Case: A 15-year-old boy presented with intermittent pain, in the left nondominant hand, for the past 3 years. He recently developed numbness in the radial 3 and a half digits. Ultrasonography revealed a bifid median nerve (BMN) with a persistent median artery (PMA). An open carpal tunnel release was performed, which revealed an accessory lumbrical muscle in addition to the BMN and a PMA. Conclusion: The surgeon should be aware of the possible coexistence of 3 anomalous structures while performing carpal tunnel release in a young patient.

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Resuming joint replacement arthroplasty amidst the COVID-19 pandemic and lockdown has come with various challenges that had to be dealt with utmost caution. Patients with severe arthritis experiencing a state of intolerable pain, could not be left unaddressed. Guidelines published by surgical associations, collaborative surgical author groups including public health organisations had to be modified to suit the Indian scenario and obtain optimal functional outcomes in these patients. Methods: A retrospective cohort analysis of 147 patients who underwent arthroplasty during the pandemic (March 2020 to April 2021), for either primary or secondary arthritis, was performed. We assess the efficacy and safety of the newly established Institutional surgical peri-operative protocol at our tertiary care centre in the National Capital Region, India in response to COVID-19 guidelines. The primary outcome measures appraised was 30-day mortality and the secondary outcome measures included length of stay, peri-operative complications and COVID-19 infection. Result: The most common indication for arthroplasty during the pandemic was neglected trauma. One patient died, due to myocardial infarction during the follow-up period. About 67% of patients were discharged to their usual residence within 7 days of admission. Two patients tested positive for COVID-19 postoperatively, but none required Intensive Care Unit admission. Conclusion: Joint replacement arthroplasty can be undertaken safely with diligent patient selection, application of a stringent COVID appropriate behaviour and a 'ring-fenced' peri-operative pathway.

Case: We present a rare combined convergent-divergent carpometacarpal (CMC) fracture dislocation with median nerve involvement in a young adult after a motorbike accident. Radiographs revealed a volar dislocation of the second and fifth metacarpals and dorsal dislocation of the third and fourth metacarpals with bases of the second and fifth metacarpals found to be converging in the coronal plane. Open reduction and fixation was performed with carpal tunnel release. Conclusion: Combined convergent-divergent CMC fracture dislocation should be kept as a differential while evaluating CMC dislocations. Metacarpal cascade line (posteroanterior view) and 2 lateral views (radial side up and ulnar side up) with computed tomography scan (3-dimensional reconstruction) prove to be vital in such high-energy trauma.

Introduction: Surgical intervention through the ‘triangle of auscultation’ is less morbid to patients, as it is devoid of muscles and provides an easy access to tumours arising on the ventral aspect of scapula especially near inferior angle. Method: Three patients presented to us with pseudo-winging of scapula and an audible thud on abduction of the arm. A bony mass, painful in two and painless in one patient, was palpable along the anterior aspect of the inferior angle of scapula. A clinical diagnosis of osteochondroma was made which was corroborated by X-rays and computed tomography (CT) imaging. Ventral scapular osteochondroma excision is challenging due to multiple muscle attachments, requiring extensive soft tissue dissection and muscular release. Numerous blood vessels and nerves in the vicinity may also add to the degree of difficulty. This necessitates the need of a minimally invasive and muscle-sparing procedure. We hereby describe a novel surgical approach to the ventral aspect of scapula through the triangle of auscultation for excision of scapular osteochondroma. Results: Pseudo-winging disappeared following surgery. Snapping of the scapula resolved with early, full shoulder range of motion. Quick disabilities of arm, shoulder and hand (DASH) score improved from mean 20.2 preoperatively to 0 postoperatively at 3 months in all the patients. Conclusion: The approach is simple with minimal blood loss as it does not involve splitting or cutting of trapezius, rhomboid major or subscapularis muscles.

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Case: A 9-year-old girl, with a history of crush injury to her right hand 2 years ago, presented with inability to extend her index finger. Exploration revealed segmental loss of extensor tendons to the index finger with a pre-existing scar in the route of tendon transfer. The juncturae tendinum (JT) between extensor digitorum communis of the middle and ring fingers (Von Schroeder -3y) was transferred to reconstruct the extensor tendon. At 1-year follow-up, finger extension was restored, with improved grasp and release. Conclusion: JT transfer could prove useful in reconstructing zone II extensor tendon injuries with scarring and fibrosis in the route of conventional tendon transfer/graft.