Anatomical variations of the lumbrical muscles causing carpal tunnel syndrome

Many anatomical variations exist in and around the carpal tunnel. However, symptomatic anomalies causing carpal tunnel syndrome is rare. Additionally, carpal tunnel surgery is considered a simple operation commonly done by junior surgeons who are usually unaware of variations resulting in unfavorable surgical outcomes. We highlight a case of lumbrical muscle variation causing carpal tunnel syndrome. A 73-year-old male presented with numbness and pain of both hands associated with abnormal fullness over both wrists and distal forearms. Initially the right hand was numb and subsequently a year later, the left hand became numb. Physical examination was positive for Durkan, Phalen and Tinel signs at the carpal tunnel. Magnetic Resonance Imaging (MRI) showed abnormal muscle tissues in the carpal tunnel. During the carpal tunnel release and exploratory surgery, we noted an abnormally proximal origin of the lumbrical muscles in the forearm rather than the typical palmar origin. He also had lumbrical muscle hypertrophy in the left side. These two factors resulted in overcrowding within the carpal tunnel. Post-operatively the patient recovered well with pain relief and gradual improvement of his numbness. Variations in the anatomy of the lumbrical muscles is not uncommon and may result in carpal tunnel syndrome. Hence, carpal tunnel release surgeries may not be as straight forward as expected and surgeons should be aware of this possibility

Educating Future Generations of Surgeons across Borders:Novel Global Linked Hybrid Live Cadaveric Peripheral Nerve Surgical Training Course

Background: This study aimed to evaluate a novel, multi-site, technology-facilitated education and training course in peripheral nerve surgery. The program was developed to address the training gaps in this specialized field by integrating a structured curriculum, high-fidelity cadaveric dissection, and surgical simulation with real-time expert guidance. Methods: A collaboration between the Global Nerve Foundation and Esser Masterclass facilitated the program, which was conducted across three international sites. The curriculum was developed by a panel of experienced peripheral nerve surgeons and included both text-based and multimedia resources. Participants’ knowledge and skills were assessed using pre- and postcourse questionnaires. Results: A total of 73 participants from 26 countries enrolled and consented for data usage for research purposes. The professional background was diverse, including hand surgeons, plastic surgeons, orthopedic surgeons, and neurosurgeons. Participants reported significant improvements in knowledge and skills across all covered topics (p &lt; 0.001). The course received a 100% recommendation rate, and 88% confirmed that it met their educational objectives. Conclusions: This study underscores the potential of technology-enabled, collaborative expert-led training programs in overcoming geographical and logistical barriers, setting a new standard for globally accessible, high-quality surgical training. It highlights the practical and logistical challenges of multi-site training, such as time zone differences and participant fatigue. It also provides practical insights for future medical educational endeavors, particularly those that aim to be comprehensive, international, and technologically facilitated.</p

Use of albumin infusion for cirrhosis-related complications. An international position statement

Background &amp; Aims: Numerous studies have evaluated the role of human albumin (HA) in managing various liver cirrhosis-related complications. However, their conclusions remain partially controversial, probably because HA was evaluated in different settings, including indications, patient characteristics, and dosage and duration of therapy. Methods: Thirty-three investigators from 19 countries with expertise in the management of liver cirrhosis-related complications were invited to organise an International Special Interest Group. A three-round Delphi consensus process was conducted to complete the international position statement on the use of HA for treatment of liver cirrhosis-related complications. Results: Twelve clinically significant position statements were proposed. Short-term infusion of HA should be recommended for the management of hepatorenal syndrome, large volume paracentesis, and spontaneous bacterial peritonitis in liver cirrhosis. Its effects on the prevention or treatment of other liver cirrhosis-related complications should be further elucidated. Long-term HA administration can be considered in specific settings. Pulmonary oedema should be closely monitored as a potential adverse effect in cirrhotic patients receiving HA infusion. Conclusions: Based on the currently available evidence, the international position statement suggests the potential benefits of HA for the management of multiple liver cirrhosis-related complications and summarises its safety profile. However, its optimal timing and infusion strategy remain to be further elucidated. Impact and implications: Thirty-three investigators from 19 countries proposed 12 position statements on the use of human albumin (HA) infusion in liver cirrhosis-related complications. Based on current evidence, short-term HA infusion should be recommended for the management of HRS, LVP, and SBP; whereas, long-term HA administration can be considered in the setting where budget and logistical issues can be resolved. However, pulmonary oedema should be closely monitored in cirrhotic patients who receive HA infusion

Diagnostic accuracy of non-invasive tests to screen for at-risk MASH—An individual participant data meta-analysis

\ua9 2024 The Authors. Liver International published by John Wiley &amp; Sons Ltd.Background &amp; Aims: There is a need to reduce the screen failure rate (SFR) in metabolic dysfunction-associated steatohepatitis (MASH) clinical trials (MASH+F2-3; MASH+F4) and identify people with high-risk MASH (MASH+F2-4) in clinical practice. We aimed to evaluate non-invasive tests (NITs) screening approaches for these target conditions. Methods: This was an individual participant data meta-analysis for the performance of NITs against liver biopsy for MASH+F2-4, MASH+F2-3 and MASH+F4. Index tests were the FibroScan-AST (FAST) score, liver stiffness measured using vibration-controlled transient elastography (LSM-VCTE), the fibrosis-4 score (FIB-4) and the NAFLD fibrosis score (NFS). Area under the receiver operating characteristics curve (AUROC) and thresholds including those that achieved 34% SFR were reported. Results: We included 2281 unique cases. The prevalence of MASH+F2-4, MASH+F2-3 and MASH+F4 was 31%, 24% and 7%, respectively. Area under the receiver operating characteristics curves for MASH+F2-4 were.78,.75,.68 and.57 for FAST, LSM-VCTE, FIB-4 and NFS. Area under the receiver operating characteristics curves for MASH+F2-3 were.73,.67,.60,.58 for FAST, LSM-VCTE, FIB-4 and NFS. Area under the receiver operating characteristics curves for MASH+F4 were.79,.84,.81,.76 for FAST, LSM-VCTE, FIB-4 and NFS. The sequential combination of FIB-4 and LSM-VCTE for the detection of MASH+F2-3 with threshold of.7 and 3.48, and 5.9 and 20 kPa achieved SFR of 67% and sensitivity of 60%, detecting 15 true positive cases from a theoretical group of 100 participants at the prevalence of 24%. Conclusions: Sequential combinations of NITs do not compromise diagnostic performance and may reduce resource utilisation through the need of fewer LSM-VCTE examinations

Complete Brachial Plexus Injury - An Amputation Dilemma. A Case Report

Brachial plexus injuries with intact yet flail limb presents with problems of persistent neuropathic pain and recurrent shoulder dislocations, that render the flail limb a damn nuisance. As treating surgeons, we are faced with the dilemma of offering treatment options, bearing in mind the patient’s functional status and expectations. We present a case of a 55-year old housewife with complete brachial plexus injury begging for surgical amputation of her flail limb, 6 years post-injury. Here we discuss the outcome of transhumeral amputation and the possibility of offering early rather than delayed amputations in this group of patients

A Palmar Lipoma with Median and Ulnar Nerve Compressive Symptoms

Although lipoma is common in the upper limbs, it rarely occurs in the palm, and usually does not compress the surrounding structures. Here, we report a patient presenting with compressive neuropathy of the ulna and median nerves secondary to a palmar lipoma. Surgical excision led to full neurological recovery

Adhesions as an uncommon complication of k-wiring in paediatric phalangeal fractures

Paediatric hand fractures are common and prompt management is mandatory to achieve a good functional outcome. However many fail to realize that treating a fracture does not only involve bones but the soft tissues, as well. K-wiring itself can be difficult with multiple attempts inadvertently injuring the flexor or extensor tendons and resulting in adhesions. We highlight this possible complication of K-wiring which we believe is under reported due to the perception that K-wiring is a simple procedure. We present a case of a 9-year-old child, who sustained a closed displaced fracture of the base of the proximal phalanx (Salter Harris type 2) of the left index finger. He underwent percutaneous K-wiring but was complicated with severe adhesions of the flexor digitorum profundus (FDP) and flexor digitorum superficialis tendons (FDS). He was unable to flex the proximal and distal interphalangeal joints of the affected finger. We subsequently performed tendon adhesiolysis twice together with A2 pulley reconstruction, to restore movement of the finger. K-wiring of the fingers are not just simple bony procedures but also involve soft tissue components which can be prone to adhesions

Splinting after Carpal Tunnel Release: Does it really Matter?

Splinting of the wrist after carpal tunnel release (CTR) has been practised by many surgeons especially in North America. The main reason was to prevent possible adverse events of bowstringing of flexor tendons and the median nerve, pillar pain, entrapment of the median nerve in scar tissue and wound dehiscence. Studies on the effect of splinting after standard CTR have had dismal results. The duration of splinting in standard CTR has been either too long (for 2-4 weeks) or too short (48 hours only). The aim of our study was to compare the effects of post-operative splinting for a duration of one week with no splinting. Methods: All 30 of our patients underwent a standardized limited open CTR by a designated surgeon. Post operatively, they were randomized into a splinted (n=16) and a nonsplinted (n=14) group. The splint was kept for a week. Patients were reviewed at regular intervals of one week, two months and six months. At each follow up, these patients were clinically assessed for the following outcome measures: VAS (visual analogue score), 2PD (two-point discrimination), pinch grip, grip, Abductor Pollicis Brevis (APB) power and completion of the Boston questionnaire. Results: All patients presented with significant improvement in the postoperative evaluation in the analyzed parameters within each group. However, there was no significant difference between the two groups for any of the outcome measurements at sequential and at final follow-up. Conclusion: We conclude that wrist splinting in the immediate post-operative period has no advantage when compared with the unsplinted wrist after a limited open carpal tunnel release