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Fulltext Giant pyogenic granuloma gravidarum of the hand

Khan ES, Ariff MS, Eshagroni A, Haflah NHM, Abdullah S, Sapuan J

International Medical Journal Malaysia, 2014;13(2):55-58.
MyJurnal

We describe a case of a giant pyogenic granuloma affecting the left index finger of a 23-year-old pregnant lady requiring surgical excision. Pyogenic granuloma gravidarum is a benign hyperplastic lesion that commonly presents on oral mucosa, typically the gums, in approximately 5% of pregnant women. Skin lesions over the fingers are an unusual site during pregnancy with only a few cases reported in the literature. The lesion was excised and a diagnosis of lobular capillary haemangioma was made based on histopathological evaluation. We delayed surgery until after parturition since recurrence is likely to be lower due to lower levels of circulating oestrogen and progesterone. The prognosis is usually excellent following resection. However, recurrences have been reported regardless of the treatment method.
An insight into industrial accidents involving the hand

Abdullah S, Jaafar JM, Das S, Sapuan J

Clin Ter, 2009;160(6):427-33.
PMID: 20198282

BACKGROUND: Industrial hand injuries are a common occurrence and contributes to a large segment of workers' morbidity. The main aim of this study was to look into the day pattern, types and location of upper limbs injures, identify the types of machines involved and highlight the treatment received.
MATERIALS AND METHODS: The present study was performed on 57 industrial workers admitted and treated by the Orthopaedic team of Universiti Kebangsaan Malaysia Medical Centre (UKMMC) for acute injuries sustained whilst working.
RESULTS: The majority of the workers were male (93%). The commonest age group involved was between 25-35 years (48%). The right hand was injured more then the left with majority of injuries involving the fingers. Interestingly, we also observed that injuries occurred more on Saturdays. Laceration was the most common injury followed by fractures and crush injuries. Treatment depends on the type and severity of injuries. For most lacerated wounds, treatment was debridement, primary suturing and antibiotic therapy. Injuries on Saturdays indicated that workers needed a longer time break especially during weekends after a long hectic week.
CONCLUSIONS: Injuries sustained by workers may be prevented by proper working techniques and conditions together with wearing of protective gadgets.

Study site: Pusat Perubatan Universiti Kebangsaan Malaysia (PPUKM)
Fulltext The Flail and Pulseless Upper Limb: an Extreme Case of Traumatic Scapulo-thoracic Dissociation

Maria SW, Sapuan J, Abdullah S

Malays Orthop J, 2015 Jul;9(2):54-56.
PMID: 28435612 MyJurnal DOI: 10.5704/MOJ.1507.002

Scapulo-thoracic dissociation is an infrequent injury resulting from high energy trauma which is often associated with severe neurological and vascular injuries which may be unrecognised at the time of presentation. A 24 year-old female presented with bilateral rib fractures, pneumothorax, liver and kidney injuries following a road traffic accident. She also sustained fractures of her right scapula, odontoid, right transverse processes of the thoracic and lumbar vertebrae and a closed fracture of her right femur. Her right upper limb was later noted to be flail and pulseless, due to complete right brachial plexus injury, scapula-thoracic dissociation and subclavian artery avulsion. We managed the upper limb injuries non-operatively, and focused on resuscitation of the patient. Early exploration of the complete brachial plexus injury was not undertaken in spite of the possible associated poor functional outcome as there was no life-threatening indication.
Fulltext Gouty wrist arthritis causing carpal tunnel syndrome--a case report

Sikkandar MF, Sapuan J, Singh R, Abdullah S

Med J Malaysia, 2012 Jun;67(3):333-4.
PMID: 23082430

A 63 year old male with a history of gout and hypertension presented with carpal tunnel syndrome. He gave history of bilateral wrist pain associated with numbness over the median nerve distribution of the hand. Tinels sign and Phalens test were positive with no obvious thenar muscle wasting on examination. Tophaceous deposits in the flexor tendons and within the synovium of the wrist joint was seen during surgery and this established gout as the cause of median nerve entrapment in this patient.
Outcome of corticosteroid injection versus physiotherapy in the treatment of mild trigger fingers

Salim N, Abdullah S, Sapuan J, Haflah NH

J Hand Surg Eur Vol, 2012 Jan;37(1):27-34.
PMID: 21816888 DOI: 10.1177/1753193411415343

We compared the effectiveness of physiotherapy and corticosteroid injection treatment in the management of mild trigger fingers. Mild trigger fingers are those with mild crepitus, uneven finger movements and actively correctable triggering. This is a single-centred, prospective, block randomized study with 74 patients; 39 patients for steroid injection and 35 patients for physiotherapy. The study duration was from Jun 2009 until August 2010. Evaluation was done at 6 weeks, 3 months and 6 months post-treatment. At 3 months, the success rate (absence of pain and triggering) for those receiving steroid injection was 97.4% and physiotherapy 68.6%. The group receiving steroid injection also had lower pain score, higher rate of satisfaction, stronger grip strength and early recovery to near normal function (findings were all significant, p
Glomus tumor in the second toe: a clinical insight

Sapuan J, Paul AG, Abdullah S

J Foot Ankle Surg, 2008;47(5):483-6.
PMID: 18725132 DOI: 10.1053/j.jfas.2008.05.008

Glomus tumors are rare benign tumors commonly occurring in the digits of the hand. Surprisingly, considering the fingertips are of a similar make-up to the toes, there have been few reports of glomus tumor in the toes. The present case highlights a glomus tumor observed in the right second toe of a 56-year-old Indian female who presented with the classical triad of spontaneous pain, cold hypersensitivity, and pressure tenderness. There was a delay in diagnosis for approximately 18 years by various general practitioners who were not aware of the rare presentation of the glomus tumor. The tumor, which measured 5 x 3 mm, was excised from the nail bed of the toe. Histopathological inspection confirmed the diagnosis of glomus tumor. We believe that reporting this rare case may make clinicians more aware of this unusual diagnosis.
A randomized controlled trial of trigger finger release under digital anesthesia with (WALANT) and without adrenaline

Mohd Rashid MZ, Sapuan J, Abdullah S

J Orthop Surg (Hong Kong), 2019 3 12;27(1):2309499019833002.
PMID: 30852960 DOI: 10.1177/2309499019833002

BACKGROUND:: Trigger finger release utilizing wide-awake local anesthesia no tourniquet (WALANT) usage in extremity surgery is not widely used in our setting due to the possibility of necrosis. Usage of a tourniquet is generally acceptable for providing surgical field hemostasis. We evaluate hemostasis score, surgical field visibility, onset and duration of anesthesia, pain score, and the duration of surgery and potential side effects of WALANT.
METHODS:: Eighty-six patients scheduled for trigger finger release between July 2016 and December 2017 were randomized into a control group (1% lignocaine and 8.4% sodium bicarbonate with arm tourniquet; given 10 min prior to procedure) and an intervention group (1% lignocaine, 1:100,000 of adrenaline and 8.4% sodium bicarbonate; given 30 min prior to procedure), with a total of 4 ml of solution injected around the A1 pulley. The onset of anesthesia and pain score upon injection of the first 1 ml were recorded. After the procedure, the surgeon rated for the hemostasis score (1-10: 1 as no bleeding and 10 being profuse bleeding). Duration of surgery and return of sensation were recorded.
RESULTS:: Hemostasis score was grouped into visibility score as 1-3: good, 4-6: moderate, and 7-10: poor. The intervention group (with adrenaline) had a 74% of good surgical field visibility compared to 44% from the controlled group (without adrenaline; p < 0.05). Duration of anesthesia was longer in the intervention group (with adrenaline), with a 2.77-h difference.
CONCLUSION:: WALANT provides excellent surgical field visibility and is safe and on par with conventional methods but without the usage of a tourniquet and its associated discomfort.
Fulltext Mistaking a Tumour for an Infection - Acrometastasis of the Finger from Endocervical Adenosquamous Carcinoma: A Case Report

Yong AS, Gill PS, Shalimar A, Sapuan J

Malays Orthop J, 2021 Nov;15(3):115-117.
PMID: 34966504 DOI: 10.5704/MOJ.2111.017

Acrometastasis is rare with a very low incidence of all bone metastasis. It can present with swelling, pain and warmth with erythema that may mimic an infection especially in the distal phalanx. Due to its rarity and subtle clinical presentation, it can be misdiagnosed as an infection causing the treatment to be delayed. We report a 42-year-old female with an acrometastasis to the distal phalanx of the left middle finger which we mistook as an infection thus delaying her treatment. It was a terminal presentation of her endocervical adenosquamous carcinoma. We would like to highlight that acrometastasis has an indistinct presentation and in cases where the lesion does not respond to treatment, acrometastasis should be included as one of the differential diagnoses. Thus, physicians need to have a high level of suspicion in patients with a primary malignant tumour.
Partial anterior interosseous nerve palsy: isolated neuropraxia of the branch to flexor pollicis longus

Haflah NH, Rashid AH, Sapuan J

Hand Surg, 2010;15(3):221-3.
PMID: 21089198

Anterior interosseous nerve palsy is rare. Isolated neuropraxia of its branch to the flexor pollicis longus is even rarer. We present a case of a 24-year-old man who presented with weakness of his left thumb flexion after sustaining closed fracture of the proximal third of his left radius. On exploration, the anterior interosseous nerve and its branches was found to be intact as was the flexor pollicis longus. Electrophysiological studies demonstrated acute left anterior interosseous nerve neuropathy. Electromyography showed discrete motor unit at the flexor pollicis longus. Two months later the patient had full recovery of the flexor pollicis longus. We would like to highlight this rare occurrence and present a detailed history of this case to increase awareness amongst clinicians regarding this condition.
An elbow dislocation in a child with missed medial epicondyle fracture and late ulnar nerve palsy

Haflah NH, Ibrahim S, Sapuan J, Abdullah S

J Pediatr Orthop B, 2010 Sep;19(5):459-61.
PMID: 20555271 DOI: 10.1097/BPB.0b013e32833b6032

Elbow dislocations associated with a medial epicondyle fracture and ulnar nerve palsy are uncommon injuries. We present the case of an 11-year-old girl with an elbow dislocation treated by closed manual reduction. The medial epicondyle fracture was missed initially until she developed an ulnar nerve palsy 2 months later. Intraoperatively we discovered the bony epicondyle piercing the joint capsule and compressing the ulnar nerve. Removal of the bony fragment relieved her symptoms and she returned to normal activities at 1 year follow-up. We would like to highlight this rare occurrence and present the detailed history and management of this case.
A case of disproportionate macrodactyly or a mild form of Proteus syndrome? An interesting case

Abdullah S, Haflah NH, Sapuan J, Das S

Acta Medica (Hradec Kralove), 2010;53(4):243-6.
PMID: 21400985

We present a 20-year-old Malay male whom we believe has Proteus syndrome, a rare congenital disorder of asymmetrical overgrowth of body tissues. There are fewer than 100 confirmed cases reported worldwide thus the clinical presentation and histopathological findings are of significance. Our patient presented with an overgrown right small finger and subcutaneous purplish pigmentation over his left upper arm and chest since birth. His small finger gradually increased in size. He had no abnormalities in sensation or power. Radiographs revealed a delta shaped middle phalanx of the small finger. His activities of daily living were uninterrupted but he requested debulking surgery for cosmetic reasons. Histopathological examination reported hypertrophic fatty tissue composed of well formed lobules of mature adipocytes interspersed with fibrous elements.
Fulltext Melorheostosis of the ulna

Abdullah S, Pang GM, Mohamed-Haflah NH, Sapuan J

J Chin Med Assoc, 2011 Oct;74(10):469-72.
PMID: 22036140 DOI: 10.1016/j.jcma.2011.08.019

Melorheostosis is a rare osteosclerotic bone dysplasia. It is usually characterized by dull and aching pain, reduced joint motion and contractures. Classic radiograph findings are of undulating cortical hyperostosis along the length of the bone, simulating a "dripping candlewax appearance". We report two cases of melorheostosis of the ulna bone, diagnosed 6 years apart in two different females in their early 20s. Both the patients presented with the characteristic features of dull and aching pain in the forearm and were treated conservatively. However, we misdiagnosed the first case as bone malignancy and subjected the patient to a biopsy. For the second case, with hindsight we made the correct diagnosis based only on the classic clinical history and radiographs. We believe that the discussion of a misdiagnosed case of melorheostosis with salient findings may be important for clinicians and orthopedicians in day-to-day clinical practice.
Fulltext A rare presentation of isolated carpal bone tuberculous osteomyelitis mimicking gouty arthritis

Abdul Hamid MF, Rajandiran SR, Yu-Lin AB, Sapuan J

Int J Mycobacteriol, 2020 8 31;9(3):325-328.
PMID: 32862171 DOI: 10.4103/ijmy.ijmy_97_20

Tuberculosis (TB) is the most prevalent infectious disease in Southeast Asia. It causes both pulmonary and extrapulmonary diseases. TB of the wrist is rare and presents as osteomyelitis or tenosynovitis. We report a middle-aged male with carpal bone tuberculous osteomyelitis. He presented with left wrist pain initially treated as gouty arthritis. Within 2 weeks, he developed seropurulent discharge with osteomyelitic changes on imaging. He underwent debridement, and intraoperatively, there was destruction of most carpal bones. Histopathological examination revealed chronic granulomatous inflammation with abscess formation. Anti-TB medication was initiated, and he made a complete recovery with almost full range of wrist movement after 9 months of treatment. This case serves as a reminder that TB is a great mimicker, and a high index of suspicion is required to make a diagnosis of TB of the wrist. Early initiation of anti-TB is pivotal to prevent complications and deterioration of joint functions.
Fulltext Ipsilateral proximal and distal radius fractures with unstable elbow joint: Which should we address first?

Akma Kamaludin NA, Ferdaus Kamudin NA, Abdullah S, Sapuan J

Chin J Traumatol, 2019 Feb;22(1):59-62.
PMID: 30745113 DOI: 10.1016/j.cjtee.2018.04.007

Simultaneous ipsilateral fractures involving radial head and distal end of radius are uncommon. We present our thoughts on which fracture should be addressed first. A 68-year-old lady sustained an ipsilateral fracture of the right radial head and distal end of radius following a fall. Clinically her right elbow was posteriorly dislocated and right wrist was deformed. Plain radiographs showed an intraarticular fracture of the distal end of radius and a comminution radial head fracture with a proximally migrated radius. Magnetic resonance imaging (MRI) showed no significant ligament injuries. We addressed her distal radius first with an anatomical locking plate followed by her radial head with a radial head replacement. Our rationale to treat the distal end radius: first was to obtain a correct alignment of Lister's tubercle and correct the distal radius height. Lister's tubercle was used to guide for the correct rotation of the radial head prosthesis. Correcting the distal end fracture radial height helped us with length selection of the radial head prosthesis and address the proximally migrated radial shaft and neck. Postoperative radiographs showed an acceptable reduction. The Cooney score was 75 at 3 months postoperatively, which was equivalent to a fair functional outcome.
Fulltext A Review of Surgically Treated Distal Radius Fractures in a University Hospital

Bahar-Moni AS, Wong SK, Mohd-Shariff N, Sapuan J, Abdullah S

Malays Orthop J, 2021 Nov;15(3):52-57.
PMID: 34966495 DOI: 10.5704/MOJ.2111.008

Introduction: Distal radius fracture (DRF) is the most common orthopaedic injury with a reported incidence of 17.5%. It is commonly seen in young males and elderly females. Over the last two decades, there is an increasing tendency to treat DRF surgically by open reduction and internal fixation (ORIF) with plate and screws owing to improved device design, better fixation and operative technique. The purpose of this study was to evaluate the demographic characteristics, type and method of fixation, and outcome in all surgically treated DRF cases from 2014 to 2018 in a university hospital.
Materials and methods: A retrospective review of all surgically treated DRF cases with one year follow-up in a tertiary hospital in Malaysia was done. Patients who left the follow-up clinic before one-year post-surgery or before fracture union were excluded. A total of 82 patients with 88 DRF were finally included into the study and outcome in terms of union time and need of multiple surgeries were analysed along with the predictors.
Results: In this study, mean age of the patient was 46.2 years. Motor vehicle accident was the commonest cause of the fracture and AO Type C fracture was the commonest fracture type. Seventeen (19.3%) out of 88 fractures were compound fracture. Open reduction and internal fixation with volar plate was the most common surgical technique done in this series (93.2%). Three (3.5%) out of 88 fractures required multiple surgeries and eighty-three (94.3%) DRF cases were united before nine months of the surgery in this study. There was statistically significant association between clinical type of the fracture and the union time (p-value <0.05).
Conclusion: There was a 1.7:1 male-female ratio with AO-C fracture being the most common type of fracture. The most common method of fixation was ORIF with volar locked plate. Patients with closed fractures have a higher rate of union compared to open fractures at nine months.
In Vitro Evaluation of Human Hand Tendon Ingrowth into A Synthetic Scaffold

Abdullah S, Mohtar F, Abdul Shukor N, Sapuan J

J Hand Surg Asian Pac Vol, 2017 Dec;22(4):429-434.
PMID: 29117830 DOI: 10.1142/S0218810417500459

BACKGROUND: Synthetic scaffold has been used for tissue approximation and reconstructing damaged and torn ligaments. This study explores the ability of tendon ingrowth into a synthetic scaffold in vitro, evaluate growth characteristics, morphology and deposition of collagen matrix into a synthetic scaffold.
METHODS: Upper limb tendons were harvested with consent from patients with crush injuries and non-replantable amputations. These tendons (both extensor and flexor) measuring 1 cm are sutured to either side of a 0.5 cm synthetic tendon strip and cultured in growth medium. At 2, 4, 6 and 8 weeks, samples were fixed into paraffin blocks, cut and stained with haematoxylin-eosin (H&E) and Masson's trichrome.
RESULTS: Minimal tendon ingrowth were seen in the first 2 weeks of incubation. However at 4 weeks, the cell ingrowth were seen migrating towards the junction between the tendon and the synthetic scaffold. This ingrowth continued to expand at 6 weeks and up to 8 weeks. At this point, the demarcation between human tendon and synthetic scaffold was indistinct.
CONCLUSIONS: We conclude that tendon ingrowth composed of collagen matrix were able to proliferate into a synthetic scaffold in vitro.
Fulltext Bilateral scaphoid stress fracture in a platform diver presenting with unilateral symptoms

Mohamed Haflah NH, Mat Nor NF, Abdullah S, Sapuan J

Singapore Med J, 2014 Oct;55(10):e159-61.
PMID: 25631904

Scaphoid stress fracture is rare and occurs mainly in gymnasts. The current literature has only two reported cases: unilateral scaphoid stress fracture in a platform diver and bilateral scaphoid stress fracture in a gymnast. We herein report bilateral stress fracture of the scaphoid in a platform diver who presented with only one symptomatic side. Our patient was a 16-year-old competitive platform diver with an 18-month history of pain in the right wrist. Radiography revealed fracture of the right scaphoid at the waist. As part of our preoperative plan of measuring the scaphoid length to determine the appropriate screw, radiography of the contralateral side was performed, revealing an unexpected fracture of the left scaphoid. Due to the frequency of stress fractures in competitive sports, especially gymnastics, we recommend that bilateral scaphoid radiography be performed for athletes presenting with a unilateral scaphoid fracture, to avoid missing a fracture in the contralateral side.
Fulltext Two-Year Outcome of Synthetic Annular Ligament Reconstruction in the Elbow: A Case Report

Kesu Belani L, Abdullah S, Harun MH, Narin Singh PSG, Sapuan J

Cureus, 2020 Nov 19;12(11):e11564.
PMID: 33364091 DOI: 10.7759/cureus.11564

Monteggia fracture is commonly treated with open anatomical reduction and fixation of the ulna fracture. The radial head will be automatically reduced once anatomical fixation of the ulna is achieved. However, it is occasionally associated with an irreducible radial head dislocation requiring an open reduction and reconstruction of the torn annular ligament. We describe a case of traumatic Monteggia fracture which underwent initial plating, however post-operative radiograph denoted an irreducible radial head secondary to a ruptured annular ligament. We reconstructed the annular ligament with a synthetic graft sling around the radial neck with an anchor suture. The radial head was stable in all directions after annular ligament reconstruction. A two-year follow-up shows full range of motion of the elbow joint with osteolysis of the radial head, no other operative morbidity was observed.
Pain Perception During the Phases of Manual Reduction of Distal End Radius Fracture With a Periosteal Block

Wan Ali WAA, Soh EZF, Abdullah S, Narin Singh PSG, Ahmad AA, Sapuan J

Cureus, 2021 Jan 13;13(1):e12691.
PMID: 33604222 DOI: 10.7759/cureus.12691

Introduction Closed reduction is an effective method of treatment for distal end radius fractures. We present a case series of patients with distal end radius fractures who underwent closed manipulative reduction using the periosteal block. We describe the technique in detail and examine its efficacy in pain lowering effect during closed reduction. Methods Nineteen patients with distal end radial and ulnar fractures were included and grouped based on the Frykman classification. The reduction was performed using a periosteal block of 10 ml of 2% lignocaine injection. The severity of pain was recorded by utilizing the visual analog scale (VAS) in five phases: 1) before injection, 2) after 15 minutes of analgesia in a resting position, 3) during minimal motion, 4) during full manipulation and reduction, and 5) post-procedure. The VAS scoring was classified as painless (VAS score of 0), mild pain (VAS score between 1-3), and painful (VAS score of 4 and above). Results The study included 19 patients [median age of 53 years (range: 18-88 years)]; there were 11 (58%) males and eight (42%) females. The mechanism of injury was a fall (n=12, 63%) or a motor vehicle accident (n=7, 37%). There was a statistically significant reduction of pain between phase one and all the other phases. Between the different fracture configurations, there was no significant difference in pain reduction. The most painful phase was expected to be phase four, ie, during full manipulation, in which four (21%) patients had a VAS score of 0, 12 (63%) patients had a VAS score between 1-3, and three (16%) patients had a VAS score of 4. Thus, 16 out of 19 patients (84%) had no or minimal pain during the most painful phase. There were no complications from the periosteal blocks. Conclusions The periosteal nerve block is an effective procedure providing satisfactory analgesia during the reduction of distal radial and ulnar fractures. It has no side effects and is free from complications associated with conventional sedation.
Fulltext Coverage of a Firecracker Blast Injury of the Right Hand With a Chest Wall Flap Under Wide Awake Local Anaesthesia no Tourniquet Technique

T AS, Abdullah S, Narin Singh PSG, Poh Yuen Wen A, Sapuan J

Cureus, 2021 Aug;13(8):e16962.
PMID: 34527453 DOI: 10.7759/cureus.16962

A flap is done to cover expose structures such as bone, tendon and ligament. Chest wall flaps are usually performed under general anaesthesia due to a fairly large area of surgery and at two different sites which are the chest and the hand. This is the first known reported case of a chest wall flap for coverage of the hand under Wide awake local anaesthesia no tourniquet technique (WALANT). We here report the case of a 32-year-old man who had a firecracker injury over his right hand with bone exposed in his right index and middle finger and distal amputation of the thumb with first carpometacarpal joint dislocation. Chest wall flap reconstruction for coverage of a severe blast injury in the hand is possible and safe under WALANT. The proper technique and administration will lead to a successful surgery without general anesthesia complications and risks. This alternative option may be useful in districts or smaller hospitals where resources are limited.

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