A Rare Variation of the Extensor Indicis Proprius Tendon With Important Clinical Implications

Introduction: Anatomical variations of the extensor tendons to the fingers are of great clinical interest, due to the relatively high frequency of tendon injury in clinical practice. Material and methods: During routine dissection of the right upper limb of a 67-year-old female preserved corpse, the extensor indicis proprius (EIP) muscle belly originated 3 independent tendons, each with a separate fascial sheath, forming a triple EIP tendon. There was a larger tendon, which occupied a central position, that represented the usual single EIP tendon. In addition, there were two thinner radial and ulnar accessory EIP tendons. The radial-EIP tendon crossed deep to the extensor digitorum communis (EDC) tendon to the index finger in the distal half of the dorsum of the hand to reach the radial side of the extensor expansion hood of the index finger. Discussion: According to the literature, the frequency of a triple EIP tendon ranges from 0%, to as high as 7%, although most authors do not acknowledge the presence of this variant in their series. This variant of the EIP tendon, in which the radial-EIP terminated laterally to the termination of the tendon of the EDC to the index finger, may be a source of confusion intraoperatively, as the EIP tendon has traditionally been identified on the basis of its ulnar location with respect to the EDC tendon. Conclusion: The possibility of a triple EIP tendon should certainly be born in mind by all surgeons when performing tendon repairs, tenoplasties or tendon transfers.

A Posterior Interosseous Nerve Syndrome Associated With Spontaneous Rupture of the Extensor Pollicis Longus Tendon

Posterior interosseous nerve entrapment syndrome and spontaneous rupture of the extensor pollicis longus tendon are rare conditions. The authors describe the bizarre combination of a spontaneous rupture of the extensor pollicis longus tendon in a 82-year-old lady with a posterior interosseous nerve syndrome. As far as the authors know, this is the first description of such an association in the literature. Surgical exploration revealed compression of the posterior interosseous nerve at the proximal portion of the supinator muscle and at Henry's leash. The nerve was freed, and the tendon of the extensor index proprius was transferred to the extensor pollicis longus. Six months after the procedure, the patient had resumed her daily activities, showing a good functional result.

Morphometric Analysis of the Extensor Tendons of the Hallux and Potential Implications for Tendon Grafting

Although several tendon sources are available for reconstructive surgical procedures, all have one or more shortcomings. The aim of this work was to evaluate if the extensor tendons of the hallux showed anatomical characteristics that could make them an additional source for tendon grafting procedures.The authors performed a detailed morphometric analysis of the extensor tendons of the hallux in 26 lower limbs in order to evaluate the putative association of anatomical variants with hallux valgus, and to attempt to assess the feasibility of using part of the extensor apparatus of the hallux as a source of tendon for grafting procedures.An accessory extensor hallucis longus ten-don was found in 92.3% of cases. The extensor hallucis brevis tendon length was 10.5 ± 0.6 cm; its width was 0.5 ± 0.1 cm, and its thickness varied between 1-2 mm, making it a potentially good candidate as a source of ten-don grafts. Several anatomical variations were observed, namely the fusion of the tendons of the extensor hallucis brevis and the accessory extensor hallucis longus muscles in the distal part of the foot.This new therapeutic option, if implemented, would possibly increase the supply of autogenous donor tissue for reconstructive procedures, thereby enhancing the reconstructive surgeon’s armamentarium.

Intraocular Pressure Correlates with Optic Nerve Sheath Diameter in Patients with Normal Tension Glaucoma

PURPOSE: 1. Identify differences in optic nerve sheath diameter (ONSD) as an indirect measure of intracranial pressure (ICP) in glaucoma patients and a healthy population. 2. Identify variables that may correlate with ONSD in primary open-angle glaucoma (POAG) and normal tension glaucoma (NTG) patients. METHODS: Patients with NTG (n = 46) and POAG (n = 61), and healthy controls (n = 42) underwent B-scan ultrasound measurement of ONSD by an observer masked to the patient diagnosis. Intraocular pressure (IOP) was measured in all groups, with additional central corneal thickness (CCT) and visual field defect measurements in glaucomatous patients. Only one eye per patient was selected. Kruskal-Wallis or Mann-Whitney were used to compare the different variables between the diagnostic groups. Spearman correlations were used to explore relationships among these variables. RESULTS: ONSD was not significantly different between healthy, NTG and POAG patients (6.09 ± 0.78, 6.03 ± 0.69, and 5.71 ± 0.83 respectively; p = 0.08). Visual field damage and CCT were not correlated with ONSD in either of the glaucoma groups (POAG, p = 0.31 and 0.44; NTG, p = 0.48 and 0.90 respectively). However, ONSD did correlate with IOP in NTG patients (r = 0.53, p < 0.001), while it did not in POAG patients and healthy controls (p = 0.86, p = 0.46 respectively). Patient's age did not relate to ONSD in any of the groups (p > 0.25 in all groups). CONCLUSIONS: Indirect measurements of ICP by ultrasound assessment of the ONSD may provide further insights into the retrolaminar pressure component in glaucoma. The correlation of ONSD with IOP solely in NTG patients suggests that the translaminar pressure gradient may be of particular importance in this type of glaucoma.

Defying Standard Criteria for Digital Replantation: A Case Series

INTRODUCTION: There is much controversy regarding the current indications and contraindications for digital replantation. PRESENTATION OF CASE: Three patients with absolute contraindications for digital replantation according to classical criteria are presented (Case 1: multilevel amputation of the hand and fingers; Case 3: avulsion of the thumb; Case 4: index amputation proximal to the insertion of the flexor digitorum superficialis). In addition a patient with a very distal digital amputation (Case 2), whose indication for replantation is controversial is also presented. In all cases, the patients were replanted and showed good functional and aesthetical results. DISCUSSION: Most authors advocate that the classical indications for replantation have been validated by experience, are predicated on the potential for long-term function, and should be followed in most if not all cases. However, some surgeons have been adopting a more liberal attitude with good results. CONCLUSION: The clinical cases presented in this paper suggest that the standard criteria for digital replantation should not be followed rigidly but instead should be regarded as a general guide.

Conexão Venosa Pulmonar Anómala. Estudo de Vinte e Quatro Crianças com Angiografia de Subtracção Digital

Objectivo: Avaliar a acuidade da angiografia de subtracção digital (ASD) no diagnóstico morfológico da conexão venosa pulmonar anómala (CVPA) em crianças. Concepção do estudo: Estudo prospectivo de doentes consecutivos entre Janeiro de 1989 e Julho de 1992. Tipo de Atendimento: Serviço de Cardiologia Pediátrica de um Hospital Central. População: Vinte e quatro doentes com CVPA. Métodos: Todos os doentes fizeram avaliação clínica e ecocardiográfica completa (modo M, bidimensional e Doppler) antes da realização do exame hemodinâmico. Em todos os casos se fizeram, de modo sistemático, injecções selectivas de contraste de baixa osmolaridade (0,5-1 ml/kg; dose total <6 mi/kg) no tronco e ramos da artéria pulmonar com registo em angiografia com subtracção digital (ASD). As imagens colhidas foram trabalhadas, selecciona das e armazenadas em video-cassetes e películas fotográficas (câmara multiformato). Resultados: Dezasseis doentes tinham CVPA total (CVPAT): onze à veia cava superior (VCS), dois ao seio coronário e três infradiafragmáticos (dois à veia cava inferior (VCI) e um à veia porta). Oito crianças tinham CVPA parcial (CVPAP): três à VCS, uma à aurícula direita (AD), três à VCI (síndroma da cimitarra) e num caso a CVPA era mista. Em oito doentes (seis com CVPAT e dois com CVPAP), a ASD contribuiu significativamente para o diagnóstico final tendo completado ou corrigido a informação obtida por ecocardiografia. Nos dezoito doentes submetidos a cirurgia cardíaca foi confirmado o diagnóstico obtido por ASD. Conclusões: A ASD é um método muito útil para o diagnóstico anatómico de doentes com CVPA. Na nossa experiência foi particularmente informativa a análise de registos em «video». A ASD está indicada nos casos em que os achados clínicos e ecocardiográficos não sejam típicos.