High-pressure injection injuries of the hand are uncommon but are associated with significant morbidity and require urgent surgical intervention. We describe a case of high-pressure injection of cement into the digit of a male patient while using an airless spray gun. We outline the initial assessment and surgical intervention, patient counselling regarding definitive management, and long-term outcomes of his injury. We also discuss mechanisms of high-pressure injection injuries, reconstructive options, and present a review of outcomes in patients sustaining similar injuries.

Flexor sheath infections (FSIs) are soft tissue infections affecting the hand, which, if mismanaged, can have devastating consequences. Clinical assessment is key to diagnosis, with many relying on Kanavel cardinal signs as an aid. To prevent unnecessary operative intervention and the associated post-operative combined patient and healthcare burden, it is key that patients with FSIs are correctly identified. It would also be useful to stratify severity of FSIs without surgical exploration. To date, there is no accepted method to assist clinicians in doing so. We retrospectively analysed data from a five-year period to see if we could identify pre-operatively (a) accurate predictors of FSIs and (b) severity of the FSIs. We established that only the presence of all four Kanavel cardinal signs significantly predicted the presence of an FSI. No other variable that was available prior to surgery could predict either presence or severity of infection.

Aneurysmal disease can occur in any vessel in the body and occur most commonly the aorta, cerebral and popliteal arteries; however, aneurysms of the digital artery remain a rare presentation. They form an important differential diagnosis in any patient presenting with a mass in the hand. This report presents the case of a 64-year-old man with a true aneurysm of the common palmar digital artery who underwent successful repair, following excision and end to end anastomosis. Only 21 cases of true digital artery aneurysm have been reported; we review the literature pertaining to the diagnosis and management of digital artery aneurysms since they were first described by Baruch et al in 1977.

Objective Delayed reconstruction of the articular surface of the distal radius after trauma is a difficult problem for hand surgeons, and the common solution is usually partial or total wrist fusion, relieving pain but sacrificing motion. A relative novel reconstructive technique addresses the problem with a free microvascular osteochondral flap, using the 3rd metatarsal (3MT) bone. We investigate the possibility of using the same donor as a graft rather than a free flap. Methods This was a prospective clinical study of patients with isolated lunate facet damage following trauma who underwent surgery to remove the damaged articular surface and in whom the defect was reconstructed with an osteochondral graft from the base of the 3MT. All of the patients were followed-up at specific time intervals, with pre- and postoutcome measures taken, including pain, grip strength, range of motion (ROM), and postoperative radiographs and computed tomography (CT) scans to evaluate graft resorption and union. Only patients with isolated distal radius defects were included. Results The average follow-up period was of 51 months (range: 14–73 months). The results of 7 patients included an average improvement of the pain score in the visual analogue scale (VAS) by 3 points, with an average arc of motion of 135°. In all, there was radiographic evidence of full incorporation of the graft, with no resorption. Donor site morbidity was minimal. Conclusions The current gold standard for distal radius articular surface reconstruction remains a free 3MT osteochondral flap. However, our results using the base of the 3MT as a graft shows promise, and if further follow-up confirms comparable results to the free flap technique, this would mean an easier and equally robust reconstruction without complicated microsurgery. Level of Evidence Therapeutic, Level V case series.

The hemi-hamate arthroplasty for proximal interphalangeal joint (PIPJ) dorsal fracture dislocations relies on complete dislocation of the joint using the 'shotgun' approach which provides excellent exposure but damages the delicate intrinsic joint stabilisers. We present a new approach to the PIPJ when performing the hemi-hamate arthroplasty. The volar surgical approach involves freeing up the whole tendon sheath-periosteal unit as a single layer, and retracting this to one side. The articular surface of the joint can then be accessed with a little distraction and hyperextension. The method does not breach the tendon sheath, nor does it damage the collateral ligaments or volar plate. It is akin to the radical total anterior teno-arthrolysis (TATA) technique used for contracted joints, with some crucial differences. We postulate that the new approach causes far less iatrogenic damage and reduces the risk of contractures developing, and in chronic cases, allows concurrent joint release.

\(\textit {Introduction:}\) Human papillomavirus (HPV) alone is thought to cause ~ 610,000 cases of cancer per year, and is the dominant aetiological agent for ano-genital (esp. cervical) and head and neck cancers (esp. oropharyngeal). Merkel cell polyomavirus (MCV) is a more recently discovered virus which causes Merkel cell car cinoma, a rare but highly aggressive skin malignancy. \(\textit {Methods:}\) We explored the available published evidence to see if transmission of live HPV or MCV virus in smoke generated by laser or diathermy was feasible, and would pose an infection risk. Long-term infection with such carcinogenic viruses would then pose an increased risk for the development of virus-induced cancers in medical personnel. \(\textit {Results:}\) The morphological structures of both HPV and MCV are very similar, and the size, external capsids and genomic structures show striking similarity. Both viruses have a non-enveloped external protein capsid consisting of 72 capsomeres, and a double-stranded DNA core. Sizes of both viruses range from 50 to 60 nm. There are now recent data demonstrating live and infectious HPV in smoke, and that these viruses can be used to infect cells in vitro. Further, anecdotal reports of virus transmission leading to disease causation in the production of respiratory airway viral warts (benign disease), and, finally, reports of HPV-induced oropharyngeal carcinoma (malignant disease) in two gynaecological surgeons as an occupational health hazard have been published recently. \(\textit {Conclusion:}\) There is now sufficient evidence to support the hypotheses that live infectious carcinogenic viruses can be transmitted via smoke generated from surgical procedures, and, in rare instances, actually cause significant disease. Protective measures such as smoke extraction and airway protection should be instituted for all healthcare personnel, particularly those with multiple repeated exposures such as gynaecological surgeons.

Human papillomavirus (HPV) alone is thought to cause ~610,000 cases of cancer per year, and is the dominant aetiological agent for ano-genital (esp. cervical) and head and neck cancers (esp. oropharyngeal). Merkel cell polyomavirus (MCV) is a more recently discovered virus which causes Merkel cell carcinoma, a rare but highly aggressive skin malignancy.

A seroma is a common complication encountered amongst plastic, reconstructive and aesthetic surgeons. Some regard it as the most commonly occurring post-operative complication after lymphadenectomy or flap harvest and it can be thought of as more of a rule than an exception in those undergoing reconstructive procedures.

Dear Editor, We note with interest the recent article by Thekkinkattil et al. [1] studying the feasibility of the barbed suture (BS) (V-Loc) to close latissimus dorsi donor sites (LDD). Their seroma rates were fairly high (33% in the BS group) compared with the recently published literature [2,3], although they did not demonstrate any statistical difference with traditional interrupted quilting. The higher than expected seroma rates may well reflect the fact that a significant number of their patients underwent complete autologous breast reconstruction (29 out of 30) in the immediate reconstruction group; however, this was not clearly elucidated. As for the delayed reconstruction patients, this same critical point was again not clearly highlighted and no firm conclusions can be made. Complete autologous breast reconstruction with latissimus dorsi flaps (LD) tends to be reserved for patients with smaller natural breasts, if harvested in a non-extended manner. Extended LD flaps, on the other hand, require a much more extensive dissection by virtue of the technique, in order to increase the flap size. Hence, it is unsurprising that the seroma rates were increased with this technique [4]. Despite this omission of relevant information, Thekkinkattil et al. [1] have commendably demonstrated that the barbed suture is a very viable alternative to traditional quilting methods when used to close LDD. We recently reviewed our own LDD data in our unit from January 2005 till the present, having started using the V-Loc suture since January 2010. Before 2010, 31 patients underwent conventional closure of LDD with interrupted quilting sutures using 2.0 polyglactin (Vicryl) sutures (Ethicon, Johnston & Johnston, Livingston, Scotland) according to the technique described by Titley et al. [5]. Seventeen developed clinical seromas (55%), with volumes varying from 20 to 800 mL in total on aspiration. Most had minimal volumes, and only 7 patients had more than 50 mL aspirated in total. In the BS group of 42 patients (8 patients with bilateral LD flaps), only 2 patients developed a seroma (40 to 70 mL) i.e., 2/50 (4%). This represents a highly significant seroma reduction (P=0.0001; two-tailed Fisher's exact test). Both groups were similar in terms of age, body mass index, delayed/immediate reconstruction, autologous or implant-based reconstruction, and axillary lymphadenectomy. All patients were operated on by the senior author, with harvest of the flap using standard monopolar cutting diathermy. The striking difference in the seroma rate has prompted us to change our practice and adopt the BS on a regular basis when quilting LDD. The reason for such a reduction in the seroma rate is unclear but may well be related to at least 3 differences compared with traditional quilting: firstly, the spread of the suture 'bites' are noticeably closer together compared with traditional quilting, as the tension on the suture is not exacted until a few tissue passes have been made. This is clearly different from interrupted quilt stitches that must be tied off immediately, making suture placement more difficult than with the continuous technique. Secondly, the continuous nature of the quilt makes cheese-wiring through tissues more difficult. Thirdly, the nature of the barbed suture allows better distribution of tension throughout the apposed tissues. All these factors suggest that the tissues will necessarily be apposed better, reducing dead space and shear. Traditional interrupted quilting is very operator dependent, which may account for our high seroma rates in our patients (pre-2010). We believe that in our practice, the BS technique is easier to perform than traditional quilting, reduces seroma formation, and is an excellent alternative for LDD closure.