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Objectives: Analyze the donor site morbidity of the dorsalis pedis neurovascular flap in traumatic injuries with hand tissue loss., Material and Methods: The study involved dorsalis pedis neurovascular flaps that were used to reconstruct the hands of eight male patients, between 1983 and 2003, aged between 21 and 53 years (mean 34.6, SD ± 10.5 years). The size of the lesions ranged from 35 to 78 cm2 (mean 53, SD ± 14.4 cm2). Surgical procedures were performed two to 21 days after the injuries had occurred. The patients were followed up for an average of 10.3 years (ranging 8-14, SD ± 2.1 years)., Results: Regarding the donor site, in one case there was hematoma formation, which was drained; in another case, the skin graft needed to be reassessed. All patients experienced delayed healing, with complete healing from 2 to 12 months after the surgery (mean 4.3, SD ± 3.2 months)., Conclusion: Despite the advantages of the dorsalis pedis neurovascular flap, we consider that the sequelae in the donor site is cosmetically unacceptable. Nowadays, this procedure is only indicated and justified when associated with the second toe transfer. Level of Evidence IV; Case series ., Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: This study aims to present lines A1 and A2 in association with Kaplan's cardinal line (LCK), and relate them to the thenar motor branch of the median nerve (RMTNM) and to the deep branch of the ulnar nerve (RPNU)., Methods: Ten hands of five adult cadavers were dissected., Results: The RMTNM origin was positioned proximal to the LCK in all limbs. In two, the RMTNM was positioned exactly on the A1 line; in seven, it was on the ulnar side in relation to A1. In one, it was on the radial side relative to the A1. The origin of the RPNU was identified between the pisiform and the LCK in nine limbs; in one, the RPNU was positioned from the ulnar nerve in relation to A2; and in two, the A2 passed exactly at the point of division of the ulnar nerve into superficial branches and deep. We did not identify the positioning of the RPNU on the radial side of the A2 line., Conclusion: The impact of this study was to identify the anatomical trajectory of these nerves by detaching A1 and A2 along with the KCL, avoiding iatrogenic lesions during surgical procedures. Level of Evidence IV, Case Series. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Introduction: At the beginning of the medical career, the orthopedic surgeon in academic training needs valid methodologies for training complex surgeries in tissues that simulate real situations. With training in animal tissue, adapted to approach human tissue, it is possible to simulate procedures and decisions that will be necessary in real situations., Objective: This study consists in presenting a simple and reproducible simulation model for surgical repair of tendons by training on fresh tendons fixed on a wooden frame., Methodology: The model construction consists of a flat piece of Medium Density Fiberboard (MDF) and two threaded hooks were used on the board, to which Nylon threads are attached to tie the tendon, allowing a satisfactory simulation of a human tendon., Conclusion: This is a simple, inexpensive, and effective method for tendon suturing training, through which the trainee can develop repair techniques and basic surgical principles, such as instrument handling, safety, and sharps disposal. This approach aims to improve the trainee's skills and dexterity when placed in live surgery. The surgical techniques developed include the modified Kessler and Bunnel sutures. Level of Evidence IV, Descriptive Study ., Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: To report the use of the serratus anterior free tissue transfer in the treatment of traumatic injuries., Methods: Twenty-six free flaps or serratus pedicled flaps were performed for reconstruction of traumatic extremity injuries., Results: Complete flap survival was recorded in 20 limbs and 3 patients had circulatory complications. Even with the review of vascular anastomoses, partial flap necrosis could not be prevented and required a skin graft after debridement in the necrotic area. Another flap also required reexploration as a result of heavy congestion due to impaired venous return. Superficial wound infection was found in three patients and treated with conservative measures. Regarding the donor area, seroma formation was found in 8 cases; drainage was necessary in 2, and the others were resolved spontaneously. In 2, bruises formed and were later drained. In 1 limb there was long thoracic nerve injury and scapular winging., Conclusion: According to this study, the serratus anterior muscle flap is an excellent tool for treating small complex lesions in the extremities. Level of Evidence IV; Case series ., Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: The main purpose of this work was to evaluate the advantages and disadvantages of reconstructive procedures applied in upper limb soft tissue injuries according to their location., Methods: The study involved 94 male and 22 female patients (116 total) operated between April 2001 and November 2017 due to traumatic injuries in a upper limb. Individuals were evaluated considering their age, sex, etiology, reconstruction area , applied methodology and complications. The finger injuries were excluded., Results: The performed reconstruction procedures include 29 skin grafts; six advancement flaps; seven rotation flaps; 33 pedicled fasciocutaneous flaps, 9 free fasciocutaneous flaps; 5 pedicled muscle flaps; 12 free muscle flaps, three pedicled musculocutaneous flaps; one free musculocutaneous flap; 11 neurovascular free flaps., Conclusion: Reconstructive procedures in the upper limbs are diverse, varying from skin grafting to free flaps. The indication of the best option depends on the type of injurie and the surgeon. The final goal is to reach the best functional result combined with the lowest possible morbidity. Level of Evidence IV, Case series. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: To analyse the anatomical variations of the median nerve motor branches in the elbow region., Methods: Twenty upper limbs of 10 adult male cadavers were prepared by intra-arterial injection of a solution of 10% glycerol and formaldehyde. All cadavers belonged to the institution anatomy laboratory., Results: We found a great variability within the distribution of median nerve branches leading to forearm muscles. Only three limbs (14%) presented the normal standard of innervation described in anatomy treatises. The pronator teres muscle (PTM), flexor carpi radialis (FCR), palmaris longus (PL), and the flexor digitorum superficialis (FDS) received exclusive innervation from the median nerve in all forearms. The anterior interosseous nerve (AIN) also originated from the median nerve in all dissected limbs., Conclusion: A thorough understanding of the anatomy of the median nerve branches is important for performing surgeries such as: approach to the proximal third of the forearm, alleviation of pronator teres and anterior interosseous nerve compression syndromes, and distal nerve transfers. It also enables a better understanding the recovery of muscle function after a nerve injury. Level of Evidence IV, Case series. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: This anatomical study aimed to analyze the possibility of transferring the radial nerve branches destined to the brachioradialis (BR), extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), and supinator (SM) muscles to innervate the AIN., Methods: Ten limbs from five male cadavers were prepared by intra-arterial injection of a solution of 10% glycerol and formalin., Results: The presence of only one branch to the BR muscle was noted in 7 limbs and two branches were noted in three limbs. In two members of a common trunk with branch to the ECRL. In eight cases, we identified one branch for the ERLC and two branches in two cases. We identified only one branch for the ECRB, while in six limbs, two branches were noted, penetrating the muscular body at two different points. We identified at least two branches innervating the supinator muscle. The AIN was detached from the median nerve distal to the intercondylar line of the humerus. In seven limbs, it originated from the nervous fascicles of the posterior region of the median nerve and from the posterolateral fascicles in three limbs. The flexor pollicis longus and flexor digitorum profundus muscles received more than one branch of the AIN in all limbs., Conclusion: The radial nerve branches for the ECRL, ECRB, and supinator muscles can be transferred directly to the AIN or to one of its branches after intraneural dissection, without tension even in elbow movements. Level of Evidence IV; Case series. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: The objective of this paper was to study the anatomical variations of the flexor carpi radialis muscle (FCR) and determine in cadaver limbs whether the FCR nervous branch can be connected to the posterior interosseous nerve (PIN) without tension and how close to the target muscles the transfer can be performed., Method: Thirty cadaveric upper limbs were dissected., Results: The FCR received exclusive innervation of the median nerve, distally to the intercondylar line of the humerus. In 5 limbs, an isolated branch was found and in 25, a common trunk with other nervous branches occurred. We investigated whether the branch for the FCR was long enough to be transferred to the PIN. The diameter of the nerve branch for the FCR corresponded on average to 50% of the PIN., Conclusion: In 12 limbs, the branch destined to the FCR could be connected to the PIN, distally to the nerve branches to the supinator muscle even during the movements of the forearm and the elbow. In 18 specimens, it was necessary to mobilize the PIN for this innervation. Level of Evidence IV, Case Series. , Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: The arcade of the flexor digitorum superficialis muscle (FDS) is an anatomical structure which has not yet been widely studied and is a site of nerve compression. The aim of this study was to analyze the arcade of the FDS muscle and its relations with the median and anterior interosseous nerves through anatomic dissections., Method: Fifty arms from 25 adult cadavers (21 males and 4 females) were dissected; 18 were previously preserved in formalin and glycerin and 7 fresh specimens were dissected in the Laboratory of Anatomy., Results: The arcade of the superficial flexor muscle was identified in all dissected limbs. The radial and humeral heads were present in all specimens, and the ulnar head in 16 (32%). We identified two varieties of the arcade structure: a fibrous arcade in 32 specimens (64%), and a muscular arcade in 11 specimens (22%). In 4 specimens (8%) the arcade was very fine and so transparent that the nerve could be seen within the arcade. In 3 forearms the arcade was considered irregular because of discontinuity between the fibers that comprised this structure., Conclusion: The fibrous arcade of the FDS muscle may be a potential cause of nerve compression of the median and interosseous anterior nerves. Level of Evidence IV; Case series., Competing Interests: All authors declare no potential conflict of interest related to this article.

Objective: The objective of this study was to determine the frequency and anatomical characteristics of Struthers' ligament and the supracondylar humeral process and evaluate the clinical implications in compressive neuropathy of the median nerve ., Method: We dissected 60 arms from 30 cadavers (26 males and 4 females): 15 were previously preserved in formalin and glycerin and 15 were dissected fresh in the Anatomy Laboratory for this paper. The relationships between Struthers' ligament and the median nerve and brachial artery and veins were documented with drawings and photos ., Results: The supracondylar humeral process was not found in any of the 60 dissected arms. Struthers' ligament was identified in six arms (two bilateral); in all cases high insertion of the pronator teres muscle was observed ., Conclusion: Struthers' ligament is an aponeurotic structure that may or may not be associated with the supracondylar humeral process, and is an important potential site of median nerve compression in the lower third of the arm. Level of Evidence IV, Case Series., Competing Interests: All authors declare no potential conflict of interest related to this article