.0001). Looking at far objects in-between the work was significantly (p=0.0008) associated with less frequency of CVS symptoms. The use of radiation filter on the screen (p=0.6777) did not help in reducing the CVS symptoms. CONCLUSION: Ninety percent of university students in Malaysia experienced symptoms related to CVS, which was seen more often in those who used computer for more than 2 hours continuously per day.

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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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This study evaluates various wrist and thumb positions for tensioning the extensor indicis proprius when transferred to the extensor pollicis longus tendon to determine which positions provide optimum passive range of flexion and extension of the thumb. In five adult cadaver upper limbs, transfer of the extensor indicis proprius to the extensor pollicis longus was simulated. The limbs were fixed with the elbow in 90 degrees flexion and the forearm and wrist in neutral. Surface bone markers were digitized to determine the thumb and wrist positions in three-dimensional space and their intersegmental joint angles. Twelve combinations of thumb (the interphalangeal and metacarpophalangeal joints) and wrist positions for tensioning were tested. A fixed tension of 80 N was applied to the tendon ends for each of the tensioning positions and during the transfer to ensure that the tendon remained taut. A wrist tenodesis effect was used subsequently to assess the passive range of thumb motion as an indicator of the outcome of the transfer. The results showed that the better tensioning position was with the thumb fully extended and the wrist in neutral. In six patients in whom an extensor indicis proprius to extensor pollicis longus transfer was done, the tendons were tensioned with the thumb in full extension and the wrist in neutral. A prospective review and functional assessment at an average of 18.6 months' followup was done. No significant differences between the surgically treated and normal thumbs were seen for the Jebsen Taylor, 9-peg, and grip and pinch strength tests. The study suggests that in an extensor indicis proprius to extensor pollicis longus transfer, tensioning of the tendons with the thumb in full extension and the wrist in neutral gives good thumb flexion and extension range.

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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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Neuromas can be painful and physically and psychologically disabling. Among the many methods of treatment available, translocation away from noxious stimuli, such as implantation in muscle or bone, has been used. Veins are easily available and accessible to nerves. The outcome of a nerve ending implanted into a vein and the effects of the implanted nerve on the vein have not been studied. This study evaluated neuroma prevention with a new technique that involves implanting a nerve ending into a vein. The medial branches of the right femoral nerve of 20 rats were transected at midthigh level. The distal segments were excised. The proximal segments were implanted into the femoral vein. The epineurium was sutured to the tunica adventitia using interrupted 10-0 Ethilon sutures. The left side served as controls where the proximal nerve stumps were left lying in their beds. The animals were sacrificed 12 weeks after the operation. Histologic analysis of 12 controls showed neuromas. Twelve implanted nerves showed neuromas that were smaller than those of the controls. The difference was statistically significant. The regenerated nerve fibers were found within the adventitia and muscular wall of the vein. There was no extension of nerve tissue into the vessel lumen and no thrombosis of the vein. Electron microscopic study on the other eight rats showed abnormal large myelinated fibers in the controls and in the implanted nerves. The fibers in the implanted group were degenerated.

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INTRODUCTION: Joint reconstruction following trauma at the proximal interphalangeal or metacarpophalangeal levels remain a difficult problem in hand surgery. Function of the injured finger depends on the mobility and stability at these joints. In fingers amputated at these levels with joint destruction, the hand surgeon can perform either an arthrodesis or a replacement arthroplasty (either as an emergency or as a secondary procedure). Arthrodesis will give a stable pain-free joint, but at the cost of sacrificing mobility and even cosmesis. CLINICAL PICTURE: We report a case of traumatic amputation through the proximal interphalangeal joint (PIPJ) of the right middle finger. Arthrodesis of the PIPJ in extension using Kirschner wires was performed following replantation due to extensive periarticular soft tissue loss, so as to enable repair and healing of the extensor mechanism. This results in poor cosmesis and stiffness of finger interfering with function three months after surgery. TREATMENT AND OUTCOME: A prosthetic total joint replacement of PIPJ was performed as a secondary procedure. Satisfactory hand function and finger movement ensued two years after the procedure, with no loosening or infection of the implant. CONCLUSION: Total interphalangeal joint arthroplasty is a useful secondary procedure, after the initial replantation, for finger amputation with periarticular soft tissue loss.

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AIM OF STUDY: A retrospective review on the outcomes of four floating shoulder, ipsilateral scapular neck and clavicular fractures, treated with open reduction and internal fixation of the clavicle alone using plate and screws. METHODS: All patients were evaluated by interview, physical examination and radiological examination at an average follow up period of 3.3 years (range: 2-4 years). Functional outcomes were rated using Rowe's score. RESULTS: Radiological union of both fractures occurred at an average of 2.8 months (range: 8-12 weeks). Excellent result was seen in three cases and good in one. CONCLUSION: Plating of clavicle alone restored stability of shoulder and allowed early range of motion exercises. All cases gained good and excellent function.

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Neuroma can be painful and physically and psychologically disabling. Among the many methods of treatment available, one of the more successful is centrocentral nerve union with an autologous graft. However, it cannot be used in small nerves that lack two fascicles. This study evaluated neuroma prevention in an end-to-side anastomosis, a new technique applicable to all nerves. The lateral branch of the right sciatic nerve in 20 rats was transected at the midthigh level. The proximal segment was looped back to the main nerve and an end-to-side epineural anastomosis was performed. The lateral branch of the left sciatic nerve was transected to serve as a control, and the proximal nerve stump was closed by interrupted epineural sutures. The animals were sacrificed 12 weeks after the operation. Histologic analysis of specimens from the 12 controls showed neuroma formation. Specimens from 12 side-to-end anastomoses contained regenerated nerve tissues and formed smaller masses compared with that of the controls. The regenerated tissues at the anastomoses were orientated more orderly than were tissues from the controls in 75% of cases. The differences were statistically significant. Electron microscopic study on specimens from the remaining eight controls showed the presence of abundant large abnormal myelinated fibers (10-15 microns) with thick irregular myelin sheaths scattered among smaller myelinated fibers (2-10 microns) that had thin myelin sheaths. In the remaining eight end-to-side anastomoses, large abnormal myelinated fibers were absent. The myelinated fibers were 2 to 10 microns in diameters and had a normal appearance with thin myelin sheaths. End-to-side anastomosis formed a smaller mass of regenerated nerve tissues. Ultrastructurally they were formed better and orientated more orderly resembling normal nerve.

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A 51-year-old patient suffered a near amputation of the right arm. Replant of the arm was performed and the brachial artery was grafted with a vein. A week later, there was severe bleeding from a leaking pseudoaneurysm at the proximal junction of the grafted artery. This was managed with embolization using coils and resulted in successful obliteration of the pseudoaneurysm without necrosis of the replanted arm.

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Extraarticular form of pigmented villonodular synovitis is rare and usually presents as an extension of a primary intraarticular process. Purely extraarticular lesions are even less common. Pigmented villonodular synovitis involving the synovium around the tendoachilles has not been reported. We report a unique case in a healthy 22-year-old male who presented with a swelling around the tendoachilles for a year. It became painful following a traumatic event 4 weeks prior to consultation. Magnetic resonance imaging (MRI) revealed an extraarticular soft tissue mass moulded to the posterior surface of the calcaneum. It was excised and histology revealed pigmented villonodular synovitis.

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A post-menopausal patient with bilateral primary osteoarthritis of the first carpometacarpal joint (CMCJ) was treated by 2 different surgical techniques. The non-dominant left CMCJ was arthrodesed in 1992 while excision of trapezium and tendon suspensionplasty was done for the dominant right side in 1997. She reported good pain relief with both procedures and she was able to fully oppose both thumbs at 6 years after arthrodesis and 1 year after arthroplasty. The grip and pinch strength was stronger on the arthrodesed side while hand function tests revealed the arthroplasty side to be more dexterous. Subjectively, she preferred the right thumb. Radiographs showed no peritrapezial arthritis in the arthrodesed CMCJ and no proximal migration of the metacarpal on the reconstructed side. Both procedures offered excellent relief of symptoms and she was able to return to work as a machine operator.

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Thoracoscopic sympathectomy is an acceptable form of treatment for palmar hyperhidrosis. Many authors have reported favourable results. Complications range from pneumo-haemothorax, Horner's syndrome, compensatory hyperhidrosis and bleeding. Plas et al reported 2.7% of the procedures had complications requiring intervention and 9.7% had non-interventive complications. There have been isolated reports of other rare complications including false aneurysm of intercostal artery, inferior brachial plexus injury and abnormal suntanning. We report an unusual case of isolated extensor pollicis longus paralysis after a thoracoscopic sympathectomy for palmar hyperhidrosis, in a fit young male. Such complications have not been previously reported. We recognise that such isolated nerve injury is uncommon.

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We report a case in which a groin flap was used to cover the degloved fingers. Subsequently, Ilizarov's technique was used to expand the groin flap before the syndactylized digits were separated.

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Aggressive fibromatosis is a locally infiltrative fibroblastic tumour that arises from fascial planes of soft tissue but does not metastasize. It is known to invade muscle, subcutaneous tissue and neurovascular structures. However, bone involvement is very rare and there has been few reports of bone involvement. We present a case of a young man with aggressive fibromatosis of the right lower leg with fibula involvement.

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The use of the abductor digiti minimi transfer to restore opposition in patients with hypoplasia of the thumb has been widely described in the literature. It has been found to be effective in restoring abduction, but less so in restoring the rotational component of opposition. In cases where there is concomitant supination of the thumb, abductor digiti minimi transfer alone would not result in a good pinch as the thumb pulp is rotated away from the opposing finger. We present a case of a 6-year-old girl with a hypoplastic supinated left thumb which resembled a digit. There was also hypoplasia of the index finger. The hand had poor function as a result of lack of opposition of the thumb. The thumb function was restored by combining a derotational osteotomy (80 degrees) with the abductor digiti minimi transfer originally described by Huber. Patient was able to hold small object using key pinch and she could pinch with opposition of the thumb pulp to the middle, ring and little finger pulps when reviewed 2 years post-surgery.

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A 24-year-old man presented with a stress fracture over his left tibia following an infantry training 6 years ago. X-rays of his left tibia revealed a stress fracture and bone scan showed marked tracer uptake at the fracture. He was treated conservatively but his pain persisted since then. Five years later, X-rays and histological examination confirmed the diagnosis of osteoid osteoma. The stress fracture may act as a trigger for the formation of osteoid osteoma and caused a delay in diagnosis.

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A 25-year-old man presented with hook nail and painful atrophic pulp over the tip of the terminal phalanx of the right thumb 3 months following a crush injury. Lateral nail folds were poorly defined and the nail was curved. The patient was unable to pick up objects with a precision pinch. Reconstruction was performed with Atasoy antenna procedure. One year later, normal pulp contour of the injured thumb was restored and appearance of the nail was normal.

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