Schwannomas are the most common benign tumors developing in peripheral nerves. They account for 5% of all tumors in upper extremity. They usually present as a slow-growing mass, sometimes associated to pain and paresthesia. Preoperative evaluation is based on US and MRI, but final diagnosis requires histopathology. The aim of this study is to define clinical findings and MRI characteristics in identification, localization, and possible differential diagnosis of schwannomas.

When approaching a palpable mass in the upper limbs, the possibility of a peripheral nerve tumour should always be considered. It is important to look for typical signs of schwannomas, such as a positive Tinel sign and peripheral paraesthesia. Imaging assessment with magnetic resonance imaging (MRI) and ultrasonography enables the determination of where the tumour takes its origin and from which nerve. Microsurgical techniques and know-how are recommended in approaching the resection in order to respect as many nerve fibres as possible.

The anterolateral thigh flap was thin enough for defects on the dorsum and/or palm of the hand and for first web reconstruction after scar contracture release. It has many advantages in free flap surgery including a long pedicle with a suitable vessel diameter, and the donor-site morbidity is acceptable. The thin anterolateral thigh flap is a versatile soft-tissue flap that achieves good hand contour with low donor-site morbidity.

The findings of this study indicate that both with the use of TBW and plate fixation excellent/good clinical outcomes with minimal loss of physical capacity, little pain and disability can be obtained in the majority of patients with simple and comminuted displaced olecranon fractures. Hardware removal was most frequently observed after TBW.

Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the upper extremity have expanded in recent years. Between 1993-2000, 12 patients with segmental bone defects following forearm trauma were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16-65 years). The reconstructed site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6-13 cm. In 4 cases, the fibular graft was harvested and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The follow-up period ranged from 10-93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8 months (range, 2.5-8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.

BackgroundThe treatment of radial neck fractures in children varies according to the displacement, angulation, and skeletal maturity. There is a general agreement that displaced radial neck fractures with more than 30° angulations (Judet type III and IV fractures) should be surgically treated. There are several treatment possibilities for Judet type III and IV fractures including percutaneous pin reduction, elastic stable intramedullary nailing (ESIN), and open reduction with or without internal fixation. In this retrospective study we compared the clinical and radiographical outcomes, and complications following intramedullary versus percutaneous pinning in displaced radial neck fractures in children.Materials and methodsBetween 2000 and 2011, 20 patients were treated using closed reduction: in 12 cases we used percutaneous pinning, and in 8 cases we used ESIN. According to Judet classification the two groups were composed as follows: 10 (77 %) type III and 3 (23 %) type IV fractures in the percutaneous pinning group; 4 (57 %) type III, and 3 (43 %) type IV fractures in the ESIN group.ResultsAfter an average of 42 months, excellent results in Mayo elbow performance scores (MEPS) were obtained in 71 and 69 % of ESIN and percutaneous pinning groups respectively, with good results in the remaining cases apart from one fair case (8 %) in the percutaneous pinning group. After a radiological evaluation, all fractures healed in excellent or good alignment. When comparing the two groups, the subjects treated with the ESIN technique had higher range of motion (ROM) in flexion, extension and pronation. No patients developed complications, except three cases of asymptomatic enlargements of the radial head, reported only in the percutaneous pinning group.ConclusionIn this research the clinical outcome, assessed with the MEPS, and the radiological alignment, were comparable between the subjects that were treated with percutaneous pinning and those with ESIN techniques; whereas the ESIN technique demonstrated higher ROM in flexion, extension and pronation. The ESIN technique seems to be the ideal approach both for the higher ROM values and for the absence of complications.

Therapeutic level IV.

Ring avulsion injuries have long presented complex management problems. Despite microsurgical advances, it is difficult to achieve good functional results in complete degloving injuries or amputations, and their management remains somewhat controversial. Ten patients with class IV injuries according to Kay's classification were treated from 1986 to 2000. In this study the authors subdivided class IV injuries into those with amputation distal to the insertion of the flexor digitorum superficialis tendon (class IVd, 5 cases); those with amputation proximal to the insertion of the flexor digitorum superficialis tendon (class IVp, 3 cases); and complete degloving injuries leaving the tendons intact (class IVi, 2 cases). Replantation was done in class IVi and class IVd injuries, and 6 cases were revascularized successfully. In all these patients range of motion was complete at the metacarpal and proximal interphalangeal joints, but reestablishing sensibility was more difficult. Patients with class IVp injuries were treated by surgical amputation of the digit. Modifications of Kay's classification system based on anatomic injury is more predictive of functional outcome for completely amputated ring avulsion injuries. The authors conclude that complete ring avulsion amputations are salvageable, with acceptable functional results in select patients.