Neurotomy interrupts the stretch reflex and can be used for the treatment of spasticity. We hypothesized that neurotomy with nerve repair reduces spasticity while preserving motor function due to the preferential recovery of efferent over afferent fibres. This study reports the 1-year outcomes of neurotomy and immediate repair of the musculocutaneous nerve in the proximal arm for treatment of elbow flexor spasticity, comparing these to outcomes in the literature for neurectomy without nerve repair. A total of 10 adult patients with spasticity of the elbow flexors from stroke or traumatic brain injury who had undergone neurotomy and immediate repair of the musculocutaneous nerve were prospectively studied. The results suggest that this procedure effectively reduces elbow flexor spasticity, improves elbow resting position, active elbow extension and is useful for achieving patient goals with effects lasting at least 12 months.Level of evidence: IV (therapeutic).

» Tumors of the brachial plexus are uncommon and can present as a mass, with or without neurological symptoms. At times, asymptomatic tumors are also picked up incidentally when imaging is performed for other reasons. » Magnetic resonance imaging is the main imaging modality used to evaluate tumors of the brachial plexus. Other imaging modalities can be used as required. » Benign tumors that are asymptomatic should be observed. Excision can be considered for those that are found to be growing over time. » Biopsies of tumors of the brachial plexus are associated with the risk of nerve injury. Despite this, they should be performed for tumors that are suspected to be malignant before starting definitive treatment. » For malignant tumors, treatment decisions should be discussed at multidisciplinary tumor boards, and include both the oncology and peripheral nerve surgical team, musculoskeletal radiology, neuroradiology, and general radiology.

>> Tumors of the brachial plexus are uncommon and can present as a mass, with or without neurological symptoms. At times, asymptomatic tumors are also picked up incidentally when imaging is performed for other reasons.>> Magnetic resonance imaging is the main imaging modality used to evaluate tumors of the brachial plexus. Other imaging modalities can be used as required. >> Benign tumors that are asymptomatic should be observed. Excision can be considered for those that are found to be growing over time. >> Biopsies of tumors of the brachial plexus are associated with the risk of nerve injury. Despite this, they should be performed for tumors that are suspected to be malignant before starting definitive treatment. >> For malignant tumors, treatment decisions should be discussed at multidisciplinary tumor boards, and include both the oncology and peripheral nerve surgical team, musculoskeletal radiology, neuroradiology, and general radiology.

Background: We noted that patients with thoracic outlet syndrome (TOS) have elevation of the ipsilateral scapula and named this the scapular elevation sign (SES). The aim was to determine the prevalence of SES in a normal cohort, compare SES with other provocative tests and to determine the treatment effect on SES. Methods: First, normal asymptomatic subjects were prospectively assessed to determine the prevalence of SES in a normal cohort. Second, patients with TOS were retrospectively examined for the presence of SES and four provocative tests: supraclavicular pressure, scalene test, elevated arm stress test (EAST) and the military brace manoeuvre. All patients were initially treated non-surgically. Surgery was offered to patients with persistent symptoms at 6 months. Patients were re-examined for the presence of the SES after treatment. Results: The prevalence of SES in our normal cohort was 4% (2/53). Our study cohort included 20 patients with TOS. The SES was positive in 18 patients (90%). Supraclavicular pressure was positive in 11 (55%), scalene test in 13 (65%), EAST in 9 (45%) and military brace manoeuvre in 11 patients (55%). Following non-surgical treatment, six patients had symptom resolution, three had improvement, nine persistent symptoms and two were lost to follow-up. The SES was positive in one out of six patients with symptom resolution, two out of three patients with improvement and in all nine patients with persistent symptoms. Patients with persistent symptoms underwent surgery with symptom resolution in eight and improvement in one patient. The SES remained positive in two patients after surgical treatment. Conclusions: The SES is simple and sensitive, does not rely on variations in performance of the test and suitable for diagnosis and assessment of outcomes of TOS. Level of Evidence: Level III (Diagnostic)

Objectives: Volar locking plate (VLP) fixation is a very common procedure due to the high incidence of distal radius fractures (DRFs). Attritional flexor tendon rupture is a rare, but recognized complication after VLP fixation. There is no current consensus to prevent the condition. Our objective was to highlight the long-term risk for flexor tendon rupture after VLP fixation. Methods: We conducted a retrospective single-center review of patients with attritional flexor tendon rupture after VLP fixation for DRFs between 2016 and 2021. Patient demographics, DRF details including AO fracture classification, Soong grading and tendon reconstruction were collected. Thumb interphalangeal joint (IPJ) motion and Kapandji score were used as outcome measures forAthe tendon reconstruction. Results: We identified five patients with attritional flexor pollicis longus (FPL) ruptures. The median age of the patients at the time of DRF was 48 (34-56) years. All VLP fixations were Soong grade 2. Median time from VLP fixation to tendon rupture was 7 (3-14) years. Longest surgery-to-rupture interval was 14 years. One rupture was treated conservatively. Four were reconstructed using palmaris longus (PL) tendon graft. Thumb IPJ active range of motion median was 48 (20-55) degrees and Kapandji score 9/10 (7-9/10). Conclusion: Older generation VLP fixations with Soong grade 2 pose a long-term risk for attritional FPL rupture, which can be reconstructed with PL tendon graft with fair to good outcomes.

The loss of function resulting from peripheral nerve injuries confers a significant burden to the patient and society. The treatment of peripheral nerve injuries requires an accurate diagnosis and formulation of a functional reconstructive plan. Advances in peripheral nerve imaging complement electrodiagnostic studies, and provide us with detailed information regarding the status of nerve injury, repair, and regeneration in order to prognosticate recovery and determine the need for surgical intervention. When direct nerve repair is not possible, the methods for bridging a nerve gap are the nerve autograft, allograft and conduit. While current research supports the use of conduits and nerve allografts for shorter nerve gaps, the nerve autograft still remains the gold standard for bridging a nerve gap. When direct nerve repair or nerve grafting fails, or is anticipated to be insufficient, nerve transfers are an alternative for reconstruction. Knowledge of axonal counts, upper limb innervation patterns, location and clustering of upper limb peripheral nerves allows for the design of new nerve transfers. The options of nerve transfers for radial, ulnar and median nerve injuries are outlined, as well as their outcomes. Nerve transfers are an attractive option for restoring motor and sensory function while minimizing donor site morbidity. However, one must consider their limitations, and preserve donor sites for secondary tendon transfer options. This article presents the latest information regarding the imaging of peripheral nerves, methods to bridge a nerve gap, and nerve transfers to aid the peripheral nerve surgeon in choosing a reconstructive plan.

Abstract Introduction: The treatment of open lower limb fractures represents a major challenge for any trauma surgeon, and this even more so in resource-limited areas. The aim of the study is to describe the intervention, report the treatment plan, and observe the effectiveness of the Norwegian Open Fracture Management System in saving lower limbs in rural settings. Materials and Methods: A retrospective and prospective interventional study was carried out in the period 2011 through 2017 in six rural hospitals in Cambodia. The fractures were managed with locally produced external fixators and orthosis developed in 2007. Based on skills and living locations, two local surgeons and one paramedic without reconstructive surgery experience were selected to reach the top of the reconstructive ladder and perform limb salvage surgeries. This study evaluated 56 fractures using the Ganga Hospital Open Injury Score (GHOIS) for Gustilo-Anderson Type IIIA and Type IIIB open fracture classification groups. Results: The primary success rate in open tibia fractures was 64.3% (95% CI, 50.3 - 76.3). The average treatment time to complete healing for all of the patients was 39.6 weeks (95% CI, 34.8 - 44.4). A percentage of 23.2% (95% CI, 13.4 - 36.7) experienced a deep infection. Fifteen of the patients had to undergo soft tissue reconstruction and 22 flaps were performed. Due to non-union, a total of 15 bone grafts were performed. All of the 56 patients in the study gained limb salvage and went back to work. Conclusion: The given fracture management program proves that low-resource countries are able to produce essential surgical tools at high quality and low price. Treatment with external fixation and functional bracing, combined with high-level training of local surgeons, demonstrates that a skilled surgical team can perform advanced limb salvage surgery in low-resource settings.

Introduction: Coronavirus disease 2019 affected the timing of management of patients with cutaneous malignancies, delaying their surgical care by several months. The study objective is to determine the impact of delays on patients' oncologic and reconstructive management in comparison to 2 standard years. Method: A retrospective review of all patients with surgical management for their cutaneous malignancies at a single institution in the departments of otolaryngology and plastic surgery was conducted from January 2018 to January 2021. The 2020 group was considered to have delayed care due to the health care restrictions. Demographics, malignancy characteristics, ablative and reconstructive surgery, and adjuvant management were all evaluated comparing the pre-2020 and 2020 groups. Univariate analysis was performed using a 2-sample t test for continuous variables and chi-squared test and Fisher exact test for categorical variables. Significance was determined if P < .05. Results: In total 80 patients underwent cutaneous malignancy management and reconstruction during the time period, in which the squamous cell carcinoma was the most common pathology (38.75%) and the nose was the most common subsite (38.75%). In 2020 there were no cutaneous cases that were managed surgically between February and June compared with cases occurring monthly during the prior standard years, suggesting a delay in care anywhere from 1 to 4 months during this time. Despite delays, there was no significant difference between the pre-2020 and 2020 groups in terms of staging, oncologic management, or reconstruction. There were no differences in the variables between the groups. Conclusion: There was no significant difference in presentation, oncologic management, or reconstruction required for patients requiring a several-month delay in care for the management of cutaneous malignancy compared with the 2 prior standard years. This suggests that this delay did not significantly affect management of cutaneous malignancy in this subset of patients, leading us to understand more about urgency of management in patients with cutaneous malignancies.

Background: Migrant worker dormitories-residential complexes where 10-24 workers share living spaces-account for the majority of cases of SARS-CoV-2 infection in Singapore. To prevent overspill of transmission to the wider population, starting in early April 2020, residents were confined to their dormitories while measures were put in place to arrest the spread of infection. This descriptive study presents epidemiological data for a population of more than 60 000 migrant workers living in two barracks-style and four apartment-style dormitories located in western Singapore from April 3 to June 10, 2020. Methods: Our report draws from data obtained over the first 50 days of outbreak management in order to describe SARS-CoV-2 transmission in high-density housing environments. Cumulative counts of SARS-CoV-2 cases and numbers of housing units affected were analyzed to report the harmonic means of harmonic means of doubling times and their 95% confidence intervals (CI). Results: Multiple transmission peaks were identified involving at least 5467 cases of SARS-CoV-2 infection across six dormitories. Our geospatial heat maps gave an early indication of outbreak severity in affected buildings. We found that the number of cases of SARS-CoV-2 infection doubled every 1.56 days (95% CI 1.29-1.96) in barracks-style buildings. The corresponding doubling time for apartment-style buildings was 2.65 days (95% CI 2.01-3.87). Conclusions: Geospatial epidemiology was useful in shaping outbreak management strategies in dormitories. Our results indicate that building design plays an integral role in transmission and should be considered in the prevention of future outbreaks. (C) 2020 The Authors. Published by Elsevier Ltd on behalf of International Society for Infectious Diseases.

Journal of Hospital MedicineVolume 15, Issue 5 p. 281-283 Perspectives in Hospital Medicine Understanding the Singapore COVID-19 Experience: Implications for Hospital Medicine Arpana R Vidyarthi MD, Corresponding Author Arpana R Vidyarthi MD [email protected] Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California Duke-NUS Medical School, SingaporeCorresponding Author: Arpana Vidyarthi, MD; Email: [email protected].Search for more papers by this authorNatasha Bagdasarian MD, MPH, Natasha Bagdasarian MD, MPH Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, SingaporeSearch for more papers by this authorArmond M Esmaili MD, Armond M Esmaili MD Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CaliforniaSearch for more papers by this authorSophia Archuleta MD, Sophia Archuleta MD Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorBradley Monash MD, Bradley Monash MD Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California, San Francisco, CaliforniaSearch for more papers by this authorNiraj L Sehgal MD, MPH, Niraj L Sehgal MD, MPH Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CaliforniaSearch for more papers by this authorAdrienne Green MD, Adrienne Green MD Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CaliforniaSearch for more papers by this authorAymeric Lim MBBS, Aymeric Lim MBBS Yong Loo Lin School of Medicine, National University of Singapore, Singapore Division of Hand and Reconstructive Microsurgery, Department of Orthopedic Surgery, National University Hospital, National University Health System, SingaporeSearch for more papers by this author Arpana R Vidyarthi MD, Corresponding Author Arpana R Vidyarthi MD [email protected] Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California Duke-NUS Medical School, SingaporeCorresponding Author: Arpana Vidyarthi, MD; Email: [email protected].Search for more papers by this authorNatasha Bagdasarian MD, MPH, Natasha Bagdasarian MD, MPH Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, SingaporeSearch for more papers by this authorArmond M Esmaili MD, Armond M Esmaili MD Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CaliforniaSearch for more papers by this authorSophia Archuleta MD, Sophia Archuleta MD Division of Infectious Diseases, Department of Medicine, National University Hospital, National University Health System, Singapore Yong Loo Lin School of Medicine, National University of Singapore, SingaporeSearch for more papers by this authorBradley Monash MD, Bradley Monash MD Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California, San Francisco, CaliforniaSearch for more papers by this authorNiraj L Sehgal MD, MPH, Niraj L Sehgal MD, MPH Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CaliforniaSearch for more papers by this authorAdrienne Green MD, Adrienne Green MD Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, CaliforniaSearch for more papers by this authorAymeric Lim MBBS, Aymeric Lim MBBS Yong Loo Lin School of Medicine, National University of Singapore, Singapore Division of Hand and Reconstructive Microsurgery, Department of Orthopedic Surgery, National University Hospital, National University Health System, SingaporeSearch for more papers by this author First published: 16 April 2020 https://doi.org/10.12788/jhm.3436Citations: 9Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat No abstract is available for this article. References 1Wang CJ, Ng CY, Brook RH. Response to COVID-19 in Taiwan: big data analytics, new technology, and proactive testing. JAMA. 2020. https://doi.org/10.1001/jama.2020.3151. 10.1001/jama.2020.3151 Google Scholar 2Legido-Quigley H, Asgari N, Teo YY, et al. Are high-performing health systems resilient against the COVID-19 epidemic? Lancet. 2020; 395(10227): 848–850. https://doi.org/10.1016/S0140-6736(20)30551-1. 10.1016/S0140?6736(20)30551?1 CASPubMedWeb of Science®Google Scholar 3Wong JEL, Leo YS, Tan CC. COVID-19 in Singapore—current experience: critical global issues that require attention and action. JAMA. 2020; 323(13): 1243–1244. https://doi.org/10.1001/jama.2020.2467. 10.1001/jama.2020.2467 CASPubMedWeb of Science®Google Scholar 4Fisher D, Hui DS, Gao Z, et al. Pandemic response lessons from influenza H1N1 2009 in Asia. Respirology. 2011; 16(6): 876–882. https://doi.org/10.1111/j.1440-1843.2011.02003.x. 10.1111/j.1440?1843.2011.02003.x PubMedWeb of Science®Google Scholar 5Wong ATY, Chen H, Liu SH, et al. From SARS to avian influenza preparedness in Hong Kong. Clin Infect Dis. 2017; 64(suppl_2): S98–S104. https://doi.org/10.1093/cid/cix123. 10.1093/cid/cix123 PubMedGoogle Scholar 6Tan CC. SARS in Singapore–key lessons from an epidemic. Ann Acad Med Singapore. 2006; 35(5): 345–349. 10.47102/annals-acadmedsg.V35N5p345 PubMedWeb of Science®Google Scholar 7 National Centre for Infectious Diseases. About NCID. https://www.ncid.sg/About-NCID/Pages/default.aspx. Accessed April 5, 2020. Google Scholar 8Cutter J. Preparing for an influenza pandemic in Singapore. Ann Acad Med Singapore. 2008; 37(6): 497–503. 10.47102/annals-acadmedsg.V37N6p497 PubMedGoogle Scholar 9 Singapore Ministry of Health. What do the different DORSCON levels mean. http://www.gov.sg/article/what-do-the-different-dorscon-levels-mean. Accessed April 5, 2020. Google Scholar 10Lee J-W, McKibbin WJ. Estimating the global economic costs of SARS. In: S Knobler, A Mahmoud, S Lemon, et al, eds. Institute of Medicine (US) Forum on Microbial Threats. Washington, DC: National Academies Press (US); 2004. Google Scholar 11James EH, Wooten L. Leadership as (un)usual: how to display competence in times of crisis. Organ Dyn. 2005; 34(2): 141–152. https://doi.org/10.1016/j.orgdyn.2005.03.005 10.1016/j.orgdyn.2005.03.005 Web of Science®Google Scholar 12 The Joint Commission. Emergency Management: Coronavirus Resources. 2020. https://www.jointcommission.org/covid-19/. Accessed April 4, 2020. Google Scholar 13Wachter RM, Goldman L. Zero to 50,000 – the 20th anniversary of the hospitalist. N Engl J Med. 2016; 375(11): 1009–1011. https://doi.org/10.1056/NEJMp1607958. 10.1056/NEJMp1607958 PubMedWeb of Science®Google Scholar 14 Singapore Ministry of Health. Official Update of COVID-19 Situation in Singapore. 2020. https://experience.arcgis.com/experience/7e30edc490a5441a874f9efe67bd8b89. Accessed April 5, 2020. Google Scholar 15 Chronicle Digital Team. Coronavirus tracker. San Francisco Chronicle. https://projects.sfchronicle.com/2020/coronavirus-map/. Accessed April 5, 2020. Google Scholar Citing Literature Volume15, Issue5May 2020Pages 281-283 ReferencesRelatedInformation

The case spectrum in hand surgery is one of extremes-purely elective day surgery cases under local anesthesia to mangling limb injuries that require immediate, and frequently, lengthy, surgery. Despite the cancellation of most elective orthopedic and plastic surgical procedures, hand surgeons around the world continue to see a steady stream of limb-threatening cases such as severe trauma and infections that require emergent surgical care. With the increase in community-spread, an increasing number of COVID-19-infected patients may be asymptomatic or have mild, nonspecific or atypical symptoms. Some of them may already have an ongoing, severe infection. The time-sensitive nature of some of these cases means that hand surgeons may need to operate urgently on patients who may be suspected of COVID-19 infections, often before confirmatory test results are available. General guidelines for perioperative care of the COVID-19-positive patient have been published. However, our practices differ from those of general orthopedic and plastic surgery, primarily because of the focus on trauma. This article discusses the perioperative and technical considerations that are essential to manage the COVID-19 patient requiring emergency care, without compromising clinical outcomes and while ensuring the safety of the attending staff.

Management of malignant peripheral nerve sheath tumours (MPNSTs) is primarily surgical, involving surgical resection with wide margins, and frequently radiation therapy. When a MPNST involves a major peripheral nerve, wide resection leads to significant distal neurologic deficits. A patient who underwent resection of a MPNST involving the median nerve above the elbow is presented. Staged tendon and nerve transfers were performed to restore sensation to the thumb and index finger, thumb opposition and flexion, finger flexion and forearm pronation. These included: 1. radial sensory nerve branches to digital nerves of thumb and index finger, 2. ulnar nerve branch of flexor carpi ulnaris to pronator teres, 3. brachioradialis to flexor pollicis longus, 4. side-to-side transfer of flexor digitorum profundus tendon of index finger to middle, ring and little fingers, 5. extensor indicis proprius to abductor pollicis brevis. The rationale, approach, and favourable results of functional reconstruction in this patient are detailed.

Nerve compression occurs in fibro-osseous tunnels as the nerves cross joints. The pathology involves traction and adhesion, aside from compression. This can occur at multiple sites along the course of the nerve. Regardless of level, clinical assessment is standard and a systematic approach to uncover all sites of compression is advised. Evolution of management for carpal tunnel and cubital tunnel syndrome is reviewed with an emphasis on natural history and nonsurgical treatment, which are not commonly discussed. Treatment is multimodal and the systemic factors that contribute to nerve dysfunction should also be addressed.

BACKGROUND:Nerve transfers are planned based on the following parameters: location, number of branches, and axon count matching of the donor and recipient nerves. The authors have previously defined the former two in upper limb muscles. In the literature, axon counts are obtained from various sources, using different methods of histomorphometry. This study describes the axon counts of the same primary motor nerve branches from the authors' previous study using a uniform method of manual histomorphometry and completes the authors' blueprint of upper limb neuromuscular anatomy for reconstructive surgery.METHODS:The distal ends of the primary nerve branches of 23 upper limb muscles were harvested from 10 fresh frozen cadaveric upper limbs. Manual quantitative histomorphometry was performed by two independent investigators, and the average was reported.RESULTS:The primary nerve branches of the arm muscles had higher average axon counts (range, 882 to 1835) compared with those of the forearm muscles (range, 267 to 883). In the forearm, wrist flexor (range, 659 to 746) and extensor (range, 543 to 745) nerve branches had axons counts that were similar to those of potential donors (e.g., supinator, n = 602; pronator teres, n = 625; flexor digitorum superficialis, n = 883; and flexor digitorum profundus, n = 832).CONCLUSIONS:Apart from describing the axon counts of the upper limb, the authors have found that the forearm axon counts are very comparable. This insight, when combined with information on the location and number of primary nerve branches, will empower surgeons to tailor bespoke nerve transfers for every clinical situation.

OBJECTIVE:There has been an increase in the number and complexity of patient complaints against healthcare institutions. An understanding of the resources needed in this area is important for proper planning.DESIGN:Cohort study.SETTING:A 1250-bed tertiary-care teaching hospital.PARTICIPANTS:All patient complaints received between 1 February 2014 and 31 January 2015 were prospectively included in this cohort study.MAIN OUTCOME MEASURES:The amount of time spent on the investigation and liaising with the complainant for each case was recorded. The complainant's personal details and characteristics were recorded anonymously.RESULTS:In total, 908 patient complaints were recorded from 801 individuals during the study period. Longer median person-hours were spent on managing complaints that were brought forward by men (1.48 h), those who were distant relatives of the patients (2.08 h), foreigners (1.58 h) and non-subsidised patients (1.83 h). Patient complaints falling into the categories of clinical domain (3.00 h) and patient rights (2.54 h), quality (3.00 h) and safety (2.83 h) required the longest median time to manage. Multiple logistic regression analysis revealed that the total amount of time spent on the complaints was predicted by the gender of the complainant, the relationship of the complainant with the patient, the subsidy status of the patient, the severity and the domain of the complaint.CONCLUSIONS:This study reported the time required to manage patient complaints in a larger tertiary-care academic medical centre. Predictors of the time spent on resolving patient complaints can be used as parameters for resource planning.

Purpose Muscle remodeling occurs after tendon transfer. However, it is not known whether these adaptations are permanent and clinically significant. This study examined the early and late structural adaptations following a standard tendon transfer in a primate model. Methods A flexor carpi ulnaris (FCU) to extensor digitorum communis (EDC) transfer was performed in 8 adult monkeys. A sham operation was performed in the contralateral forearm. Four animals were sacrificed at 5 months (early cohort) and 4 at 16 months (late cohort). The transferred FCU, contralateral FCU, and EDC muscles were removed for analysis. Fiber length (FL), physiological cross-sectional area (PCSA), and gross morphology of the transferred FCU were compared with the contralateral EDC and FCU. Results In the early cohort, the FL of the transferred FCU was longer than the control FCU and similar to the contralateral EDC. The PCSA of the transferred FCU was lower than that of the control FCU but greater than the control EDC. In the late cohort, the difference in FL and PCSA between the transferred FCU and the control FCU persisted. The PCSA of the transferred FCU was similar to that of the control EDC. The bipennate transferred FCU had also undergone gross morphological changes to resemble the multipennate EDC. Conclusions This study demonstrates, in a primate model, that the FCU undergoes structural adaptations to resemble the EDC following an FCU-to-EDC transfer. However, these adaptations are incomplete and not sustained over time. Copyright (C) 2019 by the American Society for Surgery of the Hand. All rights reserved.)

Hospitals around the world are faced with the issue of boarders in emergency department (ED), patients marked for admission but with no available inpatient bed. Boarder status is known to be associated with delayed inpatient care and suboptimal outcomes. A new care delivery system was developed in our institution where boarders received full inpatient care from a designated medical team, acute medical team (AMT), while still residing at ED. The current study examines the impact of this AMT intervention on patient outcomes.

Background: The authors previously studied the intramuscular innervation of 150 upper limb muscles and demonstrated that certain patterns of intramuscular innervation allowed muscles to be split into compartments with independent function. This study aims to determine the location, extramuscular course, and number of motor nerve branches of upper limb peripheral nerves. The authors want to combine this information with their previous work to create a blueprint of upper limb neuromuscular anatomy that would be useful in reconstructive surgery. Methods: Ten fresh frozen cadaveric upper limbs were dissected. The origin of branches from the peripheral nerve trunk, their course, and the number of motor nerves per muscle were determined. The authors reviewed all the images of the Sihler-stained muscles from their earlier study. Results: Motor nerve branches arise at the intersection of nerve trunk and muscle belly and are clustered near the origin of muscle groups. Two patterns of extramuscular innervation were noted, with one group having a single motor nerve and another group with consistently more than one motor nerve. A modified classification of muscles was proposed based on the orientation of muscle fibers to the long axis of the limb, the number of muscle compartments, and the number of heads of origin or the tendons of insertion. Conclusions: Motor nerve clusters can be located based on fixed anatomical landmarks. Muscles with multiple motor nerves have morphology that allows them to be split into individual compartments. The authors created a muscle and nerve blueprint that helps in planning nerve and split muscle transfers.

Introduction: Undergraduate medical education training has recently shifted towards making content relevant and applicable for future clinical practice. However, students often encounter difficulties in visualizing the functional living human and apply clinically relevant anatomy content. Hence, the aim of this study is to evaluate the role and efficacy of ultrasound in teaching clinical anatomy to first year medical students. Methods: 300 Year 1 students took part in the practical sessions either using ultrasound mannequins or volunteer. All students were given a specially designed pre-test and post-test using Katz's Percentage to assess their level of ultrasound knowledge. A feedback survey was sought from the students and anatomists after the programme. Results: The results were analyzed based on the 100 students who have taken both pre- and post-tests. The study showed that there was statistical significant difference on normal US images of abdominal organs knowledge before and after the intervention. About 98% of students would like the continuation of this programme into the clinical years. Tutor's perception survey also revealed positive results particularly the interdepartmental collaboration. Conclusion: An ultrasound programme was successfully implemented to complement and enhance the conceptualizing of normal gross anatomy with clinical anatomy for first year medical students.